Angeles University Foundation

Angeles City
A.Y: 2015-2016
COLLEGE OF NURSING
NAME: ________Danica P. Vega____________________

DATE: ___________December 2, 2016_________________

YEAR & SECTION: ____BSN IV-A, Group 3___________

DIAGNOSIS:_______CVA Bleeding____________________

NURSING CARE PLAN

ASSESSMENT
S:
O: The pt. manifested the
following:
Altered mental status
Altered motor function
Pale palpebral
conjunctiva
Vital signs taken as
follows:
T: 36.0
P: 76 bpm
R: 21 cpm
BP: 140/90 mmHg
The pt. may manifest the
following:
Hemiplegia
Restlessness
Difficulty in
swallowing
Parethesia
Diminished or absent
pulses
Edema
Delayed peripheral
wound healing
Narrowed pulse
pressure
Decreased in Hct and
Hgb
Behavioral changes
Memory loss

NURSING DIAGNOSIS
Ineffective cerebral tissue
Perfusion related to
interruption to blood flow
secondary to CVA

SCIENTIFIC
EXPLANATION
Cerebrovascular Accident
is the presence of partial or
complete blockage of the
blood vessel and it can be
multifactorial. These can
be due to vasoconstriction,
platelet adherence on
rough surface, and fat
accumulation. Therefore, it
decreases elasticity of
vessel wall leading to
alteration of blood
perfusion with the
initiation of the clotting
sequence. This may later
leaf to the development of
thrombus which can be
loosened and dislodged is
some areas of the brain
such as cerebral carotid
artery that may lead to
alteration of blood
perfusion and further to
cerebral infarct causing
altered mental status,
decrease muscle strength,
pale and palpebral
conjunctiva

OBJECTIVES
Short Term:
- After 4 hours of nursing
intervention, the patient
will be able to demonstrate
stable vital signs and
absence of signs of
increased ICP
Long Term:
- After 2-3 days of nursing
intervention, the patient
will be able to display no
further deterioration/
recurrence of deficits

NURSING
INTERVENTIONS
- Monitor and recorded
vital signs
- Assist pt. in semifowlers position with
head midline

- Encourage quiet and

restful atmosphere
- Check capillary refill and
conjunctiva for paleness
- Perform GCS monitoring
as ordered
- Avoid neck flexion and
extreme hip/knee
extension
- Observe skin for
reddened areas/shearing
- Reposition pt. every 2
hours

RATIONALE
- To established baseline
data
- To aid with proper
perfusion of flow of blood
(circulation or venous
drainage)
- To conserve energy which
could aid in lowering the
oxygen tissue demand
- To determine blood
circulation
- To detect changes
indicative of worsening or
improving condition
- To avoid obstruction of
arterial and venous blood
flow
- To reduce friction and
maintain skin integrity
- To prevent complications
like skin ulcer
- To provide safety

- Provides safety measures

(raise side rails, lower bed,
pad side rails)

EXPECTED
OUTCOME
- The patient shall
demonstrate stable vital
signs and absence of signs
of increased ICP
- The patient shall display
no further deterioration/
recurrence of deficits

- Evaluate pupils, noting

size, shape, equality, light
reactivity
- Prevent straining at stool

- Administer supplemental
oxygen as indicated

- Pupil reactions is useful

in determining whether
brain stem is intact
- Valsava maneuver
increases ICP and
potentiates risk of
rebleeding
- Hypoxemia can cause
cerebral vasodilatation and
increase pressure or edema
formation

- Administer medications
as order:
- Alteplase (Activase), tPA;

- Anticoagulants:warfarin
sodium (Coumadin), lowmolecular-weight heparin
(Lovenox);
- Antiplatelet agents:
aspirin (ASA),
dipyridamole (Persantine),
ticlopidine (Ticlid)

- Thrombolytic agents are

useful in dissolving clot
when started within 3 hr of
initial symptoms. Thirty
percent are likely to
recover with little or no
disability. Treatment is
based on trying to limit the
size of the infarct, and use
requires close monitoring
for signs of intracranial
hemorrhage. Note: These
agents are contraindicated
in cranial hemorrhage as
diagnosed by CT scan.
- May be used to improve
cerebral blood flow and
prevent further clotting
when embolism and/or
thrombosis is the problem
- Contraindicated in
hypertensive patients
because of increased risk of
hemorrhage

- Antifibrinolytics:
aminocaproic acid
(Amicar)

- Antihypertensives

- Refer to physical
therapist

- Encourage patients SO
involvement in decision
making as much as
possible

- Used with caution in

hemorrhagic disorder to
prevent lysis of formed
clots and subsequent
rebleeding.
- Chronic hypertension
requires cautious treatment
because aggressive
management increases the
risk of extension of tissue
damage.
- Provide full range of
motion four or ve times a
day to maintain joint
mobility, regain motor
control,prevent contracture
s in the paralyzed
extremity, prevent
further deterioration of the
neuromuscular system, and
enhance circulation. If
tightness occurs in any
area, perform a range of
motion exercises more
frequently.
- Enhances commitment to
plan optimizing outcomes

- To impart health teaching

- Involve SO in care,
assisting them to learns
ways of managing
problems of immobility
- Provide counseling and
support to the family

- To involve others in
patients care and to know
stress management
techniques and
maintenance of personal
health for family coping