NURSING CARE PLAN

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

OBJECTIVE: Ineffective Cerebral After 24 hours, the patient 1. Assess factors 1. Assessment will determine After 24 hours, the patient
 Loss of Perfusion maybe r/t will maintain; related to individual and influence the choice of will maintain;
consciousness coagulopathy as 1. Maintain usual situation for interventions. Deterioration in 1. Maintain usual
VS taken: evidenced by altered or improved decreased cerebral neurological signs or failure to or improved
BT: 36 LOC. LOC, cognition, perfusion and improve after initial insult LOC, cognition,
BP: 180/120 and motor and potential for may reflect decreased and motor and
PR: 78 sensory function. increased ICP. intracranial adaptive capacity sensory function.
RR: 18 2. Demonstrate 2. Changes in blood requiring patient to be 2. Demonstrate
stable vital signs pressure, compare transferred to critical area for stable vital signs
and absence of BP readings in both monitoring of ICP, other and absence of
increased ICP. arms. therapies. If the stroke is increased ICP.
3. Display no evolving, patient can 3. Display no
further 3. Heart rate and deteriorate quickly and require further
deterioration or rhythm, assess for repeated assessment and deterioration or
recurrence of murmurs. progressive treatment. If the recurrence of
deficits. 4. Respirations, noting stroke is “completed,” the deficits.
patterns and neurological deficit is GOAL WAS NOT MET
rhythm (periods nonprogressive, and treatment
of apnea after is geared toward rehabilitation
hyperventilation), and preventing recurrence.
Cheyne-Stokes 2. Fluctuations in pressure may
respiration. occur because of cerebral
injury in vasomotor area of
5. Evaluate pupils, the brain. Hypertension or
noting size, shape, postural hypotension may
equality, light have been a precipitating
reactivity. factor. Hypotension may
occur because of shock
6. Document changes (circulatory
in vision: reports of collapse). Increased ICP may
blurred vision, occur because of tissue edema
alterations in visual or clot formation. Subclavian
field, depth artery blockage may be
perception. revealed by difference in
7. Assess higher pressure readings between
functions, including arms.
speech, if patient is 3. Changes in rate, especially
 alert. bradycardia, can occur
because of the brain damage.
8. Position with head Dysrhythmias and murmurs
slightly elevated may reflect cardiac disease,
and in neutral which may have precipitated
position. CVA (stroke after MI or from
9. Maintain bedrest, valve dysfunction).
provide quiet and 4. Irregularities can suggest
relaxing location of cerebral
environment, insult or increasing ICP and
restrict visitors and need for further intervention,
activities. Cluster including possible respiratory
nursing support.
interventions and 5. Pupil size and equality is
provide rest periods determined by balance
between care between parasympathetic and
activities. Limit sympathetic innervation.
duration of Response to light reflects
procedures. combined function of the
optic (II) and oculomotor (III)
cranial nerves.
6. Specific visual alterations
reflect area of brain involved,
indicate safety concerns, and
influence choice of
interventions.
7. Changes in cognition and
speech content are an
indicator of location and
degree of cerebral
involvement and may indicate
deterioration or increased ICP.
8. Reduces arterial pressure by
promoting venous drainage
and may improve cerebral
perfusion.
9. Continuous stimulation or
activity can increase
 intracranial pressure
(ICP). Absolute rest and quiet
may be needed to prevent
rebleeding in the case of
hemorrhage.
ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION
OBJECTIVE: Impaired verbal After 24 hours, the 1. Listen for 1. Feedback helps patient After 24 hours, the
errors in realize why caregivers
 CVD patient communication r/t patient will; conversation are not understanding patient will;
and provide or responding
 Difficulty of to alteration in feedback. appropriately and
1. Indicate an 2. Point to provides opportunity 1. Indicate an
speech perception as objects and ask to clarify meaning.
understanding understanding
patient to 2. Tests for expressive
of the of the
 Restlessness name them. aphasia. Patient may
evidenced by communication communication
3. Ask patient to recognize item but not
problems. write his name be able to name it. problems.
 NGT Feed difficulty of
2. Establish and a short 3. Tests for writing 2. Establish
method of sentence. If disability (agraphia) method of
 Unable to comprehending or unable to and deficits in reading
communication communication
write, have comprehension
communicate in which needs in which needs
maintaining patient read a (alexia), which are
can be can be
short sentence. also part of receptive
VS taken: communication. expressed. 4. Write a notice and expressive expressed.
3. Use resources at the nurses’ aphasia. 3. Use resources
BT: 36 station and 4. Allays anxiety related
appropriately. appropriately.
patient’s room to inability to
BP: 180/120 about speech communicate GOAL WAS NOT MET
impairment. and fear that needs
PR: 78 Provide a will not be met
special call promptly.
RR: 18 bell that can be 5. Helpful in decreasing
activated by frustration when
minimal dependent on others
pressure if and unable to
necessary. communication
5. Anticipate and desires.
provide for 6. Reduces confusion and
patient’s allays anxiety at
needs. having to process and
6. Talk directly respond to large
to patient, amount of information
speaking at one time. As
slowly and retraining progresses,
distinctly. advancing complexity
Phrase of communication
questions to be stimulates memory
answered and further enhances
simply by yes word and idea
or no. Progress association.
in complexity 7. Assesses individual
as patient verbal capabilities and
responds. sensory, motor, and
7. Respect cognitive functioning
patient’s to identify
preinjury deficits/therapy needs.
capabilities;
avoid
“speaking
down” to
patient or
making
patronizing
remarks.
8. Consult and
refer patient to
speech
therapist.