Nursing Care Plan for Guillain-Barre Syndrome
Guillain-Barre syndrome or GBS is a severe inflammatory disorder of the peripheral nerves.
Guillain-Barre Syndrome is an inflammatory disorder in which the body's immune system attacks the nerves, causing severe weakness and numbness and eventually leading to muscular paralysis.
The symptoms of Guillain-Barre syndrome are lack of feeling, weakness or itchiness in arms or legs, and possible loss of feeling and movement in the upper body, face, arms and legs. The symptoms can remain in this phase and can cause little difficulty in walking. However, in some cases the illness can progress resulting in entire paralysis of arms and legs.
Nursing Diagnosis: Impaired Physical Mobility related to neuromuscular damage
Goals:
To maintain the position of function with no complications (contractures, pressure sores).
Outcomes:
Clients can improve the strength and function of the affected part
Nursing Interventions and Rationale:
1. Assess motor strength / functional ability by using a scale of 0-5.
R / Define the development / re-emergence of signs that hinder the achievement of goals / expectations of the patient.
2. Give the patient a position that causes a sense of comfort. Make changes to the position on a regular schedule as needed on an individual basis.
R / Reduce fatigue, increase relaxation. Reduce the risk of ischemia / damage to the skin.
3. Chock extremities and joints with a pillow.
R / Maintain extremity in a physiological position, prevent contractures.
4. Perform passive range of motion exercises. Avoid active exercise during the acute phase.
R / Stimulates circulation, improve muscle tone and increase joint mobilization.
5. Coordinate care provided and the period of uninterrupted rest.
R / Excessive use of muscles can increase the time it takes to remielinisasi, arena may extend the time for healing.
6. Encourage you to do the exercise that continues to be developed and depend on individual tolerance.
R / exercise activities in the affected areas gradually improved / fixed, improve organ function normally and have a positive psychological effect
7. Give lubrication / oil artificially within their needs.
R / Prevent from drying the client's body.
Collaboration
1. Confirm with / refer gets physical therapy / occupational therapy.
R / Helpful in creating individual muscle strength / exercise conditioned and running training programs and identify tools to maintain the mobilization and independence in performing daily activities.
Showing posts with label Neurosurgical Nursing. Show all posts
Showing posts with label Neurosurgical Nursing. Show all posts
Disturbed Body Image - Nursing Care Plan for Brain Tumor
A brain tumor is an intracranial solid neoplasm, a tumor within the brain or the central spinal canal.
The most common primary brain tumors are:
The most frequent symptoms of brain tumors include:
Nursing Care Plan for Brain Tumor
Nursing Diagnosis : Disturbed Body Image related to hair loss, and changes in the structure and function of the body.
Goal:
Interventions:
The most common primary brain tumors are:
- Gliomas (50.4%)
- Meningiomas (20.8%)
- Pituitary adenomas (15%)
- Nerve sheath tumors (8%)
The most frequent symptoms of brain tumors include:
- Headaches that tend to be worse in the morning and ease during the day
- Seizures or convulsions
- Nausea or vomiting
- Weakness or loss of feeling in the arms or legs
- Stumbling or lack of coordination in walking
- Abnormal eye movements or changes in vision
- Drowsiness
- Changes in personality or memory
- Changes in speech
Nursing Care Plan for Brain Tumor
Nursing Diagnosis : Disturbed Body Image related to hair loss, and changes in the structure and function of the body.
Goal:
- Patients express a positive self-image with the criteria of patients receiving changes to body image.
Interventions:
- Assess the patient's reaction to body changes.
- Observation of patient social interaction.
- Maintain a therapeutic relationship with the patient.
- Instruct the patient to open communication with health care or other important person.
- Help patients find effective coping about body image.
- Determine the patient's reaction to changes in body image.
- Social withdrawal may occur due to rejection.
- Facilitate a therapeutic relationship that is open.
- Expression of fears openly to reduce anxiety.
- Help patients find coping strategies that can reduce anxiety and fear.
Risk for Injury - Multiple Sclerosis Care Plan
Multiple Sclerosis (MS) is a progressive and chronic disease that attacks the central nervous system.
More than 2.5 million people around the world are said to be affected by multiple sclerosis. Disease onset is usually seen more in young adults, and it is more common in women. Almost 98% of the MS population is Caucasian. MS is generally more common in people living in temperate zones.
MS can be difficult to diagnose since its signs and symptoms may be similar to other conditions. A number of specialized tests may be necessary for accurate diagnosis. Medical organizations have set diagnostic criteria to standardize the process. Currently diagnosis is based on The McDonald criteria which focus on a demonstration with clinical, laboratory and radiological data.
Nursing Diagnosis for Multiple Sclerosis : Risk for Injury
related to :
Goal :
Risk for Injury did not occur
Outcomes:
Intervention and Rational :
1. Maintain bed rest and immobilization as indicated.
Rational : Minimize the pain caused by stimulation of grit between the bone fragments with the surrounding soft tissue.
2. Give goggles that fit with the client.
Rational : Eye shields or goggles cover implus can be used to block vision in one eye when a client is experiencing diplopia or double vision.
3. Minimize the effects of immobility.
Rational: Because physical activity and immobilization often occur in multiple sclerosis, the complications which connect with immobilization and rare covers to prevent pressure sores.
4. Modification of injury prevention.
Rational: Injury prevention is done on the client if the motor dysfunction of multiple sclerosis causes no problems in coordination and any stiffness or if there's ataxia, the risk of falling.
5. Environmental modifications.
Rational: the inability to cope, to encourage clients with empty legs on a vast space to provide a broad base and to improve the ability to walk steadily.
6. Teach walking technique.
Rational: if the loss of sensation to the body position, encourage clients to see the foot while walking.
7. Provide occupational therapy.
Rational: Occupational therapy is a resource that helps individuals to provide advice and assistance to ensure increased independence.
8. Minimize the risk of decubitus.
Rational: Because of sensory loss can lead to increased loss of motoric move. Continue to be addressed to inegritas decubitus skin. Wheelchair use increases the risk.
9. Distal section of skin inspection, every day (monitor skin and mucous membranes to irritation, redness, or blisters).
Rational : early detection of circulatory disorders and loss of sensation of the high risk of damage to skin integrity possible complications of immobilization.
10. Minimize spasticity and contractures .
Rational : Muscle spasticity is common and occurs at an advanced stage , which is visible in the form of heavy addukor on hips, with a spasm of the hip and knee flexors.
11. Teach exercise techniques.
Rational: Exercise every day to strengthen the muscles supplied to minimize joint contractures. Special attention is given to the thigh muscles, the gastrocnemius muscle, adductor, biceps and wrists, and fingers flexors.
12. Maintain a 90-degree joints of the foot board.
Rational: The soles of the feet in position 90 degrees to prevent footdrop.
13. Evaluation of signs / symptoms of the expansion of tissue injury (inflammation of local / systemic, just as increased pain, edema and fever).
Rational: Assessing the development of the client's problem.
More than 2.5 million people around the world are said to be affected by multiple sclerosis. Disease onset is usually seen more in young adults, and it is more common in women. Almost 98% of the MS population is Caucasian. MS is generally more common in people living in temperate zones.
MS can be difficult to diagnose since its signs and symptoms may be similar to other conditions. A number of specialized tests may be necessary for accurate diagnosis. Medical organizations have set diagnostic criteria to standardize the process. Currently diagnosis is based on The McDonald criteria which focus on a demonstration with clinical, laboratory and radiological data.
Nursing Diagnosis for Multiple Sclerosis : Risk for Injury
related to :
- sensory impairment and vision,
- effects of prolonged bed rest and spastic weakness.
Goal :
Risk for Injury did not occur
Outcomes:
- Clients want to participate to the prevention of trauma.
- Decubitus : no.
- Joint contractures : no.
- Clients do not fall out of bed.
Intervention and Rational :
1. Maintain bed rest and immobilization as indicated.
Rational : Minimize the pain caused by stimulation of grit between the bone fragments with the surrounding soft tissue.
2. Give goggles that fit with the client.
Rational : Eye shields or goggles cover implus can be used to block vision in one eye when a client is experiencing diplopia or double vision.
3. Minimize the effects of immobility.
Rational: Because physical activity and immobilization often occur in multiple sclerosis, the complications which connect with immobilization and rare covers to prevent pressure sores.
4. Modification of injury prevention.
Rational: Injury prevention is done on the client if the motor dysfunction of multiple sclerosis causes no problems in coordination and any stiffness or if there's ataxia, the risk of falling.
5. Environmental modifications.
Rational: the inability to cope, to encourage clients with empty legs on a vast space to provide a broad base and to improve the ability to walk steadily.
6. Teach walking technique.
Rational: if the loss of sensation to the body position, encourage clients to see the foot while walking.
7. Provide occupational therapy.
Rational: Occupational therapy is a resource that helps individuals to provide advice and assistance to ensure increased independence.
8. Minimize the risk of decubitus.
Rational: Because of sensory loss can lead to increased loss of motoric move. Continue to be addressed to inegritas decubitus skin. Wheelchair use increases the risk.
9. Distal section of skin inspection, every day (monitor skin and mucous membranes to irritation, redness, or blisters).
Rational : early detection of circulatory disorders and loss of sensation of the high risk of damage to skin integrity possible complications of immobilization.
10. Minimize spasticity and contractures .
Rational : Muscle spasticity is common and occurs at an advanced stage , which is visible in the form of heavy addukor on hips, with a spasm of the hip and knee flexors.
11. Teach exercise techniques.
Rational: Exercise every day to strengthen the muscles supplied to minimize joint contractures. Special attention is given to the thigh muscles, the gastrocnemius muscle, adductor, biceps and wrists, and fingers flexors.
12. Maintain a 90-degree joints of the foot board.
Rational: The soles of the feet in position 90 degrees to prevent footdrop.
13. Evaluation of signs / symptoms of the expansion of tissue injury (inflammation of local / systemic, just as increased pain, edema and fever).
Rational: Assessing the development of the client's problem.
Subscribe to:
Comments (Atom)