N Impaired Physical Mobility 5s235v

X. Nursing Care Plan Assessment

Nursing Diagnosis

Inference

Planning

Intervention

Subjective: “Nahihirapan ako na igalaw ang kaliwang kamay at paa ko” as verbalized by the patient

Impaired Physical mobility related to neuromuscular impairment secondary to CerebroVascular infarction as evidenced by (+) leftsided body weakness, Limited Range of Motion, Tremors noted on left arm and leg with muscle strength of 3/5.

CerebroVascular infarction in which nerve cells in the brain die for lack of oxygen can result in permanent disability for the patient because of the pathways that transmit information in the brain are interrupted. The symptoms often primarily affect only one side of the body because the blood flow will be cutoff only to that part of the brain.

Short term Goal:

Independent:

Objective: - (+) leftsided body weakness - Limited Range of Motion - Tremors noted on left arm and hands when he tried to move it - Requires help from his live-in partner in order for him to sit, eat and drink medication. - According to the Modified Ashworth Scale, the muscle strength of the left Arm and left Leg is 3/5

After 8 hours of nursing intervention the patient will be able to maintain increased strength and function of affected or compensatory part as evidenced by increase range of motion and muscle strength of 4/5.

.

Rationale

Evaluation Short term Goal:

- Reviewed Medication regimen for possible effects on alertness, energy level and perception.

- to determine issue affecting ability of individual to participate in own care

- Advised his significant other to change the position of the patient at least every 2hrs, from supine to left or right side-lying.

- Reduces risk of tissue ischemia or injury.

- Provided an adequate rest periods as well as comfort and safety measures to the patient.

- To prevent further stress, fatigue and injury.

-Encouraged adequate intake of fluids and nutritious food.

- Promotes well being and to recover quickly.

After 8 hours of nursing intervention the patient are already maintained increased strength and function of affected of compensatory part as evidenced by increased range of motion and muscle strength of 4/5.

Goal met!

- Instructed patient significant other to inspect skin regularly, particularly over bony prominences. Then gently massage any reddened areas and provide aids such as pads as necessary.

- To help prevent skin breakdown and decubitus development.

- Instructed patient and his live-in partner to begin active or ive Range of Motion to all extremities and do it every 8 hours for 15-30 minutes.

- To minimize muscle atrophy, promotes circulation and also helps prevent contractures.

Dependent: - Due medications given as prescribed

- To maintain the therapeutic effects of medication and in order for the patient to recover quickly.