- Acute Confusion related to Cerebral hypoxia and Ineffective cerebral tissue perfusion due to Brain injury or trauma as evidenced by difficulty initiating purposeful behavior and cognitive dysfunction
- Deficient Knowledge related to lack of information about when to seek medical attention when having a TIA and a sudden change in health status as evidenced by Questions about TIA symptoms and treatments
- Ineffective Cerebral Tissue Perfusion related to Lack of blood supply due to atherosclerosis as evidenced by Speech difficulty and Motor weakness
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Hallucinations Paranoia Objective Data: -Fluctuation in cognition/consciousness -Agitation/restlessness -Inappropriate perceptions -Lack of understanding or follow-through with tasks -Tremors | Acute Confusion related to Cerebral hypoxia and Ineffective cerebral tissue perfusion due to Brain injury or trauma as evidenced by difficulty initiating purposeful behavior and cognitive dysfunction | Patient will regain orientation to person, place, time, and situation with an appropriate level of consciousness. Patient will initiate lifestyle changes to prevent reoccurrence of acute confusion/delirium. Patient will verbalize contributing factors of fluctuations in cognition. | 1. Orient the patient to their surroundings and activities as needed. Frequent reorientation is essential to promote safety, cooperation, and a trusting relationship with a patient who is confused. 2. Provide a calm environment and eliminate unnecessary environmental stimuli. Excessive environmental stimuli can cause anxiety or agitation in the patient who is confused. Reduce noise and bright lighting when possible. 3. Encourage sleep. Sleep is crucial to allow the brain to recover after a TIA, repairing neural connections and improving confusion and cognitive symptoms. 4. Continuously monitor the patient’s level of consciousness. While the symptoms of a TIA may resolve quickly, there is an increased risk of stroke following a TIA. Continuous monitoring of the patient’s level of consciousness and overall mental status allows prompt treatment and reduces complications. | Patient regained orientation to person, place, time, and situation with an appropriate level of consciousness. Patient initiated lifestyle changes to prevent reoccurrence of acute confusion/delirium. Patient verbalized contributing factors of fluctuations in cognition. |
| Subjective Data: -Verbalizes poor understanding -Seeks additional information -Denial of a need to learn Objective Data: -Inaccurate demonstration or teach-back of instructions -Inability to recall instructions -Exhibiting aggression or irritability regarding teaching follow-up -Poor adherence to recommended treatment or worsening medical condition -Avoiding eye contact or remaining silent during teaching | Deficient Knowledge related to lack of information about when to seek medical attention when having a TIA and a sudden change in health status as evidenced by Questions about TIA symptoms and treatments | Patient will identify risk factors of their disease process and how to prevent worsening of symptoms. Patient will participate in the learning process. Patient will demonstrate the proper execution self-care skills such as wound care/insulin administration/blood pressure monitoring/etc. Patient will identify barriers to their learning and recognize potential solutions to these barriers where possible. | 1. Ask the patient to describe F.A.S.T. Remembering the acronym F.A.S.T.—for face, arms, speech, and time—will help the patient recognize the signs of a TIA and a stroke. Explain to the patient that “time is tissue” when dealing with a TIA or stroke. 2. Ask the patient to differentiate between a TIA and a stroke. A TIA often called a “mini-stroke,” differs from other forms of stroke in that blood supply to the brain is interrupted for a brief period, typically no longer than five minutes. 3. Teach the patient about cholesterol numbers. Since atherosclerosis is a significant cause of TIA and is heavily influenced by cholesterol in the arteries, the nurse can explain and teach patients what their cholesterol numbers should be. 4. Have the patient verbalize the preventive measures of a TIA/stroke. The nurse can evaluate if the patient is learning effectively by having them list preventative steps to decrease the risk of a TIA/stroke. These include not smoking, limiting fatty foods and sodium, exercising, and controlling their weight. 5. Advise the patient to wear a medical alert bracelet. Patients should be advised to carry identification or wear a medical alert bracelet when taking anticoagulants following a TIA, due to the risk of bleeding. | Patient identified risk factors of their disease process and how to prevent worsening of symptoms. Patient participated in the learning process. Patient demonstrated the proper execution self-care skills such as wound care/insulin administration/blood pressure monitoring/etc. Patient identified barriers to their learning and recognize potential solutions to these barriers where possible. |
| Subjective Data: Nausea Abdominal pain Bloating Objective Data: -Hypoactive or absent bowel sounds -Distended abdomen -Vomiting -Electrolyte imbalance | Ineffective Cerebral Tissue Perfusion related to Lack of blood supply due to atherosclerosis as evidenced by Speech difficulty and Motor weakness | Patient will maintain adequate peripheral perfusion as evidenced by strong pedal pulses, warm skin temperature, and intact skin without edema. Patient will maintain cardiopulmonary perfusion as evidenced by normal sinus heart rhythm, heart rate within normal limits, no complaints of shortness of breath and normal Sa02. Patient will demonstrate appropriate lifestyle modifications to support adequate tissue perfusion. Patient will have an improvement in cerebral perfusion as evidenced by intact orientation to person, place, and time. | 1. Keep the blood pressure manageable. Elevated blood pressure (BP) can damage arteries. Maintain the desired BP parameters as ordered by the healthcare provider to preserve brain perfusion. 2. Activate the Rapid Response Team (RRT). Patients at risk of developing fatal conditions (like TIA developing into full-blown stroke) will benefit from the Rapid Response System (RRS). Activation of RRT provides immediate professional assistance and monitoring to decrease the mortality rate. 3. Administer antiplatelet medications as prescribed Antiplatelet medications stop platelets from adhering to one another and reduce the risk of developing a clot that obstructs blood flow to the brain. Aspirin and clopidogrel may be prescribed following a TIA. 4. Provide anticoagulants as ordered. A clot causing a TIA or stroke can be fatal. Anticoagulants cannot dissolve a clot but can prevent it from getting bigger or prevent more from developing. A client with AFib may be prescribed an anticoagulant for long-term use. 5. Control cholesterol levels. One of the causes of TIA is hypercholesterolemia—lower cholesterol with statin medications and diet and exercise modifications. 6. Advise the patient about following the recommended diet. A poor diet can increase the chance of developing a TIA through hypertension and high cholesterol. Advise following a low-fat, low-sodium, high-fiber diet with daily fruit, vegetables, and whole grains. 7. Prepare for possible surgery. A carotid endarterectomy procedure creates an incision in the carotid artery to remove plaque. Carotid angioplasty places a stent into the artery to keep the artery open. | Patient maintained adequate peripheral perfusion as evidenced by strong pedal pulses, warm skin temperature, and intact skin without edema. Patient maintained cardiopulmonary perfusion as evidenced by normal sinus heart rhythm, heart rate within normal limits, no complaints of shortness of breath and normal Sa02. Patient demonstrated appropriate lifestyle modifications to support adequate tissue perfusion. Patient improved cerebral perfusion as evidenced by intact orientation to person, place, and time. |