Impaired Physical Mobility - Ineffective Cerebral Tissue Perfusion related to CVA / Stroke

Nursing Diagnosis and Nursing Interventions for CVA / Stroke

1. Nursing Diagnosis: Impaired Physical Mobility related to the function of neurological damage.

Nursing Interventions:

• 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.

Nursing Interventions:

• 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).

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Impaired Physical Mobility related to Rheumatoid Arthritis

Rheumatoid Arthritis

Nursing Diagnosis : Impaired Physical Mobility

related to:

• Skeletal deformities
• Pain
• Inconvenience
• Activity intolerance
• Decreased muscle strength.

Characterized by:

• Reluctance to try moving / inability to move in with their own physical environment
• Limit the range of motion, imbalance of coordination, decreased muscle strength / control and mass (advanced stage).

Expected results, patients will:

• Maintain the function of the position with the absence / limitation contractures.
• Maintain or improve strength and function of and / or compensation of the body.
• Demonstrate techniques / behaviors that allow the activity.

Nursing Interventions Impaired Physical Mobility related to Rheumatoid Arthritis

1. Evaluation / continue monitoring the level of inflammation / pain in the joints
Rationale: The level of activity / exercise depends on the development / resolution of the inflammatory peoses.

2. Keep the rest - bed rest / sit, if necessary schedule of activities to provide a continuous period of rest and sleep at night undisturbed.
Rational: Rest of systemic, recommended during the acute exacerbation phase of disease and all that is important to retain the power to prevent fatigue.

3. Assist with range of motion active / passive, and resistive exercises as well as isometris if possible.
Rationale: Maintaining / improving joint function, muscle strength and general stamina.
Note: Inadequate training cause joint stiffness, hence the excessive activity can damage the joints.

4. Change positions frequently with sufficient number of personnel. Demonstrate / aids removal techniques and the use of mobility aid, eg, trapeze
Rationale: Eliminates pressure on the tissue and increase circulation. Facilitate patient self-care and independence. Proper removal techniques can prevent skin abrasion tear.

5. Position with pillows, sand bags, rolls trokanter, splint, brace
Rationale: Increasing the stability (reduce the risk of injury) and memerptahankan necessary joint position and body alignment, reduced contractor.

6. Use a small pillow / thin under the neck.
Rationale: Prevent flexion of the neck.

7. Encourage patients to maintain an upright posture and sitting height, standing, and walking
Rational: To maximize joint function and maintain mobility.

8. Provide a safe environment, for example, raise the chair, use the handrails on the toilet, use a wheelchair.
Rational: Avoiding injuries due to accidents / falls.

9. Collaboration: consul with physiotherapy.
Rational: Useful in formulating training programs / activities based on individual needs and in identifying the tool.

10. Collaboration: Provide foam mat / converter pressure.
Rational: Reduce pressure on fragile tissue to reduce the risk of immobility.

11. Collaboration: Giving drugs as indicated.
Rational: It may be necessary to suppress the acute inflammatory system.

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