Impaired Physical Mobility Related To Neuromuscular Impairment 70m3h

Nursing Care Plan ASSESSMENT

SCIENTIFIC

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

Subjective:

EXPLANATION Impaired physical

Neuromuscular

Short term

• Monitor V/S

• To note changes

After 4 hours of

mobility related to

disorders affect the

”Hindi ko maigalaw

neuromuscular

nerves that control

After 4 hours, the

ang aking kaliwang

impairment

the voluntary

patient verbalize

kamay at medyo

muscles. Voluntary

understanding

hindi ko rin maigalaw

muscles are the

situation or risk

diagnosis that

about the

ang kaliwa kong

ones that can be

factors and

contributes to

situations that may factors and

paa.”

controlled, like in the

individual treatment

immobility

restrict

individual treatment

arms and legs. The

regimen and safety

movements

regimen and safety

nerve cells, also

measures

Objective:

called neurons, send Left hemi paralysis

and for baseline

nursing intervention

comparison.

the patient was able to verbalize

• Determine the

• To be informed

understanding situation or risk

measures • Encourage and

• The longer the

the messages that

Long term

facilitate early

patient remains

After 4 months of

control these

After 4 months of

ambulation and other

immobile the

continuous ,effective

Limited range of

muscles. When the

continuous ,effective

ADLs when possible.

motion (ROM)

neurons become

and collaborative

Assist with each

greater the level of and collaborative nursing debilitation that

unhealthy or die,

nursing

initial change:

will occur

Functional level:

communication

interventions,

dangling, sitting in

was able to maintain

level 2-requires help

between the nervous patient will

chair, ambulation

position and function

interventions, patient

from another person.

system and muscles

maintain position,

breaks down. As a

function and skin

result, the muscles

integrity

and skin integrity as • Perform ive or

• Exercise promotes evidenced by the

active ROM

increased venous

absence of

weaken and waste

exercises to all

return, prevents

contractures,

away. The

extremities

stiffness, and

footdrop, decubitus

weakness can lead

maintains muscle

and so forth

to twitching, cramps,

strength and

aches and pains,

endurance

and t and movement

• Turn and position

• This optimizes

problems.

every 2 hours or as

circulation to all

Sometimes it also

needed.

tissues and

affects heart function

relieves pressure.

and ability to breathe. Many

• Provide safety

• To provide safety

neuromuscular

measures(side rails,

and reduce the

diseases are

using pillow to

risk of pressure

genetic, which

body part)

ulcers

means they run in families or there is a mutation in your

genes. Sometimes,

• Massage back and

• It provides comfort

an immune system

bony prominences

to the patient and

disorder can cause

promotes good

them. Most of them

circulation

have no cure. The goal of treatment is

• Consult with physical

• To develop

to improve

or occupational

individual exercise

symptoms, increase

therapist as

therapy or

mobility and

indicated

program

lengthen life.

Reference: http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=35

ASSESSMENT

SCIENTIFIC EXPLANATION

INFERENCE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

A decrease in a

After 8 hours, the

•

• Assist in

Subjective:

Constipation related

“Hindi ako

to insufficient physical person's normal

patient will establish

color, consistency,

identifying

patient was able to

mapadumi.”

activity

frequency of

or return to normal

frequency and

causative and

establish or return to

defecation,

patterns of bowel

amount

contributing

normal patterns of

Objective:

accompanied by

functioning

factors and

bowel functioning as

Abdominal pain,

difficult or

appropriate

evidenced by easy

urgency

incomplete age

interventions

age of

Determine stool

of stool and/or Altered bowel

age of

sounds

excessively hard,

Left Hemi paralysis

long, round, and •

Auscultate

• Bowel sounds are

smooth brown-

generally

shaded stool with a

dry stool. A lack of

decreased in

texture similar to

physical activity can

constipation

creamy peanut

bowel sounds

lead to constipation. Limited ROM

After 8 hours, the

For example,

butter •

Encourage

• Assists in

constipation often

increased fluid

improving stool

Constipated for five

occurs after an

intake, 2500-3000

consistency

days

accident or during

ml/day within

an illness when one

cardiac tolerance

must stay in bed and cannot exercise. Lack of

•

Encourage to eat high-fiber rich

• To enhance easy defecation

physical activity is

foods • Decrease gastric

thought to be one of the reasons

•

Recommend

distress and

constipation is more

avoiding gas-

abdominal

common in older

forming foods

distention

people. Moreover, increased physical activity is more likely

• Prevents skin •

Assist in

to stimulate bowel

perianal skin

motility and improve

condition frequently,

the symptoms of

noting changes or

constipation.

beginning

excoriation and breakdown

breakdown • Facilitates •

Discuss use of

defecation when

stool softeners, mild

constipation is

stimulants, bulk-

present

forming laxatives, or enemas as indicated. Monitor

effectiveness • Constipation is a •

Identify factors

common side

(e.g., medications,

effect of many

bed rest, diet) that

drugs including

may cause or

narcotics and

contribute to

antacids.

constipation. Evaluate medication profile for gastrointestinal side effects. • Fiber absorbs water, which adds •

Consult dietitian

bulk and softness

to provide well-

to the stool and

balanced diet high

speeds up

in fiber and bulk

age through the intestines

Reference: http://www.med.umich.edu/1libr/aha/umconstipation.htm

ASSESSMENT

DIAGNOSIS

SCIENTIFIC

PLANNING

INTERVENTION

RATIONALE

SUBJECTIVE:

Impaired adjustment

EXPLANATION Inability to modify

Short Term Goal

Independent

“ayoko kumain ng

related to health

lifestyle in a manner

After 4 days of

• Vital signs

walang lasa”

status requiring

consistent with a

nursing intervention,

monitored and

change in lifestyle

change in status.

there will be an

recorded. BP

through participation

OBJECTIVE:

The objective of

increase interest and

monitored regularly

and demonstration of

>pale to pinkish

nursing care for

participation on the

conjunctiva and lips

hypertensive patients demonstration of self

After 4 days of • For baseline comparison

• Assist the patient in • These risk factors

care and will initiate

identifying

have been shown

and controlling the

lifestyle changes that

modifiable risk

to contribute to

blood pressure

will permit adaptation

factors like diet

hypertension

>fair appetite,

without adverse

to present medical

high in sodium,

selective with food

effects and without

situation

saturated fats and

preferences

undue cost. To achieve these goals,

nursing interventions the goal is met

lifestyle changes

focuses on lowering >weak looking

EVALUATION

cholesterol

BP-130/90 mmHg

• Instruct and

• This will promote

and teach

emphasize

trust and will on

the patient to adhere

necessary care and

the patient to

to the treatment

lifestyle changes

adhere to such

regimen by

that will enhance

activities that will

implementing

her recovery.

enhance fast

the nurse must

necessary lifestyle

recover

changes like avoidance of foods

• Plan necessary

• Planning with the

high in sodium and

care and

relative will add

fats and taking

assistance in ADLs

more cooperation

medications as

with the relative

of the patient

prescribed. • Emphasize the importance of

• This will lower the patient’s BP

adequate rest • Emphasize the

• Hypertension

importance of

needs medications

adherence to

to maintain the BP

medications • Provide an open

in its normal range • Expression of

environment

feelings

encouraging

concerning

communication

impaired function is dealt with realistically

Reference: http://www.medicinenet.com/high_blood_pressure/article.htm

DRUG STUDY

Name of Drug

Classification

Indications

Side Effects

Contraindications

Nursing

Monitoring

Responsibilities

Parameters

•

Generic Name:

Mannitol •

Brand Name:

Osmofudin 20% •

Reduction of

•

Dizziness

•

Hypersensitivity

increased

•

Headache

•

Severe renal

condition before

signs, CVP, and

intracranial

•

Convulsions

disease

therapy and

urine specific

Action

pressure

•

Blurred vision

Severe

regularly

gravity

-increase osmotic

associated with

Diuresis

dehydration

thereafter to

pressure of

cerebral edema

• •

Dry mouth

Pulmonary

monitor drug

manifestations of

•

Loss of hearing

congestion

effectiveness

electrolyte

Assess for

imbalance

Miscellaneous Fluids or Diuretics

• •

•

Assess patient’s

•

•

Monitor vital

Monitor

Route and

glomerular filtrate

Frequency:

which inhibits tubular

increased ocular

re-absorption of

pressure

possible drug

Promotion of

induced adverse

and during the

electrolytes and

diuresis in the

reactions.

therapy with

increases urinary

prevention and/or

Assess patient for

patient lying,

output

treatment for

possible drug

standing and

oliguria or anuria

induced adverse

sitting, orthostatic

due to acute renal

reactions.

hypotension can

Teach patient to

occur rapidly.

IV q4

water and •

•

Dose:

100 cc

•

•

Reduction of

failure

•

•

•

recognize and immediately report adverse reactions

•

Assess BP before

•

Asses patient’s and family’s knowledge of drug therapy

Name of Drug • Generic Name:

Classification CNS stimulants or

Citicholine

Neurotonics

•

Brand Name:

Indications • CVA in acute and

Action

Cytidine Diphosphate -A derivative of choline and cytidine Choline involved in the •

Route and

biosynthesis of

Frequency:

lecithin. It is claimed

IV q12

to increased blood

•

flow and oxygen

Dose:

1 gm

consumption.

•

Contraindications • Hypertonia of the

recovery phase.

•

Hypersensitivity

parasympathetic

Signs and

•

Hypotension

nervous system

symptoms of

•

Insomnia

cerebral

•

Stimulates

insufficiency. •

Side Effects • Shock

•

Nursing

Monitoring

Responsibilities • Evaluate patient

Parameters • Monitor vital signs

medical history •

Pregnancy and lactation

•

reaction like GI

condition

disturbances

Should not be istered to

Recent cranial

action and

patient with

trauma

fleeting and

hypertonia of the

Parkinson’s

discreet

parasympathetic

disease

hypotension

nervous system •

Assess allergic

Assess patient

parasympathetic

effect

•

Caution that large doses could aggravate

increase in cerebral blood flow in episodes of persistent intracranial hemorrhage. •

Teach patient to gain benefits and not to miss any dose

Name of Drug

Classification

Indications

Side Effects

Contraindications

Nursing

Monitoring

Responsibilities

Parameters

•

Generic Name:

Simvastatin •

Brand Name:

Altovast

To reduce LDL

•

Abdominal pain

cholesterol,

•

Constipation

to any component

fat , protein,

phophokinase

apolipoprotein

•

Flatulence

of the

carbohydrates;

levels due to

Action

beta and

•

Insomnia

preparations

nutritional

possibility of

-Inhibits HMG-COA

triglycerides

•

Headache

Children and

analysis should

myopathy; serum

To increase HDL

•

Rashes

lactation

be completed by

cholesterol

•

Dizziness

Active liver

dietitian before

•

Muscle cramps

disease

treatment is

triglycerides,

Unexplained

initiated

cholesterol

Assess liver

baseline and

Cardiovascular Statins

reductase enzyme, •

•

•

Route and

which reduces

cholesterol in the

Frequency:

cholesterol

treatment of

production

hyperlipidaemias

Oral Od

• •

Dose:

40 mg

•

• • •

Hypersensitivity

•

•

Assess nutrition:

•

•

Monitor creatinine

Monitor

Coronary heart

persistent

disease

elevations of

function tests

throughout

serum

prior to therapy

treatment

transaminases

and periodically thereafter •

Evaluate therapeutic response and adverse reactions on a regular basis

•

Assess

knowledge or teach patient proper use

Monitoring

Responsibilities • Establish

Parameters • Monitor blood

Name of Drug • Generic Name:

Classification Indications Cardiovascular drugs • Treatment of

Side Effects • Dry cough

Imidapril

“antihypertensive”

•

Headache

known

baselines in

•

Rash

hypersensitivity to

renal, liver

•

Palpitation

angiotensin

function tests

orthostatic

•

Fatigue

converting

before therapy

hypotension

•

Discomfort in the

•

Brand Name:

Vascor

Action -inhibits angiotensin converting enzyme;

•

Route and

reduction of

Frequency:

angiotensin II

Oral OD Dose:

50 mg

throat

and reduction of vascular resistance

•

Monitor bp,

•

Check for edema

or with history of

•

Asses for patient

electrolytes

allergic reactions

during the firs 2

Advise patient to

weeks of therapy

edema •

studies

enzyme inhibitors angioneorotic

resulting in dilation of peripheral vessels

•

hypertension

Contraindications • Patients with

Nursing

•

•

Monitor

Pregnancy and

avoid potassium,

lactation

salt substitutes

studies and

Teach patient

symptoms

•

how to take Bp

•

Monitor renal

and normal readings for age group

Nursing Name of Drug • Generic Name:

Classification Cardiovascular drugs

Clonidine

“Centrally-acting

all grades of

drugs”

hypertension with

•

Drowsiness

the exception of

•

Dry mouth

Action

HPN due to

•

-stimulates central-

phaeochromooyto

Route and

alpha adrenergic

ma

Frequency:

receptors to inhibit

•

Brand Name:

Catapres •

Oral OD •

Indications • Management of

Dose:

75 mcg

•

Prophylactic

Side Effects • Local skin

Contraindications Responsibilities • Hypersensitivity to • Assess pain,

irritation

Parameters • Monitor baselines

clonidine

location, intensity,

for renal, liver

Sick sinus

character,

function test

syndrome

alleviating,

before therapy

Headache

aggravation

begins

•

Fatigue

factors, baseline

•

Anorexia

•

Anxiety

•

•

Monitor BP, standing, sitting,

Perform blood

supine, mental

studies,

status, and heart rate.

treatment of

cardioaccelareators

migraine or

neorophils,

and vasoconstrictor

recurrent

decreased

centers

vascular

platelets •

•

and frequency

sympathetic

treatment of

Monitoring

Perform renal

migraine •

studies •

For relief of cancer pain

Assess Bp and apical pulse before initial dose

•

Note allergic reactions

NAME OF DRUG

CLASSIFICATION

SIDE EFFECTS

CONTRAINDICATIONS

NURSING

MONITORING PARAMETERS  Monitor AST,

Used in

•

Bradycardia

 Hypersensitivity

RESPONSIBILITIES  Use caution in

hepatobiliray Drugs”

management of

•

Headache

 History of acute

presence of renal

ALT, Serum

H2 Receptor

gastrointestinal

•

Fatigue

or hepatic

creatinine, signs

Antagonists”

(GI) disorders.

•

Depression

impairment.

and symptoms of

Prophylaxis of

 Rashes

Generic Name:

Gastrointestinal /

Ranitidine Brand Name:

INDICATIONS

Zantac

•

• Mechanism of

GI hemorrhage

Action:

porphyria  Long-term therapy

 Assess for

peptic ulcer

potential for

disease, occult

from stress

interactions with

blood with GI

ulceration and in

other

bleeding.

at H2 receptor site

patients at risk of

pharmacological

Frequency:

in the gastric

developing acid

agents patient

function to

q 12

parietal cells, which

aspiration during

may be taking.

correct dos.

inhibits gastric acid

general

Route: I.V

Inhibits histamine

 Constipation

 Evaluate results of

 Monitor renal

Dose: 50 mg

secretion.

anesthesia.

laboratory tests, therapeutic effectiveness.