ASSESSMENT DIAGNOSIS NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE

Subjective: Impaired Physical Impaired Physical Short term: Independent: Independent:

No Verbal Cues Mobility related to Mobility Limitation in After 8 hours of nursing 1. Assess the knowledge 1. Giving the patient’s
neuromuscular independent, interventions the patient of patient’s relative relative the knowledge
impairment as purposeful physical will be able to: about immobility and will help them to
Objective: evidenced by body movement of the body implications manage her condition
weakness, stiffness or of one or more a. verbalize well. To have effective
Vital signs: of upper extremities extremities. This might understanding of the nurse- patient
BP: 100/80mmHg and low level of be a result of damage in situation interaction.
HR: 93 bpm muscle strength the brain (CVD/CVA). b. know the risk factors
RR: 30 and individual 2. Perform physical 2. Assess degree of
Temp: 36.2 c. participate in the activity independently or mobility produce by
O2 Sat: 94% interventionsrendered by with assistive devices as the disease
the nurse. needed
(+) Weekness
Long term: 3. Teach patient’s 3. Giving the patient’s
(+) Stiffness of After 4 days of nursing relative on what relative the knowledge
Upper Extremities interventions the client exercises and how to do will help them to
(Hard to Mobilize) will be able to: exercises that can help manage her condition
patient’s condition well. To have effective
(+) Low level of a. Demonstrate nurse- patient
Muscle Strength resumption of activities interaction.
b. Maintain incresed
muscle control 4. Encourage patient’s 4. To maintain and
relative to continue to enhance gains in
exercise the patient strength and muscle
Source: control
https://nurseslabs.com/
impaired-physical- 5. Instruct patient’s 5. To effectively assist
mobility/ relative in methods of and help the patient
moving patient relative
to mobility needs
 6. Ensure side rails up 6. To prevent patient
from possible fall or
accident that might
happen

Collaborative: Collaborative:

1. Assist in Physical 1.To regain function of

therapy of client gross motor movement
of patient.

2. Plan meals for client 2. To give sufficient

especially high protein energy to client and for
and caloric meals muscle strength

ASSESSMENT DIAGNOSIS NURSING ANALYSIS PLANNING INTERVENTIONS RATIONALE

Subjective: Impaired verbal A CVD, which may be Short term: Independent: Independent:
No Verbal Cues communication caused by hemorrhage, After 8 hours of nursing 1. Establish rapport. 1. To build trusting
related to alteration thrombus, embolism or interventions the patient relationship.
of motor speech vasospasm, can result will be able to:
Objective: area of the brain in a local area of cell 2. Monitor and record 2. To have baseline
death, called infarct. It a. Display interest in V/S. data.
Vital signs: is caused by a lack of communication
BP: 100/80mmHg blood supply which is b. Establish method of 3. Establish good 3. To maintain good
HR: 93 bpm then surrounded by an communication in which relationship, listening communication skills
RR: 30 area of cells that are needs can be expressed. carefully and attending to with the patient.
Temp: 36.2 secondarily affected. c. Demonstrate eye client’s verbal and non-
O2 Sat: 94% Since symptoms contact to his healthcare verbal expressions.
depends on the location providers
(+) Inability to of the stroke and size of 4. Kept communication 4. Long and complex
articulate the infarct, it could simple, speaking in short sentences will confuse
involve the brain’s sentences, using patient.
(+) Absence of eye Brocca’s area, which is Long term: appropriate words.
contact primarily responsible After 4 days of nursing
for communication interventions the client 5. Maintained eye 5. To get patients
(+) Lack of interest through facial will be able to: contact. attention.
in communication expressions and speech.
By causing damage to a. Participate in 6. Used gestures 6. To provide
this area, the patient’s therapeutic congruent to words reinforcement to the
communicating skills communication. when speaking to the spoken words for easy
are greatly altered and b. Maintain good patient. understanding
affected. environment.
c. Enhance participation 7. Taught patient to use 7. To minimize
and communication plan. other means of patient’s frustration
communication such as: and promote
nodding and shaking of understanding of
head to indicate yes or patient
no, signing, and writing
Source: (Medical- to a paper. 8. Noise may interfere
Surgical Nursing, vol.2, with communication
9th edition, Brunner & 8. Provided silent process
Suddarths, page 1259) environment.

Collaborative: Collaborative:

1. Administer 1. Sometimes,
medications as medications are given
prescribed, on time. to stimulate the brain
to function well.
2. Referred to
speech/language 2. To treat speech
therapist. disorder.