ISCHEMIA

ENERGY FAILURE

ACIDOSIS ION IMBALANCE

GLUTAMATE DEPOLAROZATION

INTRACELLULAR CALCIUM
INCREASED

Cell membranes and proteins break down

Formation of free radicals Protein production
decreased.

CELL INJURY AND DEATH

 Assessment Nursing Diagnosis Planning Intervention Expected Outcome
Short term Independent
Subjective: Impaired physical mobility related 8 hours of nursing intervention - Monitor the Neurological Status. After 8 hours of nursing
- Changing patient’s position every intervention
“hindi ko maramdaman ang paa to decrease in muscle control - Achieve a form of 2 hours.
ko” as verbalized by the patient. as evidenced by Motor leg left is communication.  Patient achieve a proper
- Elevate the head of the bed at form of communication
unable to maintain in air ( grade 2) - Maintaining skin integrity least 30 degrees to prevent
 Patient maintain skin
aspiration.
and “hindi ko maramdaman ang - patient will breath properly integrity
- Monitor patient’s v/s.  Patient is breathing properly
paa ko” as verbalized by the - patient vital sign will be: patient vital sign:
patient. BP: 120/90 mm Hg - Assess motor strength or BP: 120/90 mm Hg
functional level of mobility.
RR: 23 Cpm RR: 23 Cpm
02: 96% - Ensure the safety of the patient’s
02: 96%
bed. Raise side rails.
Temperature: 36.6 Temperature: 36.6
- Promote to the patient a easy
communication to understand 1 month
each other.  Patient had demonstrate a
measure of increase
- Assist patient for muscle
mobility.
exercises
 Patient relief the sensory
Objectives Dependent and perceptual deprivation
BP: 130/90 mm Hg - Administer warfarin sodium  Patient regains the ability to
(coumadin) as doctor prescribed perform physical ability
RR: 28 cpm independently
O²: 88 % - Administer IV heparin or low  Patient had improved
molecular weight heparin as strength and function of
Temperature: 36.8℃ affected extremity.
prescribed by the doctor.
Numbness and tingling of lower - administer oxygen as prescribed
by the doctor.
extremities
Long term ( 1 month) Collaborative
- Motor leg left is unable to
- Improved mobility Refer to Physical therapist
maintain in air ( grade 2).
- Relief of sensory and perceptual Refer to Occupational therapist
- - Dysarthria Grade 1
deprivation. Refer to Nutritionist
- Pt. Will regains ability to perform
physical activity independently
- Patient will have an improved
strength and function of the
affected extremity.