CHAPTER VII

MANAGEMENT OF CARE
Patient: Patient X
Diagnosis: CVD Infract LMCA TERRITORY Hypertension NIHSS 9

ASSESSMENT EXPLANATION OF GOALS AND INTERVENTION RATIONALE EVALUATION

PROBLEM OBJECTIVES
OBJECTIVES: A 73 year old STO:  Monitor vital  After 8 hours
 “Ganyan talaga female patient was  Within 8 hours signs; that is, of nursing
sya halos hindi admitted due to CVD of nursing note: intervention
nagigising at for the 6th time. intervention -Hypertension/  Fluctuations in patient is
hindi Stroke (CVD) is a the patient hypotension, pressure may occur still
gumagalaw”, as result of an should: compare BP reading because of cerebral unconscious
verbalized by interruption in -demonstrate in both arms pressure/injury in and
the watcher blood supply to a stable vital vasomotor area of unresponsive.
 Unconscious portion of the signs and the brain.
 Glasgow coma brain. In her case improved -Heart rate and  Changes in rate,
scale=4 there is a decrease movements rhythm; auscultate especially
 Functional oxygen supply in for murmurs bradycardia, can
level=4 the brain. LTO: occur because of
 Minimal Including of the  Within 2 days brain damage.
movements affected part of nursing Dysrhythmias and
 Unable to move results to the intervention murmur may reflect
whole body inability of the patient’s level cardiac disease.
 Responsive patient to move and of -Respiration,  Irregularities can
pupils upon perform activities consciousness, noting patterns and suggest location of
exposure to of daily living. cognition, and rhythm cerebral
light mobility will insult/increasing
 Vital signs improve ICP and need for
BP=90/80- further intervention
150/100mmHg
RR=20-30bpm
PR=112-145bpm  Assess functional  Identify strength or
T˚=36.7˚C- level deficiencies and may
37.5˚C provide necessary
intervention

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  Assess for color,  Edematous tissue id
Nursing Diagnosis: edema, or other more easily
Impaired Physical signs of traumatized and
Mobility related compromised healing is slow.
to neuromuscular circulation
impairment
 Provide needed  To render the needs
assistance of the patient.

 Administer  Reduces hypoxemia,

supplemental oxygen which can cause
as indicated cerebral
vasodilation and
increase pressure/
edema formation

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