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Nursing Care Plan


Assessment Subjective: Nahihirapan ako na igalaw ang kaliwang kamay at paa ko as verbalized by the patient Nursing Diagnosis 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. Inference 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. Planning Short term Goal: 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. Intervention Independent: - Reviewed Medication regimen for possible effects on alertness, energy level and perception. - Advised his significant other to change the position of the patient at least every 2hrs, from supine to left or right side-lying. - Provided an adequate rest periods as well as comfort and safety measures to the patient. -Encouraged adequate intake of fluids and nutritious food. - to determine issue affecting ability of individual to participate in own care - Reduces risk of tissue ischemia or injury. Rationale Evaluation Short term Goal: 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.

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

- To prevent further stress, fatigue and injury.

Goal met!

- Promotes well being and to recover quickly.

- 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 passive 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.