ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

S: N/A Risk for Ineffective Short-term Goal: Independent: Short-term Goal:

Tissue Perfusion After 4 hours of The goal was met the
related to nursing intervention the - Assess airway patency - Neurologic deficits of a patient was able to;
hemorrhage of patient will able to: and respiratory pattern. stroke may include loss of -demonstrated stable
cerebral vessel as -demonstrate stable gag reflex or cough reflex; vital signs and absence
evidenced by vital signs and absence thus, airway patency and of signs of increased
O: hypertension of signs of increased breathing pattern must be ICP.
- Contralateral ICP. part of the initial
sensorimotor assessment.
deficits Long-term Goal:
- Long-term Goal: - Assess factors related to - The extensive The goal was not met
Unconsciousness After 8 hours of decreased cerebral neurologic examination the patient was not able
nursing intervention the perfusion and the potential will help guide therapy to:
- GCS: 7 (E1, patient will able to: for increased intracranial and the choice of -maintained
V1, M5) -maintain pressure (ICP). interventions. usual/improved level of
usual/improved level of consciousness,
consciousness, - Recognize the clinical - Patients with TIA cognition, and
VS: cognition, and manifestations of a present with temporary motor/sensory function.
PR: 91 bpm motor/sensory function. transient ischemic attack neurologic symptoms - Patient displayed
RR: connected to - Patient will display no (TIA). such as sudden loss of further
mechanical further motor, sensory, or visual deterioration/recurrence
ventilator deterioration/recurrenc function caused by of deficits
TEMP: 38.4°C e of deficits transient ischemia to a
BP:130/90 specific region of the
mmHg brain, with their brain
O2sat: 94.1% imaging scan showing no
evidence of ischemia.

- Frequently assess and - Assess trends in the

monitor neurological status. level of consciousness
 (LOC), the potential for
increased ICP, and help
determine location, extent,
and progression of
damage.
- Monitor changes in blood
pressure, compare BP - Hypertension is a
readings in both arms. significant risk factor for
stroke. Fluctuation in
blood pressure may occur
because of cerebral injury
in the vasomotor area of
the brain. Hypertension or
postural hypotension may
have been a precipitating
factor. Hypotension may
occur because of shock
(circulatory collapse), and
increased ICP may occur
because of tissue edema
or clot formation.

- Monitor heart rate and

rhythm, assess for - Changes in rate,
murmurs. especially bradycardia,
can occur because of brain
damage. Dysrhythmias
and murmurs may reflect
cardiac disease,
precipitating CVA (stroke
after MI or valve
dysfunction).
- Monitor respirations, - Irregular respiration can
noting patterns and rhythm, suggest the location of
Cheyne-Stokes respiration. cerebral insult or
increasing ICP and the
need for further
intervention, including
possible respiratory
support.

- Monitor computed - CT scan is used to

tomography scan. determine if the event is
ischemic or hemorrhagic
as the type of stroke will
guide therapy.

- Evaluate pupils, noting - Pupil reactions are

size, shape, equality, light regulated by the
reactivity. oculomotor (III) cranial
nerve and help determine
whether the brain stem is
intact. Pupil size and
equality are determined
by the balance between
parasympathetic and
sympathetic innervation.
Response to light reflects
the combined function of
the optic (II) and
oculomotor (III) cranial
nerves.

- Nuchal rigidity (pain and

- Assess for nuchal rigidity, rigidity of the back of the
twitching, increased neck) may indicate
restlessness, irritability, the meningeal irritation.
onset of seizure activity. Seizures may reflect an
increase in ICP or cerebral
injury requiring further
evaluation and
intervention.

- Position with head - Reduces arterial pressure

slightly elevated and in a by promoting venous
neutral position. drainage and may
improve cerebral
perfusion. During the
acute phase of stroke,
maintain the head of the
bed less than 30 degrees.

- Maintain bedrest, provide - Continuous stimulation

a quiet and relaxing or activity can increase
environment, restrict intracranial pressure
visitors and activities. (ICP). Absolute rest and
quiet may be needed to
prevent rebleeding.

- Monitor laboratory - Provides information

studies as indicated: about drug effectiveness
prothrombin time (PT), and therapeutic level.
activated partial
thromboplastin time
(aPTT), and Dilantin level.

Dependent:
- Administer supplemental - Reduces hypoxemia.
oxygen as indicated. Hypoxemia can cause
cerebral vasodilation and
increase pressure or
edema formation.

- Administer medications - Used with caution in

as indicated: hemorrhagic disorder to
-Antifibrinolytics: prevent lysis of formed
aminocaproic acid clots and subsequent
(Amicar) rebleeding.

-Antihypertensives: ACE- - Antihypertensives:

Inhibitors, Diuretics ACE-Inhibitors, Diuretics

- Peripheral vasodilators: - Transient hypertension

cyclandelate often occurs during an
(Cyclospasmol), papaverine acute stroke and usually
(Pavabid), isoxsuprine resolves without
(Vasodilan). therapeutic intervention. It
is used to improve
collateral circulation or
decrease vasospasm.

- Phenytoin (Dilantin), - Used if there is an

phenobarbital. increase in ICP and
occurrence of seizures.
Phenobarbital enhances
the action of
antiepileptics.
- Stool softeners. - Prevents straining during
bowel movement and the
corresponding increase of
ICP. Constipation
frequently occurs after a
stroke