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S: Activity Risk factor Short term: 1. Monitor vital / - To watch for Goal Met
O: -left sided intolerance Family History After 2 hours of cognitive signs changes in BP, RR, Short term:
extremity related to left Lifestyle nursing intervention HR After 2 hours of
weakness sided extremity Ļ the patient will be 2. Provide positive - Helps to minimize nursing
- appear weak weakness Ĺ blood pressure able to: atmosphere, while frustration and intervention the
- level II Ļ - verbalize measure acknowledging rechannel energy patient was able
function Thrombus formation that increase difficulty of the to:
classification Ļ activity tolerance. situation for the - verbalized
- doing ADL Thrombus dislodge -participate willingly client. measure that
with assistance and joins circulation in desired activity 3. Turn pt. side to side - To prevent the increase activity
Ļ every 2 hrs. development and tolerance.
Embolus formation Long term: progression of -participated
Ļ After 2-3 days of pressure ulcer willingly in desired
Occludes in the nursing intervention 4. Assist on ROM - To prevent activity
artery of the brain the patient will be exercises contractures Long term:
Ļ able to: 5.Plan care to - To reduce After 2-3 days of
Ļ O2 supply on right - report measurable carefully balance rest fatigue nursing
side of the brain increase in activity periods with intervention the
Ļ tolerance as activities patient was able
CVA evidence by to do 6. Increase activity - To manage to report
Ļ simple activity gradually as tolerated activity within measurable
Left sided extremity within limitation limits. increase in
weakness Collaborative activity tolerance
Ļ 7. Provide/monitor - to prevent as evidence by to
Activity intolerance response to hypoxemia do simple activity
supplemental oxygen within limitation
and medication.