Need help with care plan

[payal0301]

Hello everyone,

i am a nursing student working on a project & need some help with my care plan i had a pt with hemorragic stroke and MI. i was using the ND: Ineffective tissue perfusion (cerebral) related to decreased cerebral blood flow secondary to hemorrhage and increased intracranial pressure. I am having hard time comming up with goals for this patient because he is unconcious with GCS of 7 so i cant think of any "measurable" goals...can anyone plz help me with this...

following are some of his symptoms.

- Decreased Level of consciousness.

- GCS of 6

- Increased ICP

- Capillary refill > 4 seconds.

- Pupillary reaction sluggish; pupil size 4 bilaterally.

- Atrial flutter noted on ECG.

- Weak peripheral pulse bilaterally 1+

- Irregular S1 and S2

- Patient unable to talk moans at times.

- History of high blood pressure.

any help would be appreciated.

THank you so much :)

[AggieNurse99, BSN, RN]

What interventions do you have planned? How would you measure the outcome of them? What is acheivable in your shift with this pt? What are you already measuring routinely on this pt?

I would like to see this pt's SBP kept below 140. Does the pt have a line that measures ICP? What are good parameters for this?

[Ahimsa82]

First of all when coming up with short range goals restate your nursing diagnosis in your goal

Patient will have improved tissue perfusion (time frame... during my shift....during hospitalization ect.) AEB:

(look at your information the abnormal values returned to normal values is your goal)

Ex. capillary refill