Nursing Care Plan

GANADIN, MARIA JERISSA ANN M CN 101 - GROUP 2
NURSING CARE PLAN
AUGUST 24, 2013 UDMC- MED. WARD
ASSESSMENT
S > -----O Limited range of motion Difficulty turning Slowed movement Limited ability to perform gross or fine motor skills Uncoordina -ted movements Postural instability
DIAGNOSIS
Impaired Physical Mobility r/t Neuromuscular involvement: weakness, paresthesia; hemiplegia as evidenced by Inability to purposefully move within the physical environment; impaired coordination; limited range of motion; decreased muscle strength/control
PLANNING
After 8 hours of rendering care to the client, patient will be able to increase strength and function of affected body part.
INTERVENTION
RATIONALE
EVALUATION
After 8 hours of rendering care to the client, patient attained increase strength and functioning on her affected body part.
Assess functional Identifies strengths/deficiencies ability/extent of impairment and may provide information initially and on a regular basis. regarding recovery. Assists in Classify according to 04 scale. choice of interventions, because different techniques are used for flaccid and spastic paralysis. Change positions at least every 2 hr (supine, sidelying) and possibly more often if placed on affected side. Reduces risk of tissue ischemia/injury. Affected side has poorer circulation and reduced sensation and is more predisposed to skin breakdown/decubitus. Helps maintain functional hip extension; however, may increase anxiety, especially about ability to breathe. Prevents contractures/footdrop and facilitates use when/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
Position in prone position once or twice a day if patient can tolerate. Prop extremities in functional position; use footboard during the period of flaccid paralysis. Maintain neutral position of head.
Use arm sling when patient is in upright position, as
indicated.
subluxation and shoulder-hand syndrome. 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
Evaluate use of/need for positional aids and/or 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
Place knee and hop in extended position; Maintain leg in natural position with trochanter roll Begin active/passive ROM to all extremities (including splinted) on admission. Encourage exercises such as quadriceps/gluteal exercise, squeezing rubber ball, extension of fingers and legs/feet. Assist to develop sitting balance (e.g., raise head of bed; assist to sit on edge of bed, having patient use the
Minimizes muscle atrophy, promotes circulation, helps prevent contractures. Reduces risk of hypercalciuria and osteoporosis if underlying problem is hemorrhage. Note: Excessive/impr udent stimulation can predispose to rebleeding. Aids in retraining neuronal pathways, enhancing proprioception and motor response.
strong arm to support body weight and strong leg to move affected leg; increase sitting time) and standing balance (e.g., put flat walking shoes on patient, support patients lower back with hands while positioning own knees outside patients knees, assist in using parallel bars/walkers). Get patient up in chair as soon as vital signs are stable, except following cerebral hemorrhage. Helps stabilize BP (restores vasomotor tone), promotes maintenance of extremities in a functional position and emptying of bladder/kidneys, reducing risk of urinary stones and infections from stasis. Note: If stroke is not completed, activity increases risk of additional bleed/infarction.
Pad chair seat with foam or Prevents/reduces pressure on the water-filled cushion, and assist coccyx/skin breakdown. patient to shift weight at frequent intervals. Set goals with patient/SO for Promotes sense of expectation of participation in progress/improvement, and activities/exercise and position provides some sense of changes. control/independence. Encourage patient to assist with movement and exercises using unaffected extremity to May respond as if affected side is no longer part of body and needs encouragement and active training
support/move weaker side.
to reincorporate it as a part of own body. Promotes even weight distribution, decreasing pressure on bony points and helping to prevent skin breakdown/decubitus formation. Specialized beds help with positioning,enhance circulation, and reduce venous stasis to decrease risk of tissue injury and complications such as orthostatic pneumonia.
Provide egg-crate mattress, water bed, flotation device, or specialized beds (e.g., kinetic), as indicated.

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GANADIN, MARIA JERISSA ANN M CN 101 - GROUP 2

NURSING CARE PLAN

AUGUST 24, 2013 UDMC- MED. WARD

Use arm sling when patient is in upright position, as

support/move weaker side.

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