PATIENT'S PROFILE

Name: Mr. W
Age: 78 years old
Address: New England
agnosis: Right cerebrovascular accident (CVA)
with left hemiparesis
 Assessment
Subjective:
“They tell me I had a shock, but I
don’t believe it. See? I can move my
arm.”
 Assessment
Objective:
Hemiparesis
Hemiplegia
Impaired ocular motor control
-his gaze was to the right
- his eyes could not cross
midline
 Assessment
Objective
Vital Signs:
90%
130/100mmHg

13cpm

96bpm
 Diagnosis

Impaired physical mobility related to

motor deficit as evidenced by
hemiparesis and hemiplagia
 Planning
Short term:
After 8 hours of nursing intervention,
the client the client will maintain no
signs of further recurrent of deficits.

Long term:
After 6 months of nursing intervention, the
client will verbalized improved motor mobility
as evidenced by functional movement of all
parts of the body.
 INDEPENDENT
NURSING
INTERVENTION
 Place a pillow under the client's
Intervention arm to keep the arm away from
the chest. Position the elbow
higher than the shoulder and the
wrist higher than the elbow.

Rationale
A patient with hemiplegia has a uniparalysis and the control of
voluntary muscles is lost, the strong flexor muscles exert control
over the extensors. The arms tend to adduct and to rotate
internally. This pillow will help to prevent shoulder adduction
and internal rotation and to prevent edema.
 Intervention
Position the hand and fingers.
The hand is placed slight
supination (palm faces upward)

Rationale
To maintain fingers
barely flexed, it
stimulates the grasp
reflex.
 Intervention
Reposition the client every 2
hours.

Rationale

To prevent pressure
ulcers.
 Intervention
Place pillow between client's
legs before turning the patient
into side - lying position.
Rationale

To promote venous
return and prevent
edema.
 Intervention
Reposition the client into prone position for 15 to
30 minutes several times a day, if possible. Place a
pillow under the pelvis, extending from the level of
the umbilicus into the upper third of the thigh
Rationale
To helps promote
hyperextension of the hip joints,
which is essential for normal
gait and helps prevent knee and
hip flexion contractures.
 Intervention
Assist the client to
perform range of
motion exercises daily.
Rationale
To maintain joint mobility,
regain motor control, prevent
contractures in the paralyzed
extremity, prevent further
deterioration of the
neuromuscular system, and
enhance circulation.
 DEPENDENT
NURSING
INTERVENTION
 Intervention
Maintain supplemental
oxygen as ordered by
the physician.
Rationale

To promote adequate
ventilation and stabilized O2
saturation.
COLLABORATIVE
NURSING
INTERVENTION
 Intervention
Together with the physician,
refer the patient into
rehabilitation program.
Rationale

To meet the appropriate needs,

strengths, and capaties of the
client to regain the optimum
level of well mobilitation.
 Evaluation
Short term:
After 8 hours of nursing intervention,
the client the client maintained no
signs of further recurrent of deficits.

Long term:
After 6 months of nursing intervention, the
client verbalized improved motor mobility as
evidenced by functional mobility of all parts of
the body.