Assessment Diagnosis Planning Intervention Evaluation

Subjective:
 1 pack of Impaired physical Short term: Independent: Goal has been met.
cigarettes per mobility r/t to  Within 8 hours of  Assess extent of
day for 18 years paralysis nursing intervention, impairment initially and
 Alcohol the client will on a regular basis.
consumption of demonstrate Classify according to 0–4
2-4 beer daily techniques/behavior scale.
and have no s that enable Rationale: Identifies
plans of stopping. resumption of strengths and
 Denied chest activities. deficiencies that may
pain, Long term: provide information
palpitations,  Within 3-5 days the regarding recovery.
headache and client will increase Assists in choice of
fever. strength and function interventions, because
of affected or different techniques are
Objective: compensatory body used for flaccid and
 Presented with part. spastic paralysis.
upper and lower  Observe affected side for
extremity color, edema, or other
weakness, signs of compromised
associated with circulation.
facial drop and Rationale: Edematous
stutter starting 2 tissue is more easily
hours before traumatized and heals
presentation. more slowly.
 Patient’s vitals  Inspect skin regularly,
were stable in particularly over bony
the emergency prominences. Gently
room. massage any reddened
 On his physical areas and provide aids
examination, such as sheepskin pads as
right sided facial necessary
droop, dysarthia, Rationale: Pressure
 and right sided points over bony
paralysis. prominences are most at
 NIHSS score of 6 risk for decreased
perfusion. Circulatory
stimulation and padding
help prevent skin
breakdown and decubitus
development.
Dependent:
 If client is immobile,
consult with physician for
a safety evaluation
before beginning an
exercise program; if
program is approved,
begin with the following
exercises:
1. Active ROM
exercises using
both upper and
lower extremities
(e.g., flexing and
extending at
ankles, knees,
hips)
2. Chin-ups and
pull-ups using a
trapeze in bed
(may be
contraindicated
in clients with
cardiac
conditions)
3. Strengthening
 exercises such as
gluteal or
quadriceps sitting
exercises
Rationale: These
exercises help reverse
weakening and atrophy
of muscles.
Collaborative:
 Consult with physical
therapist for further
evaluation, strength
training, gait training, and
development of a
mobility plan.
Rationale: Techniques
such as gait training,
strength training, and
exercise to improve
balance and coordination
can be very helpful for
rehabilitating clients.