Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective: Ineffective Short term: Independent: Short term:

tissue After 3-5 hrs of o Determine factors o Influences choice of After 3-5 hrs of
Objective: perfusion nursing related to individual interventions. nursing
- BP: (cerebral) intervention, situation/ cause for Deterioration in intervention,
180/11 related to the client and coma/ decreased neurological signs/ the client and
0 bleeding as the relative cerebral perfusion symptoms or failure the relative
- Dizzine evidenced by will be able to and potential to improve after was able to
ss altered level verbalize increased ICP. initial insult may verbalize
- Inability of understanding reflect decreased understanding
to lift consciousnes of condition, intracranial adaptive of condition,
eyelid s, changes in therapy capacity requiring therapy
- Letharg vital sign and regimens, and patient be regimens, and
ic changes in when to transferred to critical when to
- Vomitin motor contact health care area for contact health
g responses. care provider. monitoring of ICP, care provider.
o Monitor/ document other therapies.
Long term: neurological status Long term:
After 5-6 days frequently and o Assess trends in After 5-6 days
of nursing compare with level of of nursing
intervention baseline. consciousness and intervention
the client will potential for the client was
be able to increased ICP and is able to
demonstrate useful in determining demonstrate
increased location, extent, and increased
perfusion as progression/ perfusion as
individually o Monitor vital signs. resolution of CNS individually
appropriate, Take note of damage. appropriate,
vital signs are Hypertension and vital signs are
on client’s hypotension. o Fluctuations in on clients
normal range, pressure may occur normal range,
alert and because of cerebral alert and
oriented. pressure/ injury in oriented.
o Heart rate and vasomotor area of
rhythm; Auscultate the brain.
 for murmurs
o Changes in rate,
especially
bradycardia, can
occur because of the
brain damage.
Dysrhythmias and
murmurs may reflect
cardiac disease,
o Respirations, noting which may have
patterns and rhythm. precipitated CVA.
Periods of apnea
after o Irregularities can
hyperventilation, suggest location of
Chyne-Stokes cerebral insult/
respiration. increasing ICP and
need further
intervention,
o Provide information including possible
regarding the client’s respiratory support.
condition.
o To increase the
o Maintain bed rest; client’s relatives,
provide quiet knowledge about the
environment; restrict condition.
visitors/ activities as
indicated. Provide o Continual
rest periods between stimulation/ activity
care activities, limit can increase ICP.
duration of Absolute rest and
procedures. quiet may be needed
to prevent
o Prevent straining at rebleeding in the
stool, holding breath. case hemorrhage.
 o Valsalva maneuver
o Assess for nuchal increases ICP and
rigidity, twitching, potentiates risk for
increased rebleeding.
restlessness,
irritability, onset of o Indicative of
seizure activity. meningeal irritation,
especially in
o Interview client’s hemorrhagic
relatives regarding disorders.
their perception of
situation.
o To assist client’s
o Discuss to relatives relatives in
for meeting the understanding the
client’s self care client’s condition.
needs.
o Varying levels of
assistance may be
required/ need to be
Collaborative: planned for bases on
o Administer individual situation.
supplemental oxygen
as indicated.
o Reduces hypoxemia,
which can cause
cerebral vasodilation
Dependent: and increase
o Administer pressure/ edema
antihypertensive as formation.
ordered.
o Preexisting/ chronic
hypertension
requires cautious
treatment because
aggressive
o Administer stool management
softeners as ordered. increases the risk of
extension of tissue
damage.

o Prevent straining
during bowel
movement and
corresponding
increase of ICP.