CUES Subjective: (no subjective cues since patient is unconscious) Objective: ?

? Hemiplegia GCS = 7 Stuporous Pale nail beds Hemoglobin 10.40 g/dl

NURSING DIAGNOSIS Ineffective cerebral tissue perfusion r/t interruption of blood flow secondary to CVA

OBJECTIVES Short Term: After 4 hrs of nursing interventions, patient will be able to display decrease signs of ineffective tissue perfusion as evidence by gradual improvement of vital signs. Long Term: After 16 hours of nursing interventions, patient will be able to gradually improve tissue perfusion as evidenced by good capillary refill and pink conjunctiva.

INTERVENTIONS Independent: Elevate head of bed to 03 avoid neck flexion and extreme hip/knee extension Pperform passive ROM exercises on the extremities every 2-4 hours Collaborative: Perform GCS monitoring as ordered

RATIONALE

EVALUATION Short Term: Goals were fully met. After 4 hours of nursing interventions; Vital Signs: T: P: R: BP: O2: Long Term: Goals were partially met. After 16 hours of nursing interventions

To promote circulation To avoid obstruction of arterial and venous blood flow Prevents venous stasis and helps maintain muscle tone of extremities

To detect changes indicative of worsening or improving condition This saturates circulating hemoglobin and increases

Provide and maintain oxygen as ordered

the effectiveness of blood that is reaching the ischemic tissues Administer Telmisartan 80mg, 1tab, OD as ordered To control blood pressure