FATHER SATURNINO URIOS UNIVERSITY

San Francisco St. Butuan City 8600, Region XIII Caraga, Philippines
Nursing Program

PRIORITIZATION OF PROBLEMS

Rank Problem Identified

1 Impaired Urinary Elimination related to neuromuscular
impairment as evidenced by increasing urinary frequency and
urgency
2 Self-care Deficit related to neuromuscular impairments,
decreased strength and endurance, and motor impairment as
evidenced by numbness and weakness of the right arm and
inability to hold objects
3 Risk for Ineffective Coping related to physiological changes,
anxiety, and fear
 NURSING CARE PLAN #1
By A.T., Cuenca, FSUU, SN

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective data: Impaired Within 8 hours of nursing INDEPENDENT After 8 hours of nursing
No statements were Urinary intervention, the patient will 1. Note reports of urinary - Provides information about the intervention, the patient
verbalized by the Elimination be able to: frequency, urgency, burning, degree of interference with was able to:
patient related to incontinence, nocturia, and size or elimination or may indicate a
neuromuscular • Demonstrate behaviors force of the urinary stream. Palpate bladder infection. Fullness over • Demonstrate behaviors
Objective data: impairment as or techniques to bladder after voiding. bladder following void is indicative of or techniques to
• Increasing evidenced by prevent or minimize inadequate emptying or retention prevent or minimize
urinary increasing infection and requires intervention. infection
frequency and urinary • Be free of urine 2. Review drug regimen, including - A number of medications such as • Be free of urine
urgency frequency and leakage, achieve prescribed, over-the-counter some antispasmodics, leakage, achieve
• Episodes of eye urgency normal elimination (OTC), and street. antidepressants, and narcotic normal elimination
fuzziness pattern, and empty analgesics; OTC medications with pattern, and empty
associated with bladder complete and anticholinergic or alpha agonist bladder complete and
diplopia and regularly properties; or recreational drugs regularly
flashes of such as cannabis may interfere with
brightness bladder emptying. Goal met.
• Ascending 3. Encourage adequate fluid - Sufficient hydration promotes November 6, 2021
numbness and intake, avoiding caffeine and use urinary output and aids in preventing 11:00 AM
weakness of the of aspartame, and limiting intake infection. Note: When the patient is
right arm during the late evening and at taking sulfa drugs, sufficient fluids
• Inability to hold bedtime. Recommend use of are necessary to ensure adequate
objects cranberry juice/ vitamin C. excretion of the drug, reducing the
• Rapid risk of cumulative effects. Note: A.T., Cuenca, FSUU, SN
progression of Aspartame, a sugar substitute (e.g.,
weakness in the Nutrasweet), may cause bladder
legs irritation leading to bladder
dysfunction.
No vital signs data 4. Institute bladder training - Helps restore adequate bladder
were recorded program or timed voidings as functioning; lessens the occurrence
appropriate. of incontinence and bladder
infection.
5. Promote continued mobility. - Decreases risk of developing UTI.
6. Recommend good hand
washing and proper perineal care.
7. Obtain periodic urinalysis and
urine culture and sensitivity as
indicated.
8. Encourage patient to observe
for sediments or blood in urine, foul further evaluation or treatment.
odor, fever, or unexplained
increase in MS symptoms.
9. Teach self-catheterization and
instruct in the use and care of the
indwelling catheter.
COLLABORATIVE
10. Refer to urinary continence
specialist as indicated.
- Reduces skin irritation and the risk
of ascending infection.
- Monitors renal status. Colony
count over 100,000 indicates the
presence of infection requiring
treatment.
- Indicative of infection requiring
- Helps patient maintain autonomy
and encourages self-care. An
indwelling catheter may be required,
depending on the patient’s abilities
and degree of the urinary problem.
- Helpful for developing an
individual plan of care to meet
patient’s specific needs using the
latest techniques, continence
products.
 NURSING CARE PLAN #2
By A.T., Cuenca, FSUU, SN

Assessment Diagnosis Planning Implementation Rationale Evaluation

Subjective data: Self-care Within 8 hours of nursing INDEPENDENT After 8 hours of nursing
No statements were Deficit related intervention, the patient will 1. Determine the current activity - Provides information to develop a intervention, the patient
verbalized by the to be able to: level and physical condition. plan of care for rehabilitation. Note: was able to:
patient neuromuscular Assess degree of functional Motor symptoms are less likely to
impairments, • Demonstrate impairment using a 0–4 scale. improve than sensory ones. • Demonstrate
Objective data: decreased techniques and lifestyle 2. Encourage patient to perform - Promotes independence and techniques and lifestyle
• Increasing strength and changes to meet self- self-care to the maximum of ability sense of control; may decrease changes to meet self-
urinary endurance, care needs as defined by the patient. Do not feelings of helplessness. care needs
frequency and and motor • Perform self-care rush the patient. • Perform self-care
urgency impairment as activities within level of 3. Assist according to the degree - Participation in own care can ease activities within level of
• Episodes of eye evidenced by own ability of disability; allow as much the frustration over the loss of own ability
fuzziness numbness and autonomy as possible. independence.
associated with weakness of 4. Encourage patient input in the - Patient’s quality of life is enhanced Goal met.
diplopia and the right arm planning schedule and encourage when desires and likes are November 6, 2021
flashes of and inability to scheduling activities early in the considered in daily activities. 3:35 PM
brightness hold objects day or during the time when the Patients with MS expend a great
• Ascending energy level is best. deal of energy to complete ADLs,
numbness and increasing the risk of fatigue, which
weakness of the often progresses through the day.
right arm 5. Note presence of fatigue. - Fatigue experienced by patients A.T., Cuenca, FSUU, SN
• Inability to hold with MS can be very debilitating and
objects greatly impact the ability to
• Rapid participate in ADLs. The subjective
progression of nature of reports of fatigue can be
weakness in the misinterpreted by healthcare
legs providers and family, leading to
conflict and the belief that the
No vital signs data patient is “manipulative” when, in
were recorded fact, this may not be the case.
6. Allot sufficient time to perform - Decreased motor skills and
tasks, and display patience when spasticity may interfere with the
movements are slow.

7. Encourage stretching and
toning exercises and use of
medications, cold packs, and
splints and maintenance of proper
body alignment, when indicated.
8. Problem-solve ways to meet
nutritional and fluid needs.
9. Provide assistive devices and
aids as indicated: shower chair,
elevated toilet seat with arm
supports.
COLLABORATIVE
10. Consult with a physical and/or
occupational therapist.
ability to manage even simple
activities.
- Helps decrease spasticity and its
effects.
- Provides for adequate intake and
enhances the patient’s feelings of
independence or self-esteem.
- Reduces fatigue, enhancing
participation in self-care.
- Useful in identifying devices
and/or equipment to relieve spastic
muscles, improve motor functioning,
prevent and reduce muscular
atrophy and contractures, promoting
independence and an increasing
sense of self-worth.