Medical Diagnosis: Cerebrovascular Accident Problem: Self Care Deficit RT Musculoskeletal Impairment Assessment Subjective: (none) Objective:

right hemiplegia

Nursing Diagnosis
Risk for Injury r/t right hemiplegia secondary to CVA infarct

Scientific Explanation
CVA pt is a t risk for injury since it may affect the anterior or middle cerebral artery leading to an infarction in the motor strip of the frontal cortex and this may cause hemiparesis or hemiplegia with the manifestations it may predisposed an individual for any injury since part of their body is not functioning well.

Planning Short Term:

After 4 hrs of NI, pt will be able to seek help to perform tasks that are beyond her capabilities

Interventions 1. establish rapport 2. monitor vital signs 3. keep the side rails of the bed raised 4. remind client to walk slowly, rest adequately between intervals of walking use effective lighting 5. inform pts so not to leave her in the bathroom

Rationale 1. >to promote cooperation 2. >to have a baseline data 3. to protect from falling out of bed 4. to prevent injury

Evaluation Short Term:

Pt shall have seek help to perform task that are beyond her capabilities.

Long Term:
After 3 days of NI, pt. will be able to remain free from injury AEB absence of abrasion/falls

Long Term:
Pt shall have remained free from injury AEB absence of abrasions/falls

5. >for continuous monitoring and guidance to the client

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