N - Tissue Perfusion (cerebral) 4a5l2g
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Problem: Ineffective Tissue Perfusion: Cerebral ASSESSMENT EXPLANATION OF THE PROBLEM S>
OBJECTIVES STO
‘mejo mahirap igalaw ang kaliwang kamay at paa ko’
O>
dizziness left-sided weakness facial asymmetry speech slurring unexplained headache at the occipital and nape area dyspnea
Clot, thrombus or embolism forms within cardiovascular system Cerebral artery
After 8 hours of effective nursing interventions the client will verbalize understanding of condition and therapy regimen
Oxygen and Glucose cannot reach part of brain Brain cells die (infarction)
Dx Assess general health status.
Brain Blood flow is disrupted
INTERVENTIONS
LTO After 2 days of effective nursing interventions the client will verbalize understanding of condition, therapy regimen, side effects of medications and when to healthcare provider
Monitored for other signs of ineffective tissue perfusion.
Nursing Diagnosis Ineffective tissue perfusion related to interruption of blood flow secondary to CVD/CVA
The patient understands his condition and complies with therapeutic regimen.
Radical changes may indicate that the condition got worse.
To promote circulation / increase gravitational blood flow
Elevated HOB
Anticoagulants and hypertensive drugs help to prevent further damage
Alleviates the effects of the stroke
Enhances venous return
Conserves energy / lowers tissue O2 demands
istered medications
Edx Encourage early ambulation
Perform assistive/active range-ofmotion exercises
EVALUATION & EXPECTED OUTCOME STO
Provides baseline data for nursing care. To accurately gauge severity of condition.
Monitored and recorded vital signs.
Tx
RATIONALE
Promote quiet, restful atmosphere
Encourages compliance to therapeutic regimen.
Reiterated importance of medical restrictions.
To assist patient in incorporating disease
LTO
The patient understands his condition, complies with therapeutic regimen, is fully aware of possible side-effects of medication and when to a healthcare provider.
Discussed necessary changes in lifetyle
Encouraged verbalization of feelings.
management into ADLs.
Provides basis for nursing care.
OBJECTIVES STO
‘mejo mahirap igalaw ang kaliwang kamay at paa ko’
O>
dizziness left-sided weakness facial asymmetry speech slurring unexplained headache at the occipital and nape area dyspnea
Clot, thrombus or embolism forms within cardiovascular system Cerebral artery
After 8 hours of effective nursing interventions the client will verbalize understanding of condition and therapy regimen
Oxygen and Glucose cannot reach part of brain Brain cells die (infarction)
Dx Assess general health status.
Brain Blood flow is disrupted
INTERVENTIONS
LTO After 2 days of effective nursing interventions the client will verbalize understanding of condition, therapy regimen, side effects of medications and when to healthcare provider
Monitored for other signs of ineffective tissue perfusion.
Nursing Diagnosis Ineffective tissue perfusion related to interruption of blood flow secondary to CVD/CVA
The patient understands his condition and complies with therapeutic regimen.
Radical changes may indicate that the condition got worse.
To promote circulation / increase gravitational blood flow
Elevated HOB
Anticoagulants and hypertensive drugs help to prevent further damage
Alleviates the effects of the stroke
Enhances venous return
Conserves energy / lowers tissue O2 demands
istered medications
Edx Encourage early ambulation
Perform assistive/active range-ofmotion exercises
EVALUATION & EXPECTED OUTCOME STO
Provides baseline data for nursing care. To accurately gauge severity of condition.
Monitored and recorded vital signs.
Tx
RATIONALE
Promote quiet, restful atmosphere
Encourages compliance to therapeutic regimen.
Reiterated importance of medical restrictions.
To assist patient in incorporating disease
LTO
The patient understands his condition, complies with therapeutic regimen, is fully aware of possible side-effects of medication and when to a healthcare provider.
Discussed necessary changes in lifetyle
Encouraged verbalization of feelings.
management into ADLs.
Provides basis for nursing care.
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