BACKGROUND EVALUATION

CUES DIAGNOSIS PLANNING INTERVENTIONS RATIONALE

KNOWLEDGE
SUBJECTIVE: Ineffective After 4 hours of Independent: After 4 hours of
Tumaas na po cerebral Hypertension nursing Established To gain the nursing
ang BP niya, perfusion intervention the rapport. clients trust. intervention the
tapos bigla nalng related to Rupture of clients condition clients condition
po siya intracranial cerebral blood will improve as Monitored vital To assess did not improve
bumagsak, as hemorrhage & vessels evidenced by signs specially clients response as evidenced by
verbalized by the cerebral GCS of 15 and a clients BP and progress to GCS 9 and a BP
patients wife vasospasm Hemorrhage decrease of the treatment. of 150/90.
process as blood pressure
evidenced by a Increase from 180/90 to Monitored mental To monitor of *The goal was
OBJECTIVE: BP of 180/90 intracranial 90-120 sBP and status clients level of not met.
and GCS of 9. pressure 60-80 dBP. assessment. consciousness Continued
T: 36.3 and response to monitoring the

P: 73 bpm Assisted in treatment. patient and
Ineffective
RR. 20 cpm passive range of To prevent same
cerebral
BP: 180/90 motion exercises muscle atrophy, interventions
perfusion
GCS: E2V2M5 & turning the DVT, and bed was performed.
patient/ sores.

Lethargic Dependent:
Administered
Right Sided osmotic diuretics To decrease
paralysis (Mannitol 100cc cerebral swelling
Q 8hours

Administered
antihypertensive To decrease
drugs. blood pressure.
(Amlodipine10m
g tab.
OD)

Administered
antifibronilytic To reduce
drug intracranial
(Tranexamic Acid hemorrhage.
500mg)
 CUES DIAGNOSIS BACKGROUND PLANNING INTERVENTIONS RATIONALE EVALUATION
KNOWLEDGE
SUBJECTIVE: Impaired After 8 hours of Independent: After 8 hours of
Yung kanang physical Hypertension nursing Established To gain the nursing
parte ng mobility related intervention the rapport. clients trust. intervention the
katawan niya to left-sided Rupture of client will be able client maintained
yung hindi niya brain damage as cerebral blood to maintain Monitored vital To assess position of
maigalaw, as evidence of right vessels position of signs specially clients response function and skin
verbalized by the sided paralysis, function and skin clients BP and progress to integrity as
patients wife facial drooping, Hemorrhage integrity as the treatment. evidenced by
and speech evidenced by absence of
difficulty. Left-sided brain absence of Assisted client To prevent contractures,
OBJECTIVE: damage contractures, reposition self on bedsores. foot drop and
foot drop and a regular bedsores.

T: 36.3 bedsores. schedule.
Impaired
P: 73 bpm
physical mobility
RR. 20 cpm Supported To maintain
BP: 180/90 affected body position of
GCS: E2V2M5 parts using function
pillows.

Lethargic Instructed the For position

use of side rails. changes and
Right Sided transfers and to
paralysis prevent falls
(Hemiplegia)

Facial Drooping Encouraged Promotes well-

adequate intake being and
Speech Difficulty of fluids and maximizes
nutritious foods. energy
Functional Level production
Classification:
3 Requires .
help from
another person
and equipment
device.