Problem: Ineffective Tissue Perfusion: Cerebral

ASSESSMENT EXPLANATION OF THE OBJECTIVES INTERVENTIONS RATIONALE EVALUATION &

PROBLEM EXPECTED OUTCOME

S> STO Dx STO

 ‘mejo mahirap igalaw Clot, thrombus or embolism  After 8 hours of  Assess general health  Provides baseline data  The patient
ang kaliwang kamay at forms within cardiovascular effective nursing status. for nursing care. understands his condition
paa ko’ system interventions the client will  To accurately gauge and complies with
verbalize understanding of  Monitored for other severity of condition. therapeutic regimen.
O> condition and therapy signs of ineffective tissue
 dizziness Cerebral artery regimen perfusion.  Radical changes may
 left-sided weakness indicate that the condition
 facial asymmetry  Monitored and got worse.
 speech slurring Brain recorded vital signs.
 unexplained headache
at the occipital and  To promote circulation
Blood flow is disrupted LTO Tx LTO
nape area / increase gravitational
 dyspnea  After 2 days of  Elevated HOB blood flow  The patient
effective nursing understands his condition,
Oxygen and Glucose cannot interventions the client will
 Anticoagulants and complies with therapeutic
reach part of brain verbalize understanding of
hypertensive drugs help to regimen, is fully aware of
condition, therapy regimen,  Administered possible side-effects of
prevent further damage
side effects of medications medications medication and when to
Brain cells die (infarction) and when to contact
 Alleviates the effects contact a healthcare
healthcare provider provider.
of the stroke
 Perform
assistive/active range-of-
motion exercises
 Enhances venous
return
Edx
 Conserves energy /
 Encourage early
lowers tissue O2 demands
ambulation
Nursing Diagnosis
 Ineffective tissue  Promote quiet, restful
 Encourages
perfusion related to atmosphere
compliance to therapeutic
interruption of blood regimen.
flow secondary to
CVD/CVA  Reiterated importance
 To assist patient in
of medical restrictions.
incorporating disease
 Discussed necessary
changes in lifetyle
 Encouraged
verbalization of feelings.
management into ADLs.
 Provides basis for
nursing care.