Assessment Subjective: indi sya masyado maka bati kung tagwon sya namon as verbalized b y his wife.

Objective: Loss of sensation in the lower extremities. Mask like facial expressions. Altered level of consciousness,

Nursing Diagnosis ineffective cerebral tissue perfusion related to interruption of the blood flow secondary to CVA as manifested by Altered LOC, loss of sensation in the lower extremities and mask like facial expressions. Definition: Decrease in oxygen resulting in failure to nourish the tissues at the capillary level. Source: - Nurses Pocket Guide 11th Edition

Rationale Clot, thrombus or embolism forms within cardiovascular system Cerebral artery Brain Blood flow is disrupted Oxygen and glucose cannot reach part of the brain Brain cells die (infarction)

Desired Outcome After 3 days of nursing intervention the client will be able to:

Nursing Intervention Independent: Determine factors related to individual situation, cause for coma or decreased cerebral perfusion, and potential for increased ICP Assess motor response to simple commands, noting purposeful (obeys command, attempts to push stimulus away) and nonpurposeful movement. Monitor vital sign noting: hypertension or hypotension; compare blood pressure(BP) readings in both arms. Dependent: Administer medication, as indicated. Collaborative: Refer for laboratory studies as indicated, such as prothrombin time (PT),activated PTT, and dilantin level,

Justification Influences choice of interventions. Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity, requiring the client be transferred to critical care for monitoring of ICP. Measures overall awareness and ability to respond to external stimuli and best indicates state of consciousness in the client whose eyes are closed because of trauma. Fluctuations in pressure may occur because of cerebral pressure or injury in vasomotor area of the brain. Hypotension may follow stroke because in circulatory collapse. To prevent further damage. Provides information about effectiveness and therapeutic level of anticoagulants when used.

Evaluation After 3days of nursing intervention, the client was able to: Goal partially met: Maintain usual or improve LOC, cognition, and motor or sensory function Display no further deterioration or recurrence of deficit. Demonstrate stable vital sign s and absence of signs of increased ICP.

Risk Factor: Smoking Diet Stress Environment Strength: Family

Maintain usual or improve LOC, cognition, and motor or sensory function Display no further deterioration or recurrence of deficit. Demonstrate stable vital sign s and absence of signs of increased ICP.