ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION

DIAGNOSIS
OBJECTIVE OF INTERVENTION RATIONALE
CARE

Subjective cues: Ineffective tissue After 8 hours of Assess airway patency Gag or cough reflex loss Patient’s airway patency After 8 hours of
“Palaging mataas ang perfusion related nursing intervention, and respiratory pattern. is one of the neurologic and respiratory pattern nursing intervention,
BP niya tapos palagi to cerebral edema the patient will be able deficits of a stroke, thus were assessed. the patient was be
niyang sinasabi na and increased to: airway patency and able to:
masakit raw ulo niya”, intracranial breathing pattern must
as verbalized by the pressure secondary  Re-establish be considered in the  Re-establish
patient’s daughter. to stroke as effective initial assessment. effective
evidenced by cerebral tissue cerebral
Objective cues: headache, perfusion as Monitor changes in Hypertension is a Changes in blood tissue
 Headache irritability, shown by blood pressure; compare significant risk factor pressure were monitored perfusion as
 Irritability confusion, and improved BP readings in both for stroke. Blood assessed by comparing shown by
 Confusion memory problems. consciousness arms. pressure fluctuations can BP reading of both arms. improved
 Drowsiness (i.e. awake and develop as a result of consciousnes
 Memory alert) and cerebral damage in the s (i.e. awake
problems orientation with vasomotor region of the and alert)
 BP: 140/70 people, places, brain. and
mmHg and things. orientation
 HR: 57 Elevate the head of the To promote venous Ensured that the head of
 Demonstrate with people,
beats/min. bed at 30 degrees. outflow from the the bed is elevated at 30
stable vital places, and
 RR: 11
signs and patient's head to the rest degrees. things.
breaths/min.
absence of signs of the body in order to  Demonstrate
of increased minimize ICP and stable vital
ICP. cerebral edema. signs and
 Display no absence of
further Prevent straining at Valsalva maneuver or Patient was advised to signs of
deterioration/re stool, holding breath, straining during avoid straining when increased
currence of physical exertion. elimination may passing stool. ICP.
deficits. increase the ICP even  Display no
 further, worsening the further
condition. deterioration/
recurrence of
Maintain bed rest, Continuous stimulation Ensured that the room deficits.
provide a calm and or activity may cause an was free from
relaxing environment, increase in intracranial disturbances by limiting
and limit visits and pressure (ICP). Absolute visits and activities and
activities. Nursing rest and quiet may be maintaining the patient
interventions should be needed to prevent on bed rest. Rest periods
clustered and rest rebleeding. were provided, nursing
periods should be interventions were
provided between care clustered, and procedures
tasks. Procedures should were kept to a minimum.
be kept to a minimum
duration.

Administer This helps reduce Supplemental oxygen

supplemental oxygen as hypoxemia. Hypoxemia was given as indicated.
indicated. can cause cerebral
vasodilation and
increase pressure or
edema formation.

Administer osmotic To promote blood flow Administered mannitol to

diuretics as prescribed. to the brain and to the patient as prescribed.
reduce cerebral edema.
 ASSESSMENT NURSING PLANNING IMPLEMENTATION EVALUATION
DIAGNOSIS
OBJECTIVE OF INTERVENTION RATIONALE
CARE

Subjective cues: Impaired physical After 8 hours of Assess the level of Identifies strengths and Patient’s level of After 8 hours of
“Lagi niyang sinasabi mobility related to nursing intervention, impairment and deficiencies that may impairment and nursing intervention,
sa amin na gustong neuromuscular the patient will be able functional ability. Use a provide information functional ability was the patient was be
gusto niya nang involvement to: 0-4 scale to classify. regarding recovery. checked using a 0-4 able to:
lumakad, pumunta sa secondary to scale.
cr mag-isa, kumain stroke as  Perform  Perform
mag-isa pero ayun nga evidenced by activities of Assess the patient’s This helps in creating an Patient’s ability to activities of
hindi niya magawa”, limited range of daily living ability to perform accurate diagnosis and perform activities of daily living
as verbalized by the motion, within the limits ADLs. monitor effectiveness of daily living was assessed. within the
patient’s daughter. generalized of the present treatment and therapy. limits of the
weakness, condition. present
Objective cues: unsteady gait, and  Maintain Assist the patient during To encourage the patient Patient was assisted condition.
 Limited range of inability to do optimal position exercises and when to do muscle- during exercises and  Maintain
motion activities of daily of function as performing activities of strengthening activities activities of daily living. optimal
 Generalized living as normal. evidenced by daily living. and promote dignity by position of
weakness absence of allowing the patient to function as
 Muscle contractures, do ADLs while evidenced by
weakness remaining safe.
foot drop. absence of
 Unsteady gait
 Maintain skin contractures,
integrity. Encourage the patient to Improve venous return, Patient was advised and foot drop.
perform range of motion muscular strength, and encouraged to perform  Maintain
(ROM) exercises in all stamina while range of motion exercises skin
extremities. preventing stiffness and in all extremities. integrity.
contracture deformation.

Assess the skin on a Pressure points over Skin was assessed on a

regular basis, paying bony prominences are regular basis, and
special attention to bony especially vulnerable for inflamed areas were
 prominences. Massage decreased perfusion. massaged.
any inflamed areas Circulatory stimulation
gently and use aids such and cushioning aid in
as sheepskin pads as the prevention of skin
necessary. breakdown and the
development of
decubitus.

Change positions at least Frequently changing the Patient’s position was

every 2 hours (supine, position of the patient changed every 2 hours,
side-lying) and possibly can reduce the risk of such as in a supine or
more often if placed on tissue injury. side-lying position.
the affected side.

Position in prone The patient should be Patient was placed in a

position once or twice a positioned in a prone prone position once since
day if the patient can posture for 15 to 30 it was tolerable according
tolerate. minutes multiple times to her.
each day, with a pillow
under the pelvis. This
position promotes
normal gait by
hyperextending the hip
joints and avoiding knee
and hip flexion
contractures.