Impaired Physical Mobility
Assessment| Nursing Diagnosis| Scientific explanation| Objectives| Nursing Interventions| Rationale| Expected Outcome| S > θO > Patient manifest:- weak and pale appearance - difficulty in standing and sitting - slowed movement - limited range of motion | Impaired Physical Mobilityr/t neuromuscular impairment aeb slowed movement | Limitation in independent, purposeful physical movement of the body or of one more extremities.Due to the patient’s general status because of his brain damage secondary to CVA, patient develops weakness due to affectation in his cerebral artery. This can result in decrease perfusion and the development of infarct. The reflex or muscular strength of a particular limb affected becomes weak, because of its altered control and function. Due to the brain affectation, with this prolonged status on the muscle limb it further weakens the body that may result to activity intolerance and there insufficient physiological or psychological energy to endure or complete required or desired daily activities.| After 2 hours of Nursing Intervention, the patient will demonstrate technique or behaviors that enable resumption of activities. | Instruct to change positions at least every 2 hours and placed on affected side.Position in prone position once or twice a day if patient can tolerate.monitor affected side for color edema, or other signs of compromised circulation.Support affected body parts using pillowsSchedule activities with adequate rest periods during the dayEncourage participation in self-care, occupational activitiesIdentify energy-conserving techniques for ADLs.| Reduces risk of tissue ischemia/injury.Helps maintain functional hip extension but may cause increase anxiety, especially about ability to breath.Edematous tissue is more easily traumatized and heals more slowly.To maintain position of function and reduce risk of pressure ulcers To reduce fatigue.Enhances self-concept and sense of independence. Limits fatigue, maximizing participation| The patient demonstrated techniques that enable resumption of activities. |
Risk for impaired skin integrity
Assessment| Nursing Diagnosis| Scientific explanation| Objectives| Nursing Interventions| Rationale| Evaluation| S>ØO> Patient manifested:>right sided paralysis>limited /difficulty of movements| Risk for impaired skin integrity r/t decreased bed mobility a.e.b limited/difficulty of movements.| Pressure ulcers develop when soft tissue (skin, SQ tissue and muscle) are compressed between a bony prominence and a firm surface for a prolonged period of time. | After 1-hour of Nursing intervention, the client and SO will verbalize and demonstrate understanding on the proper bed positioning that can help reduce risk of developing pressure ulcers.| -monitor V/S-provide bedside care-support affected body parts using pillows -encourage adequate fluid intake-change clients bed position every two(2) hours| -gather baseline data for further comparison-to give comfort to the patient-to maintain position of function and reduce risk of pressure ulcers.-to avoid dehydration and skin dryness.-to generate blood flow and reduce the risk of pressure ulcers.| After 1-hour of Nursing intervention, the client and SO have verbalized and demonstrated understanding on the proper bed positioning that can help reduce risk of developing pressure ulcers.|
Risk for unilateral neglect
Assessment| Nursing Diagnosis| Scientific Explanation| Objectives| Nursing Interventions| Rationale| Expected Outcomes| S- OO- muscle strength test of right arm:3/5; right leg:2/5; left arm: 4/5; left leg:4/5-needs assistance in performing ADLs| Risk for unilateral neglect r/t muscle weaknesssecondary to CVA| A cerebrovascular accident (CVA) is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. A stroke is an upper motor neuron lesion...