NCP Impaired Physical Mobility

X. Nursing Care Plan Assessment

Nursing Diagnosis

Inference

Planning

Intervention

Subjective: “Nahihirapan ako na igalaw ang kaliwang kamay at paa ko” as verbalized by the patient

Impaired Physical mobility related to neuromuscular  impairment secondary to CerebroVascular  infarction as evidenced  by (+) leftsided body weakness, Limited Range of  Motion, Tremors noted on left arm and leg with muscle strength of  3/5.

CerebroVascular  infarction in which nerve cells in the  brain die for  lack of  oxygen can result in  permanent disability for the  patient  because of  the  pathways that transmit information in the brain are interrupted. The symptoms often  primarily affect only one side of  the body  because the  blood flow will be cutoff only to that part of  the brain.

Short term Goal:

Independent:

Objective:

- (+) leftsided body weakness - Limited Range of  Motion - Tremors noted on left arm and hands when he tried to move it - Requires help from his live-in  partner in order for him to sit, eat and drink  medication. - According to the Modified Ashworth Scale, the muscle strength of  the left Arm and left Leg is 3/5

After 8 hours of  nursing intervention the patient will be able to maintain increased strength and function of  affected or  compensatory part as evidenced  by increase range of  motion and muscle strength of  4/5.

.

- Reviewed Medication regimen for   possible effects on alertness, energy level and  perception. - Advised his significant other to change the  position of the  patient at least every 2hrs, from supine to left or right side-lying. - Provided an adequate rest  periods as well as comfort and safety measures to the patient. -Encouraged adequate intake of  fluids and nutritious food.

Rationale

Evaluation

Short term Goal:

- to determine issue affecting ability of  individual to  participate in own care

After 8 hours of  nursing intervention the patient are already maintained increased strength and - Reduces function of  risk of tissue affected of  ischemia or  compensainjury. tory part as evidenced  by increased range of  motion and muscle strength of  4/5. - To prevent further  stress, fatigue and injury.

- Promotes well being and to recover  quickly.

Goal met!

- Instructed - To help  patient  prevent skin significant  breakdown other to and inspect skin decubitus regularly, develop particularly ment. over bony  prominences. Then gently massage any reddened areas and provide aids such as  pads as necessary.

- Instructed - To  patient and his minimize live-in partner  muscle to begin active atrophy, or passive  promotes Range of  circulation Motion to all and also extremities helps and do it every  prevent 8 hours for  contractures. 15-30 minutes.

Dependent:

- Due medications given as  prescribed

- To maintain the therapeutic effects of  medication and in order  for the  patient to recover  quickly.