2 SOAPIERS November 12, 2012 S: O O: received on bed with GCS of 14/15 scoring (E3V5M6) with an ongoing IVF # 1 PNSS

1L X 80 cc @400 cc level with variations in blood pressure readings, S3 sounds, restlessness noted, prolonged capillary refill time of more than 4 seconds, with signs of fatigue and dyspnea, FC connected to UB draining to urine bag of light yellow urine, with left sided weakness as evidenced by weak grip on left hand and strong grip on right, inability to change position, needs assistance, vital signs taken as follows: T: 35.4c/ axilla; RR: 17 bpm; PR: 122 bpm; bp: 110/ 60 mmhg A: Ineffective cerebral tissue perfusion r/t interruption of cerebral blood flow secondary to CVA infarction P: After 4hrs of nursing interventions, the patient will exhibit increase perfusion as evidenced by vital signs and neurological status within normal range I: > Obtain vital signs. >Determine hemodynamic parameters and neurologic status >Monitor cardiac rhythm continuously >Keep patient on bed or chair rest in position of comfort every 2 hours rendered >Raise legs 20-30 degrees >Assess urine output hourly or periodically, noting total fluid balance >Monitor rate of IV drugs closely >Decrease stimuli >Schedule activities and assessments >Instruct patient to avoid/limit activities that may stimulate a valsalva reponse. >Provide oxygen therapy as ordered.

E: After 4hrs of nursing interventions, the patient shall have displayed hemodynamic stability.

November 13, 2012 S: O O: received on bed, conscious and coherent, GCS of 15/ 15 (E4V5M6) with O2 inhalation via nasal cannula @ 2 LPM, with NGT patent intact and negative residual, with # 4 PNSS 1L X 100 cc/ hr infusing well on left hand with SD f dobutamine(double dose) at 15 kcg/ kg/ min. @ 27 hr ;with FC connected to UB draining to urine bag of light yellow urine, with left sided weakness as evidenced by weak grip on left hand and strong grip on right, inability to change position, needs assistance, vital signs taken as follows: T: 36 c / axilla; RR: 18bpm; PR: 117 bpm; bp: 100/ 50mmhg O2 sat. of 99%. A: Impaired physical mobility related to neuromuscular involvement secondary to CVA infarct P: After 4 hours of nursing intervention, the patient will participate in activities necessary for the patient I: < Established a professional nurse - patient relationship <monitored and recorded vital signs, fluid status, NVS, urine output every 1 hour < Positioned every 2 hours rendered < encouraged bed rest without bathroom privileges < encouraged verbalization of feelings < raised side rails E: After 4 hours of nursing intervention, the patient shall have participated in activities necessary for the patient