Вы находитесь на странице: 1из 3

c    

     


 
 

 

 

Subjective: Ineffective tissue Decrease in Short term: 1. Determine 1. Provide Short term:
Loss of perfusion related oxygen resulting After 30 minutes presence of baseline for After 30 minutes
consciousness to cerebral in the failure to of nursing visual, comparison to of nursing
(which is the vasospasm as nourish the intervention, the sensory/motor follow trends intervention, the
chief complaint of manifested by tissues at the patient will be changes, and evaluate patient was able
the patient) altered level of capillary level. able to: headache, response to to:
consciousness, dizziness, altered interventions.
Objective: slurred speech; Display mental status, Displayed
LOC: Lethargic pupils: unequal, hemodynamic personality hemodynamic
BP: 200/110 sluggish reaction, stability changes. stability
mmHg
Pupils: unequal Manifest change Manifested
sluggish reaction in level of 2. Elevate head of 2. To promote change in level of
Right sided consciousness the bed (e.g., 10 circulation/ve consciousness
paralysis from lethargic to degrees) and nous from lethargic to
conscious state. maintain circulation. conscious state.
head/neck in
Maintain blood midline or Maintained blood
pressure within neutral position. pressure within
the desired the desired
parameters. 3. Adequate 3. Adequate parameters.
oxygenation cerebral blood
Long term: begins with flow is Long term:
After 3- 6 months pulmonary care, essential for After 3- 6 months
of nursing maintenance of cerebral of nursing
intervention, the patent airway, oxygenation. intervention, the
patient will be and patient was able
able to: administration of to:
supplemental
Improve mobility oxygen as Improved
needed. mobility
Relief of sensory 4. Correct 4. To prevent Relieved of
and perceptual positioning of the contractures. sensory and
deprivation patient. perceptual
deprivation
5. Assist in maintain 5. Flexor
good body muscles are
alignment and stronger than
prevent extensor
compressive muscles; a
neuropathies, posterior
especially of the splint applied
ulnar and at night to the
peroneal affected
muscles. extremity may
prevent
flexion and
maintain
correct
positioning
during sleep.

6. The affected 6. To maintain


extremities are joint mobility,
exercised regain motor
passively and put control,
through a full prevent
range of motion contractures
four to five times in the
a day. paralyzed
extremity,
prevent
further
deterioration
of the
neuromuscula
r system and
enhance
circulation.

7. Encourage client 7. To
to turn head and compensate
eyes in full for visual field
rotation and scan loss.
the environment.

Dependent:
1. Administer 1. To lower the
medications blood
(anti- pressure.
hypertensive
agents, anti-
coagulants).

Collaborative:
1. Consult with 1. To develop
physical/occupati individual
onal therapist, as exercise/mobi
indicated. lity program
and identify
appropriate
program.