NURSING INTERVENTIONS 1. Establish rapport 2. Monitor vital signs 3. Note emotional/ behavioral responses to problems of immobility 4.

Determine readiness to engage /exercises 5. Assist patient reposition self on a regular schedule 6. Provide safety measures including fall preventions 7. Assess cardiopulmonary response to physical activity, changes to BP 8. Plan care with rest period between activities 9. Assess for type and severity of immobility, impairment, muscle flaccidity, spasticity and coordination, ability to walk, sit, move in bed perform. 10. Passive ROM to all limbs and progress to assistive and then active rom in all joints 4 times a day 11. Use assistive devices as appropriate for ambulation, clothing with zipper closures, suction cups on personal hygiene 12. Keep patient in an NPO 13. Obtain actual or estimated body weight
14. Provide alternative methods of communication, like

RATIONALE To promote cooperation with the patient To have a baseline data To assess functional ability To assess expected level of participation To promote optimal level of functions and complications To prevent occurrence of injury To note progress to fatigue To decrease fatigue of patient To provide data regarding mobility and ability to perform activities with in limitations without injury or frustrations. To promote circulation, muscle tone, joint flexibility, prevents contractures and weakness Provides safe support for immobility and other self care activities to promote independence. To decrease the risk of aspiration Use as a baseline data to compare for the previous days of confinement. Provide communication needs or desires based on individual situation or underlying deficit Helpful in decreasing frustration when dependent on others and unable to communicate desires To identify the possible signs and symptoms of the disease and to serve as a baseline data. It is to determine any imbalance in hydration state of the client

pictures or visual cues, gestures or demonstration 15. Anticipate and provide for patients needs 16. Obtain laboratory results 17. Monitor Input and output

1. 2. 3. 4. 5. 6.

MEDICAL INTERVENTIONS Provide I.V. fluids Maintain a patent airway Administer oxygen therapy with possible intubation and mechanical ventilation Administer dexamethasone Administer sedatives, such as Phenobarbital Consider surgical procedures

RATIONALE To support blood pressure and maintain volume To promote adequate oxygenation To ensure adequate tissue perfusion To reduce cerebral edema To decrease metabolic requirements To correct circulatory impairment, prevent repeated hemorrhage, or relieve cerebral pressure To preserve mobility and prevent deformities To provide support or rehabilitation To have an idea on the status of the client and not to cause further complication. To assess for further progress of the client or for any complication present. To prevent the formation of blood clots that can become lodged in a cerebral artery and cause strokes - Serve as baseline data. - To know the signs and symptoms and possible cause of the disease.

7. Begin bedside range-of-motion exercise 8. Direct the family to community groups 9. Correct cardiovascular abnormalities, such as atrial fibrillation 10. Assess the patients neurologic status; observe for CVA progression and level of consciousness (LOC) change as evidenced by decreasing numerical score on the GLASGOW COMA SCALE. 11. Administer anticoagulants and antiplatelet drugs for thrombotic conditions after hemorrhage has been ruled out 12. Perform diagnostic procedures

References: 1. Medical-Surgical Nursing: Clinical Management for Positive Outcomes. 7th ed. by Joyce M. Black, and Jane Hokansan Hawks. Medical Singapore: Elsevier Inc. 2005 2. Fundamentals of Nursing. 7th ed. by Barbara Kozier, Glenora Erb, Audrey Berman, and Shirlee Synder. Singapore. Pearson Education Inc. 2004 3. Nurses Pocket Guide. 9th ed. by Marilyn Doenges, Mary Frances Moorhouse, and Alice Geissler- Murr; Thailand. Davis Company. 2004 4. Davis Drug Guide For Nurses, 9th ed. by Judith Hopfer Deglin, et.al. Philadelphia. F.A. Davis Company. 2005 5. Principles of Anatomy and Physiology 11th ed. by Gerard J. Tortora, Bryan Derickson