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payal0301

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  1. Need help with care plan

    payal0301 posted a topic in Nursing Student Assistance
    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 :)

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