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Based on nursing care was conducted on 05 April 2017 until 08 April 2017 from

the assessment, data analysis, priority nursing diagnoses, nursing interventions,


implementation, and evaluation. Key components and foundation are the nursing
process of assessment. An in-depth assessment allows nurses critical to detect
rapid changes, early intervention and do the nursing care (Talbot, Marquardt, &
Meyers, 2007).

The assessment was done on Monday 05th of April 2017 at 04.00 pm in the Medical
Intensive Care Unit, St. Paul Hospital Tuguegarao Philippines. Data obtained by observation,
physical examination and data-existing supporting data such as lab results and Ct Scan.

Client initials. R aged 45 years, male, private job, married, has been hospitalized
since Saturday 05 april 2017 hours of 14:30 pm, no RM 1.23.xx.xx, clients
treated in the Medical Intensive Care Unit, the medical diagnosis CVA ( cerebro
Vascular Accident). Clients major complaints of dizziness and unable to speak
with GCS: E3 V1 M3 oxygen by nasal cannula attached 2 lpm and SPO2: 100%.

Current medical history, family clients tell the client suddenly can not talk and
feel the weakness in the limbs, then the client was taken to the Hospital of St.
Paul Hospital.

Past medical history, family clients said before the client was never hospitalized,
the client has a history of hypertension four years ago, and the client does not
have a communicable disease such as tuberculosis, HIV / AIDS and hepatitis.

Family medical history, familys client say they dont have a family members who
are suffering the same disease like client.

In theory, one cause of stroke is hypertension. Strokes can cause paralysis.


Paralysis can occur in the extremities due to the ineffectiveness of tissue
perfusion caused by thrombi and emboli will cause ischemia on networks that are
not fed by blood, if this continues continuously then the network proficiency level
will infarcted and then will disturb persyarafan system in the body such as :
decline in voluntary control that would cause hemiplagia or hemiparese so that
the body will experience impaired mobility (Price, 2006).

The main nursing problems which appear in this case is the risk for ineffective
cerebral tissue perfusion is characterized by increased blood pressure of 170/100
mmHg, and examination results are Ct Scan intracerebral hemorrhage on the
frontal part as much as 17 cc. When given nursing intervention and
implementation of nursing carried the client's problem is not resolved.

In taking the action of nursing, the group collaborated with room nurses and
doctors. For plan nursing groups such as the following: monitor vital signs,
monitor headache, monitor the level of awareness and orientation, monitor
nystagmus, diplopia, blurred vision, visual acuity, monitor ICT, management of
peripheral sensation, collaborative activity: Keeping the thermodynamic
parameters within the recommended range, giving the drugs to increase of
intravascular volume, as requested, give the drug the which causes hypertension
to maintain cerebral perfusion pressure According to demand, elevate the head
of the bed of 0 to 45 degrees, Depending on the patient's condition and medical
demands, give loap and osmotic diuretics, According to demand.

Results from the records of clients at the development of the date of 04 April
2017 until 08 April 2017 generally do not progress.

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