Impaired Thalamic Connectivity Pattern in Alzheimer’s Disease and Mild Cognitive Impairment
60376572 Impaired Physical Mobility Related to Neuromuscular Impairment
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Transcript of 60376572 Impaired Physical Mobility Related to Neuromuscular Impairment
Nursing Care Plan
ASSESSMENT SCIENTIFIC
EXPLANATION
INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
”Hindi ko maigalaw
ang aking kaliwang
kamay at medyo
hindi ko rin
maigalaw ang kaliwa
kong paa.”
Objective:
Left hemi paralysis
Limited range of
motion (ROM)
Functional level:
level 2-requires help
Impaired physical
mobility related to
neuromuscular
impairment
Neuromuscular
disorders affect the
nerves that control
the voluntary
muscles. Voluntary
muscles are the
ones that can be
controlled, like in the
arms and legs. The
nerve cells, also
called neurons,
send the messages
that control these
muscles. When the
neurons become
unhealthy or die,
communication
between the
Short term
After 4 hours, the
patient verbalize
understanding
situation or risk
factors and
individual treatment
regimen and safety
measures
Long term
After 4 months of
continuous ,effectiv
e and collaborative
nursing
interventions,
Monitor V/S
Determine the
diagnosis that
contributes to
immobility
Encourage and
facilitate early
ambulation and
other ADLs when
possible. Assist with
each initial change:
dangling, sitting in
chair, ambulation
To note changes
and for baseline
comparison.
To be informed
about the
situations that
may restrict
movements
The longer the
patient remains
immobile the
greater the level
of debilitation that
will occur
After 4 hours of
nursing intervention
the patient was able
to verbalize
understanding
situation or risk
factors and
individual treatment
regimen and safety
measures
After 4 months of
continuous ,effective
and collaborative
nursing
interventions,
patient was able to
maintain position
from another person. nervous system and
muscles breaks
down. As a result,
the muscles weaken
and waste away.
The weakness can
lead to twitching,
cramps, aches and
pains, and joint and
movement
problems.
Sometimes it also
affects heart
function and ability
to breathe. Many
neuromuscular
diseases are
genetic, which
means they run in
families or there is a
mutation in your
patient will
maintain position,
function and skin
integrity
Perform passive or
active ROM
exercises to all
extremities
Turn and position
every 2 hours or as
needed.
Provide safety
measures(side rails,
using pillow to
support body part)
Massage back and
Exercise
promotes
increased venous
return, prevents
stiffness, and
maintains muscle
strength and
endurance
This optimizes
circulation to all
tissues and
relieves pressure.
To provide safety
and reduce the
risk of pressure
ulcers
and function and
skin integrity as
evidenced by the
absence of
contractures,
footdrop, decubitus
and so forth
genes. Sometimes,
an immune system
disorder can cause
them. Most of them
have no cure. The
goal of treatment is
to improve
symptoms, increase
mobility and
lengthen life.
bony prominences
Consult with
physical or
occupational
therapist as
indicated
It provides comfort
to the patient and
promotes good
circulation
To develop
individual exercise
therapy or
program
Reference:
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/Constructor/index.cfm?plan=35
ASSESSMENT SCIENTIFIC
EXPLANATION
INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Subjective:
“Hindi ako
mapadumi.”
Objective:
Abdominal pain,
urgency
Altered bowel
sounds
Left Hemi paralysis
Limited ROM
Constipated for five
days
Constipation related
to insufficient
physical activity
A decrease in a
person's normal
frequency of
defecation,
accompanied by
difficult or
incomplete passage
of stool and/or
passage of
excessively hard,
dry stool. A lack of
physical activity can
lead to constipation.
For example,
constipation often
occurs after an
accident or during
an illness when one
must stay in bed
and cannot
exercise. Lack of
After 8 hours, the
patient will establish
or return to normal
patterns of bowel
functioning
Determine stool
color, consistency,
frequency and
amount
Auscultate
bowel sounds
Encourage
increased fluid
intake, 2500-3000
ml/day within
cardiac tolerance
Encourage to
eat high-fiber rich
foods
Assist in
identifying
causative and
contributing
factors and
appropriate
interventions
Bowel sounds are
generally
decreased in
constipation
Assists in
improving stool
consistency
To enhance easy
defecation
After 8 hours, the
patient was able to
establish or return to
normal patterns of
bowel functioning as
evidenced by easy
passage of
long, round, and
smooth brown-
shaded stool with a
texture similar to
creamy peanut
butter
physical activity is
thought to be one of
the reasons
constipation is more
common in older
people. Moreover,
increased physical
activity is more
likely to stimulate
bowel motility and
improve the
symptoms of
constipation.
Recommend
avoiding gas-
forming foods
Assist in
perianal skin
condition frequently,
noting changes or
beginning
breakdown
Discuss use of
stool softeners, mild
stimulants, bulk-
forming laxatives, or
enemas as
indicated. Monitor
effectiveness
Decrease gastric
distress and
abdominal
distention
Prevents skin
excoriation and
breakdown
Facilitates
defecation when
constipation is
present
Identify factors
(e.g., medications,
bed rest, diet) that
may cause or
contribute to
constipation.
Evaluate medication
profile for
gastrointestinal side
effects.
Consult
dietitian to provide
well-balanced diet
high in fiber and
bulk
Constipation is a
common side
effect of many
drugs including
narcotics and
antacids.
Fiber absorbs
water, which adds
bulk and softness
to the stool and
speeds up
passage through
the intestines
Reference:
http://www.med.umich.edu/1libr/aha/umconstipation.htm
ASSESSMENT DIAGNOSIS SCIENTIFIC
EXPLANATION
PLANNING INTERVENTION RATIONALE EVALUATION
SUBJECTIVE:
“ayoko kumain ng
walang lasa”
OBJECTIVE:
>pale to pinkish
conjunctiva and lips
>weak looking
>fair appetite,
selective with food
Impaired adjustment
related to health
status requiring
change in lifestyle
Inability to modify
lifestyle in a manner
consistent with a
change in status.
The objective of
nursing care for
hypertensive
patients focuses on
lowering and
controlling the blood
pressure without
adverse effects and
Short Term Goal
After 4 days of
nursing intervention,
there will be an
increase interest and
participation on the
demonstration of self
care and will initiate
lifestyle changes that
will permit
adaptation to
present medical
Independent
Vital signs
monitored and
recorded. BP
monitored regularly
Assist the patient
in identifying
modifiable risk
factors like diet
high in sodium,
saturated fats and
For baseline
comparison
These risk factors
have been shown
to contribute to
hypertension
After 4 days of
nursing interventions
the goal is met
through participation
and demonstration
of lifestyle changes
preferences
BP-130/90 mmHg
without undue cost.
To achieve these
goals, the nurse
must support and
teach the patient to
adhere to the
treatment regimen
by implementing
necessary lifestyle
changes like
avoidance of foods
high in sodium and
fats and taking
medications as
prescribed.
situation cholesterol
Instruct and
emphasize
necessary care
and lifestyle
changes that will
enhance her
recovery.
Plan necessary
care and
assistance in ADLs
with the relative
Emphasize the
importance of
adequate rest
Emphasize the
This will promote
trust and will on
the patient to
adhere to such
activities that will
enhance fast
recover
Planning with the
relative will add
more cooperation
of the patient
This will lower the
patient’s BP
Hypertension
needs medications
importance of
adherence to
medications
Provide an open
environment
encouraging
communication
to maintain the BP
in its normal range
Expression of
feelings
concerning
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
Responsibilities
Monitoring
Parameters
Generic Name:
Mannitol
Brand Name:
Osmofudin 20%
Route and
Frequency:
IV q4
Dose:
100 cc
Miscellaneous Fluids
or Diuretics
Action
-increase osmotic
pressure of
glomerular filtrate
which inhibits tubular
re-absorption of
water and
electrolytes and
increases urinary
output
Reduction of
increased
intracranial
pressure
associated with
cerebral edema
Reduction of
increased ocular
pressure
Promotion of
diuresis in the
prevention and/or
treatment for
oliguria or anuria
due to acute
renal failure
Dizziness
Headache
Convulsions
Blurred vision
Diuresis
Dry mouth
Loss of hearing
Hypersensitivity
Severe renal
disease
Severe
dehydration
Pulmonary
congestion
Assess patient’s
condition before
therapy and
regularly
thereafter to
monitor drug
effectiveness
Assess for
possible drug
induced adverse
reactions.
Assess patient
for possible drug
induced adverse
reactions.
Teach patient to
recognize and
immediately
report adverse
Monitor vital
signs, CVP, and
urine specific
gravity
Monitor
manifestations of
electrolyte
imbalance
Assess BP
before and during
the therapy with
patient lying,
standing and
sitting, orthostatic
hypotension can
occur rapidly.
reactions
Asses patient’s
and family’s
knowledge of
drug therapy
Name of Drug Classification Indications Side Effects Contraindications
Nursing
Responsibilities
Monitoring
Parameters
Generic Name:
Citicholine
Brand Name:
Cytidine
Diphosphate Choline
Route and
Frequency:
IV q12
Dose:
CNS stimulants or
Neurotonics
Action
-A derivative of
choline and cytidine
involved in the
biosynthesis of
lecithin. It is claimed
to increased blood
flow and oxygen
consumption.
CVA in acute and
recovery phase.
Signs and
symptoms of
cerebral
insufficiency.
Recent cranial
trauma
Parkinson’s
disease
Shock
Hypersensitivity
Hypotension
Insomnia
Stimulates
parasympathetic
action and
fleeting and
discreet
hypotension
effect
Hypertonia of the
parasympathetic
nervous system
Pregnancy and
lactation
Evaluate patient
medical history
Assess patient
condition
Should not be
administered to
patient with
hypertonia of the
parasympathetic
nervous system
Caution that
large doses could
Monitor vital
signs
Assess allergic
reaction like GI
disturbances
1 gm 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
Responsibilities
Monitoring
Parameters
Generic Name:
Simvastatin
Cardiovascular
Statins
To reduce LDL
cholesterol,
Abdominal pain
Constipation
Hypersensitivity
to any
Assess nutrition:
fat , protein,
Monitor
creatinine
Brand Name:
Altovast
Route and
Frequency:
Oral Od
Dose:
40 mg
Action
-Inhibits HMG-COA
reductase enzyme,
which reduces
cholesterol
production
apolipoprotein
beta and
triglycerides
To increase HDL
cholesterol in the
treatment of
hyperlipidaemias
Coronary heart
disease
Flatulence
Insomnia
Headache
Rashes
Dizziness
Muscle cramps
component of the
preparations
Children and
lactation
Active liver
disease
Unexplained
persistent
elevations of
serum
transaminases
carbohydrates;
nutritional
analysis should
be completed by
dietitian before
treatment is
initiated
Assess liver
function tests
prior to therapy
and periodically
thereafter
Evaluate
therapeutic
response and
adverse
reactions on a
regular basis
Assess
knowledge or
teach patient
phophokinase
levels due to
possibility of
myopathy; serum
cholesterol
Monitor
triglycerides,
cholesterol
baseline and
throughout
treatment
proper use
Name of Drug Classification Indications Side Effects Contraindications
Nursing
Responsibilities
Monitoring
Parameters
Generic Name:
Imidapril
Brand Name:
Vascor
Route and
Frequency:
Oral OD
Dose:
50 mg
Cardiovascular
drugs
“antihypertensive”
Action
-inhibits angiotensin
converting enzyme;
reduction of
angiotensin II
resulting in dilation
of peripheral vessels
and reduction of
vascular resistance
Treatment of
hypertension
Dry cough
Headache
Rash
Palpitation
Fatigue
Discomfort in the
throat
Patients with
known
hypersensitivity
to angiotensin
converting
enzyme inhibitors
or with history of
angioneorotic
edema
Pregnancy and
lactation
Establish
baselines in
renal, liver
function tests
before therapy
Check for edema
Asses for patient
allergic reactions
Advise patient to
avoid potassium,
salt substitutes
Teach patient
how to take Bp
and normal
readings for age
Monitor blood
studies
Monitor bp,
orthostatic
hypotension
Monitor
electrolytes
during the firs 2
weeks of therapy
Monitor renal
studies and
symptoms
group
Name of Drug Classification Indications Side Effects Contraindications
Nursing
Responsibilities
Monitoring
Parameters
Generic Name:
Clonidine
Brand Name:
Catapres
Route and
Frequency:
Oral OD
Dose:
75 mcg
Cardiovascular drugs
“Centrally-acting
drugs”
Action
-stimulates central-
alpha adrenergic
receptors to inhibit
sympathetic
cardioaccelareators
and vasoconstrictor
centers
Management of
all grades of
hypertension with
the exception of
HPN due to
phaeochromooyto
ma
Prophylactic
treatment of
migraine or
recurrent
vascular
treatment of
migraine
For relief of
Local skin
irritation
Drowsiness
Dry mouth
Headache
Fatigue
Anorexia
Anxiety
Hypersensitivity to
clonidine
Sick sinus
syndrome
Assess pain,
location, intensity,
character,
alleviating,
aggravation
factors, baseline
and frequency
Perform blood
studies,
neorophils,
decreased
platelets
Perform renal
studies
Assess Bp and
apical pulse
Monitor baselines
for renal, liver
function test
before therapy
begins
Monitor BP,
standing, sitting,
supine, mental
status, and heart
rate.
cancer pain before initial dose
Note allergic
reactions
NAME OF DRUG CLASSIFICATION INDICATIONS SIDE EFFECTS CONTRAINDICATIONS NURSING
RESPONSIBILITIES
MONITORING
PARAMETERS
Generic Name:
Ranitidine
Brand Name:
Zantac
Route:
I.V
Frequency:
q 12
Dose:
50 mg
Gastrointestinal /
hepatobiliray Drugs”
H2 Receptor
Antagonists”
Mechanism of
Action:
Inhibits histamine
at H2 receptor site
in the gastric
parietal cells, which
inhibits gastric acid
secretion.
Used in
management of
gastrointestinal
(GI) disorders.
Prophylaxis of
GI hemorrhage
from stress
ulceration and in
patients at risk
of developing
acid aspiration
during general
anesthesia.
Bradycardia
Headache
Fatigue
Depression
Rashes
Constipation
Hypersensitivity
History of acute
porphyria
Long-term therapy
Use caution in
presence of renal
or hepatic
impairment.
Assess for
potential for
interactions with
other
pharmacological
agents patient
may be taking.
Evaluate results
of laboratory
tests, therapeutic
Monitor AST,
ALT, Serum
creatinine, signs
and symptoms
of peptic ulcer
disease, occult
blood with GI
bleeding.
Monitor renal
function to
correct dos.
effectiveness.