Medical Diagnosis: Cerebrovascular Accident Problem: Risk for Unilateral Neglect RT Hemiparesis Assessment Subjective: (none) Objective

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   slight irritability right hemiplegia muscle strength test of right arm:0/5; right leg:o/5; left arm: 5/5; left leg:5/5 needs assistance in performing ADLs decrease attention to the affected side

Nursing Diagnosis
Risk for unilateral neglect r/t hemiparesis secondary to CVA

Scientific Explanation
An ischemic stroke, cerebrovascular accident (CVA), or “brain attack” is a sudden loss of function resulting from disruption of the blood supply to a part of the brain. In an ischemic brain attack, there is disruption of the cerebral bloodflow due to obstruction of a bloodvessel. This can cause a wide variety of neurologic deficits depending on the location of the lesion with which vessels are obstructed. A stroke is an upper motor neuron lesion and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate (cross), a disturbance of voluntary motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. The most common motor dysfunction is hemiplegia (paralysis on one side of the body).

Planning Short Term:
After 1-2 hrs of NI, the pt will participate in the performance of range of motion exercises on the extremities.

Interventions 1. Established rapport 2. Monitored and assessed vital signs 3. Assessed patient’s general physical condition 4. Performed AM care 5. Monitored vital signs frequently

Rationale 1. To gain trust 2. To obtain baseline data

Evaluation Short Term:
The pt shall have participated in the performance of range of motion exercises on the extremities.

Long Term:
After 2-3 days of NI, the pt will increase the utilization of the affected extremities with due assistance from the SO.

3. To note for any abnormality

Long Term:
The pt shall have increased the utilization of the affected extremities with due assistance from the SO.

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6. Instructed pt to a low fat, low salt diet with SAP 7. Performed muscle strength test

4. To enhance wellbeing & provide comfort 5. To note significant changes in vital signs 6. To help reduce risk of second attack & prevent a rise in BP 7. To determine muscle functioning on the extremities 8. To increase strength and mobility

8. Instructed pt on a PROM on the right extremities 9. Promoted adequate rest 10. Assisted pt with self-care activities 11. Maintain body alignment in functional position

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To prevent injury 11.NursesLabs. To promote comfort and relaxation 10.com . To promote and stimulate circulation 12. To stimulate and increase pt’s awareness on the affected side 13. Shift pt’s attention towards the affected side 13.12. To treat underlying medical condition www. Administer due meds 9.

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