Nara3105

Hello, my client also was diagnosed with CVA about a month ago. he has a Peg tube + oral reg. diet, R hemiplegia, L weakness, edema +2 on L hand and L extremities; R side skin is cool to touch. he can't move his body nor he can talk. my priority diagnosis are: Ineffective tissue perfusion(cerebral) R/T decreased cerebral blood flow ST/ CVA AEB unable to turn and reposition; edema present +2. Two short terms goals are: 1) The client will maintain tissue perdusion AEB O2 Sat within defined limits and pink moucous membrane within my 8 hr shift. 2) The client will be turned and repositionned q1-2 hr and will have a strong peripheral pulses by the end of my shift. Ineffective airway clearance R/T immobility and ineffective cough S/T CVA AEB R hemiplegia and pt'h an ineffective cough. The two short term goals are: 1) The client will maintan a clear airway AEB have increased fluid intake, turn and repositioend q1 -2 hr within my 8 hr shift. 2) the client will perform DB and C exercise during my 8 hr shift Please I need your advice on these nrs dx and short term goals. your help will be appreciated Nara