Nursing

Problems with
cues

Nursing Diagnosis
with Rationale

Objectives
(SMART)

Nursing Interventions

Problem:
Altered level of
consciousness
Subjective:
Patient
complained of
dizziness before
admission. Also
reported
weakness and
numbness on
left extremities 3
hours prior to
admission as
verbalized by
patients son
Objective:
Vital signs
Blood pressure:
160/100 mmHg
RR: 21, CR: 62
bmp
Temp: 36.8

Ineffective cerebral
tissue perfusion
related to
a. interruption of
blood flow
(ischemic
stroke)

Within the 12 hour

shift of nursing
intervention patient
will not:
manifest or display
any signs of further
deterioration or
recurrence of
deficits. (e.g.,
Increase GCS score
from baseline score)
display any signs of
increased ICP (e.g.,
hypertension,
altered LOC,
seizures)

Assessment
Monitor and document neurologic
status frequently and compare with
baseline. (e.g., GCS)

GCS score: 8
Eyes-2, verbal-2,
motor- 4
Pupils: equal in
size: right- 3mm,
left-3mm, both
reactive to light
accommodation

b. hemorrhage
(hemorrhagic
stroke)

Rationale

Assess trends in level of consciousness and

potential for increased ICP and is useful for
determining location, extent, and progression of
CNS damage. May also reveal presence of TIA,
which may warn of impending thrombotic CVA

Monitor vital signs:

Hypertension/hypotension

Fluctuations in pressure may occur because

cerebral pressure/injury in vasomotor area of the
brain. Hypertension or postural hypotension may
have been a precipitating factor. Hypotension may
occur because of shock. Increased ICP may occur
because of tissue edema or clot formation.

Respirations, noting patterns and

rhythm;
(e.g., Cheyne-stokes respirationrhythmic respiration with periods of
apnea and may indicate dysfunction in
the cerebral hemisphere or basal
ganglia)
Notify physician for any signs of
respiratory deterioration. Prepare for
intubation and mechanical ventilator
support if patient is not on respiratory
assistive device.

Irregularities can suggest location of cerebral

insult/increasing ICP and need for possible
respiratory support.

Diagnostic
studies:
CT scan:
standard
diagnostic study
to identify
location and
type of stroke.
May reveal
ischemic
infarction or
hemorrhagic
stroke.
Usual laboratory
studies for
patients
suspected with
stroke:
CBC, platelet and
clotting factors
like PT (INR)
and PTT, ESR,
fibrinogen,
blood sugar

Evaluate pupils, noting size, shape,

equality, light reactivity.
Watch out for anisocoric pupils
greater then 2mm. (e.g., Left pupil2mm, right pupil- 4mm). Notify
physician immediately. It may indicate
progression of hemorrhage. Prepare
for further diagnostic evaluation (CT
scan, laboratory studies like PT or
aPTT)

Pupil reactions are regulated by the oculomotor

(III) cranial nerve and are useful in determining
whether the brainstem is intact. Pupil size/equality
is determined by balance between
parasympathetic and sympathetic enervation.
Response to light reflects combined function of the
optic (III) and oculomotor (III) cranial nerves.

Document changes in vision; e.g.,

reports of blurred vision, alterations in
the visual field/depth perception.
Assess higher functions, including
speech, if client is alert.

Specific visual alterations reflect area of brain

involved, indicate safety concerns, and influence
choice of interventions.
Changes in cognition and speech content are an
indicator of location or degree of cerebral
involvement and may indicate
deterioration/increased ICP.

You may use stroke scale (National

Institutes of Health Stroke Scale) for
monitoring or evaluating progression
or regression of patients condition. If
possible obtain baseline data, as soon
as patient is admitted in the
institution. Baseline data will serve as
comparison to evaluate if management
is effective or not.

(Please see discussion for further

information regarding this type of
assessment)
Assess for nuchal rigidity, twitching,
increased restlessness, irritability,
onset of seizure activity,

Indicative of meningeal irritation, especially in

hemorrhagic disorders. Seizures may reflect
increased ICP/cerebral injury, requiring further
evaluation and intervention.

Independent
Position with head slightly elevated
and in neutral position.

Reduces arterial pressure by promoting venous

drainage and may improve cerebral circulation or
perfusion.

Maintain bed rest, provide quiet

environment, and limit
visitors/activities.

Continual stimulation or activity can increase ICP.

Absolute rest and quiet may be needed to prevent
recurrence of bleeding in the case of hemorrhage.

Prevent straining at stool or holding

breath. (Administer laxative as
prescribed, provide diapers to patient
and clean under pads, provide privacy
and comfort, maintain patient on
complete bed rest, instruct patient not
to exert effort while defecating, assist
with changing of diapers)

Valsalva maneuver increases ICP and potentiates

recurrence of bleeding.

Collaborative
Administer supplemental oxygen as
indicated.

Administer medications as indicated:

Intravenous thrombolytics; tissue
plasminogen activator (tPA), alteplase
(Activase)
This is used only for patients with
ischemic stroke and not for
hemorrhagic stroke.

Reduces hypoxemia, which can cause cerebral

vasodilation and increase pressure/edema
formation.
Proven therapy for acute stroke, t-PA is useful in
minimizing the size of the infarcted area by
opening blocked vessels that are occluded with the
clot. Treatment must be started within 3 hours of
initial symptoms to improve outcomes. (please see
discussion regarding t-PA medication)

(Please see discussion for more

information regarding criteria of
thrombolytic administration)
Anticoagulants; e.g warfarin sodium
(Coumadin), heparin (Enoxaparin)
Antiplatelet; e.g: aspirin (ASA),
clopidogrel (Plavix)
Neuroprotective agents; calcium
channel blockers Nomodipine
(Nimotop),

Nootropics; Citicoline (Zynapse),

Phenytoin (Dilantin)
Prepare patient for surgery as
appropriate; microvascular bypass or
cerebral angioplasty.
For patient with increased intracranial
pressure, usual management is
surgical evacuation or excision,
ventriculostomy insertion.

May be used to improve cerebral blood flow and

prevent further clotting/thrombosis is the
problem.
Maybe used to prevent further clotting/reduce risk
of recurrence of stroke.
Agents protect the brain by interrupting the
destructive cascade of biochemical events to limit
ischemic injury.
Increases blood flow and consumption of oxygen in
the brain
May be used to control seizures or for sedative
purposes.

Maybe necessary to resolve situation, reduce

neurologic symptoms, and risk for recurrent
stroke.