Medical Diagnosis: Cerebrovascular Accident Problem: Impaired Physical Mobility RT Neuromuscular Involvement Assessment Subjective: (none) Objective:

right hemiplegia limited ROM difficulty turning slowed movement Muscle strength of right arm: 0/5; right leg: 0/5; left arm:5/5; left leg:5/5 gait changes Postural Instability during performance of routine ADLs movement induced shortness of breath/tremors

Nursing Diagnosis
Impaired Physical Mobility R/t neuromuscular involvement secondary to CVA infarct

Scientific Explanation
Stroke in w/c nerve cells in the brain die for lack of oxygen can result in permanent disability for the patient Because the pathways that transmit information in the brain are interrupted. The symptoms often primarily affect only one side of the body because blood flow is cut off to only part of the brain.

Planning Short Term:

After 4 hrs. of NI, pt. is willing to participate in activities necessary for the patient

Interventions 1. establish rapport 2. monitor vital signs 3. note emotional/behavio ral responses to problems of immobility 4. determine readiness to engage in activities/exercises 5. assist patient reposition self on a 6. regular schedule

Rationale 1. to promote cooperation 2. to have a baseline data 3. to assess functional ability 4. to assess expected level of participation 5. to promote optimal level of function and prevent complications

Evaluation Short Term:

Patient shall have participated in activities necessary for the patient.

Long Term:
After 3 days of NI, pt will be able to improve and increase strength and function of affected body part..

Long Term:
Pt shall have improved and increase strength and function of affected body part.

7. provide for safety measures including fall prevention 8. identify energy conserving techniques for ADLs 9. involve patient and SO in care assisting them to learn ways of managing problems of immobility 10. assist patient to do

6. to prevent occurrence of injury

7. limits fatigue, maximizing participation

8. to promote wellness

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passive range of motion 11. provide restful environment for patient after periods of exercise

9. to promote circulation and prevent contracture 10. >to facilitate recuperation

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