Assessment Subjective: “Hindi ko magalaw yung kaliwang braso at binti ko.

Namamanhid pero pag may gumalaw, masakit” Objective: Patient had Cerebrovascu lar accident Left-sided paralysis

Nursing Diagnosis Impaired physical mobility related to damage to motor cortex or motor pathways

Rationale CVA

Goal Short Term:

Nursing Interventio n Independent: Maintain functional alignment in positioning the patient at rest.

Rationale

Evaluation Short Term:

After four hours Motor nerves are of nursing damaged interventions, contractures and pressure sores Left hemiplegia will be prevented Impaired physical mobility Long Term: After 8 hours of nursing interventions, further complications of immobility will be prevented.

Functional position prevents contractures and deformities that can further complicate recovery and can help reduce intracranial pressure. The weight of an unsupported arm may cause shoulder dislocation, joint inflammation, or both To help maintain muscle tone and establish new impulse pathways and neuron

After four hours of nursing interventions, Contractures and pressure sores are prevented as evidenced by intact skin and freely movable joints. Goal Met Long Term: After 8 hours of nursing interventions, further complications of immobility were prevented as evidenced by, intact skin, maintained muscle tone, no

Support affected arm when patient is out of bed.

Provide passive range-of-motion exercise at least four times a day

regeneration Turn the patient from side to side at least every 2 hours. Goal Met Dependent: Administer Citicoline as ordered . Watch for fragile. Begin bladder training as soon as possible Moisture promotes bacterial growth and increases skin friability. Turning and massage help prevent pressure sores from developing and promote circulation. Bladder training establishes patterns and bolsters the patient’s confidence in resuming activities as permitted. thin. or excoriated skin. no contractures. which may shear during turning. Keep bedding clean and dry. Citicoline increases blood flow and oxygen consumption in joint inflammation or dislocation. Maintain adequate elimination. and maintained functional alignment of the extremities. Massage bony prominences.

the brain .

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