Name of Patient: Ali Mohammed Al Shaman

Nursing Diagnosis: Impaired Physical Mobility

NURSING CARE PLAN

Medical Diagnosis:
Students Name:
Cerebrovascular Accident
Area:

Date:
Section/Group:

R/t neuromuscular involvement secondary to CVA

infarct

Assessment
(1 mark)
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
(1 mark)
Impaired Physical
Mobility R/t
neuromuscular
involvement secondary
to CVA infarct

Scientific
Explanation
(0.5 mark)
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
(0.5 mark)
Short Term:
After 4 hrs. of Nursing
Intervention, pt. is
willing to participate in
activities necessary for
the patient

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

Interventions
(0.5 mark)
1. establish rapport
2. monitor vital signs

Rationale
(1 mark)
1. to promote
cooperation
2. to have a
baseline data
3. to assess
functional ability

3. note emotional/
behavioral
responses to
problems of
immobility
4. determine
4. to assess
readiness to
expected level of
engage in
participation
activities/exercises
5. assist patient
5. to promote
reposition self on a
optimal level of
regular schedule
function and
prevent
complications

6. provide for safety

measures
including fall
prevention

6. to prevent
occurrence of
injury

7. identify energy
conserving
techniques for
ADLs

7. limits fatigue,
maximizing
participation

Evaluation
(0.5 mark)
Short Term:
Patient shall have
participated in
activities necessary for
the patient.

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

8. involve patient
and SO in care
assisting them to
learn ways of
managing
problems of
immobility

8. to promote
wellness

9. assist patient to do
passive range of
motion

9. to promote
circulation and
prevent
contracture

10. provide restful

environment for
patient after
periods of exercise

10. to facilitate
recuperation

Name of Patient: Ali Mohammed Al Shaman

Nursing Diagnosis: Ineffective cerebral tissue

Medical Diagnosis:
Cerebrovascular Accident

Students Name:
Area:

Date:
Section/Group:

perfusion r/t interruption of blood flow secondary

to CVA

Assessment
(1 mark)
Subjective: (none)
Objective:

hemiplegia
assess for muscle
strength
altered mental
status
restlessness
changes in
pupillary
Reactions
difficulty in
swallowing

Nursing Diagnosis
(1 mark)
Ineffective cerebral
tissue perfusion r/t
interruption of blood
flow secondary to CVA

Scientific
Explanation
(0.5 mark)
The presence of partial
blockage of the blood
vessel can be
multifactorial. These
can be due to
vasoconstriction,
platelet adherence on
rough surface, fat
accumulation and
therefore decreases
elasticity of vessel wall
leading to alteration of
blood perfusion with
the initiation of the
clotting sequence. This
may later lead to the
development of
thrombus which can be
loosened and dislodged
in some areas of the
brain such as mid
cerebral carotid artery
that may lead to
alteration of blood
perfusion and further
develop to cerebral
infarct.

Planning
(0.5 mark)
Short Term:
After 4 hours of NI,
patient will be able to
display decrease signs
of ineffective tissue
perfusion as evidence
by gradual
improvement of vital
signs.

Long Term:
After 3 days of NI,
patient will be able to
gradually improve
tissue perfusion AEB
good capillary refill and
pink conjunctiva.

Interventions
(0.5 mark)
1.

Establish rapport

2.

Monitor vital signs

3.

4.

Check capillary refill

and conjunctiva for
paleness
elevate head of bed
to 30 degrees as
ordered

Rationale
(1 mark)
1.

To promote
cooperation

2.

To have a baseline
data, assess
changes in
neurologic status

3.

To determine
blood circulation

4.

To promote
circulation

5.

Advise patient to
have enough rest

5.

Enough rest is
needed to
conserve energy

6.

Avoid neck flexion

and extreme
hip/knee extension

6.

To avoid
obstruction of
arterial and venous
blood flow

7.

Provide and
maintain oxygen as
ordered

7.

Aids in difficulty of
breathing

To detect changes
indicative of
worsening or
improving
condition
To promote
wellness

8.

Perform GCS
monitoring as
ordered

8.

9.

Administer
medications as
ordered

9.

Evaluation
(0.5 mark)
Short Term:
Patient shall have
displayed a decrease
signs of tissue
perfusion AEB gradual
improvement of vital
signs

Long Term:
Patient shall have
gradually improved
tissue perfusion AEB
good capillary refill and
pink conjunctiva