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Ischemic THE occur as a result ES LE N
of an obstruction within a blood STO: 1. Assess the patients The patient may only need After 48 hours of nursing
Objective: PROBLEM
vessel supplying blood to the After 48 hours of strength to help with some self-care interventions goal is:
brain. The underlying condition nursing interventions, accomplish ADLs measures. FIM measures 18 Fully met if he
On Coma for this type of obstruction is the patient will be able to efficiently and self-care items related to was able to
Intact and patent development of fatty deposits identify personal cautiously on a eating, bathing, grooming, identify personal
ET tube connected lining the vessel walls. This resources that can daily basis using a dressing, toileting, bladder resources that can
to mechanical condition is called atherosclerosis provide assistance and proper assessment and bowel management, provide assistance
ventilator The brain stem is located at the be able to verbalize tool, such as the transfer, ambulation, and be able to
GCS of 3/15 (M-1; very base of the brain right above knowledge of health Functional stair climbing. verbalize
V-1; E-1) the spinal cord. Many of the care practices. Independence knowledge of
Babinski reflex body's vital "life-support" Measures (FIM). health care
noted functions such as heartbeat, blood LTO: practices.
pressure, and breathing are After 5 days of nursing 2. Assess for type and Provides data regarding Partially met if he
Inability to feed controlled by the brain stem. It interventions, patient severity of mobility and ability to was able to
self also helps to control the main will be able to immobility perform activities with in verbalize the need
independently nerves involved with eye demonstrate impairment, muscle limitations without injury or for assistance
movement, hearing, speech, techniques/ lifestyle flaccidity, spasticity frustrations. Not met if patient
Inability to dress chewing, and swallowing. Some changes to meet self- and coordination, has no change in
self common effects of a stroke in the care needs ability to walk, sit, condition. Still
independently move in bed
brain stem include problems with unconscious.
the following: breathing and heart perform
Inability to
functions, body temperature After 5 days of nursing
bathe and
groom self
control, balance and coordination, interventions goal is:
weakness or paralysis in all four 3. Determine the Various etiological factors Fully met if patient
limbs, chewing, swallowing, and specific cause of may need more explicit was able to do
speaking, vision and coma. These each deficit (e.g., interventions to enable self- ADLS
Inability to
visual problems, care.
perform toileting problems are evident on the independently
tasks patients condition. weakness, cognitive Partially met if
independently impairment). patient needs
assistance in doing
4. Place patient in
Inability to Proper positioning can ADLS
optimal position
ambulate make the task easier while Not met if patient
independently for feeding also reducing the risk for is still completely
aspiration. dependent and
Nursing diagnosis: cannot perform
Self-Care Deficit in ADLS.
bathing /hygiene, The need for privacy is
dressing /grooming, 5. Provide privacy fundamental for most
feeding and toileting during dressing. patients.
related to
impairment, secondary These reduce energy
to cerebrovascular 6. Provide frequent
assistance as
disease (CVD)
needed with

7. Use of clothing A large size guarantees

one size larger. easier dressing and comfort.

8. Consider or use This saves energy,

energy- decreases fatigue, and
improves patients
capability to execute tasks.

9. Suction oral, ET
tube/Tracheosto Promotes airway to the
my tube as patient.

To promote optimum care to
morning care
the patient despite of
such as
stretching linens, condition
diapers, and
sponge bath.
To provide patient quality
11.Instruct S.O on care continuously through
different participation of the S.O in
interventions his/her care.
such as draining
IFC bag, To prevent formation of bed
positioning etc. ulcers.
12.Log rolling every
2 hours. Promotes circulation,
muscle tone, joint
13.Passive ROM to flexibility, prevents
all limbs and contractures and weakness
progress to
assistive and
then active ROM
in all joints four
times a day