Scribd Logo
Upload

Welcome to Scribd!

  • 604 views

    Activity Intolerance

    Uploaded by

    Christian Karl B. Llanes
    The patient presented with left-sided weakness after a cerebrovascular accident (CVA) affecting the right side of the brain. Nursing interventions included assessing the affected left side, assisting with activities of daily living, range of motion exercises, and patient/caregiver education. The goals were to improve mobility and self-care activities within a few days while preventing complications like edema and joint deformities.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Activity Intolerance

    Uploaded by

    Christian Karl B. Llanes
    604 views1 page
    The patient presented with left-sided weakness after a cerebrovascular accident (CVA) affecting the right side of the brain. Nursing interventions included assessing the affected left side, assisting with activities of daily living, range of motion exercises, and patient/caregiver education. The goals were to improve mobility and self-care activities within a few days while preventing complications like edema and joint deformities.

    Original Description:

    Activity Intolerance

    Copyright

    © © All Rights Reserved

    Available Formats

    DOCX, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    The patient presented with left-sided weakness after a cerebrovascular accident (CVA) affecting the right side of the brain. Nursing interventions included assessing the affected left side, assisting with activities of daily living, range of motion exercises, and patient/caregiver education. The goals were to improve mobility and self-care activities within a few days while preventing complications like edema and joint deformities.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    604 views1 page

    Activity Intolerance

    Uploaded by

    Christian Karl B. Llanes
    The patient presented with left-sided weakness after a cerebrovascular accident (CVA) affecting the right side of the brain. Nursing interventions included assessing the affected left side, assisting with activities of daily living, range of motion exercises, and patient/caregiver education. The goals were to improve mobility and self-care activities within a few days while preventing complications like edema and joint deformities.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    ASSESSMENT EXPLANATION OF THE

    PROBLEM
    OBJECTIVES NURSING INTERVENTION RATIONALE EVALUATION
    S> Hindi sya masyadong
    maka galaw as verbalized
    by SO.

    O>Left sided weakness
    noted
    >Weak in appearance
    >Needs assistance in
    doing ADLs
    >Numbness in the left leg
    and arm


    A>Activity intolerance
    related to generalized
    weakness secondary to
    CVD.
    In an ischemic brain attack,
    there is a disruption of
    cerebral blood flow due to
    obstruction of blood
    vessels. The disruption of
    blood flow results to brain
    damage. In our pt.s case,
    the right side of the brain is
    affected. This in turn
    affects the left side of the
    pt.s body resulting to
    paralysis and weakness of
    the affected side.



    Reference:
    Textbook of Medical-
    Surgical Nursing 12
    th

    Edition.
    STO> After 5-6 hours of
    effective Nursing
    Intervention, the patient
    should be able to set
    realistic goals to
    enhance self-care
    activities such as :
    a. Combing the
    hair
    b. Brushing the
    teeth
    c. eating


    LTO> After 2-3 days of
    effective Nursing
    Intervention, the patient
    should be able to do
    activities in improving
    mobility and preventing
    joint deformities such as
    ROM exercises.
    Dx> Assessed affected side of the
    pts body

    >Promote rest and comfort


    >Prevented shoulder adduction


    Tx> Assisted in changing positions


    >Assisted in positioning the hands
    and fingers

    >Assisted in doing ROM exercises

    Edx> Emphasized the importance of
    ROM exercises

    >Instructed SO to change pt.s
    position every 2 hours

    >Instructed SO to watch out for
    nasal regurgitation during feeding
    >To determine activities that the
    patient can tolerate

    >To decrease stress and minimize
    workload

    >To prevent edema and joint
    deformities

    >To promote venous return and
    prevent edema

    >To prevent hand edema and spasticity
    of the hand

    > To prevent joint deformity

    >To prevent joint deformity and
    improve mobility

    >To promote venous return and edema


    >To prevent aspiration and further
    complications
    STO> Goal partially
    met, after 5-6 hours of
    effective Nursing
    Intervention, the
    patient was able to set
    realistic goals to
    enhance self-care but
    were not able to do
    them all.




    LTO> Goal met, after
    2-3 days of effective
    Nursing Intervention,
    the patient was able to
    do activities in
    improving mobility and
    preventing joint
    deformities such as
    ROM exercises.

    You might also like