Problem: Ineffective Tissue Perfusion: Cerebral

ASSESSMENT EXPLANATION OF THE OBJECTIVES INTERVENTIONS RATIONALE EVALUATION &

PROBLEM EXPECTED OUTCOME

S> STO Dx STO

Clot, thrombus or embolism After 8 hours of Assess general health Provides baseline data The patient
forms within cardiovascular effective nursing interventions status. for nursing care. understands his condition
O> system the client will verbalize To accurately gauge and complies with
dizziness understanding of condition Monitored for other severity of condition. therapeutic regimen.
left-sided weakness and therapy regimen signs of ineffective tissue
facial asymmetry Cerebral artery perfusion. Radical changes may
speech slurring indicate that the condition
unexplained headache Monitored and recorded got worse.
at the occipital and nape Brain vital signs.
area
dyspnea LTO To promote
Blood flow is disrupted After 2 days of Tx circulation / increase LTO
CT Scan result:
effective nursing interventions Elevated HOB gravitational blood flow The patient
bleeding in intracranial
frontal 17 ml the client will verbalize understands his condition,
Oxygen and Glucose cannot understanding of condition, Anticoagulants and complies with therapeutic
reach part of brain therapy regimen, side effects hypertensive drugs help to regimen, is fully aware of
of medications and when to Administered prevent further damage possible side-effects of
contact healthcare provider medications medication and when to
Brain cells die (infarction) Alleviates the effects of contact a healthcare
the stroke provider.

Perform assistive/active
range-of-motion exercises
Enhances venous return

Edx Conserves energy /

Encourage early lowers tissue O2 demands
ambulation

Promote quiet, restful Encourages compliance

Nursing Diagnosis atmosphere to therapeutic regimen.
Ineffective cerebral
tissue perfusion related To assist patient in
to interruption of blood Reiterated importance incorporating disease
flow secondary to CVA of medical restrictions. management into ADLs.

Discussed necessary Provides basis for

 changes in lifetyle nursing care.

Encouraged
verbalization of feelings.