ASSESSMENT NURSING DIAGNOSIS
Subjective Data:
➢ “Dili na makalihok2 si mama sukad sya
na stroke” as verbalize by the
daughter of the patient.
➢ Nursing Diagnosis Statement:
Objective Data:
➢ General body weakness
➢ Tremors noted on left arm and hands
➢ Inability to perform gross/fin e motor
skills
➢ Paralysis of left side of the body
➢ Functional level scale: 4 (does not
participate in activity )
Problem Identified:
➢ Hemorrhagic stroke caused by
intracerebral hemorrhage
➢ Impaired physical mobility related to
Neuromuscular impairment
Cause Analysis:
Trauma (slipping)
bone fracture at pelvic bone
Disruptions of periosteum and blood vessels
Destruction if tissue
Bleeding occurs
Pain
Impaired bed mobility
PLANNING
Short-term objectives:
After 8 hours of nursing intervention the
significant other of the patient will:
➢ Verbalize understanding of the
situation /risk factors, individual
therapeutic regimen and safety
measures.
➢ Maintain position of function and
skin integrity of the patient.
➢ Demonstrate techniques/ behaviors
that will enable safe repositioning.
Long-term objectives:
After hospitalization, the patient will:
➢ Display improvement and increase
strength and function in the affected
body part.
 INTERVENTION
Independent:
➢ Determine diagnoses that contribute
to immobility (e.g. fractures,
hemi/para/tetra/q quadriplegia).
➢ Change positions at least every 2
hours. (Supine, side lying) and
possibly more often if placed on
affected side.
➢ Observe skin for reddened
areas/shearing. Provide appropriate
pressure to relief.
➢ Provide for safety measures including
fall prevention.
➢ Involve patient and SO in care
assisting them to learn ways
of managing problems of immobility.
Dependent/ Collaborative
Administer medications as indicated by the
physician; q.i.d antifibrinolytics
RATIONALE
Independent:
➢ To identify causative/ contributing
factors.
➢ To reduced risk for skin injury. An
affected side has poor circulation and
reduced sensation.
➢ To reduce friction, maintain safe
skin/tissue pressures and wick away
moisture.
➢ To prevent occurrence of injury
➢ To promote wellness
Dependent/Collaborative:
Used with caution in hemorrhagic disorder to
prevent lysis of formed clots and subsequent
rebleeding.
EVALUATION
Short-term objectives:
Goals met. After 8 hours of nursing
intervention the significant other of the
patient was able to:
➢ Verbalized understanding of the her
mother situation and explained the
risk factors, individual therapeutic
regimen and safety measures.
➢ Maintained position of function and
skin integrity of the patient as
evidenced by absence of
contractures, foot drop, decubitus.
➢ Demonstrate techniques/ behaviors
that enable safe repositioning.
Long-term objectives:
Goals not met. After hospitalization, the
patient:
Shall have improvement and increase
strength and function of affected body part.