PRINCESS Q PIMENTEL

ASSESSMENT DIAGNOSI SCIENTIFIC OBJECTI NURSING RATIONALE OUTCO

S EXPLANATI VES INTERVENTIO ME
ON NS
Subjective: Impaired Stroke in Short 1. establish 1. to Short
(none) Physical w/c nerve Term rapport prom Term
  Mobility cells in the : 2. monitor ote :
R/t brain die for After 4 vital signs cooperation Patient
Objective:
neuromusc lack of hrs. of NI, 3. note 2. to shall
⁃ right ular oxygen can
hemiplegia pt. is emotional/beh have have
involvemen result in willing to a
⁃ limite avio participat
t secondary permanent participat
d ROM ral responses baseline data ed in
to CVA disability e in
⁃ difficu infarct for the to 3. to activities
lty turning activities asses necessary
patient problems of 
⁃ slowe necessary s for
Because the for immobility
d movement pathways functional the
the 4. determine
⁃ Muscl that ability patient.
e strength of  patient readiness to
transmit Long 4. to Long
right arm: 0/5; engage in
information Term asses Term
right leg: 0/5; in the activities/exerc s
: :
left brain are ises
expected Pt shall
arm:5/5; left interrupted. After 3 5. assist patient level of  have
The days of reposition self
leg:5/5 participation improved
symptoms NI, pt on a
⁃ gait will be 5. to and
changes often 6. regular prom increase
primarily able to schedule
⁃ Postur improve ote strength
al Instability affect only 7. provide for
one side of and optimal level and
during increase safety of  function
performance the body measures
because strength function and of 
of  and including fall affected
blood flow prevent
routine ADL’s is function prevention body
complication
⁃ move cut off to of  8. identify s part.
ment only part of  affected energy
body part. 6. to
induced the brain. conserving prev
shortness techniques for ent
of ADL’s occurrence
breath/tremors
of 
injury
7. limit
s
fatig
ue,
maximizing
participation
8. to
prom
 ote
wellness