N Cva Impaired Physical Mobility 104a5w

NURSING CARE PLAN

Pt name: R.Asperin Assessment Nursing Dx Subjective: Impaired physical • Client said, mobility r/t “namamanhid neuromuscular yung kanang damage involvement kamay ko, (Right arm pero numbness) as nagagalaw ko evidenced by ↓ naman xha motor control medyo hirap lng ako.” Objective: • Limited range of motion (client can’t fully extend his right arm and hold up his right shoulder) • Limited ability and difficulty to perform gross motor skills like extending and lifting of the right arms • Unsteady gait • Slowed movement • Right arm

Inference CVA can be caused by an occlusion in the blood flow. This can lead to ↓O2 and the cause failure to nourish the tissues at the capillary level and that can cause neuromuscular damage w/c can cause impaired physical mobility

AGE: 63 Goals Long term: After 4 days of nursing intervention, client will be able to ↑ physical mobility Expected outcome: • Demonstrate resumption of activities • Participate in ADL’s • Maintain or ↑ muscle control Short term: After 8 hrs of nursing intervention, client will be able to participate in therapeutic regimen Expected outcome: • Verbalize understanding of the situation • Verbalization of understanding the therapy • Able to participate in the interventions rendered by the nurse

Intervention Independent: 1. Determine degree of immobility 2. Observe movement when client is unaware 3. affected part with pillows 4. Give rest periods to activities 5. Encourage adequate fluids and right diet as necessary to the client

DIAGNOSIS: CVA Rationale Evaluation Independent: Long term goals met: 1. To Client is able to establish ↑physical mobility as compara evidenced by tive resumption of activities, baseline participation in his ADL’s and ↓ right arm 2. To note numbness any incongru Short term goals met: ence The client is able to with the participate on the reports therapeutic regimen as of evidenced by abilities verbalization of 3. Reduce understanding of the risk of situation, therapy, and pressure he is able to participate ulcers in the interventions 4. To help rendered by the nurse reduce fatigue and O2 demand 5. ↑ energy producti on

numbness