Medical Diagnosis: Cerebrovascular Accident

Problem: Ineffective Cerebral Tissue Perfusion RT

NURSING SCIENTIFIC
ASSESSMENT PLANNING INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS EXPLANATION
Subjective: (none) Ineffective cerebral The presence of partial Short Term: 1. Establish rapport 1. To promote Short Term:
tissue perfusion r/t blockage of the blood After 4 hours of NI, cooperation Patient shall have
Objective: interruption of blood vessel can be patient will be able to 2. Monitor vital signs displayed a decrease
 hemiplegia flow secondary to CVA multifactorial. These display decrease signs 2. To have a baseline signs of tissue
 assess for muscle can be due to of ineffective tissue data, assess perfusion AEB gradual
strength vasoconstriction, perfusion as evidence changes in improvement of vital
 altered mental platelet adherence on by gradual neurologic status signs
status rough surface, fat improvement of vital 3. Check capillary refill
accumulation and signs. and conjunctiva for 3. To determine
 restlessness
therefore decreases paleness blood circulation
 changes in
elasticity of vessel wall Long Term: 4. elevate head of bed Long Term:
pupillary
leading to alteration of to 30 degrees as 4. To promote
 Reactions After 3 days of NI, Patient shall have
blood perfusion with ordered circulation
 difficulty in the initiation of the
patient will be able to gradually improved
swallowing gradually improve tissue perfusion AEB
clotting sequence. This tissue perfusion AEB 5. Advise patient to 5. Enough rest is good capillary refill and
may later lead to the good capillary refill and have enough rest needed to pink conjunctiva
development of pink conjunctiva. conserve energy
thrombus which can be
loosened and dislodged 6. Avoid neck flexion 6. To avoid
in some areas of the and extreme obstruction of
brain such as mid hip/knee extension arterial and venous
cerebral carotid artery blood flow
that may lead to 7. Provide and
alteration of blood maintain oxygen as 7. Aids in difficulty of
perfusion and further ordered breathing
develop to cerebral
infarct.
8. Perform GCS 8. To detect changes
monitoring as indicative of
ordered worsening or
improving
condition
9. Administer
medications as 9. To promote
ordered wellness