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27258344 Ncp Cva Ineffective Tissue Perfusion

27258344 Ncp Cva Ineffective Tissue Perfusion

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Published by Nina Glaiza Goto

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Published by: Nina Glaiza Goto on Feb 27, 2011
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Pt name: R.Asperin Assessment Subjective: y Client said, ³namamanhid yung kanang kamay ko, pero nagagalaw ko naman xha medyo hirap lng ako.´ Objective: y Arrhythmias (atrial fibrillation) y Skin temperature changes (body temperature is 36.2 ºC) y Oliguria (output is 250ml and intake is 850ml)

Nursing Dx

Inference CVA can be caused by an occlusion in the blood flow. This can lead to O2 and the cause failure to nourish the tissues at the capillary level

AGE: 63 Goals Long term: After 4 days of nursing intervention, client will be able to demonstrate perfusion Expected outcome: y Normal I/O (e.g. 1500:1500) y motor response y Absence of arrhythmia Short term: After 8 hrs of nursing intervention, client will be able to participate in therapeutic regimen and to increase skin and body temperature Expected outcome: y Verbalization of understanding the condition y Skin and body temperature is normal y Verbalization of understanding of when to contact HC provider

Intervention Independent: 1. Assess the client first 2. Take note of lab results and v/s 3. Review of diagnostic studies done 4. Determine voiding patterns 5. Measure extremities¶ circumference 6. Measure I/O 7. Elevate HOB especially at sleep time 8. Encourage relaxation 9. Encourage warm dressings and preventing exposure to cold 10. Perform health teaching about: y The signs and symptoms of the condition (paralysis, low skin and body temp) y When to contact HC provider (when symptoms are getting worst) Dependent: 1. Administer appropriate medications as ordered


DIAGNOSIS: CVA Evaluation Long term goals partially met: The pt is not able to fully demonstrate perfusion as evidenced by: y Skin is still not warm to touch (35.9 ºC body temperature) y Imbalanced I/O (output is 300ml and intake is 900ml) y motor response ( numbness) y Presence of arrhythmia Short term goals partially met: The client is able to participate on the therapeutic regimen as evidenced by verbalization of understanding of the condition, and when to contact HC provider and the client does not return to normal temperature

Ineffective tissue perfusion (cerebral) r/t interruption of blood flow (occlusive disorder) as evidenced by right arm numbness

Independent: 1. To establish comparative baseline 2. To know if the pt¶s condition is getting better or not 3. To determine the severity of the condition 4. To compare past fluid status to the current 5. To identify if there is edema 6. To monitor fluid balance 7. To promote circulation and venous drainage 8. tissue O2 demands 9. To retain heat more efficiently 10. To equip client with adequate knowledge regarding his condition Dependent: 1. To promote healing effectively

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