ASSESSMENT/ NURSING BACKGROUND GOALS AND NURSING EVALUATION

CUES DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTIONS

AND
RATIONALES
Subjective: Impaired Physical According to NOC: Mobility NIC: Exercise GOAL PARTIALLY
-The patient reported Mobility related to NANDA 15th Edition, Level Therapy MET
experiencing neurological deficits, Impaired Physical After a week of
decreased in muscle weakness Mobility is the GOAL: After a week nursing interventions,
sensorium. secondary to kimitation in of nursing the patient will be
subarachnoid independent, interventions, the fully awake, however,
hemorrhage. purposeful physical patient will be able to he can’t move his
Objective: movement of the wake up and preserve body fully.
-The patient is body or of one or muscle strength and
unconscious. more extremities. function of the
GCS: 8 compensating body
Subarachnoid parts.
Vital Signs: Hemmorhage refers
BP: 140/100 mmHg to extravasation of OBJECTIVES:
BT: 36.5 blood into the After 1-2 days of
PR: 91 bpm subarachnoid space nursing interventions,
RR: 21 bpm between the pial and the patient will be The nurse will: The patient:
SpO2: 98% arachnoid able to: A1. Conduct frequent 1. The patiernt’s GCS
membranes. 1. Show signs of neurological remained 8 in total
improvements with a assessments, and has no
GCS of higher than 8. including Glasgow improvement.
Coma Scale (GCS)
scores.
To monitor the
patient’s level of
 consciousness and
neurological status.
A2. Observe and
document any
changes in pupillary
responses, motor
function, and speech.
To determine if the
patient has
improvements.

2. Have stable blood B1. Monitor and 2. Had stable blood

pressure and adequate maintain stable blood pressure and adequate
oxygen level. pressure. oxygen level.
To prevent re-
bleeding and
minimize the risk of
complications.

B2. Monitor
respiratory status
closely, providing
supplemental oxygen
as needed.
To maintain adequate
oxygenation.

3. The patient’s C1. Elevate the head 3. The patient’s

significant other of the bed to a semi- significant other
listened to the Fowler’s position. listened to all the
advises. To reduce healthcare provider’s
intracranial pressure advises.
and promote cerebral
perfusion.

C2. Evaluate for

shoulder subluxation
(partial
separation/dislocation
of shoulder joint),
tenderness, and pain.
Subluxation is a
typical complication
for post stroke
patients caused by
traumatic SAH. This
intervention also
identifies the cause of
swelling, impaired
shoulder movement,
and regional pain.

C3. Advise the

significant other to
avoid pulling the
affected arm and
ensure it is supported
on a firm surface
when the patient
assumes a seated
position. Using
scapular motion,
direct the movements
of the upper
extremities.
Prevents subluxation,
which occurs when
the muscles are
unable to support the
arm’s weight.
Patients in bed should
be positioned slightly
forward to prevent
shoulder movement
and allow
stabilization.

C4. Assist the patient

to change positions
every 2 hours.
This intervention
reduces the risk of
tissue injury and
muscle atrophy
resulting from poor
circulation induced
by reduced mobility.
In order to shift from
a prone to a supine
position, the
 unaffected limb
should be moved first,
followed by the
affected limb. Before
assuming a side-lying
position, placing a
pillow between the
limbs can provide
muscle relaxation and
maintain the pelvis in
a neutral position.
Avoid acute flexion of
the upper thighs and
knees to improve
venous return and
avoid muscle stiffness
and edema.

D1. Collaborate with

4. The patient’s physical therapy. 4. The patient’s
significant other will To develop a significant other
collaborate to a structured mobility collaborated to a
physical therapy and program that physical therapy and
willingly accepted promotes willingly accepted
some exercise therapy independence and some exercise therapy
for the patient. helps prevent for the patient.
complications
associated with
immobility.
D2. Stress the
significance of active
and passive range of
motion exercises to
the extremities (e.g.,
gluteal, quadriceps
exercises, the
extension of limbs
and feet)
These measures
maintain and improve
circulation and
muscle strength. It
also prevents
contractures and
deterioration of
muscle mass.