1. Nursing Diagnosis: Impaired Physical Mobility related to the function of neurological damage.
- Assess the functional capabilities and severity of abnormalities.
- Maintain body alignment (using a board bed, air mattress or a standard board as indicated.
- Turn and change position every 2 hours.
- Elevate the extremity pain with pillows.
- Perform range of motion exercises for all active or passive limb every 2 hours to 4 hours.
- Encourage hands, fingers and leg exercises.
- Give the patient as indicated ancillary equipment.
- Encourage the patient to perform activities of daily needs.
- Start to order a progressive ambulation aids to sit in a balanced position from the procedures to move from bed to a chair to reach equilibrium.
- Consult with the physician and the treatment (Tucker, 1998).
2. Nursing Diagnosis: Ineffective Cerebral Tissue Perfusion related to interruption of blood flow, occlusive disorders, hemorrhage, cerebral vasospasm, cerebral edema.
- Monitor or record the neurological status as often as possible and compare it to standard or normal state.
- Monitor vital signs.
- Record the data changes such as the blindness of vision, or visual field disturbances in perception.
- Assess the higher functions, such as speech function.
- Put your head slightly elevated position and the anatomical position (neutral).
- Maintain a state of bed rest, creating a peaceful environment, limit the activities of visitors or patients as indicated.
- Help prevent the occurrence of straining during defecation and breathing force (continuous cough).
- Collaboration in pembarian oxygen and drugs as indicated (Doenges, 2000).