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Rene John Francisco BN4-A Patient: N.T.

Age: 64 years old Gender: Female

February 21, 2013

Chief Complaints: Left sided weakness Assessment Actual/ Abnormal cues


Admitting Diagnosis: Cardiovascular disease (CVD), probably cardio-embolism Rationale Desired Outcomes After 3 days of nursing interventions, the patient will be able to: Nursing Interventions Independent and Collaborative Nursing Interventions Justifications Independent and Collaborative Nursing Interventions Evaluation After 3 days of nursing interventions, the patient was able to:

Level Classification: 3 (Requires help from another person and equipment device)

Muscle strength of 2/5 score (muscle can contract but cannot move the body Definition: Limitation in part fully against gravity) independent, purposeful physical Assisted with hourly turning movement of the body or of one or to different more extremities positions. Source:

Nursing Diagnosis Impaired physical mobility of the upper and lower extremities r/t neuromuscular skeletal impairment as evidence by limitation in moving, decrease muscle strength, and assisted when turning and moving.

Precipitating Factors: - Sedentary lifestyle -(+) Diabetes Mellitus

Predisposing Factors: - Age: 64 years old -Gender (menopausal period)

1.)Demonstrate techniques or behaviors that enable Fatty deposits migrate into the blood resumption of vessels clump up and aggravated by activities viscous blood due to DM

1.1 Assess degree of immobility produced by injury/treatment.

1.1 To initiate proper care and be able to assist in some part of the patients ADLs

Arteriosclerosis and atherosclerosis will occur causing thrombus formation

Thrombus becomes bigger associated also with blood components (RBC, platelets) which precipitates to pile up

1.2 Encourage participation in diversional/ recreational activities. Maintain stimulating environment, e.g., radio, TV, newspapers, personal possessions/pictures, clock, calendar, visits from family/friends. 1.3 Encourage use of isometric exercises starting with the unaffected limb.

1.2 Provides opportunity for release of energy, refocuses attention, enhances patients sense of self-control/selfworth, and aids in reducing social isolation.

1.)Goal partially met. demonstrated partially in meeting basic needs by cooperating with the student nurses as well to other health care team by doing ADLs.

Thrombus breaks away from the its

1.3 Isometrics contract muscles without bending joints or moving limbs and help maintain muscle

Facial mask of pain when turning the patient Weakness and limitation in motion of body parts Limited range of motion

Doenges, M.E, et. Al. Nurses Pocket Guide Edition 11. F.A. Davis Company. Philadelphia, Pennsylvania. 2008.

attachment and become a free moving emboli

strength and mass. Note: These exercises are contraindicated while acute bleeding/edema is present. 2.)Participate in ADLs and desired activities 2.1 Instruct patient in/assist with active/passive ROM exercises of affected and unaffected extremities. 2.1 Increases blood flow to muscles and bone to improve muscle tone, maintain joint mobility; prevent contractures/atrophy and calcium resorption from disuse 2.)Goal partially met. participated in the activites conducted by the student nurses such as frequent turning every 2 hours, allowing to have an oral care, responding 2.2 Improves muscle by nodding in closed strength and circulation, ended questions since enhances patient control in patient have difficulty situation, and promotes self- in uttering words. directed wellness. 3.1 Useful in maintaining functional position of extremities, hands/feet, and preventing complications (e.g., contractures/footdrop). 3.2 Prevents/reduces incidence of skin and respiratory complications (e.g., decubitus, atelectasis, pneumonia). 3.3 Bed rest, use of analgesics, and changes in 3).Goal partially met. Maintained position and function of skin integrity by not manifesting any early signs of skin impairment.

Embolus will travel to the blood vessel pathways going to the heart and lodge within the narrow blood vessel

Impairment of blood supply in the heart causing deterioration and deprived of oxygenation and nutrients (such as the brain)

Strengths: Strong family support Good compliance to treatment and medications Brain cells compensate with the lack of viable products needed for its stability 3.) Maintain position of function and skin integrity as evidenced by absence of contractures, footdrop, decubitus, and so forth.

2.2 Assist with/encourage self-care activities (e.g., bathing, shaving).

Further, brain deteriorates slowly causing neurologic and muscular impairment

3.1 Provide footboard, wrist splints, trochanter/hand rolls as appropriate.

Peripheral nerves (those in the extremities) will gradually lose its functionality

3.2 Reposition periodically every 2 hours and encourage coughing/deepbreathing exercises. 3.3 Auscultate bowel sounds. Monitor

Impaired physical mobility of the upper and lower extremities Source: Medical-Surgical Book Edition 16 by Williams and Wilkins.

elimination habits and provide for regular bowel routine. Place on bedside commode, if feasible, or use fracture pan. Provide privacy.

dietary habits can slow peristalsis and produce constipation. Nursing measures that facilitate elimination may prevent/limit complications. Fracture pan limits flexion of hips and lessens pressure on lumbar region/lower extremity cast. 3.4 Creates positive assurance in maintaining the quality of care and update the current status of the patient.

3.4 Work hand in hand with other allied health care team in maintaining patients treatment and functionality