Admitting Diagnosis: Multiple Cerebral Infarction Assessment Subjective The client complained of slight difficulty of breathing Objective - The

patient appears lethargic -P: 8 am 57 bpm 12 pm 57 bpm -BP: 8 am 130/70 12 pm 140/80 -Speech abnormalities: slurred speech -Extremity weakness; pain and discomfort on lower extremities -Restless; Diagnosis Ineffective Cerebral Tissue Perfusion related to interruption of blood flow secondary to multiple cerebral infarctions as manifested by altered level of consciousness , changes in motor & sensory response, and language deficits Planning Goal The client will have an effective cerebral tissue perfusion after 2 to 3 weeks of proper nursing intervention Objectives 1. To assess contribut ing factors 2. To note degree of impairm ent 3. To maximiz e tissue perfusio n Implementation
Determine factors related to individual situation, decreased cerebral perfusion and potential for ICP.

Rationale
Influences choice of interventions. Deterioration in neurological signs and symptoms or failure to improve after initial insult may reflect decreased intracranial adaptive capacity, which requires that client be admitted to critical care area for monitoring of ICP and for specific therapies geared to maintaining ICP within a specified range. If the stroke is evolving, client can deteriorate quickly and require repeated assessment and progressive treatment. If the stroke is completed, the neurological deficit is nonprogressive, and treatment is geared toward rehabilitation and preventing recurrence. Assesses trends in LOC and potential for increased ICP and is useful in determining location, extent, and progression or resolution of CNS damage. Fluctuations in pressure may occur because of cerebral pressure or injury in vasomotor area of the brain. Hypertension or hypotension may have been a precipitating factor. Visual and sensory/motor changes/ involvement indicate safety concerns and influence the

Evaluation After 2-3 weeks of nursing intervention the client will be able to demonstrat e increased perfusionm( e.g., vital signs within normal range, alert/oriente d, free of pain/discom fort)

Monitor and document neurological status frequently and compare with baseline.

Monitor vital signs noting: Hypertens ion or hypotension

Keeps on calling out for his wife and son -facial weakness

Determine the presence of visual, sensory/motor change, headache, dizziness, altered mental status, personality changes Elevate HOB

choice of nursing intervention.

To promote circulation/venous drainage Some medications may be used to decrease edema

Administer medications (e.g. antihypertensives, diuretics)

Maintain bedrest, provide quiet environment, and restrict visitors or activities, as indicated. Provide rest periods between care activities, limiting duration of procedures.

Continual stimulation can increase ICP. Absolute rest and quiet may be needed to prevent recurrence of bleeding, in the case of hemorrhagic stroke.

Prevent straining at stool or holding breath.

Valsalvas maneuver increases ICP and potentiates risk of bleeding. Reduces hypoxemia.

Administer supplemental oxygen, as indicated.