Assessment February 23, 2010 01:30am Subjective: Stated: “na stroke siya” stated by the client’s cousin Objectives

:

Nursing diagnosis

Scientific explanation ⬆ intake of Na Cigarette smoking Imbalanced nutrition vasoconstriction ⬆ intravascular pressure ⬆resistance to flow Scarring of vessel

Planning Discharge outcome: After 2 weeks of nursing intervention the client will be able to:  Demonstrate behaviors/lifestyle changes, therapy regimen to improve circulation example: cessation of smoking, relaxation techniques, exercise/dietary program.  Demonstrate increased perfusion as individually appropriate Example: skin warm/dry, peripheral pulses present/strong, pulses present/strong, vital signs within

Intervention independent:  Note customary baseline data  Review result of diagnostic study

Scientific rationale

Evaluation February 24, 2010 12:00pm Discharge outcome:

Ineffective cerebral tissue perfusion related to interruption of blood flow secondary to hemorrhage as evidenced by GCS of 7

 Provide comparison with current findings

 Speech abnormality  Behavioral changes: restlessness  Changes in motor response; extremity weakness: paralysis  Muscle strength of 1/5

Thrombus formation Emboli formation Blocks the vessel in the brain CVA

 Note history of syncope, brief/intermittent periods of confusion  Instruct in blood pressure monitoring at home, advice purchase of home monitoring equipment refer to community resources as indicated  Elevate HOB example: 10 degrees and

Reference: medical surgical nursing: 11th edition volume 1 Brunner and Suddarath

Partially achieve  To determine location/severity of After 2 weeks of nursing intervention condition the client can be able to:  Suggestive of  Demonstrate transient ischemic behaviors/lifestyle attack changes, therapy regimen to improve circulation example:  Facilitate cessation of management of smoking, hypertension, relaxation which is a major techniques, risk factor for exercise/dietary damage blood program. vessels/organ function Short term outcome:  To promote circulation/ venous drainage Achieve

 GCS of 7

normal range, alert/oriented, balanced intake/output, absence of edema, free of pain/discomfort.

maintain head /neck in midline or neutral position  Administer medication such as catapress  Assist with monitor hypothermia therapy  To promote pharmacologic regimen  Which may be used to decreases metabolic and O2 needs.  To have contact with other health care provider

After 2 days of nursing intervention the client cannot be able to:  Verbalize understanding of condition therapy regimen, side effects of medication and when to contact health care provider

Short term out come: After 2 days of nursing intervention the client will be able to:  Verbalize understanding of condition therapy regimen, side effects of medication and when to contact health care provider.

 Recommend with physical rehabilitation therapy

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