DIAGNOSIS BACKGROUND Subjective Risk factors: Short-term goals: Independent: Short-term goals: “May mga times Ineffective Asthma, After 1-4 hours of Assess patient’s vital To aid in the After 1-4 hours of daw po na bigla Cerebral tissue prediabetes, nursing signs and creation of an nursing bigla na lang perfusion hypertension, interventions, neurological status accurate interventions, nakakaramdam si related to poor Patient will at least every 4 diagnosis and Patient’s LOC papa ng ischemic compliance to reestablish hours, or more to assess the is still altered pagkamanhid at stroke as medications effective frequently if there is efficacy of as he is parang may nagingiliti sa evidenced by an increased ↓ cerebral tissue perfusion as a change in them stroke medical slightly confused of Disruption of kanyang kaliwang blood evidenced by treatment. persons, sympathetic bahagi ng pressure, increased LOC Assess airway Neurologic places and nervous system katawan, minsan altered level of and will show patency and deficits of a things (Goal din po ay confused consciousness, na din siya sa mga altered ↓ orientation with persons, respiratory pattern. stroke may include loss of not met) Loss of nangyayari. At sensation, places, and gag reflex or sympathetic may mga times din speech tone things. cough reflex; Patient’s vital po na di na problems, and Patient will thus, airway signs became naming slight carotid ↓ demonstrate patency and stable with naiintidihan mga bruits on the Decreased stable vital breathing VS as follows: sinasabi niya,” as right venous return signs and pattern must BP- 120/80 verbalized by absence of be part of the Pulse- 79 patient’s daughter. ↓ signs of initial RR- 17 Objective: Decreased increased ICP. assessment Temp-37.4 Confused stroke volume Observe and To facilitate O2Sat- 97% Left facial ↓ monitor the patient early And showed droop for any signs and detection and no signs of Slurred Decreased symptoms of further management increased ICP speech cardiac output increase in ICP of ICP. (Goal met) Left motor weakness ↓ Assess baseline functions such as Sudden changes in Upper limb- ability to swallow, patient’s speak and move symptoms can 0/5 Lower Decreased Long-term goals: signify new Long-term goals: limb-0/5 cellular oxygen After 5-7 days of stroke or After 5-7 days of Decreased supply nursing worsening of nursing tone Altered ↓ interventions: Patient will Position with head condition Reduces interventions: Patient still sensation Impaired tissue display no slightly elevated and arterial shows Mild left perfusion further in a neutral position. pressure by altered LOC sided neglect Slight carotid ↓ deterioration/ recurrence of promoting venous but vital signs has been bruits on the Focal cerebral deficits drainage and stable (Goal hypoperfusion may improve partially met) right Hx of asthma Hx of ↓ Patient maintains cerebral perfusion. Patient still needs further Increased Hypertension maximum Maintain bed rest Prevents interventions intracranial Grade 1 tissue and promote quiet increased to maintain pressure Hx of perfusion as and relaxing intracranial maximum prediabetes ↓ evidenced by present and environment Monitor laboratory pressure Provides tissue perfusion Vital signs: Impaired BP- 145/90 strong studies as indicated: information (Goal not cellular Pulse- 82 peripheral prothrombin time about drug met) metabolism RR- 20 pulses, vitals (PT), activated effectiveness Temp-37.8 ↓ within normal range, partial and O2Sat- 97% Ischemic stroke thromboplastin time therapeutic balance I and (aPTT), and Dilantin level. ↓ O, absence level. Decreased edema, Advise patient to Valsalva LOC, altered normal ABGs, avoid straining when maneuver or sensorium, alert LOC and passing stool. straining speech absence of Monitor bowel during problems, chest pain movements and elimination unstable vital administer may increase signs, appropriate ICP or worsen hemiplegia laxatives as needed condition Dependent: Administer Certain medications as medications indicated: maybe - Osmotic prescribed to diuretics to prevent promote brain further blood flow damage. - Anticoagulants to treat ischemic stroke - Antiplatelet agents to help decrease the incidence of cerebral infarction - Antihypertensive to control blood pressure - Vasodilators to improve collateral circulation or decrease vasospasm. Prepare and Supplemental administer oxygen oxygenation supplementation as maybe needed required to prevent cerebral vasodilation that can caused increased pressure and edema. Prepare the patient It may be for surgery as necessary to indicate. resolve the situation, reduce neurological symptoms of recurrent stroke.