c
  


  



  

 


 



 


 
 

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  !




 After 1 hour of the  After 1 hour of
ż monitor vital signs ż baseline data
³Napansin ko, Entry of nursing intervention the nursing
parang microorganisms the client will be able żelevate head of the bed żto take advantage of intervention the
nahihirapan to the nose to: gravity decreasing pressure client was:
siyang Ļ on the diaphragm and
enhancing drainage, and
huminga´ as Accumunlation of żhave patent airway for better lung expansion ż (+) crackles
verbalized by 


 microorganism on or improve airway RR from 27 it will
the patient¶s

 the lungs clearance as evidence żauscultate breath sounds żto ascertain status and range to 20cpm
daughter. 



 Ļ by and assess air movements note progress (+) use of



 Lungs become (-) crackles accessory
żobserve for signs and żto assess changes and





 infected RR from 27 it will complications/ to identify muscles
symptoms of infection


   Ļ range to 16-20cpm infectious process/ promote
(+) crackles 

 Production of (-) use of accessory timely interventions "!


(+) thick mucus muscles After 2 days of the
mucus Ļ nursing
secretions Excessive mucus Dependent: intervention the
żgive expectorants/
(+) poor secretions "!

 bronchodilators as ordered żto mobilize secretions client was
coughing Ļ After 2 days of the ż no presence of
reflex Ineffective airway nursing intervention żprovide supplemental infection or
(+) use of clearance the client will be able humidifier as ordered żto mobilize secretions complications
accessory to (nebulizer) żthick mucus
muscles żsuction as żto maintain adequate, ż (+) crackles
(+) DOB ż maintain patent naso/tracheal/oral as patent airway RR from 27 it will
RR= 27 cpm airway ordered range to 20cpm
ż(-) thick mucus (+) use of
ż no presence of Collaborative: accessory
ABG żto assess changes/
infection or progress muscles
complications
’goal no met
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 After 30 minutes of żnote concomitant å to identify causative/
ż After 30 minutes
the nursing medical problems that contributing factors of the nursing
CVA intervention the client may be factors for care intervention the


 Ļ will be able to: (BP,meds) client was:


 !

# Comatose
(+) comatose


  Ļ ż the relative will ż the relative will
(-) ADL 


 Cognitive and verbalize knowledge of żassess memory/ żto assess degree of verbalize

 Motor impairment health care practices intellectual functioning. disability knowledge of


 Ļ żpractice level of care Note developmental health care




 Self-care deficit that the client needs level to which client has practices
 (relative) regressed/progressed żpractice level of
 
  care that the client


 "!

 żhealth teach the żto provide/continue needs (relative)



 After 2 hours of duty client¶s relative support care


 the client will be able regarding to the need of "!



$ " to: care of the client After 2 hours of
duty the client
żhas a good grooming żprovide for żenhances was:
żhas a support system communication among coordination and
caring for him those who are involved continuity of care żhas a good
in caring for/ assisting grooming
the client żhas a support
system caring for



 him
żAdminister medication
as ordered by the ’goal met
physician


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 After 1 hour of the żNote presence of żto identify After 1 hour of the
 nursing illness causative/contributing nursing
 intervention the factors intervention the
 



  client will: żto promote wellness client will:
³Ang dami na  (-) oral hygiene żprovide oral care
niyang puti-puti sa 


 Ļ żhave a clean oral żhave a clean oral
bibig´ as    Proliferation of cavity żhealth teach the żto promote wellness cavity
verbalized by the 


 microorganisms client¶s relative on
client¶s daughter. 


 Ļ żdecrease white oral hygiene żdecrease white




 Disruption of oral patches techniques patches


% cavity




 Ļ "!

 żhumidify/ żto prevent drying of "!


(-) oral hygiene Presence of white After 8 hours of lubricate lips lips After 8 hours of
(+) white patches, the nursing the nursing
patches/plaques, White curdlike intervention the żroutinely monitor żto assess progress intervention the
white curdlike exudates client will: oral cavity client will:
exudates condition
żmaintain good żmaintain good
oral hygiene Dependent: oral hygiene
Administer
żno further medication as żno further
formation of ordered by the formation of
infection physician infection

żhealthy mucosa ’goal met


 
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  !

 żidentify changes żto assess causative/  !




  related to systemic and contributing factors 
³Ganyan na 


 CVA After 2 hours of the peripheral alterations in After 2 hours of
siya, laging



 Ļ nursing intervention circulation the nursing
tulog´ as 
  Interruption of the client will be intervention the
verbalized by 


 blood flow in the able to: żelevate żto promote client was:
the client¶s 
  brain HOB and maintain circulation
daughter.  Ļ żdemonstrate head/neck in midline żdemonstrate
&  
 Malfunction of the increase perfusion increase perfusion


 
'
 brain as evidence by żAssist with/monitor żto maximize tissue as evidence by





 Ļ -vital signs within hypothermia therapy perfusion -vital signs
(+) comatose




 Comatose, normal range (which may be used to RR=
BP=150/90   
 altered level of -peripheral pulses decrease metabolic and Temp=
(+) history of consciousness present/strong O2 needs) PR=
CVA BP=
(+) 2nd Stroke żencourage discussion żto promote wellness -peripheral pulses
(+) weak "!

 of feelings regarding present/strong
pulses prognosis/long term
After 3 days of the effects of condition (to "!


nursing intervention the relative)
the client will be After 3 days of the
able to:


 nursing
żAdminister żto maximize tissue intervention the
żimprove level of medications as ordered perfusion client will be able
consciousness by the physician to:
(diuretics, żeyes are opening
anticoagulants) and can move
hands
c



CT-Scan ’partially met



c

(





)   
 



  Ineffective airway clearance related to $

excessive mucus secretions



 Total self-care deficit related to cognitive *  


impairment and absence of purposeful activity
as evidence by unable to perform ADL



 Impaired oral mucous membrane related to *  


ineffective oral hygiene.



 Ineffective cerebral tissue perfusion related to c 

interruption of blood flow (occlusive disorder) as
evidence by altered level of consciousness