Nursing Diagnosis: Impaired physical Mobility May be related to: Neuromuscular involvement: weakness, paresthesia; flaccid, hypotonic paralysis

(initially); spastic paralysis, Perceptual or cognitive impairment Cause Analysis: A stroke is an upper motor neuron lesion and results in loss of voluntary control over motor movements. Because the upper motor neurons decussate (cross), a disturbance of voluntary motor control on one side of the body may reflect damage to the upper motor neurons on the opposite side of the brain. (Smeltzer et. al. [2010]. Brunner and Suddarths Medical Surgical Nursing, 12th edition, p.1897) Cues Objective Cues Inability to purposefully move within the physical environment Impaired coordination Limited range of motion (ROM), Decreased muscle strength and control Objectives Short-term Objective Within 8 hours of providing nursing interventions, the client will: Maintain or increase strength and function of affected or compensatory body part. Maintain optimal position of function as evidenced by absence of contractures and footdrop. Long-term Objective Within 3 days of providing nursing interventions, the client will: Demonstrate techniques and behaviors that enable resumption of activities. Maintain skin integrity. Independent Positioning Assess functional ability and extent of impairment initially and on a regular basis. Classify according to a 0 to 4 scale. (Refer to CP: Craniocerebral TraumaAcute Rehabilitative Phase, ND: impaired physical Mobility.) Change positions at least every 2 hours (supine, side lying) and possibly more often if placed on affected side. Nursing Interventions Rationale

Identifies strengths and deficiencies and may provide information regarding recovery. Assists in choice of interventions because different techniques are used for flaccid and spastic types of paralysis.

Reduces risk of tissue ischemia and injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown and pressure ulcers. Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe.

Position in prone position once or twice a day if client can tolerate.

Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head.

Prevents contractures and footdrop and facilitates use when or if function returns. Flaccid paralysis may interfere with ability to support head, whereas spastic paralysis may lead to deviation of head to one side. During flaccid paralysis, use of sling may reduce risk of shoulder subluxation and shoulder-hand syndrome.

Use arm sling when client is in upright position, as indicated.

Evaluate use of and need for positional aids and splints during spastic paralysis: Place pillow under axilla to abduct arm. Elevate arm and hand. Place hard hand-rolls in the palm with fingers and thumb opposed.

Flexion contractures occur because flexor muscles are stronger than extensors. Prevents adduction of shoulder and flexion of elbow. Promotes venous return and helps prevent edema formation. Hard cones decrease the stimulation of finger flexion, maintaining finger and thumb in a functional position. Maintains functional position. Prevents external hip rotation. Continued use after change from flaccid to spastic paralysis can cause excessive pressure on the ball of the foot, enhance spasticity, and actually increase plantar flexion. Edematous tissue is more easily traumatized and heals more slowly.

Place knee and hip in extended position. Maintain leg in neutral position with a trochanter roll. Discontinue use of footboard, when appropriate.

Observe affected side for color, edema, or other signs of compromised circulation. Inspect skin regularly, particularly over bony prominences.

Pressure points over bony prominences are most at risk for decreased perfusion and ischemia. Circulatory stimulation and padding help prevent skin breakdown and decubitus ulcer development.

Gently massage any reddened areas and provide aids such as sheepskin pads, as necessary.

Exercise Therapy: Muscle Control Begin active or passive ROM to all extremities (including splinted) on Minimizes muscle atrophy, promotes circulation, and helps prevent contractures.

admission. Encourage exercises, such as quadriceps or gluteal exercise, squeezing rubber ball, and extension of fingers and legs and feet.

Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. Note: Excessive and imprudent stimulation can predispose to recurrence of bleeding.

Assist client to develop sitting balance (such as raise head of bed; assist to sit on edge of bed, having client use the strong arm to support body weight and strong leg to move affected leg; increase sitting time) and standing balance put flat walking shoes on client, support clients lower back with hands while positioning own knees outside clients knees, and assist in using parallel bars and walker. Get client up in chair as soon as vital signs are stable except following cerebral hemorrhage.

Aids in retraining neuronal pathways, enhancing proprioception and motor response.

Helps stabilize BP, restoring vasomotor tone, and promotes maintenance of extremities in a functional position and emptying of bladder and kidneys, reducing risk of urinary stones and infections from stasis. Note: If stroke is not completed, activity increases risk of additional bleeding and infarction. Reduces pressure on the coccyx and prevents skin breakdown.

Pad chair seat with foam or water-filled cushion, and assist client to shift weight at frequent intervals. Set goals with client/significant other (SO) for increasing participation in activities, exercise, and position changes. Encourage client to assist with movement and exercises using unaffected extremity to support and move weaker side.

Promotes sense of expectation of progress and improvement, and provides some sense of control and independence. May respond as if affected side is no longer part of body and need encouragement and active training to reincorporate it as a part of own body.

Collaborative Positioning Provide egg-crate mattress, water bed, flotation device, or specialized bed, such as kinetic, as indicated. Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown and pressure ulcer formation. Specialized beds help with positioning, enhance circulation, and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia. Individualized program can be developed to meet particular needs and deal with deficits in balance, coordination, and strength. May assist with muscle strengthening and increase voluntary muscle control, as well as pain control. May be required to relieve spasticity in affected extremities. Administer muscle relaxants and antispasmodics as indicated, such as baclofen (Lioresal) and dantrolene (Dantrium). References: Doenges et. al. (2008) Nursing Care Plans: Guidelines for Individualizing Client Care Across the Life Span, 8th edition, p244-245

Exercise Therapy: Muscle Control Consult with physical therapist regarding active, resistive exercises and client ambulation. Assist with electrical stimulationtranscutaneous electrical nerve stimulator (TENS) unit, as indicated.