Medical Diagnosis: Cerebrovascular Accident

Problem: Activity Intolerance RT Generalized Weakness

Assessment Nursing Diagnosis Scientific Planning Interventions Rationale Evaluation

Explanation
Subjective: (none) Activity Intolerance r/t Motor deficits are the Short Term: 1. establish rapport 1. to promote Short Term:
Generalized weakness most obvious effect of After 4 hrs of NI, pt will cooperation Pt. shall have
Objective: secondary to CVA stroke. Symptoms are be able to participate 2. monitor vital signs 2. to have a participated willingly in
 right hemiplegia caused by the willingly on baseline data necessary /desired
 increase BP destruction of motor necessary/desired activities.
3. evaluate current
neurons in the activities.
 pt may manifest: limitations (degree 3. provide
pyramidal pathways
 electro of deficit in light of comparative
(nerve fibers in the Long Term: Long Term:
cardiographic visual status) baseline data
brain and passing After 2 days of NI, Pt shall have
changes reflecting
through the spinal cord patient will be able to demonstrated a
dysrythmias
to motor tract.) demonstrate a 4. assess decrease in physiologic
 abnormal heart
decrease in physiologic cardiopulmonary 4. to note progress sings of intolerance
rate in response to
activity signs of intolerance response to of fatigue (HR,BP remains in
(HR,BP remain within physical activity, normal range)
 weakness
normal range) changes BP

5. assist patient with 5. to protect from

activities injury
6. plan care with rest 6. to decrease
periods between fatigue
activities

7. increase activity 7. to manage

gradually activity within
limits
8. encourage 8. assist pt deal
expression of with contributing
feelings resulting factors
from the condition

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