Nursing Care Plan

Return to Care Plan Listing
 






Medical Diagnoses: Impaired Physical Mobility, Musculoskeletal impairment secondary to stroke

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective

 

Pt’s daughter states that her mother was experiencing progressive right sided weakness over 2 days prior to admission.

 

Objective

   

Diagnosis of stroke

   

Pt demonstrates right sided paralysis

   

Pt demonstrates decreased grips and reflexes on the left side

   

Pt demonstrates difficulty with mobility and activity.




Problem:

 

Impaired Physical Mobility

   

   

Long Term:

 

Pt will be able to ambulate around the nurses’ station 2X by discharge.

* Apply any ordered brace before mobilizing the client.

   

Rationale:

“Brace support and stablilize a body part, allowing increased mobility.” (Ackley & Ladwig, 2008, p 552).

   

*Increase independence in ADLs

   

Rationale:

“Providing unnecessary assistance with transfers and activities may promote dependence and a loss of mobility.” (Ackley & Ladwig, 2008, p 552).

   

*Obtain any assistive devices needed for activity.

   

Rationale:

“Assistive devices can help increase mobility.” (Ackley & Ladwig, 2008, p 552).

   

ü     

   

   

   

   

   

   

   

 

 

 

 

 

  

   

R/T:

 

Musculoskeletal impairment secondary to stroke

   

   

   

   

   

Short Term:

 

Pt will perform passive range of motion exercises by the end of this shift, by 1900.

   

*Assess the pt’s pain by using the 10 point pain rating scale q4 hrs or PRN.

 

Rationale:

“Single- item ratings of pain intensity are valid and reliable as measures of pain intensity.”

 

“The client’s report of pain is the single most reliable indicator of pain.”

 (Ackley & Ladwig, 2008, p. 604-605).

 

*Before activity, treat pain.

 

Rationale:

“Pain limits mobility and is often exacerbated by movement.” (Ackley & Ladwig, 2008, p 552).

 

   

 

 

AEB

 

Pt demonstrates right sided paralysis

 

Pt demonstrates decreased grips and reflexes on left side

 

Diagnosis of stroke

 

 

 

 

   

4,500 Med Surg Nursing review flash cards, download now and ace your exams

   

*I = Implementation.  Check those interventions/actions/orders that were implemented.

 

 

 

References

 

Ackley, B.J., & Ladwig, G.B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis: Mosby Elsevier.



Return to Table of Contents