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Impaired Mobility Post-CVA Nursing Care

CVA is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain, which is caused by the rupture of blood vessels leading to hemorrhage and accumulation of blood in the skull. The affected area of the brain is unable to function, leading to an inability to move the body and impaired physical mobility. Nursing interventions include assessing mobility and vital signs, determining degree of immobility and risk factors, repositioning every two hours, and providing range of motion exercises and nutrition to maintain or increase strength and function.

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294 views2 pages

Impaired Mobility Post-CVA Nursing Care

CVA is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain, which is caused by the rupture of blood vessels leading to hemorrhage and accumulation of blood in the skull. The affected area of the brain is unable to function, leading to an inability to move the body and impaired physical mobility. Nursing interventions include assessing mobility and vital signs, determining degree of immobility and risk factors, repositioning every two hours, and providing range of motion exercises and nutrition to maintain or increase strength and function.

Uploaded by

cessyanne
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd

Impaired Physical Mobility

CVA is the rapidly developing loss of brain functions due to a disturbance in the blood vessels supplying blood to the brain. This is due to the rupture of blood vessels thus causing hemorrhage wherein there is accumulation of blood in the skull. The affected area of the brain with hemorrhage is unable to function leading to inability to move the body Assessment Nursing Objectives Nursing Interventions Rationale Diagnosis S> (none) Impaired Short Term: >Establish Rapport >To gain SOs physical trust O> After 3 hours >Assess patient mobility r/t of NI, the SO condition >To obtain > GCS of neuromuscular will verbalize baseline data ____ impairment understanding >Monitor vital signs >For comparison secondary to of situation / >Determine dx that > Slowed and baseline data CVA movement risk factors & contributes to immobility >To assess individual > limited treatment ROM >Determine degree of causative factors regimen & immobility >To assess > Extremity safety weakness >Reposition client q2 functional ability measures > limited >Support dependent >Prevent Long Term: ability to body parts with pillows development of pressure ulcers After 3 days perform gross >Provide safety of NI, the pt or fine motor >To maintain measures including will maintain movement position of environmental or increase function and > management strength and prevent pressure Uncoordinated >Feed thru NGT function of ulcers or jerky affected body >Encourage SOs movements >TO reduce risk part or whole involvement in for falls and > Movement body. activities & decision further injury induced making shortness of >For optimum >Peroform passive breath energy and Expected Outcome The SO shall have verbalized understanding of situation / risk factors & individual treatment regimen & safety measures The pt shall have maintained or increased strength and function of affected body part or whole body.

range of motion exercises daily >Increase functional activities as strength improves

nutrition >Enhances commitment to plan and optimizing outcomes >To preserve muscle strength and functional ability >Limits fatigue and ability to perform ADLs.

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