Assessment Subjective: hindi na po siya makapagsalita ng maayos at malinaw AVB patients SO Objective: Stammering Unclear speech.

h. Difficulty forming words. Cannot express basic needs. Cannot participate in therapeutic communication.

Nursing Diagnosis Impaired verbal communication related to loss of oral muscle tone and control secondary to disease progress

Scientific Explanation Disease Process

Goal of Care Within 3 days of rendering nursing intervention, patient will be able to establish congruent verbal and/or nonverbal communication AEB: Patient indicates an understanding of the communication between nurse and herself Establishes a means of communication in which needs can be expressed Participate in therapeutic communication (-) stammering At least hear a clear voice. To form word/s easily.

Intervention Established rapport VS taken Identified patients ability to do verbal or nonverbal communication Instructed patient to use nonverbal behaviors Validated meanings of nonverbal behaviors Instructed the S.O to talk the patient frequently.

Rationale

Evaluation

Alteration of CNS

Decrease oxygen supply in the brain

Decrease tissue perfusion

Affectation of the Broccas area Loss of oral muscle tone Stammering speech Unclear verbalization of words

For patient trust and After 3 days of cooperation rendering nursing For baseline data intervention Goal was met as evidenced by: To determine extent of The patient care needed understood the communication between nurse and herself. To allow patient to Established a express needs in a means of simpler manner communication in which needs can be Meaning of some expressed. nonverbal behaviors Participated in may not be congruent therapeutic to nurses communication. To practice the ability (-) stammering of the patient to Was able to say express words. uwi na as verbalized by the patient.

Assessment

Nursing Diagnosis Altered tissue perfusion related to CVA.

Scientific Explanation Blood loss

Planning

Intervention

Rationale >to gain patients trust >for baseline data >to improve oxygen supply >to compensate decrease in oxygen supply >to ensure patency of the airway >will help improve venous circulation by increasing the Oxygen carrying capacity of RBCs >to increase cardiac or blood volume

Evaluation

Subjective Nahihilo siya. as verbalized by the S.O. Objective: V/s taken as T:36.7 P: 91 R:18 Bp: 100/80 >pale conjunctiva >pale mucous membrane >capillary refill: 3 secs >skin cold to touch >clammy skin >client appears dizzy.

After 4 hours of appropriate nursing intravascular intervention, the volume patient will verbalize decrease or venous return,cardiac absence of dizziness output and lowered The clients vital signs BP will be T:36.5-37.5C body compensating PR: 75-80bpm by increasing heart RR:12-20 rate to circulate the BP: systolic 120-140 decreased volume Diastolic 80-100 faster; vasoconstriction of (-)pale conjunctiva peripheral vessels. (-)pale mucous Increased respiratory membrane rate and a feeling of Capillary refill < 2 apprehension at body secs changes also occur Skin will not be cold and clammy upon decrease tissue touching. perfusion to the body and brain dizziness,cold clammy skin altered tissue perfusion

>established rapport >Assessed vital signs and circulation q15minutes >provided adequate ventilation > Instructed to have enough rest and sleep on semi fowlers position. >advised to increase iron rich foods like organ meats

After 4 hours of appropriate nursing intervention, goals were met the patient shows NO sign of dizziness. The clients vital signs recorded as T:36.7C PR: 79bpm RR:14cpm BP: 110/80

HYDRATION; >advised increase OFI

>will help improve venous circulation by increasing the Oxygen carrying capacity of RBCs

(-)pale conjunctiva (-)pale mucous membrane Capillary refill 2 secs Skin is not cold and clammy upon touching.

ASSESSMENT

NURSING DIAGNOSIS Hyperthermia r/t disease process

SCIENTIFIC EXPLANATION Release of Pyrogens (prostaglandin E1)

PLANNING

IMPLEMENTATION

RATIONALE To serve as baseline data especially temp which is altered To decrease body temperature To prevent dehydration To promote comfort To make the room cooler To relieve stress and workload To prevent injury to the patient

EVALUATION After 30 minutes of nursing interventions the patient will verbalized decrease in temperature as evidenced by: BP:90/60-120/80 Temp:36.5-37.5 PR:60-100 bpm RR:12-20 cpm Skin is not too warm to touch Body temperature is in normal range

Subjective: ang init ng katawan ng asawa ko as verbalized by the S.O Objective: BP:110/80 Temp:37.8 PR:89 RR:22 Warm to touch Increase in body temperature above normal range

After 30 minutess of Independent: nursing interventions Monitor the patient will patients vital verbalized decrease signs every 4 in temperature as hours Resetting of manifested by: Apply TSB hypothalamus BP:90/60-120/80 every 15 thermostatic set Temp:36.5-37.5 minutes point to a higher PR:60-100 bpm Encourage level RR:12-20 cpm patient to increase fluid Skin is not intake Generation of too warm to Advise patient hypothalamictouch to wear loose mediatedresponse Body clothing that raise body temperature Provide good temperature is in normal ventilation range Encourage bed rest Development Instruct SO not of fever with to leave the elevation of body patient temp. to a new unattended thermostatic set Foods rich in vitamin C

Production of temperature lowering response( Flushes etc)