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Pt name: R.Asperin AGE: 63 DIAGNOSIS: CVA

Assessment Nursing Dx Inference Goals Intervention Rationale Evaluation
Subjective: Impaired physical CVA can be caused by Long term: Independent: Independent: Long term goals met:
• Client said, mobility r/t an occlusion in the After 4 days of nursing 1. Determine degree of 1. To Client is able to
“namamanhid neuromuscular blood flow. This can intervention, client will be immobility establish ↑physical mobility as
yung kanang damage involvement lead to ↓O2 and the able to ↑ physical mobility 2. Observe movement compara evidenced by
kamay ko, (Right arm cause failure to Expected outcome: when client is tive resumption of activities,
pero numbness) as nourish the tissues at • Demonstrate unaware baseline participation in his
nagagalaw ko evidenced by ↓ the capillary level and resumption of 3. Support affected part 2. To note ADL’s and ↓ right arm
naman xha motor control that can cause activities with pillows any numbness
medyo hirap neuromuscular • Participate in 4. Give rest periods to incongru
lng ako.” damage w/c can cause ADL’s activities ence Short term goals met:
impaired physical • Maintain or ↑ 5. Encourage adequate with the The client is able to
Objective: mobility muscle control fluids and right diet reports participate on the
• Limited range Short term: as necessary to the of therapeutic regimen as
of motion After 8 hrs of nursing client abilities evidenced by
(client can’t intervention, client will be 3. Reduce verbalization of
fully extend able to participate in risk of understanding of the
his right arm therapeutic regimen pressure situation, therapy, and
and hold up Expected outcome: ulcers he is able to participate
his right • Verbalize 4. To help in the interventions
shoulder) understanding of reduce rendered by the nurse
• Limited ability the situation fatigue
and difficulty • Verbalization of and O2
to perform understanding the demand
gross motor therapy 5. ↑ energy
skills like • Able to participate producti
extending and in the interventions on
lifting of the rendered by the
right arms nurse
• Unsteady gait
• Slowed
• Right arm