ASSESSMENT DIAGNOSIS OUTCOME INTERVENTION RATIONALE EVALUATION DISCHARGE PLANN

CRITERIA
Altered After 8hrs of nursing Independent: Met: After 8hrs of Medications:
Subjective Cues: cerebral tissue intervention patient nursing Provide clear informa
“Samtang gakaon perfusion will be able to intervention patient of the importance of t
kami kagina, related to improve motor - Assess factors - Assessment will was able to the prescribed
gulpiyada lang siya interrupting of function and speech related to individual determine and improve motor medications.
nadulaan kusog kag blood flow as as well as situation for influence the function and - Inform patient and
gapukol iya evidenced by demonstrate stable decreased cerebral choice of speech as well as significant others the
hambalanon, kag facial droop, vital signs perfusion and interventions. demonstrate stable indication, frequency
nagakiwi iya nga motor particularly, blood potential for Deterioration in vital signs taking, route of
itsura.” as verbalized weakness, pressure and increased ICP. neurological particularly, blood administration and sid
by the wife. increase in absence of signs signs or failure to pressure and effects of the medica
blood pressure and symptoms of improve after absence of signs - Inform the client to
Objective Cues: and slurred increased ICP. initial insult may and symptoms of contact health care
 Blood speech. reflect decreased increased ICP. provider when he
Pressure: After 72hrs of intracranial experiences adverse
160/100mmHg nursing intervention adaptive capacity Partially met: After effects of the medica
 Left Facial patient will requiring patient 72hrs of nursing - Instruct patient how
Droop manifested no facial to be transferred intervention patient take the prescribed
 Left Motor drooping; motor to critical area for manifested no medications. Keep a
Weakness: response: upper monitoring of facial drooping; these medications.
Upper Limb limb 5/5, lower 5/5, ICP, other motor response:
0/5, Lower and clear speech. therapies. upper limb 3/5, Environment:
Limb 2/5 lower 4/5, and - Instruct significant
 Slurred - Closely assess, - Assesses trends clear speech. others to provide a sa
Speech monitor and in level of and comfortable
document consciousness environment for the
neurological status (LOC) and patient.
frequently and potential for
compare with increased ICP Treatment:
baseline. (e.g., and is useful in - With the help of the
GCS) determining physical therapist
location, extent, encourage patient to
and progression exercise to increase
of damage. May muscle strength, flexi
also reveal and balance.
presence of TIA,
which may warn Health Teaching:
of impending -Teach how to manag
thrombotic CVA. underlying conditions
including monitoring b
- Changes in blood - Fluctuations in glucose levels and bl
pressure, compare pressure may pressure as instructe
BP readings in occur because of - Educate family mem
both arms. cerebral injury in in using simple words
vasomotor area sentences and speak
of the slowly to patient.
brain. Hypertensi - Inform patient the
on or significance of using
postural hypotens pressure stockings as
ion may have directed by the physic
been a
precipitating Out-patient:
factor. Hypotensi - Instruct patient to a
on may occur by the instruction
 because of shock regarding OPD check
(circulatory to monitor the
collapse). Increa improvement of cond
sed ICP may
occur because of Diet:
tissue edema or - Advise patient to les
clot formation.  the amount of fat,
cholesterol, and salt
- Heart rate and - Changes in rate, (sodium) including re
rhythm, assess for especially processed foods.
murmurs. bradycardia, can -Instruct patient to lim
occur because of foods and drinks
the brain containing added sug
damage. such as confectionery
Dysrhythmias sugar sweetened sof
and murmurs drinks and cordials, fr
may reflect drinks, vitamin waters
cardiac disease, energy drinks and sp
which may have drinks.
precipitated CVA - Encouraged patient
(stroke after MI or include in diet of dairy
from valve foods, which can help
dysfunction). control blood pressur
- Respirations, - Irregularities can
noting patterns and suggest location Support System:
rhythm (periods of of cerebral - Family support is
apnea after insult or increasin encouraged and prov
hyperventilation), g ICP and need emotional and
Cheyne-Stokes for further psychological suppor
respiration intervention, client.
including possible - Encouraged client to
respiratory always have someon
support. their side.
- Advise family memb
- Evaluate pupils, - Pupil reactions to learn all about the
noting size, shape, are regulated by clients condition whe
equality, light the oculomotor they have to take car
reactivity. (III) cranial the patient.
nerve and are
useful in Spirituality:
determining - Encourage family
whether the brain members to pray dail
stem is intact. ask for God’s protect
Pupil size and and provision.
equality is - Highlight to the clie
determined by that spiritual health is
balance between important to optimally
parasympathetic achieve treatment. G
and sympathetic grace and mercy is th
innervation. most powerful weapo
Response to light battling against any
reflects combined conditions.
function of the
optic (II) and
oculomotor (III)
 cranial nerves.

- Document changes - Specific visual

in vision: reports of alterations reflect
blurred vision, area of brain
alterations in visual involved, indicate
field, depth safety concerns,
perception. and influence
choice of
interventions.

Dependent:

- Administer - Reduces
supplemental hypoxemia, which
oxygen as can cause
indicated. cerebral
vasodilation and
increase
pressure/edema
formation.

Administer medications as
indicated:

- Intravenous
thrombolytics; - Proven therapy
tissue plasminogen for acute strokw,
activator (tPA), t-PA is useful in
alteplase(Activase) minimizing the
size of the
infarcted area by
opening blocked
vessels that are
occluded with the
clot. Treatment
must be started
within 3 hours of
initial symptoms
to improve
outcomes.

- Anticoagulants; - May be used to

e.g heparin improve cerebral
(Enoxaparin) blood flow and
Antiplatelet; prevent further 
e.g.aspirin (ASA), clotting when
clopidogrel (Plavix) embolism and/or
thrombosis is the
problem.

- Antihypertensive - Chronic
s; e.g, trandate hypertension
(Labetol)
 requires cautious
treatment
because
aggressive
management
increases the risk
of extension of
tissue damage.
Labetol relaxes
blood vessels
and slowing heart
rate to improve
blood flow and
decrease blood
pressure.

- Peripheral - Transient
vasodilators:  hypertension
cyclandelate often occurs
(Cyclospasmol), during acute
papaverine stroke and
(Pavabid), resolves often
isoxsuprine without
(Vasodilan). therapeutic
intervention.Used
to improve
collateral
circulation or
decrease
vasospasm.

Collaborative:

- Refer the patient to

- May be helpful in
a physical
developing an
therapist.
individualized
exercise program
and can provide
instruction to the
patient and
caregiver on
exercising safely.