Problem: Ineffective Tissue Perfusion: Cerebral ASSESSMENT EXPLANATION OF THE PROBLEM S>  ‘mejo mahirap igalaw ang kaliwang kamay

at paa ko’ dizziness left-sided weakness facial asymmetry speech slurring unexplained headache at the occipital and nape area dyspnea Clot, thrombus or embolism forms within cardiovascular system Cerebral artery Brain Blood flow is disrupted Oxygen and Glucose cannot reach part of brain Brain cells die (infarction) STO

OBJECTIVES

INTERVENTIONS Dx  Assess general health status.  Monitored for other signs of ineffective tissue perfusion. Monitored and recorded vital signs.

RATIONALE

EVALUATION & EXPECTED OUTCOME STO

O>     

After 8 hours of effective nursing interventions the client will verbalize understanding of condition and therapy regimen

Provides baseline data for nursing care.  To accurately gauge severity of condition. 

The patient understands his condition and complies with therapeutic regimen.

Radical changes may indicate that the condition got worse.

LTO  After 2 days of effective nursing interventions the client will verbalize understanding of condition, therapy regimen, side effects of medications and when to contact healthcare provider

Tx 


Elevated HOB 

To promote circulation / increase gravitational blood flow Anticoagulants and hypertensive drugs help to prevent further damage Alleviates the effects of the stroke

LTO

Administered medications 

The patient understands his condition, complies with therapeutic regimen, is fully aware of possible side-effects of medication and when to contact a healthcare provider.

Perform assistive/active range-ofmotion exercises

Enhances venous return Conserves energy / lowers tissue O2 demands Encourages compliance to therapeutic regimen. To assist patient in incorporating disease

Edx  Encourage early ambulation Nursing Diagnosis  Ineffective tissue perfusion related to interruption of blood flow secondary to CVD/CVA  Promote quiet, restful atmosphere Reiterated importance of medical restrictions.

Discussed necessary changes in lifetyle Encouraged verbalization of feelings.

management into ADLs.

Provides basis for nursing care.

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