NURSING DIAGNOSIS: Impaired physical mobility
activity limitations associated with decreased motor function and spatial-perceptual impairments;
loss of muscle tone during period of flaccidity of affected extremities (flaccid paralysis may be present during the first few days following a CVA);
hypertonia of affected extremities (as muscle tone returns after period of flaccidity, it often progresses to spasticity);
reluctance to move associated with fear of injuring self (occurs mainly with ischemia of the dominant hemisphere);
loss of muscle mass, tone, and strength associated with prolonged disuse.
The client will achieve maximum physical mobility within limitations imposed by the CVA.
Nursing Actions and
Refer to Care Plan on Immobility, Diagnosis 6, for measures related to ways to maintain optimal joint mobility and muscle function.
Implement additional measures
to increase mobility:
provide adequate rest periods before activity sessions
administer muscle relaxants (e.g. baclofen, dantrolene) if ordered
to relieve spasticity in affected extremities
perform actions to prevent falls (see Diagnosis 10, action a.1)
in order to decrease client's fear of injury
instruct client in and assist with use of mobility aids (e.g. cane, walker) if appropriate
after client's condition has stabilized, assist with and reinforce the following if appropriate:
neurodevelopmental treatment (e.g. Bobath approach)
to promote more normal movement of the affected extremities
neuromuscular re-education techniques (e.g. electromyographic biofeedback)
to improve muscle strength and reduce spasticity of the affected extremities.
Encourage the support of significant others. Allow them to assist with range of motion exercises, positioning, and activity if desired.
Consult appropriate health care provider (e.g. physical therapist, physician) if client is unable to achieve expected level of mobility or if range of motion becomes restricted.