NCP: Impaired physical mobility r/t right sided body paralysis secondary to CVA

Written by admin Nursing Care Plan's Feb 10, 2011 Cues Objective: - T: 38.3 C - BP: 120/100 mmHg - NVS: 2/11 - CC: right sided weakness - Diagnosis: CVA - Appears drowsy - Aphasia noted - Unable to move the right upper & lower extremities - Weak handgrip on the left - Limited ROM - On MHBR - With NGT at left nostril - With IVF of PLR 1L @ right metacarpal vein - Decrease muscle strength - Functional level: 3 0 completely interpreted 1 requires use of equipment/ device

2- requires help from another person for assistance supervision or teaching 3- Requires help from another person and equipment/ device. 4- Dependent, does not participate in activity. Need ACTIVITY-EXERCISE PATTERN Diagnosis Impaired physical mobility related to right sided body paralysis secondary to CVA. A stoke in the dominant left hemisphere typically causes receptive or expressive aphasia , left sided sensory loss and homonymous hemianopsia and right sided paralysis resulting to impairment in physical mobility. Objectives At the end of my 8-hour shift, the patient will be able to: a. increase strength and function of affected and/or compensatory body part (from 4-0). b. maintain position of function and skin integrity as evidenced by: - absence of contractures - decubitus Interventions 1. Assess patients degree of weakness in both upper and lower extremities. There may be differing degree of involvement of the affected site. 2. Asses ability to move and change position, to transfer and walk, dor fine muscle movement and for gross muscle movements. paralysis, paresis and sensory loss are clateral to the side of the brain affected by the stroke. 3. Determine active and passive ROM capabilities. Initially muscles demonstrate hyporeflexia which later progresses to hyperreflexia. 4. Observe for activities or situations that increases or decreases tone

 activities that cause spastic response can be postpone until later recovery. 5. change position of the patient, keeping track of the position changes with a turning schedule patient may not feel in pressure or have the ability to adjust position 6. perform active and passive ROM in all extremities several times daily this preserve muscle strength and prevent contractures specially in spastic extremities 7. teach patient and family about exercises and transfer techniques. onse medically stable, the patient may have continuing deficits such as altered perception and motor strength, promote use of the affected side, and promote transfer safety. 8. use pressure relieving devices on the bed and chair. this decreases the risk of pressure ulcer development 9. perform muscle stretching activities in gentle and rhythmical motion. this provide input into CNS 10. instruct family in concept in spacity and ways to reduce tone. spasticity is a sign of of improvement. Muscle that remain flaccid are not likely to recover. Spasticity will gradually diminish as control of muscle is regained. As spasticity decreases a phenomenon known as synergy often occurs. This is the ivoluntary movement of part of an extremities after a limited voluntary movement of the whole extremities. Evaluation At the end of my 8-hour shift, the patient was not able to: a. increase strength and function of affected and/or compensatory body part (from 4-0). But was able to maintain position of function and skin integrity as evidenced by: - absence of contractures. - decubitus.