Admitting Diagnosis: Multiple Cerebral Infarction

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective Ineffective Goal Determine factors related Influences choice of After 2-3
The client Cerebral Tissue The client will have to individual situation, interventions. Deterioration in weeks of
decreased cerebral neurological signs and
complained of Perfusion related an effective nursing
perfusion and potential for symptoms or failure to improve
slight difficulty of to interruption of cerebral tissue ICP. after initial insult may reflect intervention
breathing blood flow perfusion after 2 to decreased intracranial adaptive the client will
secondary to 3 weeks of proper capacity, which requires that be able to
Objective multiple cerebral nursing client be admitted to critical care demonstrate
- The patient infarctions as intervention area for monitoring of ICP and for increased
specific therapies geared to
appears lethargic manifested by perfusionm(e.g
maintaining ICP within a specified
altered level of Objectives range. If the stroke is evolving, ., vital signs
-P: 8 am 57 bpm consciousness, 1. To assess client can deteriorate quickly and within normal
12 pm 57 bpm changes in motor contributin require repeated assessment and range,
& sensory g factors progressive treatment. If the alert/oriented,
-BP: 8 am 130/70 response, and 2. To note stroke is “completed,” the free of
neurological deficit is
12 pm 140/80 language deficits degree of pain/discomfor
nonprogressive, and treatment is
impairmen geared toward rehabilitation and t)
-Speech t preventing recurrence.
abnormalities: 3. To
slurred speech maximize Assesses trends in LOC and
tissue potential for increased ICP and is
useful in determining location,
-Extremity perfusion Monitor and document extent, and progression or
weakness; pain neurological status resolution of CNS damage.
and discomfort frequently and compare
on lower with baseline.
Fluctuations in pressure may
extremities occur because
of cerebral pressure or injury in
Monitor vasomotor area of the brain.
-Restless; Keeps
vital signs noting: Hypertens Hypertension or hypotension may
on calling out for ion or hypotension have been a precipitating factor.
his wife and son
Visual and sensory/motor
-facial weakness changes/ involvement indicate

Determine the presence of
visual, sensory/motor
change, headache,
dizziness, altered mental
status, personality changes
safety concerns and influence the
choice of nursing intervention.
To promote circulation/venous
drainage

Elevate HOB Some medications may be used

to decrease edema

Administer medications
(e.g. antihypertensives,
diuretics) Continual stimulation can
increase ICP. Absolute rest and
quiet may be needed to prevent
Maintain bedrest, provide recurrence of bleeding, in the
quiet environment, and case of hemorrhagic stroke.
restrict visitors or activities,
as indicated. Provide rest
periods between care
activities, limiting duration of
procedures.

Valsalva’s maneuver increases

ICP and potentiates risk of
bleeding.
Prevent straining at stool or
holding breath. Reduces hypoxemia.

Administer supplemental
oxygen, as indicated.