TOTAL CARE INTERNATIONAL

Eastern Region
Prince Bandar Bin Abdulaziz Street, Al Shamalia Al Khobar
Khobar, Saudi Arabia 34429
Contact No.: (+966)-55-183-2593
“In Pursuit of Excellence with a Heart.”
Nursing Care Plan

Assessment Nursing Diagnosis Plan Intervention Rationale Evaluation/

Outcome
Subjective Cue/s: Ineffective Cerebral Tissue After 8 hours of nursing Independent: After 8 hours of
“While eating Perfusion related to intervention, the patient will be nursing intervention.
interruption of blood flow to able to: The patient was able to:
breakfast, Michael the brain as evidenced by 1. Maintain improved level 1. Assess factors related to  Assessment will 1. Maintain his
experienced sudden changes in motor / sensory of consciousness, individual situation for determine and influence level of
onset of speech, had response, language and cognition, motor & decreased cerebral perfusion. the choice of consciousness,
facial droop on his sensory deficit. sensory function. interventions. cognition,
 If the stroke is evolving, motor &
left-hand side with
patient can deteriorate sensory
weakness in left side quickly and require function.
upper and lower repeated assessment and
limbs.” As verbalized progressive treatment.
by the wife during
2. Closely assess and monitor  Assesses trends in level
interview. neurological status frequently of consciousness (LOC)
and compare with baseline. and potential for
increased ICP and is
Objective Cue/s: useful in determining
location, extent, and
progression of damage.
BP: 140/90mmHg May also reveal presence
Pulse: 75bpm of TIA, which may warn
Temp.: 36.9 °C of impending thrombotic
+Left facial droop CVA.
+Left motor
weakness; upper 2. Demonstrate
limb 2/5, lower limb 2. Demonstrate stable vital 1. Monitor vital signs:  Fluctuations in pressure stable vital
signs. a. Assess for changes in may occur because of signs.
0/5
blood pressure, and cerebral injury in
Slurred speech compare BP readings in vasomotor area of the
Decreased tone both arms. brain.
Altered sensation
 b. Check heart rate and  Changes in rate,
rhythm, assess for especially bradycardia,
murmurs. can occur because of the
brain damage.
Dysrhythmias and
murmurs may reflect
cardiac disease, which
may have precipitated
CVA (stroke after MI or
from valve dysfunction).

c. Check respirations,  Irregularities can suggest

noting patterns and location of cerebral insult
rhythm or increasing ICP and
need for further
intervention, including
possible respiratory
support.

3. Display no
3. Display no further 1. Assess higher functions,  Changes in cognition and further
deterioration/recurrence including speech, if patient is speech content are an deterioration /
of deficits. alert. indicator of location and recurrence of
degree of cerebral deficits.
involvement and may
indicate deterioration or
increased ICP.
 Pupil reactions are
2. Evaluate pupils, noting size, regulated by the
shape, equality, light oculomotor (III) cranial
reactivity. nerve and are useful in
determining whether the
brain stem is intact. Pupil
size and equality is
determined by balance
between parasympathetic
and sympathetic
innervation. Response to
light reflects combined
function of the optic (II)
and oculomotor (III)
cranial nerves.
 Dependent:
1. Administer medication as
ordered by Physician:
a. Tissue Plasminogen
Activator (tPA) IV
b. Antiplatelet agent:
 Aspirin, which thins the
Aspirin 100mg tab OD
 Thrombolytic agents are
useful in dissolving clot
when started within 3 hr
of initial symptoms.
Treatment is based on
trying to limit the size of
the infarct, and use
requires close monitoring
for signs of intracranial
hemorrhage.
blood and thereby
prevents clots, is
currently used to reduce
the long-term risks of a
second stroke in patients
who've had an ischemic
stroke. Aspirin can help
prevent a second stroke
or a transient ischemic
attack (TIA).

Clopidogrel 75mg tab  Is an anti-platelet drug,

OD which is a type of blood
thinner, used to prevent
strokes, heart attacks, and
death in high-risk
patients who have had a
previous stroke, unstable
angina, heart attack, or
have peripheral arterial
disease (PAD)

The Pioneer of Healthcare Programs in KSA. Serving the Filipino and International Communities since 2008.
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