Assessment Diagnosis
S– Ineffective breathing
pattern related to
pressure on respiratory
O- center due increased ICP
Assessment Diagnosis
Objective- Ineffective Cerebral Tissue
Lethargic appearance Perfusion related to
PR 57bpm interruption of blood flow
BP: 130/70 secondary to multiple
Speech abnormalities: cerebral infarction as
slurred speech manifested by altered
Extremity weakness; level of consciousness,
pain and discomfort on changes in motor
lower extremities- &sensory response, and
Restless; language deficit
Planning
Short term:
After 30 minutes of
nursing intervention, the
patient will be able to
improve breathing by
increasing respiratory rate
from 8 cycles/min to 12
cycles/minute
Planning
Goal The client will have
an effective cerebral
tissue perfusion after2 to
3 weeks of proper nursing
intervention
Intervention Expected Outcomes
 Administer After 30 minutes of
oxygen as nursing intervention, the
prescribed by the patient will be able to
physician improve breathing by
 Position the increasing respiratory rate
patient in semi from 8 cycles/min to 12
fowlers position cycles/minute
 Auscultate lungs
 Monitor vital
signs every 2hrs
Intervention Expected Outcomes
Determine factors related The client will have an
to individual effective cerebral tissue
situation,decreased perfusion after2 to 3
cerebral perfusion and weeks of proper nursing
potential for ICP. intervention
Monitor and document
neurological status
frequently and compare
with baseline.
Monitor vital signs noting:
Hypertension or
hypotension
Advise the patient to
avoid unnecessary
movement.