Problem List

Nursing Diagnosis Date Identified Signature Date resolved Signature

Actual Problems
1. Ineffective airway clearance may be related to increased Jan . 25, 2010 Feb. 9 ,2010
amount and viscous appearance of respiratory secretions as
evidenced by:
a. presence of yellowish,viscous oral secretions approximately
10-15cc.
b. inspiratory grunting and exhalatory wheezing was noted upon
auscultation of the anterior and posterior thorax over the entire
lobes of the lungs.
c. difficulty of breathing was noted as evidenced by grasping for
air and use of accessory muscles during inhalation; and
d. presence of nasal flaring noted.

2. Ineffective cerebral tissue perfusion may be related to

interruption of cerebral blood flow as evidenced by:
a) altered level of consciousness Jan 25, 2010 Feb. 9 ,2010
b) generalized muscle weakness, characterized by inability
to move and presence of bilateral foot drop
c) no verbal response elicited by the client
d) Glasgow Coma Scale score of 9, spontaneous eye
opening, no verbal response and withdraws extremity from
pain.

3. Impaired Physical mobility may be related to weakness of

neuromuscular involvement as evidenced by: Jan. 25, 2010 Feb. 9 ,2010
a. bilateral foot drop noted;
b. contracture noted on the left upper extremity; and
c. weakness on all upper and lower extremities.

Potential problems
1. Risk for impaired swallowing
Risk factors include:
Neuromuscular / perceptual impairment Jan. 25, 2010 Feb. 9 ,2010
Presence of Nasogastric tube

Nursing diagnosis:
Ineffective airway clearance may be related to increased amount and viscosity of respiratory secretions as evidenced by:
1. presence of yellowish oral secretions approximately 10-15cc.
2. inspiratory grunting and exhalatory wheezing was noted upon auscultation of the anterior and posterior thorax over all lobes of the lungs
3. difficulty of breathing was noted as evidenced by grasping for air and use of accessory muscles during inhalation; and
 4. presence of nasal flaring noted
Goals of care
After 2 weeks of Medical and
Nursing intervention, client will be
able to:
1. Maintain patent airway with
minimal oral secretions from 10-
15cc to 2-5cc.
2. Exhibit clear breath sounds
and noiseless respirations; and
3. Display no signs of difficulty of
breathing.
Interventions
Independent
Assessment
Assess respiratory rate, depth
and chest expansion. Note
respiratory effort, including use of
accessory muscles and nasal
flaring
Auscultate chest for character of
breath sounds and presence of
secretions.
Observe amount and
characteristics of sputum or
aspirated secretion. Investigate
changes as indicated.
Rationale
Rate is usually increased.
Dyspnea (“air hunger”) and
increased work of breathing is
present (may be first or the only
sign sub acute pulmonary
embolism). Depth of respiration
varies depending on degree of
respiratory failure.
Noisy respirations , rhonchi, and
wheezes are indicative of
retained secretions.
Increased amounts of colorless,
watery secretions are normal
initially and should decrease as
recovery progresses. Presence of
thick or tenacious, bloody or
purulent sputum suggests
development of secondary
problems requiring corrections or
treatment.
.
Evaluation Patient’s response
DONE With respiratory rate of 18
breaths per minute, regular in
rate and rhythm, spontaneous
and labored. Difficulty of
breathing and use of accessory
muscles and nasal flaring were
noted.
DONE Inspiratory grunting and
exhalatory wheezing was noted
upon auscultation of both anterior
and posterior thorax; with
yellowish secretions at the oral
mucosa.
DONE Oral secretions are yellowish in
color, appears viscous and
slightly purulent with no blood
noted.
Therapeutic
Place patient in upright position
Suction patient as indicated
Collaborative
Therapeutic
Administer bronchodilators
(salbutamol) as indicated.
Provide or assist with intermittent
Positive Pressure Breathing
(IPPB), incentive spirometer,
blow bottles, postural drainage or
percussion as indicated.
Use room humidifiers or
ultrasonic nebulizer. Provide
additional IV fluids as indicated.
Upright position favors maximal
lung expansion and straightening
airway.
Stimulates cough or mechanically
clears airways in patient who is
unable to do so because of
ineffective cough, decreased
level of consciousness
Bronchodilators relaxes bronchial
smooth muscle by stimulating
beta 2 blockers.It relieves
brochospasms to improve air flow
Improves pulmonary expansion
and ventilation and facilitates
removal of secretions
Providing maximal hydration
helps loosen, liquefy secretions
to promote expectorations.
DONE Patient was positioned into high
Fowler’s position with head
elevated into 30˚ to 45.
NOT DONE Suctioning was done by staff
nurse on duty,
DONE 1 nebule of Salbutamol through
Pulmo-Aid inhalation every 6
hours was ordered and
administered to patient.
DONE Chest percussion and chest
physiotherapy was given during
positioning and after Pulmo-Aid
inhalation. IPPB, incentive
spirometer and blow bottles were
not indicated for the patient.
DONE Humidifiers were provided and
connected with oxygen therapy;
additional IV fluids were not
indicated for patient
General Evaluation:
After 2 weeks of Medical and Nursing intervention, client was able to:
1. Maintain patent airway with the same amount of oral secretions at 10-15cc
2. Exhibit normal respiratory rate and characteristics clear breath sounds and noiseless respirations; and
3. Display absence of difficulty of breathing and use of accessory muscles and nasal flaring.

Nursing Diagnosis:
Ineffective cerebral tissue perfusion may be related to interruption of cerebral blood flow as evidenced by:
1. altered level of consciousness
2. generalized muscle weakness, characterized by inability to move and presence of bilateral foot drop
3. no verbal response elicited by the client
4. Glasgow Coma Scale score of 9, spontaneous eye opening, no verbal response and withdraws extremity from pain.

Goals of care Interventions Rationale Evaluation Patient’s response

After 2 weeks of Medical and
Nursing intervention, client will be
able to:
a. display improvement in the
motor function such as
movements in upper or lower
extremities.
b. exhibit no further signs of
deterioration/recurrence of
deficits
c. demonstrate stable vital signs
and absence of signs of
increased intracranial pressure
Independent
Assessment
Monitor or document neurologic
status frequently and compare
with baseline.
Monitor vital signs.
Assess trends in LOC and
potential for increased ICP and is
useful in determining location,
extent, and progression/
resolution of CNS damage. May
also reveal presence of TIA,
which may warn of impending
thrombotic CVA.
Variations may occur of cerebral
pressure/injury in vasomotor area
of the brain. Hypotension may
occur vbecasue of shock
(circulatory collapse); increased
ICP may occur (tissue edema,
DONE Neurologic vital signs was
checked every hour. With a
Galsgow Coma Scale score of 10
spontaneous eye opening , motor
response upon localized.
DONE With stable vital signs:
T= 37.2˚
PR/CR = 82 beats per minute
RR = 19 breaths per minute
BP = 130/80 mmHg

Evaluate pupils, noting size,
shape, ezuality and light
reactivity.
Therapeutic
Position head slightly elevated
and in neutral position.
Provide rest periods between
care activities, limit duration of
procedures.
Collaborative
Assessment
Monitor laboratory studies as
indicated (ex. Prothrombin/ PTT
time)
clot formation); Bradycardia can
occur because of brain damage;
Irregular respirations can suggest
location of cerebral
insult/increasing ICP and need
for further interventions.
Pupil reactions are regulated by DONE Patient’s pupil are equally round
the Oculomotor (III) cranial nerve with average size of 2.5 mm in
and are useful in determining diameter; both reactive to light
whether the brainstem is intact. and accommodation, cranial
Pupil size/equality is determined nerves # 2 and 3, optic and
by balance between oculomotor, are intact.
parasympathetic and sympathetic
enervations. Response to light
reflects combined function of the
Optic (II) and oculomotor (III)
cranial nerves.
Reduces arterial pressure by DONE Patient is positioned into semi
promoting venous drainage and high fowler’s position with head
may improve cerebral circulation/ elevated into 30˚ to 45˚.
perfusion.
Absolute rest and quiet may be DONE Patient was able to rest in a
needed to prevent rebleeding in comfortable and quiet
the cause of hemorrhage. environment.
Provide information about drug DONE Laboratory results was monitored
effectiveness and therapeutic and presented total effectivity of
level. medications.
Administer supplemental oxygen
as indicated.
Administer medications as
indicated;
Anti coagulants (Heparin U 2500)
Antihypertensives.
Phenobarbitals Phenytoin
(Dilantin)
Stool softerners
Lactulose(Duphalac)
Reduces hypoxemia, which can DONE With oxygen at 2 Liters per
cause cerebral vasodilation and minute; signs of increased
increase pressure/edema pressure/ ICP, further edema
formation. formation were not noted.
Anti coagulants accelerate DONE Heparin U 2500 intravenous was
formation of anti thrombin III- administered. With prothrombin
thrombin complex and time of 58.1 seconds
deactivated thrombin to prevent
conversion of fibrinogen to fibrin.
Anti coagulants decreases the
ability of blood to clot.
Preexisting/ chronic hypertension NOT DONE No hypertensive medication was
requires cautious treatment, ordered for the patient.
because aggressive
management increases the risk
of extension of tissue damage.
Transient hypertension often
occurs during acute stroke and
resolves often without therapeutic
communication.
May be used to control seizures DONE Phenytoin (Dilantin) was
and/or for sedative actions. administered.
Prevents staining during bowel DONE Lactulose(Duphalac) 300 ml if no
movement and corresponding bowel movement was ordered
increase in ICP. and administered to patient.
Signs of increased ICP were not
noted.
General evaluation;
After 2 weeks of Medical and Nursing intervention, client will be able to:
1. With Glascow Coma Scale of 10, spontaneous eye opening, withdraws to pain and no verbal response
2. Exhibit no further signs of deterioration/recurrence of deficits
3. Demonstrate stable vital signs and absence of signs of increased intracranial pressure