NURSING CARE PLAN ASSESSMENT Subjective Cue: Objective Cues: Left hemiplegia (weakness) Limited ROM Difficulty turning

turning Slowed movement Decreased muscle strenght Impaired coordination

NURSING DIAGNOSIS Impaired physical mobility related to neuromuscular involvement secondary to CVA infarct as evidenced by left hemiplegia (weakness), limited ROM, difficulty turning, slowed movement, decreased muscle strenght and impaired coordination.

OUTCOME CRITERIA After 1 week of effective nursing interventions the patient will be able to verbalize:

Understanding of situation and individual treatment regimen and safety measures.

Improved strength and function of the affected body part.

Long Term Goal After 2 weeks of effective nursing interventions the patient will be able to move independently the affected body part with minimal assistance.

PLANNING The patient will be able to:

Performs physical activity independently with minimal assistance. Participate in Activities of Daily Living (ADLs) and rehabilitation program. Demonstrate increased strength, ROM, and function of affected body parts.

NURSING INTERVENTIONS AND RATIONALES Independent 1. Assess functional ability/extent of impairment initially and on a regular basis. Identifies strengths/deficiencies and may provide information regarding recovery. 2. Determine readiness to engage in activities/exercises. To assess expected level of participation.

3. Change positions at least every 2 hours (supine, sidelying) and possibly more often if placed on affected side. Reduces risk of tissue ischemia/injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/decubitus. 4. Begin active/passive ROM to all extremities. Encourage exercises such as squeezing rubber ball, extension of fingers and legs/feet. Minimizes muscle atrophy, promotes circulation, helps prevent contractures 5. Encourage patient to assist with movement and exercises using unaffected extremity to support/move weaker side. May respond as if affected side is no longer part of body and needs encouragement and active training to reincorporate it as a part of own body. 6. Schedule activitieswith adequate restperiods during the day. Reduces fatigue and increase comfort. 7. Provide for safety measures including fall prevention. To prevent occurrence of injury.

Collaborative 1. Consult with physical therapist. To develop individual exercise/mobility program and identify appropriate devices. EVALUATION Met. The patient was able to DISCHARGE PLANNING

Medication- Teach patient and the significant others about the medications, how to take them, the dose, how many times a day, what the medicine is used for and what are the possible side effects of the drugs. Encourage to finish any prescription given to him even if he is feeling good. Environment- Provide safe, quite, and calm environment. Limit visitors entering patients room. Treatment- Isolation therapy to reduce contamination. Teach proper handwashing to prevent infection transmission. Health Teaching- Change the dressing daily (twice daily if possible) or as often as necessary to prevent seepage through the dressing. On each dressing change, remove any loose tissue. Inspect the wounds for discoloration or hemorrhage, which indicate developing infection. OPD Follow up- Do keep all follow up clinic and physical therapy appointments. Diet- A well balanced, healthy diet should be consumed by the patient with plenty of fluids. Support System- Evaluate resources and support systems available to patient. Refer to outside resources and/or professional therapy as indicated/ordered.