Student Name ___Shy Wegiel__________

Expected (complete before assessment) Nursing Diagnoses (NANDA) 1. Impaired cerebral perfusion related to intracranial hemorrhage 2. Impaired physical mobility related to loss of balance and coordination and unstable gait. 3. Deficient knowledge related to nature and complications of hypertension Monitor VS (close attention to B/P, HR). Focus neurological assessment. Need more information from doctor concerning blood pressure parameters. Assess patient for any residual effects or symptoms related to his recent stroke (focused neuro exam).

Date __03/14/2014- Week 2______________

Found (complete after assessment) 1. Decreased cardiac output related to increased afterload as evidenced by hypertension 2. Acute pain related to headache 3.. Deficient knowledge related to nature and complications of hypertension Monitor VS (close attention to B/P, HR). Focus neurological assessment. Assess for S/S of both hypertension and hypotension. Need more information about: blood pressure parameters. Assess patient knowledge related to health care regimen (medications). Assess patient for any residual effects or symptoms related to his recent stroke (focused neuro exam). 1. Maintain B/P within parameters 2. Pt verbalizes acceptable level of pain control 3. Pt will verbalize understanding of medication regimen and complications of hypertension 1. Perform a focused neurological assessment (including Glasgow coma scale, LOC, cranial nerve assessments, strength and coordination). Assess vital signs (especially B/P and HR) 2. Administer antihypertensive medications accordingly to maintain B/P within parameters. 3. Assess for S/S of both hypertension (HA, blurred vision, CP, nose bleeds, dizziness or weakness, SOB) and hypotension 4. Assess pain including: intensity, duration, frequency, characteristic, and location. Assess history of pain and identify pts baseline. 5. Educate on S/S of both hypertension and hypotension. 6. Educate on medication regimen (name of med, dosage, side effects) Educate on S/S of both hypertension and hypotension. Provided teaching on importance of maintain appropriate blood pressure (within doctor recommended parameters). Provide teaching on importance of cardiac diet (low sodium and low cholesterol) in regards to reducing his blood serum cholesterol and blood pressure. Educate on medication regimen (name of med, dosage, side effects). Educate on S/S of recurrent stroke Discharge to SNF facility. PT Follow up appointment with doctor Select a PCP Education on medication regimen

N360 Mini Care Plan

Focus of physical assessment Need more information from patient/family/ doctor about: Top three priorities (goals) for patient care Nursing Interventions

1. Maintain B/P within parameters 2. Pt will perform ROM exercises 3. Pt will verbalize understanding of medication regimen 1. Assess neurological status (including Glasgow coma scale, LOC, cranial nerve assessments, strength and coordination). Assess vital signs (especially B/P, HR). 2. Change client position every 2 hours. 3. Encourage ROM exercises. 4. Assess distal pulses and assess for symptoms of DVT: pain, pulselessness, polar (coolness), pallor, paralysis, or paresthesia in limbs. 5. Apply SCD to lower extremities while in bed. 6. Encourage participation in PT 7. Educate on S/S of both hypertension and hypotension. 8. Educate on medication regimen (name of med, dosage, side effects). Educate on S/S of both hypertension and hypotension. Provided teaching on importance of maintain appropriate blood pressure. Provide teaching on importance of cardiac diet (low sodium and low cholesterol) in regards to reducing his blood serum cholesterol and blood pressure. Educate on medication regimen (name of med, dosage, side effects).

Teaching needed/provided

Discharge planning

Discharge to SNF facility. PT Follow up appointment with doctor