Assessment Diagnosis Goals Interventions Rationale55 y/o female, With primary Dx of Acute Brain Attack (cerebrovascular bleeding), Hx of diabetes and HTN.Vitals: BP 190/100 Pulse 90, Resp.16, rectal temp 100.6oF. glasglow coma scale=8Right sided weakness with loss of sensory input and facial drooping.

Impaired physical mobility r/t paralysis

Pt. will maintain maximum level of functioning x 7dys

Turn and position the patient in correct alignment every 2 hours

Patient may not feel increases in pressure or have the ability to adjust position. Loss of motor control can lead to abnormal posturing.

Practice passive and active ROM exercises in all extremities several times daily.Encourage patient to exercise unaffected side.

This preserves muscle strength and prevents contractures, especially in spastic extremities.

Increase functional activities as strength improves and patient is medically stable.Establish regular exercise routine

Early mobilization and ROM exercises should begin as soon as the patient is stable and no longer requires intensive care.

Pt. will be free of complications x 30days

Perform activities in a quiet environment with few distractions.

Impaired cognitive function that occurs with stroke may decrease the patient’s attention span and

concentration. The client may be easily distracted.

Apply heat or cold to the extremities.

This is an effort to reduce tone before initiating movement.

Perform muscle stretching activities in gentle, rhythmical motions.

These provide input into the central nervous system.

Apply splinting devices to spastic extremities as prescribed, with ongoing assessment for increasing tone.

Maintaining proper body alignment is essential. Pillows, sandbags, splints and trochanter rolls help prevent footdrop and contractures.