Professional Documents
Culture Documents
in
Neurological Ward
Prepared by:
MIGUELITO M. GULTIANO
CSA – Student Nurse
Nursing Diagnosis for Neurological/Sensory Disorders
Glaucoma
Disturbed visual sensory perception
Anxiety (specify level)
Seizure disorders
Risk for trauma or suffocation
Risk for ineffective airway clearance or breathing pattern
Low self-esteem
Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs
Disc Surgery
Ineffective tissue perfusion
Risk for trauma (spinal)
Risk for ineffective airway clearance
Risk for ineffective breathing pattern
Acute pain
Impaired physical mobility
Constipation
Risk for urinary retention
Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs
Multiple Sclerosis
Fatigue
Self-care deficit (specify)
Chronic low self-esteem (specify situation)
Hopelessness or powerlessness ( specify degree)
Risk for ineffective coping
Disabled family coping
Compromised coping
Impaired urinary elimination
Risk for caregiver role strain
Knowledge deficient (learning need) regarding condition, prognosis, treatment regimen, self-care, and discharge needs
These are individualized nursing care plans for various nursing diagnoses.
Activity Intolerance
Acute Confusion
Acute Pain
Anxiety
Caregiver Role Strain
Constipation
Chronic Pain
Decreased Cardiac Output
Deficient Fluid Volume
Deficient Knowledge
Diarrhea
Disturbed Body Image
Disturbed Thought Processes
Excess Fluid Volume
Fatigue
Hyperthermia
Hypothermia
Imbalanced Nutrition: Less Than Body Requirements
Imbalanced Nutrition: More Than Body Requirements
Impaired Gas Exchange
Impaired Oral Mucous Membrane
Impaired Physical Mobility
Impaired Swallowing
Impaired Tissue (Skin) Integrity
Impaired Urinary Elimination
Assessment is required in order to distinguish possible problems that may have lead to Hypothermia.
Assessment Rationales
Causative factors guide the appropriate treatment. Older patients have a decreased
Assess for precipitating situations and
metabolic rate and reduced shivering response; therefore the effects of cold may
risk factors.
not be immediately manifested.
For alert patients, oral temperature is regarded as more reliable than tympanic or
Note and monitor patient’s
axillary. For hypothermic patients, core temperature can be monitored using a
temperature.
temperature-sensitive pulmonary artery catheter or bladder catheter.
Monitor the patient’s HR, heart HR and BP drop as hypothermia progresses. Moderate to severe hypothermia
rhythm, and BP. increases the risk for ventricular fibrillation, along with other dysrhythmias.
Evaluate the patient’s nutrition and Poor nutrition contributes to decreased energy reserves and restricts the body’s
weight. ability to generate heat by caloric consumption.
Check for electrolytes,
arterial blood gases, and oxygen Acidosis may emerge from hypoventilation and hypoxia.
saturation by pulse oximetry.
Evaluate for the presence of Severe hypothermia generates ice crystals to form inside cells. The cells eventually
frostbite, if the patient has had
prolonged exposure to a cold burst and die.
environment.
Nursing Interventions
Interventions Rationales
Regulate the environment temperature or relocate These methods provide for a more gradual warming of the body.
the patient to a warmer setting. Keep the patient Rapid warming can induce ventricular fibrillation. Moisture promotes
and linens dry. evaporative heat loss.
Give heated oral fluids for alert patients. Warm fluids produce a heat source.
Provide extra heat source:
May be related to
Ascending paralysis
Decrease lung
Possibly evidenced by
Desired Outcomes
Assess oxygen saturation and review client’s Determines oxygenation status and provides information about the
arterial blood gases results. effectiveness of ventilation given or the need to adjust the parameters.
Acute Pain
Acute Pain: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of
such damage; sudden or slow onset of any intensity from mild to severe with anticipated or predictable end and a duration of <6
months.
May be related to
Desired Outcomes
Child rates pain as less than (specify pain rating and scale used).
Identify the child’s perception of the word “pain” and inquire family members
Facilitates better communication between
what word the child uses at home; Utilize pain scale appropriate for the child’s
the child/family and nurse.
age and developmental level.
Administer analgesics based on pain assessment and respiratory status; Eliminates or controls pain and provides
Monitor side effect after administration. comfort.
Reassure parents and child that pain Provides information about the length of
diminishes as motor function slowly time pain might be anticipated to
improve or resolved. continue.
Identify pain preventive measures around the clock; observe for behavioral and Promotes immediate identification of pain
physiological signs of pain. which enhances efficient relief of pain.
Impaired Physical Mobility: Limitation in independent, purposeful physical movement of the body or of one or more extremities.
May be related to
Neuromuscular impairment
Possibly evidenced by
Paralysis
Inability to purposefully move within physical environment including bed mobility, transfer and ambulation
Limited ROM
Decreased muscle strength and control
Trauma from falls
Desired Outcomes
Client will have an improved strength and function of the affected extremity.
Client will demonstrate the use of adaptive devices to increase mobility.
Monitor nutritional needs as they associate with Good nutrition also gives required energy for participating in an
immobility. exercise or rehabilitative activities.
Place the client in a position of comfort. Provide Promotes relaxation and prevent the development of decubitus
frequent position changes as tolerated. ulcers.
Provide padding to bony prominences such as elbow Maintain extremity in a physiological position, reduces the risk
and heels. of pressure ulcers.
Perform active, passive and isotonic range of motion Improves joint mobility, stimulates circulation and enhance muscle
exercises as appropriate. tone.
Provide rest periods in between activities. Consider Rest periods are essential to conserve energy and avoid fatigue.
energy-saving techniques.
May be related to
Neuromuscular impairment
Possibly evidenced by
Urinary retention
Paralysis
Desired Outcomes
Assess progressive degree of paralysis and effect on urinary Provides data on the effect of motor dysfunction that
elimination. travels upward from extremities.
Instruct parents to maintain fluid intake and monitor output Maintains I&O balance and adequate intake to promote
in connection to intake. urinary output.
Instruct to report any reduction or absence of urinary Avoids complication of neuromuscular impairment of disease
elimination. and effect on urinary bladder function.
Anxiety
May be related to
Possibly evidenced by
Desired Outcomes
Facilitate expression of concerns and an opportunity to Provides an opportunity to release feelings, secure
ask inquiries regarding the condition and rehabilitation
information needed to overcome anxiety.
of the ailing child.
Teach parents and child about disease condition and Provides information to relieve anxiety by knowledge of what to
manifestation. expect.
Risk for Altered Parenting: At risk for the inability of the primary caretaker to create, maintain, or regain an environment that
promotes the optimum growth and development of the child.
May be related to
Illness
Possibly evidenced by
Verbalization of decreased interactions with hospitalized child and inability to provide care
Lack of control over the situation
Request for information about parenting skills for long recovery period or permanent residual disability
Desired Outcomes
Teach about physical therapy program Facilitates muscle recovery and prevents contractures
including ROM, exercises, gait training, bracing (refer and permanent disability, promotes a sense of confidence and
as indicated). control.
Continue to inform and support parents during the Provides reassurance that recovery is slow and conserves
recovery period (provide telephone numbers). parental emotional reserves.
Ineffective Tissue Perfusion: Decreased in the oxygen resulting in the failure to nourish the tissues at the capillary level
May be related to
Increased intracranial pressure
Cerebral edema
Possibly evidenced by
Delirium, hallucinations
Drowsiness
Hypercapnia
Desired Outcomes
Child will have vital signs return to normal; child is alerted and oriented: motor, cognitive, and sensory function are
within acceptable parameters for the child’s age; normal specific urine gravity.
Assess for nuchal rigidity, twitching, increased restlessness, and These are signs of meningeal irritation, which may
irritability. happen because of infection.
During reposition, avoid bending of the knee and pushing heels These activities increase intra-thoracic and
against the mattress. intrabdominal pressures, thereby increasing ICP.
Provide comfort measures and Decrease external stimuli such as Produces relaxing effect which decreases adverse
quiet environment, soft voice, and gentle touch. physiologic response and promotes rest to maintain
or lower ICP.
Hyperthermia
May be related to
Infection
Abnormal temperature regulation
Possibly evidenced by
Desired Outcomes
Child will regain and maintain body temperature within a normal range.
Disturbed Sensory Perception: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated,
distorted, or impaired response to such stimuli
May be related to
Decreased LOC
Cerebral edema
Increased ICP
Hydrocephalus
Possibly evidenced by
Altered sensorium
Desired Outcomes
Child will maintain normal LOC.
Assess for signs of cerebral edema such as Anoxia, vasodilation, or vascular stasis can lead to cerebral edema
dizziness, headache, irregular breathing, neck pain, due to the increased intracellular and extracellular fluid in
nausea or vomiting. the brain as the symptoms progress.
Assess ability to follow simple or complex Impaired cognitive function occurs with cerebral hemisphere
commands. involvement.
Assess for signs of meningeal irritation such as Meningeal signs are a result of meningeal and spinal root
headache, photobia, nuchal rigidity, opisthotonic inflammation, and/or pooling of infectious exudates and are cardinal
position, Kernig’s sign, Brudzinki’s sign. features of meningeal irritation.
Electroencephalogram
Lumbar puncture for CSF The following diagnostic exam are done to evaluate cerebral
pressure and identify the presence of infectious organisms.
Magnetic resonance imaging (MRI),
computed tomography (CT), or
ventriculogram
Initiate seizure precautions: observe and provide Providing appropriate and precise care during a seizure prevents
care during seizure. complication and further brain damage.
Maintain a quiet environment and keep the lights Prevents stimulation that can cause or precipitate an episode of
dim. convulsion.
Assess pupil size every 3 hours during the first 24 Increased intracranial pressure (ICP) will result in uneven pupil sizes,
hours and consequently every 6 hours. fixed dilated pupil.
Allow parents to participate in the child’s care. Support better coping and decrease anxiety.
Deficient Knowledge
May be related to
Possibly evidenced by
Request for information about medications, signs and symptoms and behaviors to report
General care during convalescence of infant/child
Desired Outcomes
Provide information and explanations in clear Ensures understanding based on readiness and ability to learn; visual
language that is understandable; use
pictures, pamphlets, video tapes, model in
aids reinforce learning.
teaching about disease.
Reinforce to parents follow up to assess for Promotes identification of hearing loss (injury to 8th cranial
potential hearing impairment. nerve caused by meningitis).
Inform parents as to the benefits of routine May prevent the disease; data suggests the incidence of this form of
immunizations with H. influenzae(type B) vaccine, meningitis has decreased since the vaccine was introduced;
beginning at 2 months of age for a total of 3 doses. may decrease the spread of infection to unvaccinated infants.
Teach to promote adequate rest and Rest important for convalescence and stimulating activities needed
activities that provide age-appropriate play and for continued development or to promote stimulation if
stimulation (specify). developmental lag is present.
Provide stool softeners or mild laxative, avoid use of Prevents constipation and lessen the risk of increased ICP due to
restraints and prevent or reduce crying episodes. straining from defecation.
Risk for Injury: Vulnerable for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive
resources, which may compromise health.
May be related to
Possibly evidenced by
[not applicable]
Desired Outcomes
Assess neurologic status to include VS pattern, changes in Provides information that offers clues to possible
consciousness, behavior patterns and pupillary/ocular responses change in intracranial pressure caused
appropriate for age (measure head circumference in infant) (specify by inflammation of the brain and associated
when). edema.
Stay with infant/child and sit near Provides limited stimulation to infant/child during
and speak in a low voice. acute stage of disease.
Reposition q 2h, positioning child to optimize comfort with HOB Maintains airway patency and prevents obstruction
slightly elevated, no pillow in bed, side-lying position if nuchal rigidity by secretion which increases CO2 retention
present; avoid sudden movements such as lifting the head; have and ICP.
oxygen and suctioning equipment on hand to be administered when
needed.
Inform parents of changes in condition, reasons for physical Promotes knowledge about possible
and mental changes and effects of the disease. manifestations of the disease and causes.
Inform parents of risk for complications and need for monitoring for Allows for ongoing care and responsibility in
increased ICP; review signs and symptoms of increased ICP. preventing change in neurologic status.
Administer stool softeners, avoid use of restraints and prevent or Prevents Valsalva’s maneuver that will increase
reduce crying episodes. ICP.
Risk for Trauma: The state in which an individual is at risk of accidental tissue injury (e.g., wound, burns, fracture).
Possibly evidenced by
Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing
interventions are directed at prevention.
Desired Outcomes
Verbalize understanding of factors that contribute to the possibility of trauma and or suffocation and take steps to
correct the situation.
Identify actions or measures to take when seizure activity occurs.
Identify and correct potential risk factors in the environment.
Demonstrate behaviors, lifestyle changes to reduce risk factors and protect self from injury.
Modify environment as indicated to enhance safety.
Maintain treatment regimen to control or eliminate seizure activity.
Recognize the need for assistance to prevent accidents or injuries.
Prevents or minimizes injury
when seizures (frequent or generalized)
Use and pad side rails with bed in lowest position, or place bed up against wall and occur while patient is in bed. Note: Most
pad floor if rails not available or appropriate. individuals seize in place and if in the
middle of the bed, individual is unlikely
to fall out of bed.
Do not leave the patient during and after seizure. Promotes safety measures.
Note pre seizure activity, presence of aura or unusual behavior, type of seizure Helps localize the cerebral area of
activity (location or duration of motor activity, loss of consciousness, incontinence, involvement.
eye activity, respiratory impairment or cyanosis), and frequency or recurrence.
Note whether patient fell, expressed vocalizations, drooled, or had automatisms (lip-
Nursing Interventions Rationale
Prepare for surgery or electrode implantation as indicated. Vagal nerve stimulator, magnetic beam
therapy, or other surgical intervention
(temporal lobectomy) may be done for
intractable seizures or well-localized
Nursing Interventions Rationale
Risk for Ineffective Airway Clearance: At risk for the inability to clear secretions or obstructions from the respiratory tract to
maintain a clear airway.
Neuromuscular impairment
Tracheobronchial obstruction
Perceptual or cognitive impairment
Possibly evidenced by
Not applicable. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing
interventions are directed at prevention.
Desired Outcomes
Maintain in lying position, flat surface; turn head to side Helps in drainage of secretions; prevents tongue from
during seizure activity. obstructing airway.
Loosen clothing from neck or chest and abdominal areas. Aids in breathing or chest expansion.
Nursing Interventions Rationale
Low Self-Esteem
May be related to
Possibly evidenced by
Desired Outcomes
Identify feelings and methods for coping with negative perception of self.
Verbalize increased sense of self-esteem in relation to diagnosis.
Verbalize realistic perception and acceptance of self in changed role or lifestyle.
Express positive self-appraisal
Demonstrate behaviors to restore positive self-esteem.
Participate in treatment regimen or activities to correct factors that precipitated crisis.
Determine individual situation related to low self-esteem in Verbalization of concerns about future implications can help
the present circumstances. patient begin to accept or deal with situation.
Elaborate the positive effect of staff and SO remaining calm Tension and anxiety among caregivers is contagious and can
Nursing Interventions Rationale
A spinal cord injury (SCI) is damage to any part of the spinal cord or nerves at the end of the spinal canal. The condition often causes
permanent changes in strength, sensation, and other body functions below the site of the injury.
Motor vehicle accidents, acts of violence, and sporting injuries are the common causes of spinal cord injury (SCI). The mechanism of
injury influences the type of SCI and the degree of neurological deficit. Spinal cord lesions are classified as a complete (total loss of
sensation and voluntary motor function) or incomplete (mixed loss of sensation and voluntary motor function).
Physical findings vary, depending on the level of injury, degree of spinal shock, and phase and degree of recovery, but in general, are
classified as follows:
Nursing care planning and goals for patients with spinal cord injuries includes: maximizing respiratory function, preventing injury to
the spinal cord, promote mobility and/or independence, prevent or minimize complications, support psychological adjustment of
patient and/or SO, and providing information about the injury, prognosis, and treatment.