Assessment Diagnosis Goals Interventions Rationale

55 y/o female, Impaired Pt. will maintain Turn and position the Patient may not feel increases
With primary Dx physical maximum level patient in correct in pressure or have the ability
of Acute Brain mobility r/t of functioning x alignment every 2 to adjust position. Loss of
Attack paralysis 7dys hours motor control can lead to
(cerebrovascular abnormal posturing.
bleeding), Hx of
diabetes and
HTN.
Vitals: BP
190/100
Pulse 90,
Resp.16, rectal
temp 100.6oF.
glasglow coma
scale=8
Right sided
weakness with
loss of sensory
input and facial
drooping.
Practice passive and This preserves muscle strength
active ROM exercises in and prevents contractures,
all extremities several especially in spastic
times daily. extremities.
Encourage patient to
exercise unaffected
side.
 Increase functional Early mobilization and ROM
activities as strength exercises should begin as soon
improves and patient is as the patient is stable and no
medically stable. longer requires intensive care.
Establish regular
exercise routine
Pt. will be free of Perform activities in a Impaired cognitive function
complications x quiet environment with that occurs with stroke may
30days few distractions. decrease the patient’s
attention span and
concentration. The client may
be easily distracted.

Apply heat or cold to This is an effort to reduce tone

the extremities. before initiating movement.
Perform muscle These provide input into the
stretching activities in central nervous system.
gentle, rhythmical
motions.

Apply splinting devices Maintaining proper body

to spastic extremities alignment is essential. Pillows,
as prescribed, with sandbags, splints and
ongoing assessment for trochanter rolls help prevent
increasing tone. footdrop and contractures.