Medical Diagnosis: Cerebrovascular Accident

Problem: Activity Intolerance RT Generalized Weakness

Assessment
Subjective:
(none)
Objective:

right
hemiplegia
increase BP
pt may
manifest:
electro
cardiographic
changes
reflecting
dysrythmias
abnormal heart
rate in
response to
activity
weakness

Nursing
Diagnosis
Activity
Intolerance r/t
Generalized
weakness
secondary to CVA

Scientific
Explanation
Motor deficits are
the most obvious
effect of stroke.
Symptoms are
caused by the
destruction of
motor neurons in
the pyramidal
pathways (nerve
fibers in the brain
and passing
through the spinal
cord to motor
tract.)

Planning
Short Term:
After 4 hrs of NI, pt
will be able to
participate
willingly on
necessary/desired
activities.

Long Term:
After 2 days of NI,
patient will be able
to demonstrate a
decrease in
physiologic signs
of intolerance
(HR,BP remain
within normal
range)

Interventions
1. establish
rapport
2. monitor vital
signs
3. evaluate
current
limitations
(degree of
deficit in light
of visual
status)
4. assess
cardiopulmona
ry response to
physical
activity,
changes BP
5. assist patient
with activities
6. plan care with
rest periods
between
activities
7. increase
activity
gradually

Rationale

Evaluation

1. to promote
cooperation
2. to have a
baseline data
3. provide
comparative
baseline data

Short Term:
Pt. shall have
participated
willingly in
necessary /desired
activities.

Long Term:
Pt shall have
demonstrated a
decrease in
physiologic sings
of intolerance
(HR,BP remains in
normal range)

4. to note
progress of
fatigue

5. to protect
from injury
6. to decrease
fatigue
7. to manage
activity within
limits
8. assist pt deal
with
contributing
factors

8. encourage
expression of

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feelings
resulting from
the condition

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