ASSESSMENT

NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
PLANNING INTERVENTIONS RATIONALE EVALUATION
Subjective: (none)

Objective:
hemiplegia
assess for
muscle strength
altered mental
status
restlessness
changes in
pupillary
Reactions
difficulty in
swallowing

Ineffective
cerebral tissue
perfusion r/t
interruption of
blood flow
secondary to CVA
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.
Short Term:
After 4 hours of NI,
patient will be able
to display decrease
signs of ineffective
tissue perfusion as
evidence by
gradual
improvement of
vital signs.

Long Term:
After 3 days of NI,
patient will be able
to gradually
improve tissue
perfusion AEB good
capillary refill and
pink conjunctiva.
1. Establish rapport

2. Monitor vital
signs




3. Check capillary
refill and
conjunctiva for
paleness
4. elevate head of
bed to 30 degrees
as ordered

5. Advise patient to
have enough rest


6. Avoid neck
flexion and
extreme hip/knee
extension

7. Provide and
maintain oxygen
as ordered


8. Perform GCS
monitoring as
ordered

1. To promote
cooperation

2. To have a
baseline data,
assess changes
in neurologic
status

3. To determine
blood
circulation

4. To promote
circulation

5. Enough rest is
needed to
conserve
energy

6. To avoid
obstruction of
arterial and
venous blood
flow

7. Aids in
difficulty of
breathing


8. To detect
changes
Short Term:
Patient shall have
displayed a
decrease signs of
tissue perfusion
AEB gradual
improvement of
vital signs



Long Term:
Patient shall have
gradually improved
tissue perfusion
AEB good capillary
refill and pink
conjunctiva


9. Administer
medications as
ordered
indicative of
worsening or
improving
condition

9. To promote
wellness