ASSESSMENT NURSING PLANNING RATIONALE EVALUATION

DIAGNOSIS
SUBJECTIVE Ineffective cerebral SHORT TERM -Assess tends in -The improvement
tissue Perfusion level of of one’s condition
“Hirap siyang related to Closely assess and consciousness from worse to good
gisingin at interruption of monitor (LOC) and potential status with
makausap ng blood flow neurological status for increased ICP conscious and
maayos” as evidenced by frequently and and is useful in slightly mobility
verbalized by sensory, Language, compare with determining starting to reoccur.
patient’s son. Intellectual and baseline. location, extent,
emotional deficits. and progression of -the restoration of
OBJECTIVE LONG TERM the damage. May physical mobility
also reveal with independently
-Unconsciously but Assess factor presence of this, maintain one’s
can trigger with related to which may warn of previous lifestyle
chest push(pain) individual situation impending and amount of
-(+) general for decreases thrombotic cva. oxygen in the brain
weakness cerebral perfusion became normal
-Not responding in and potential for -Deterioration in supplied.
conversation increased ICP. neurological signs
-Difficulty in stay or the failure the
awake/waking up improvement of
one’s initial insult
BP: 180/100 may reflect
O2SAT: 93-94% decreased of the
RR: 12 (Respiration intracranial
Rate) adaptive capacity
Pulse Rate: 95 requiring patient to
Age: 61years old be transferred to
critical are for
monitoring of ICP.
 ASSESSMENT NURSING PLANNING RATIONALE EVALUATION
DIAGNOSIS
SUBJECTIVE Impaired physical SHORT TERM >Reduces risk of >Maintain/ Increase
mobility related to tissue injury. the strength and
“Nanghihina ang neuromuscular Change positions Affected side has function of affected
katawan sa bawat involvement at least every 2hour poorer circulation or compensatory
araw na lumipas” evidenced by (Supine, Side lying) and reduced body port.
as verbalized by inability to and possibly more sensation and is
the patients son” purposefully move often if placed on more predispose to >Maintain optimal
within the physical affected side. skin breakdown. position of function
OBJECTIVE environment. as evidenced by
LONG TERM >promotes sense absence of
>Impaired ability to of expectation of contractures foot
moved lower Set goals with improvement and drop.
extremities patient so for provide some
>(+) general participation in sense of control >Demonstrate
weakness activities and and independence. techniques/
>impaired ability to position changes. behaviors that can
move from supine enable resumption
to sitting vice versa of activities
.
>Maintain skin
BP: 180/100 integrity
O2SAT: 93-94%
RR: 12 (Respiration
Rate)
Pulse rate: 95
Age: 61years old
 PATHOPHYSIOLOGY SIGN AND SYMPTOMS
The disruption in the blood flow *Motor Loss
Incomes a complex series of cellular -Hemiplegia, Hemiparesis
Metabolic events. -flaccid paralysis and loss of decreased in the deep
tendon reflexes
Decreased cerebral blood flow
The Ischemic cascade begins when
Cerebral blood flow decreases to less than *Communication Loss
25mL for 100g of Blood per minute. -Dysarthria (Difficulty of speaking)
-Dysphasia (impaired speech)
Aerobic Respiration Or aphasia (Loss of speech)
At this point, neurons are unable to maintain -Apraxia (Inability to perform a previously learned
Aerobic aspiration. action)

Anaerobic Respiration
The mitochondria would need to switch to *Visual Disturbances
anaerobic respiration, which generate large -the eyes also need enough oxygen for optimal
amounts of lactic acid, causing a change in pH functioning.
rendering the neurons incapable of producing
sufficient quantities of ATP
*Change in mental status
Loss of Function -due to decreased oxygen the patient experiences
the membrane pumps that maintain electrolyte confusion.
balances fail and the cells cease to function.