Medical Diagnosis: Cerebrovascular Accident Problem: Ineffective Cerebral Tissue Perfusion RT ASSESSMENT Subjective: (none) Objective:

hemiplegia assess for muscle strength altered mental status restlessness changes in pupillary Reactions difficulty in swallowing

NURSING DIAGNOSIS
Ineffective cerebral tissue perfusion r/t interruption of blood flow secondary to CVA

SCIENTIFIC EXPLANATION
The presence of partial blockage of the blood vessel can be multifactorial. These can be due to vasoconstriction, platelet adherence on rough surface, fat accumulation and therefore decreases elasticity of vessel wall leading to alteration of blood perfusion with the initiation of the clotting sequence. This may later lead to the development of thrombus which can be loosened and dislodged in some areas of the brain such as mid cerebral carotid artery that may lead to alteration of blood perfusion and further develop to cerebral infarct.

PLANNING Short Term:

After 4 hours of NI, patient will be able to display decrease signs of ineffective tissue perfusion as evidence by gradual improvement of vital signs. 1. 2.

INTERVENTIONS
Establish rapport Monitor vital signs 2. 1.

RATIONALE
To promote cooperation To have a baseline data, assess changes in neurologic status To determine blood circulation To promote circulation Enough rest is needed to conserve energy To avoid obstruction of arterial and venous blood flow Aids in difficulty of breathing

EVALUATION Short Term:

Patient shall have displayed a decrease signs of tissue perfusion AEB gradual improvement of vital signs

3.

Long Term:
After 3 days of NI, patient will be able to gradually improve tissue perfusion AEB good capillary refill and pink conjunctiva.

4.

Check capillary refill and conjunctiva for paleness elevate head of bed to 30 degrees as ordered Advise patient to have enough rest

3.

4.

Long Term:
Patient shall have gradually improved tissue perfusion AEB good capillary refill and pink conjunctiva

5.

5.

6.

Avoid neck flexion and extreme hip/knee extension Provide and maintain oxygen as ordered

6.

7.

7.

8.

Perform GCS monitoring as ordered

8.

To detect changes indicative of worsening or improving condition To promote wellness

9.

Administer medications as ordered

9.