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Lethargic Dependent:
Administered
Right Sided osmotic diuretics To decrease
paralysis (Mannitol 100cc cerebral swelling
Q 8hours
Administered
antihypertensive To decrease
drugs. blood pressure.
(Amlodipine10m
g tab.
OD)
Administered
antifibronilytic To reduce
drug intracranial
(Tranexamic Acid hemorrhage.
500mg)
CUES DIAGNOSIS BACKGROUND PLANNING INTERVENTIONS RATIONALE EVALUATION
KNOWLEDGE
SUBJECTIVE: Impaired After 8 hours of Independent: After 8 hours of
Yung kanang physical Hypertension nursing Established To gain the nursing
parte ng mobility related intervention the rapport. clients trust. intervention the
katawan niya to left-sided Rupture of client will be able client maintained
yung hindi niya brain damage as cerebral blood to maintain Monitored vital To assess position of
maigalaw, as evidence of right vessels position of signs specially clients response function and skin
verbalized by the sided paralysis, function and skin clients BP and progress to integrity as
patients wife facial drooping, Hemorrhage integrity as the treatment. evidenced by
and speech evidenced by absence of
difficulty. Left-sided brain absence of Assisted client To prevent contractures,
OBJECTIVE: damage contractures, reposition self on bedsores. foot drop and
foot drop and a regular bedsores.
T: 36.3 bedsores. schedule.
Impaired
P: 73 bpm
physical mobility
RR. 20 cpm Supported To maintain
BP: 180/90 affected body position of
GCS: E2V2M5 parts using function
pillows.