Patient’s Name: Hospital No.

:
Age: Diagnosis:
Room No. Attending Physician:
Student/Placement: Date:

ASSESSMENT NSG. DIAGNOSIS OBJECTIVE OF NURSING RATIONALE EVALUATION

W/SCIENTIFIC CARE INTERVENTION
BASIS
S: “pang duha nani Ineffective Cerebral After 8 hours of INDEPENDENT After 8 hours of
namo nga adtos hospital Tissue Perfusion nursing intervention, nursing intervention,
tungod saiyahang sakit related to hemorrhage the patient and family - Establish rapport - To build a system of the patient and family
sir, nakalit man gud ni as evidenced by members will be able trust between the members was able to:
syag ka tumba tapos dili extremity weakness to: healthcare provider
na niya malihok ang sa and the client as well ● recognized
wala niya nga parte sa SCIENTIFIC BASIS ● recognize as its family members. symptoms of a
lawas” as verbalized by symptoms of a stroke and
the family member. The diagnosis of stroke and - Carefully assess the - Enables the immediate
Ineffective Cerebral immediate client’s vital signs and healthcare team to medical
O: - Patient is Tissue Perfusion medical have a frequent know if there is/are attention;
unconscious related to hemorrhage, attention; monitoring unusualities being ● know and
- Nonverbal as evidenced by ● know and exhibited. displayed the
- Slurred speech extremity weakness, is display the importance of
- Delayed founded on a importance of - Assess and perform - These assessments improved
comprehension comprehensive improved neurological will further help the cerebral
- Extremity understanding of cerebral assessments nurse to know what are perfusion as
weakness circulatory and perfusion as the problems that need evidenced by
- - VS take as neurological evidenced by utmost priority. vital signs
follows: principles. vital signs within ordered
● BP: 140/90 mmHg Hemorrhage, or within ordered - Maintain blood - To maintain cerebral parameters;
● Temp: 36.9 degrees significant bleeding, parameters; pressure perfusion in this case,
celsius can lead to a decrease blood pressure is kept
● RR: 21cpm in the volume of blood elevated unless the GOAL MET
● PR: 98 bpm circulating in the body. client is receiving
● 02 sat: 96% In cases of severe thrombolytic therapy.
- NVS : GCS score of 8 hemorrhage, the brain - Educate the client’s -The more that the
may not receive an family members in family member knows
adequate blood supply, terms of the risk these modifiable risk
NEEDS: which is essential for factors of stroke factors, the more they
PHYSIOLOGIC NEED maintaining its will be able to help in
function. alleviating the client’s
The diagnosis indicates health status.
that there is an The presence of
inadequate blood supply extremity weakness is - Instruct on symptoms - The sooner the
to the brain, likely due to a critical clinical of stroke using of symptoms are
hemorrhage, which is a indicator. This FAST recognized, the quicker
critical and life- weakness can be the treatment, and less
threatening condition. attributed to reduced sustained damage to
Extremity weakness blood flow to the brain, the brain tissue.
suggests neurological which impairs its
impairment, potentially ability to control and - Assure that the - Feeding a more
arising from reduced coordinate muscle nutritional status or realistic and well
cerebral blood flow. In movements. In food intake of the rounded diet through
such a medical essence, the brain client is well-observed NGT will help in
emergency, ensuring the requires a consistent and monitored. alleviating the health
physiological needs, and sufficient supply status of the client.
particularly oxygenation of oxygen and
and circulation, is nutrients carried by the DEPENDENT
paramount. blood to function
optimally. When - Administer - To help in aiding the
Immediate medical hemorrhage occurs, it medications as client’s unusualities
interventions, such as diminishes the volume prescribed by the and to help in
stabilizing blood of blood available to physician alleviating the health
pressure, administering nourish the brain, status of the client.
clotting agents or potentially leading to
surgery to stop the neurological
hemorrhage, and symptoms, such as
improving cerebral extremity weakness.
blood flow, take
precedence to safeguard Clinically, this
the client's life. Once diagnosis is established
these physiological through a combination
needs are adequately of medical
addressed, attention can assessments. This often
be given to safety, love involves imaging
and belonging, self- studies like CT scans
esteem, and self- or MRIs to identify the
actualization needs, with source and extent of
the ultimate goal of the hemorrhage, as
supporting the client's well as neurological
overall recovery and examinations to assess
well-being. However, the impact on brain
the first and foremost function and its
concern must be to manifestations in the
address the life- body, such as
threatening condition extremity weakness.
and reestablish effective
cerebral tissue perfusion Immediate medical
intervention is critical
in these cases to stop
the hemorrhage,
stabilize blood
pressure, and address
the circulatory issues.
The priority is to
restore effective
cerebral tissue
perfusion, ensuring
that the brain receives
adequate oxygen and
nutrients. Only when
this physiological need
is met can the focus
shift to other aspects of
the patient's well-
being, recovery, and
rehabilitation.