NURSING

CARE PLAN

ASSESSMENT

DIAGNOSIS

BACKGROUND
KNOWLEDGE

PLANNING

Subject:
I have pain on my
head , as verbalized
by the patient
Object:
-clammy skin
-dyspnea
-pallor
-prolonged capillary
refill
-restlessness
-grimace
Vital Signs are taken
as follows:
BP: 200/150
RR: 42
PR: 104

Ineffective
peripheral
tissue perfusion
related to
hypertension

Increased Cardiac
Output that injures
the endothelial cells
of the arteries and
the action of
prostaglandins
Vasoconstriction
occurs and blood
pressure increases

After 1hour of
nursing intervention
patient will
demonstrate
increased perfusion
as evidenced by skin
warm and dry with
decreased blood
pressure.

INTERVENTI
ON

RATIONALE

INTERVENTI
ON

RATIONALE

-monitor vital
signs
especially the
BP.

-to obtain baseline

data

-Position with
head slightly
elevated and
in neutral
position.

-Reduces arterial
pressure by
promoting venous
drainage and may
improve cerebral
perfusion

-Observe skin
color,
moisture,
temperature
and capillary
refill time.

- May be due to
peripheral
vasoconstriction or
reflect cardiac
decompensation,
decreased output.

-Measure
capillary refill.
-note clients
nutritional and
fluid status.

-to determine
adequacy of systemic
circulation.

-dehydration reduces
blood volume and
compromised
peripheral circulation.

-facilitates rest,
- Provide calm conserves energy, and
and quiet
may enhance coping
environment.
abilities.
-Maintain
activity
restrictions
(bed-rest or
chair rest).

-lessens physical
stress and tension that
affect blood pressure
and the course of
hypertension.

INTERVENTION

RATIONALE

EVALUATION

-Instruct in relaxation
techniques, guided
imagery,
distractions.

- can reduce
stressful stimuli;
produce calming
effect and thereby
reducing BP.

-determine pulse
equality as well as
intensity.

-to evaluate
distribution and
quality of blood flow,
and success or
failure of therapy.

After 1hour of nursing

intervention patient will
demonstrated
increased perfusion as
evidenced by skin warm
and dry with decreased
blood pressure of
180/100

-note location of
restrictive clothes.

-it may restrict

circulation.

-administered iv
Nicardipine as
ordered.

-to promote optimal

blood flow, organ
perfusion and
function

ASSESSMEN
T

DIAGNOSIS

BACKGROUND
KNOWLEDGE

PLANNING

Subjective:
I cant move my
right leg as
verbalized by
patient.
Objective:
-limited ROM
-difficulty turning
-Slowed
movement.

Impaired Physical
Mobility related to
weakness and
paraesthesia of
patients right leg
Evidenced by
decreased
muscle strength/
control

The presence of partial blockage

of the blood vessel can be
multifactorial. These can be due
to vasoconstriction, platelet
adherence on rough surface, fat
accumulation and therefore
decreases elasticity of vessel wall
leading to alteration of blood
perfusion with the initiation of the
clotting sequence. This may later
lead to the development of
thrombus which can be loosened
and dislodged in some areas of
the brain such as mid cerebral
carotid artery that may lead to
alteration of blood perfusion and
further develop to cerebral infarct.

After 8 hours of
nursing intervention
patient will
Maintain/increase
strength and function
of affected body part.

NTERVENTION

RATIONALE

INTERVENTION

RATIONALE

-Assess extent of
impairment initially
and on a regular
basis. Classify
according to 04
scale.

Identifies strengths
and deficiencies
that may provide
information regarding
recovery. Assists in
choice of
interventions, because
different techniques
are used for flaccid
and spastic paralysis.

-Observe affected
side for color, edema,
or other signs of
compromised
circulation.

-Edematous tissue is
more easily
traumatized and heals
more slowly

Inspect skin regularly,

particularly over bony
prominences. Gently
massage any
reddened areas and
provide aids such as
sheepskin pads as
necessary.

Pressure points over

bony prominences
are most at risk for
decreased perfusion.
Circulatory stimulation
and padding help
prevent skin
breakdown and
decubitus
development.

-Change positions at
least every 2hr
(supine, side lying)
and possibly more
often if placed on
affected side.

-Reduces risk of
tissue injury. Affected
side has poorer
circulation and
reduced sensation
and is more
predisposed to skin
breakdown..

INTERVENTION

RATIONALE

EVALUATION

-Assist patient with

exercise and perform
ROM exercises for both
the affected and
unaffected sides. Teach
and encourage patient to
use his unaffected side
to exercise his affected
side.

-Aids in retraining
neuronal pathways,
enhancing
proprioception and
motor response.

After 8 hours of nursing

intervention patient was
able to Maintain/increase
strength and function of
affected body part.

-Set goals with patient

and SO for participation
in activities and position
changes.

-Promotes sense of
expectation of
improvement, and
provides some sense of
control and
independence.