ASSESSMENT

Subjective Data
Nahihirapan na ako kumilos kasi hindi ko na maigalaw yung kanang part eng aking katawan as verbalized by the client ASSESSMENT

DIAGNOSIS
Activity Intolerance related to immobility as evidence by paralyzed right extremities.

SCIENTIFIC EXPLANATION
Stroke

PLANNING
Long Term Outcome After 2 weeks of nursing intervention, the client will be able to walk without discomfort. Short term Outcome After 3 days of nursing Long Term Outcome intervention, the client After 2 weeks will be able to of nursing intervention, >participate willingly the client will be able in necessary or desired to show increase in activities strength complete self>able to and function of affected body care activities part Short term Outcome After 1 week of nursing intervention, the client will be free of complications like changes in involuntary movements of the body that might cause injury

INTERVENTION

SCIENTIFIC EXPLANATION

EVALUATION
Partially Achieved Long Term Outcome The client was able to walk without discomfort. Short term Outcome EVALUATION the client was able to complete self-care Partially Achieved activities. Long Term Outcome The client was able to walk without discomfort. Short term Outcome the client was able to complete self-care activities.

DIAGNOSIS
Impaired Physical Mobility related to musculoskeletal impairment as evidenced by slowed movement

SCIENTIFIC EXPLANATION
Inability of neuron to Stroke conduct impulses on right extremities Paralyzed right extremities Immobility of right extremities Inability of neuron to conduct impulses on right extremities Activity Intolerance Ref: Fundamentals of Musculoskeletal Nursing Kozier impairment

Paralyzed right extremities

PLANNING

Objective Data Subjective Data the Edema on Nahihirapanfoot right na ako kumilos kasi hindi ko Immobility na maigalaw yung of kanang the rightaking part eng extremities katawan as verbalized Discomfort by the client Objective Data Stooped posture Staggering gait Slowed movement

Impaired Physical Mobility Ref: Fundamentals of Nursing Kozier

Independent: 1. Ascertain ability > to determine current to stand and status and needs move about and associated with degree of participation in assistance needed/desired activities SCIENTIFIC necessary use of INTERVENTION EXPLANATION equipments. 2. Provide positive >helps to minimize Independent: atmosphere frustration and rechannel 1. while the client Assist > to be energy able to moved to do the Range the affected extremities acknowledging of Motion difficulty of the exercise for situation withthe assistance client. 2. Schedule reduce client 3. Assist with >to protect fatiguefrom activities with and injury adequate rest provide/monitor periods use of clients during the day assistive devices 3. Provide safety Collaborative: measures as 1. Provide referral to >to develop individually indicated such other disciplines, by appropriate therapeutic individual as exercise physiologist, regimens situation, psychological including counseling, environmental occupational/ physical management/fall therapist s and prevention recreation/ leisure Collaborative: specialists as indicated 1. Administer >to permit maximal medications prior to effort.involvement in activity as needed activity for pain relief