ii.

Nursing Management

NURSING SCIENTIFIC GOALS/ NURSING

ASSESSMENT RATIONALE EVALUATION
DIAGNOSIS BASIS OBJECTIVES INTERVENTION
S> Ø Ineffective Intracerebral Short term: Independent: Short term:
Cerebral hemorrhage After 8 hours >Establish rapport - 1.To promote After 8 hours
O>Altered Tissue (ICH) is a type of nursing cooperation of nursing
LOC; memory Perfusion of stroke intervention, >Monitor vital -To have a intervention,
loss related to caused by patient will be signs baseline data, patient was
>GCS: 14/15 interruption bleeding within able to: assess changes able to:
(E4V4M6) of blood flow the brain tissue a.) Display no in neurologic a.) Display no
> left sided itself — a life- further status further
body weakness threatening deterioration/re >Check capillary -To determine deterioration/r
>dysphagia type of stroke. currence of refill and blood circulation ecurrence of
>restlessness A stroke deficits conjunctiva for deficits
>Sensory, occurs when Long term: paleness Long term:
language, the brain is After 2-3 days >Elevate head of - Reduces After 2-3 days
intellectual, and deprived of of nursing bed to 30 degrees arterial pressure of nursing
emotional oxygen and intervention, by promoting intervention,
deficits blood supply. patient will be venous patient was
>VS taken as ICH is most able to: drainage and able to:
follows: commonly a. Maintain may improve a. Maintain
T: 36.2°C caused by usual/improve cerebral usual/improve

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P: 97 bpm hypertension, d level of perfusion d level of
R: 21 cpm arteriovenous consciousness > Maintain - Continuous consciousness
BP: 140/90 malformations, , cognition, bedrest, provide stimulation or , cognition,
or head and quiet and relaxing activity can and
trauma. motor/sensory environment, increase motor/sensory
Common function. restrict visitors intracranial function.
symptoms b.) and activities. pressure (ICP). b.)
include: Demonstrate Cluster nursing Absolute rest Demonstrate
headache, stable vital interventions and and quiet may stable vital
nausea, and signs and provide rest be needed to signs and
vomiting; absence of periods between prevent absence of
lethargy or signs of care activities. rebleeding in signs of
confusion; increased ICP the case of increased ICP
sudden hemorrhage.
weakness or >Avoid neck -To avoid >Goal met
numbness of flexion and obstruction of
the face, arm extreme hip/knee arterial and
or leg, usually extension venous blood
on one side; flow
loss of >Monitor -To detect

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consciousness; Neurovital signs changes
temporary loss qhourly indicative of
of vision; and worsening or
seizures. improving
condition
Reference: Dependent:
Zuccarello, M. >Administer - an osmotic
(2016). Mannitol 100mL diuretic that is
Intracerebral IVTT q8, as used to reduce
hemorrhage ordered pressure in the
(ICH). brain
Retrieved from >Administer - reduce blood
https://www.ma Losartan pressure to
yfieldclinic.com 100mg/tab 1 tab prevent
/PE-ICH.HTM PO/ NGT, as exacerbation of
ordered intracerebral
hemorrhage

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 NURSING SCIENTIFIC GOALS/ NURSING
ASSESSMENT RATIONALE EVALUATION
DIAGNOSIS BASIS OBJECTIVES INTERVENTION
S>Ø Impaired An Short term: Independent: Short term:
Physical intracerebral After 8 hours >Establish rapport -to promote After 8 hours
O> left sided Mobility R/t hemorrhage of nursing cooperation of nursing
body weakness neuromuscul (ICH) is a intervention, >Monitor vital -to have a intervention,
> limited ROM ar condition patient will be signs baseline data patient was
of left side impairment where bleeding able to: >Note -to assess able to:
>difficulty occurs in the a.) participate emotional/behavio functional ability a.) participate
turning tissue or willingly in ral responses to willingly in
>Muscle ventricles of necessary or problems of necessary or
strength: the brain. A desired immobility desired
Right upper hemorrhage activities >Determine -to assess activities
extremity: 5/5 deprives the b.) maintain readiness to expected level b.) maintain
Left upper brain of skin integrity engage in of participation skin integrity
extremity: 2/5 oxygen while c.) free from activities/exercise c.) free from
Right lower putting accidents/injur > Change - Reduces risk accidents/injur
extremity: 5/5 pressure on y positions at least of tissue injury. y
Left lower the tissues Long term: every 2 hr Affected side Long term:
extremity: 3/5 nearby. After 4-5 days (supine, side has poorer After 5 days of
Patients with of nursing lying) and circulation and nursing

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ICH can intervention, possibly more reduced intervention,
present with patient will be often if placed on sensation and is patient was
sudden able to: affected side. more able to:
neurologic a.) improve predisposed to a.) improve
deficits. When and increase skin breakdown. and increase
hemorrhage is strength and >Place pillow -Prevents strength and
located in the function under axilla to adduction of function
hemispheres of of affected abduct arm shoulder and of affected
the brain, a body part. flexion of elbow. body part.
large b.) >Elevate arm and -Promotes b.)
hemorrhage Demonstrate hand venous return Demonstrate
can cause techniques/be and helps techniques/be
hemiparesis haviors that prevent edema haviors that
(weakness or enable formation. enable
inability to resumption of >Observe -Edematous resumption of
move on one activities. affected side for tissue is more activities.
side of the color, edema, or easily
body). The other signs of traumatized and >Goal met
hemiparesis compromised heals more
then cause circulation. slowly.

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impairment in >Inspect skin -Pressure points
physical regularly, over bony
mobility. particularly over prominences
bony are most at risk
Reference: prominences. for decreased
Shaffer, C. perfusion.
(2017). >Assist patient -To promote
Intracerebral with exercise and increased
hemorrhage perform ROM venous return,
(ICH) signs, exercises for both prevent
symptoms and the affected and stiffness, and
diagnosis. unaffected sides. maintain muscle
Retrieved from Teach and strength and
https://www.ne encourage patient endurance
ws- to use his
medical.net/he unaffected side to
alth/Intracerebr exercise his
al- affected side
Hemorrhage- >Keep side rails
(ICH)-Signs- up and bed in low -To promote

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Symptoms- position. safe
and- >provide restful environment.
Diagnosis.aspx environment for -to facilitate
patient after recuperation
periods of
exercise
Dependent:
>Provide patient
with pneumatic - This
mattress, as equipment
ordered decrease
pressure on
skin or tissues
that can
damage
circulation,
potentiating risk
of tissue
ischemia or
breakdown and

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 decubitus
Collaborative: formation.
> Assist in
Physical therapy -to enhance
twice a day, as likelihood of
ordered success and
may motivate
the client to
adopt a lifestyle
of physical
exercises for
the
enhancement of
health

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 NURSING SCIENTIFIC GOALS/ NURSING
ASSESSMENT RATIONALE EVALUATION
DIAGNOSIS BASIS OBJECTIVES INTERVENTION
S> Ø Deficient Acute Short term: Independent: Short term:
fluid volume Gastroenteritis After 8 hours >Monitor vital - Decrease in After 8 hours
O>10 episodes related to is diarrhea or of nursing signs especially circulating blood of nursing
of LBM (watery, excessive vomiting, or intervention, the blood volume can intervention,
brownish, non- fluid loss both, of more patient will be pressure and cause patient was
bloody stool) secondary to than several able to: heart rate. hypotension able to:
>Sodium level: Acute episodes or a.) and a.)
152 Gastroenterit days duration. demonstrate tachycardia. demonstrate
>decrease is Infectious lifestyle >Monitor intake -Specific gravity lifestyle
jugular vein agents are the changes to and output and is an indicator of changes to
distention usual cause of restore normal measure urine hydration and restore normal
>poor skin acute fluid volume specific gravity renal function. fluid volume
turgor gastroenteritis. b.) free from >Provide water or -water is b.) free from
>Stool exam These agents hypovolemic flush tubing 40 cc needed to treat hypovolemic
result: cause diarrhea shock before and after dehydration shock
Presence of by several Long term: feeding. Long term:
yeast cells and mechanisms, After 2-3 days >Give sips of -to replace fluid After 3 days of
hyphae including of nursing water or fluids loss and to treat nursing
adherence, intervention, little by little but dehydration intervention,

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mucosal patient will be often patient was
invasion, able to restore > Weigh daily with - Weight is the able to restore
enterotoxin normal fluid same scale, and best normal fluid
production, volume preferably at the assessment volume
and/or same time of day. data for >Goal met
cytotoxin possible fluid
production. volume
These imbalance.
mechanisms Dependent:
result in >Administer - to treat sudden
increased fluid Loperamide 2mg diarrhea. It
secretion q12 PO x 1 day, works by
and/or as ordered. slowing down
decreased the movement
absorption. of the gut. This
This produces decreases the
an increased number of
luminal fluid bowel
content that movements and
cannot be makes the stool

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adequately less watery.
reabsorbed, >Administer -to treat
leading to Hydrasec diarrhea
dehydration 100mg/tab 1 tab
and the loss of TID RTC, as
electrolytes ordered.
and nutrients. >Administer -used to treat
Erceflora 1 acute diarrhea
Reference: polyamp TID PO, due to infection;
Diskin, A. as ordered. to normalize the
(2017). intestinal flora
Emergent > Hydrate patient -to replenish
treatment of with PLR @ fluid volume and
gastroenteritis. 120cc/hr for to treat
Retrieved from replacement, as dehydration.
https://emedici ordered
ne.medscape.c
om/article/7752
77-
overview#a5

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 NURSING SCIENTIFIC GOALS/ NURSING
ASSESSMENT RATIONALE EVALUATION
DIAGNOSIS BASIS OBJECTIVES INTERVENTION
S>Ø Self-care Intracerebral After 8 hours Independent After 8 hours
deficit hemorrhage is of nursing >Establish short- -Helping the of nursing
O>left sided related to focal bleeding intervention, term goals with patient with intervention,
body weakness neuromuscul from a blood patient will be the patient. setting realistic patient was
>Inability to ar vessel in the able to: goals will able to:
ambulate impairment brain a.) identify reduce a.) identify
independently secondary to parenchyma. useful frustration. useful
> Inability to Intracerebral Intracerebral resources in >Observe -These sustain resources in
perform hemorrhage hemorrhage optimizing the preference for patient’s optimizing the
toileting tasks usually results autonomy and individual care personal autonomy and
independently from rupture of independence objects, food, and preferences. independence
>Inability to an b.) safely other stuffs. b.) safely
dress self arteriosclerotic execute self- >Avoid performing -Even though execute self-
independently small artery care activities things for patient assistance is care activities
>Inability to that has been to utmost that patient could necessary in to utmost
bathe and weakened, capability accomplish for avoiding capability
groom self primarily by self, but offer help frustration, >Goal met
independently chronic arterial as appropriate. these individual
hypertension. Permit as much may become

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Blood from an possible. afraid and
intracerebral dependent. It is
hemorrhage imperative for
accumulates patient to do as
as a mass that much as
can dissect possible for self
through and to sustain self-
compress esteem and
adjacent brain uphold
tissues, recuperation.
causing >Apply regular -An established
neuronal routines, and routine
dysfunction. allow adequate becomes rote
Symptoms time for the and requires
usually appear patient to less effort. This
suddenly complete task. helps the
during ICH. patient organize
They include and carry out
headache, self-care skills.
weakness, >Provide positive -This provides

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confusion, and reinforcement for the patient with
paralysis, all activities an external
particularly on attempted; note source of
one side of the partial positive
body. Body achievements. reinforcement.
weakness may >Render -The patient’s
cause supervision for ability to
impairment in each activity until perform self-
the ability to the patient care measures
perform or exhibits the skill may change
complete effectively and is often over time
bathing/hygien secured in and will need to
e, independent care; be assessed
dressing/groo reevaluate regularly.
ming, feeding regularly to be
or toileting certain that the
activities for patient is keeping
oneself. the skill level and
remains safe in
the environment.

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Reference: >Provide frequent -This ensures
Giraldo, E.A. assistance as easier dressing
(2017). needed with and comfort
Intracerebral dressing. Use of
hemorrhage. clothing one size
Retrieved from larger.
https://www.ms >Instruct patient -Hurrying may
dmanuals.com/ to select bath time result in
professional/ne when they are accidents and
urologic- rested and the energy
disorders/strok unhurried. required for
e/intracerebral- these activities
hemorrhage may be
substantial.
>Encourage use -Patients are
of commode or more effective
toilet as soon as in evacuating
possible. bowel and
bladder when
sitting on a

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 commode.
>Always set the -Patient will
chair on patient’s bear weight on
stronger side at the stronger
slight angle to bed side.
and lock brakes,
when transferring
to wheelchair.

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 NURSING SCIENTIFIC GOALS/ NURSING
ASSESSMENT RATIONALE EVALUATION
DIAGNOSIS BASIS OBJECTIVES INTERVENTION
S> Ø Risk for Dysphagic After 8 hours Independent: After 8 hours
aspiration symptoms of nursing > Assess level of - The primary of nursing
O>dysphagia related to occur if a intervention, consciousness. risk factor of intervention,
>poor gag impaired stroke affects patient will be aspiration is patient was
reflex swallowing the brain stem, able to: decreased level able to:
>presence of and poor such as with a.) swallow of a.) swallow
nasogastric gag reflex lacunar infarcts and digest consciousness. and digest
tube of the brain nasogastric > Assess for gag - Impaired nasogastric
>Patient was stem or a feeding without reflex and swallowing may feeding
diagnosed hemorrhage in aspiration swallowing. cause without
before with this region. b.) aspiration. aspiration
esophageal Any neurologic demonstrate > Elevate the - to prevent b.)
varices or muscular appropriate head of the bed or gastric reflux demonstrate
>GCS: 14/15 damage along maneuvers to upright position through gravity appropriate
(E4V4M6) the deglutitive prevent when feeding. maneuvers to
axes can choking and And have the prevent
cause aspiration patient to remain choking and
dysphagia. c.) free from in that position for aspiration
Thus, central signs of 1-2 hours after c.) free from

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causes of aspiration feeding. signs of
dysphagia in > Check - to ensure aspiration
stroke patients placement of proper >Goal met
include feeding tube placement of
damage to the either by the tube.
cortex or brain auscultation or
stem, and radiographically at
peripheral regular intervals
causes include (e.g., before
damage to the administering
nerves or intermittent
muscles feedings and after
involved in position changes,
swallowing. suctioning,
Swallowing coughing
abnormalities episodes or
can develop vomiting).
when these > Monitor patients - to decrease
damages result for signs of potential for
in malfunction, delayed gastric vomiting and

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discoordinated emptying such as aspiration
function, or checking the
lack of function residuals of tube
of the feedings before
neuromuscular intermittent
apparatus. feedings.
Dysphagia > Position - This
affects up to patients with a positioning
half of acute decreased level of (rescue
stroke patients consciousness on positioning)
and carries a their side. decreases the
threefold to risk for
sevenfold aspiration by
increased risk promoting the
of aspiration drainage of
pneumonia. secretions out
of the mouth
Reference: instead of down
Shaker, R. & the pharynx,
Geenen, J. where they

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(2011). could be
Management aspirated.
of dysphagia in > When feeding -so you can
stroke patients. client, watch for immediately
Gastroenterol signs of impaired stop the feeding
Hepatol (NY), swallowing or and give
7(5), 308-332. aspiration, immediate
Retrieved from including intervention
https://www.nc coughing,
bi.nlm.nih.gov/ choking, spitting
pmc/articles/P food, or excessive
MC3127036/ drooling.
> Have suction - A client with
machine available aspiration
when feeding needs
high-risk clients. If immediate
aspiration does suctioning and
occur, suction will need further
immediately. lifesaving
interventions

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