CUES NURSIN ANALY GOALS NURSING RATIONALE EVALUATI

G SIS AND INTERVENTIONS ON

DIAGNO OBJECTIVE
SIS S

Subjective Ineffective The brain After 2 days 1. Assess the Helps to detect After 2 days
: cerebral requires of nursing patient’s abnormal findings of nursing
“ tissue a steady interventions neurologic status and establish a intervention
Pangatlong perfusion supply of , the client using a Glasgow baselineof s, was the
beses na related to oxygen will coma scale. impairments which client able
akong na interruptio in order demonstrate Assess every hour assists in planning to
stroke.” n of blood to pump increase until neurologic care. demonstrat
flow due blood cerebral status is stable; e increased
As reported to effectivel perfusion as repeat at least cerebral
by the wife, hemorrha y to all of evidenced every 4 hours perfusion as
there has ge. the body. by: there after. evidenced
Oxygen • an It helps minimize by:
also been a
is increase 2. Monitor for cerebral edema, • an
change in supplied which can contribute
in level seizure activity. increase
the client's to the of to increased in level
cognitive brain in consciou ischemia. of
function. the blood sness The cerebral tissue conscio
that • stable may be more usness
The client flows vital excitable, and Yes?___
became through signs increased ICP may No ?___
arteries. • will caused seizures, Why?__
forgetful
In a prevent further decreasing
and he asks cerebrov complica tissue perfusion. • stable
the same ascular tions 3. Take vital signs. vital
questions accident, The vital signs give signs
repeatedly. one or information relevant Yes?___
more of to patient status. No? ___
He also had these Blood pressure may Why?___
a hard time arteries be elevated,
becomes respirations and
recognizing • will
blocked pulse may be rapid.
people. prevent
or If the hypothalamus
complic
ruptures function is affected
ations?
or begins result in the inability
Objective: Yes?___
to leak. to regulate
No? ___
This temperature
• Had a Why?___
deprives 4. Perform a adequately with
seizure a portion subsequent
respiratory
activity of the hyperthermia.
assessment,
• Has brain of including ABG ang
decreas vital pulse oximetry. Adequate amount of
ed level oxygen- circulating oxygen
of rich are needed to
conscio blood. maintain adequate
usness
5. Elevate the head
This cerebral
of the bed 30
• Contrale damage oxygenation.
degrees.
teral can
hemipar become Maximizes cerebral
esis permane oxygenation and
6. Decrease stimuli
• Slurred nt within reduces vasodilation.
in the
speech minutes
environment
• Weakne and Excess movement/
when providing
ss of result in activity, excitability,
care.
lower the and stress can
extreme death of increase ICP, which
ties. the can worsen the
• Seems affected symptoms.
restless brain tis 7. Administer
sue. oxygen as Maximizes cerebral
http://ww ordered. oxygenation and
w.wrong reduces vasodilation.
diagnosis
Measurem .com/ 8. Administer It inhibit platelet
ent: antipletelet aggregation and
aggregation reduce the risk of
BP: 200/140 medications as embolus formation.
mmHG ordered.
RR: 28 cpm
Tempt: 37.9 9. Administer Elevated blood
C antihypertensive pressure is common
agents as in patients with
ordered, for stroke, and for those
markedly patients with
elevated blood hemorrhagic stroke,
pressure. it tends to be more
severe, requiring
treatment.

10. If elevated Lowers temperature

temperature and decreases
occurs, give metabolic demands
antipyretics. and oxygen
requirements of the
body.
11. Administer
diuretic as It decreases
ordered. intracranial pressure
and cerebral edema,
increasing tissue
perfusion.