Cues

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

Rationale
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. monitorvital signs 3. evaluate current limitations (degree of deficit in light of visual status) 4. assess cardiopulmonary response to physical activity, changes BP 5. assist patient with activities 6. plan care with rest periods between activities 7. increase activity gradually 8. encourage expression of feelings resulting from the condition

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

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

4. to note progress of fatigue

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

5. to protect from injury 6. to decrease fatigue

7. to manage activity within limits 8. assist pt deal with contributing factors