Krishelle Anne U.

Teofilo BSN III B NDH NS1 Group 3

ASSESSMENT NURSING SCIENTIFIC PLANNING IMPLEMENTATION RATIONALE EVALUATION

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

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 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

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 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

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 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.

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