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NCP CVA Activity Intolerance
NCP CVA Activity Intolerance
right hemiplegia increase BP pt may manifest: electro cardiographic changes reflecting dysrythmias abnormal heart rate in response to activity weakness
Nursing Diagnosis
Activity Intolerance r/t Generalized weakness secondary to CVA
Scientific Explanation
Motor deficits are the most obvious effect of stroke. Symptoms are caused by the destruction of motor neurons in the pyramidal pathways (nerve fibers in the brain and passing through the spinal cord to motor tract.)
Interventions 1. establish rapport 2. monitor vital signs 3. evaluate current limitations (degree of deficit in light of visual status) 4. assess cardiopulmonary response to physical activity, changes BP 5. assist patient with activities 6. plan care with rest periods between activities 7. increase activity gradually 8. encourage expression of feelings resulting from the condition
Rationale 1. to promote cooperation 2. to have a baseline data 3. provide comparative baseline data
Long Term:
After 2 days of NI, patient will be able to demonstrate a decrease in physiologic signs of intolerance (HR,BP remain within normal range)
Long Term:
Pt shall have demonstrated a decrease in physiologic sings of intolerance (HR,BP remains in normal range)
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