DATE

CUES

NURSING DIAGNOSIS

RATIONALE

OBJECTIVES OF CARE

NURSING INTERVENTIONS 1. Determine factors related to individual situation/cause for coma/decreased cerebral perfusion.

EVALUTAION

D E C E M B E R

Subjective: Ineffective Cerebral tissue Nastroke siya as verbalized by the patients watcher perfusion r/t interruption of blood flow secondary to hemorrhage Too much pressure in the vessels can cause it to rupture and thus leads to hemorrhage. If Objective: hemorrhage occurs in the Speech brain, there would be increased intracranial

After several Nursing Interventions, the client will be able to:

After several Nursing interventions, the patient was able to demonstrate increased perfusion as evidenced by: -warm skin -strong pulse noted VS within

Demonstrate increased perfusion as individually appropriate such as warm skin, strong pulse present/VS

R: Influences choice of interventions. 2. Monitor/document neurological status frequently and compare with

2 0 1

abnormality noted

Changes in motor

pressure and the brain will swell. Therefore there would be no enough blood flow and oxygenation in the brain.

within normal range.

baseline. R: Assesses trends in level of consciousness (LOC) and potential for increased ICP and is useful in

normal range: BP=120/90 mm Hg PR= 80 RR= 20 Temp= 36.9

response; extremity

5:00 PM

weakness; paralysis

GCS of 11

determining location, extent, and

VS taken as noted: BP= 130/90 mm Hg Source: Textbook of Medical

progression/resoluti on of CNS damage. 3.

RR= 20 cpm PR= 89 bpm Temp= 37.0

Surgical 12th edition by Brunner and Suddhart pg 563

Monitored vital signs. R: Fluctuations in pressure may occur because of cerebral pressure/injury in vasomotor area of the brain.

4. Evaluate pupils, noting size, shape, equality, light reactivity. R: Pupil reactions are regulated by the oculomotor (III)

cranial nerve and are useful in determining whether the brainstem is intact. Pupil size/equality is determined by balance between parasympathetic and sympathetic enervation. Response to light reflects combined function of the optic (II) and oculomotor

(III) cranial nerves.

5. Document changes in vision, e.g., reports of blurred vision, alterations in visual field/depth perception. R: Specific visual alterations reflect area of brain involved, indicate safety concerns, and influence

choice of interventions. 6. Position with head slightly elevated and in neutral position. R: Reduces arterial pressure by promoting venous drainage and may improve cerebral circulation/perfusio n. 7. Maintain bedrest; provided quiet environment;

Provided rest periods between care activities, limit duration of procedures. R: Continual stimulation/activity can increase ICP. Absolute rest and quiet may be needed to prevent rebleeding in the case of hemorrhage.

8. Administer medications as indicated such as Manitol, Citicholine and Neuroaid. R: To promote pharmacologic treatment regimen.