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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