A Nursing Care Plan

In Partial Fulfillment of the

Requirements in NCM 212 – RLE

OXYGENATION / FLUIDS AND ELECTROLYTES ROTATION

Submitted to:
Prof. Rizza Lei Loreto, MT, RN
Clinical Instructor

Submitted by:
Fhey Bernadette M. Beltran, St. N
BSN – 3C (Group 2)

November 21, 2022

Case Scenario
A 30-year-old patient named Abigail Barber Centillo went to the emergency department last July 15, 2021 under the attending physician Dr. Milo due to a
complaint of numbness and tingling sensation at her lower extremities which later on develop into paralysis. Along with that are partial vision loss at her left eye and
severe retro-orbital headache. Upon her admission, it was found out that she was diagnosed before with GI Infection and had a surgery. With those manifestations
and other diagnostic tests, the patient was later on diagnosed with Guillain Barre Syndrome. Evoked Potential test shows slow nerve impulses and patient has
decreased visual acuity and visual field at left eye. Currently, the patient had a relapse experience of a numbness and tingling sensation at her lower extremities and
can’t able to walk without any assistive devices – like wheelchairs and crutches. Also, the patient verbalizes “Usahay bisan gusto nako ilihok akong tiil, dili nako
mafeel og makit.an na galihok. Pero usahay malihok nako siya kung makainom kog tambal pero need rasad nakog alalay.” Medications were given hence improved
motor skills movement, however did not recover fully. Current Vital Signs are T: 37ºC; BP: 115/70 mmHg; RR; 19 cpm; PR: 80 bpm; CR: 83 bpm; SpO2: 96%.
 CLUSTERING OF CUES

GORDON’S FUNCTIONAL CUES PRIORITIZATION

HEALTH PATTER
• Numbness and tingling sensation at her lower Low Priotiy
extremities.
• Paraplegia
• Unable to walk without any assistive devices
(wheelchair and crutches).
Activity / Exercise VS
• T: 37ºC
• BP: 115/70 mmHg
• RR: 19 cpm
• PR: 80 bpm
• CR: 83 bpm
• SpO2: 96%
• Partial vision loss at her left eye Medium Priority
• Evoked Potential test shows slow nerve impulses.
Cognitive Perceptual • Decreased visual acuity at the left eye.
• Decreased visual field at left eye.
 Name of the Client: A.B.C Age/Sex: 30/Female Ward: Room #: Bed #:
Chief Complaint: Numbness and Tingling Sensation @ lower extremities Attending Physician: Dr. Milo Admitting Diagnosis / Impression: GBS

Date / Cues Need Nursing Patient Nursing Implementation Evaluation

Time
N Subjective:
O “Usahay bisan gusto
V nako ilihok akong tiil,
E dili nako mafeel og
M makit.an na galihok.
B Pero usahay malihok
E nako siya kung
R makainom kog
tambal pero need
2 rasad nakog alalay.”
1 As verbalized by the
patient.
2 X
0 Objective:
2 • Numbness and
2 tingling sensation
at her lower
Diagnosis Outcome Interventions
A Risk for fall as evidenced by At the end of 3 hours 1. Assess the presence 1 November 21, 2022
C partial vision loss and muscle nursing intervention, the of a patient’s @ 11:00 AM
T spasticity at lower extremity. patient will be able to impulsive behavior.
I remain free from falls R: Instances where “GOAL MET”
V Rationale: and injury cautiously. patients show impulsive
I In severe cases of Guillain behavior increases the After 3 hours of
T Barre Syndrome, aside from risk for injury which they nursing interventions,
Y peripheral nerves being are less able to control the patient was able to
affected specifically the their own behavior or remain from any
/ Autonomic nerves, the central actions. injuries and falls
nerves are also being safely.
E compromised. Muscle 2. Make sure to put big 2
spasticity happens when there marks or stickers on
E is tightness and stiffness of the hazardous places Fhey Bernadette M.
R muscles which enables the such as stairways, Beltran, St. N
C person to move and later on kitchen and
I loss its balance (Melinosky, bathrooms.
@ extremities was S 2021). Furthermore, muscle R: By doing this, it helps
noted. E spasticity occurs then there isa the patient become more
8:00 • Partial vision loss n imbalance of signals from the cautious and careful
AM at her left eye P CNS going to the muscles while walking in
• Severe retro- A brought by damaged hazardous areas.
orbital headache T peripheral nerves due to
noted. T demyelination, hence making 3. Ensure the safety of
• Evoked Potential E balance, movement and gait the patient by making 3
test shows slow R difficult (Medtronic, 2020). the environment
nerve impulses. N harmful-free such as;
• Decreased visual References: Decluttering the
acuity and visual Medtronic. (2020). About space, providing
field at left eye. Severe Spasticity. Retrieved adequate lighting,

• Unable to walk last November 18, 2022, from and providing

without any https://www.medtronic.com/us- rubberized slippers.

assistive devices. en/patients/conditions/severe- R: The safety of the

spasticity.html
Melinosky, C. (2021).
Spasticity. WebMD. Retrieved
last November 18, 2022, from
https://www.webmd.com/pain-
environment plays a
significant role in
maintaining the safety of
the patient, whereby this
also avoids patient’s
form of any unexpected
management/pain- injuries to name a few
management-spasticity are; slippering and
tripping.

4. Ensure that the floor

is dry and free from 4
any objects.
R: This is to avoid the
patient from slipping or
falling from the floor
which impose greater
risks.

5. Reinforce the use of

assistive devices, 5
such as canes,
crutches and
wheelchairs.
R: These assistive
devices serves as a
support for the patient in
order to have balance
while walking or
standing.

6. Teach the patient to

maintain sitting 6
position before
assuming standing
position for
ambulating.
R: Maintaining this
position for a few
minutes gives the patient
time to get to feet flat
and under self-balance
and minimizes any
dizziness that may occur
because of rapid position
changes.

7. During ambulation,
stand on the patient’s
weak side to assist 7
 with balance and
support. Also, a
transfer belt can be
utilize.
R: These measure
minimizes risk of falls in
cases that it provides
assistance and
surveillance.

8. Place items within

patient’s reach.
R: Items that are too far 8
from their reach may
impose harmful risks.

9. Encourage patient to
do simple exercises
to gradually mobilize 9
the affected area.
R: Doing simple
exercises facilitates
strengthening of the
lower extremities which
is a help for
rehabilitation.

10. Instruct the significant

other to closely
supervise and
encourage patient to 10
do simple exercises if
caregiver is not
around.
R: Continuous
supervision to the patient
with the significant
others will allow
continuous monitoring
that ensures maximum
safety and avoid harmful
risks of injuries.
References
Brewer, B. (2020). Paraplegic exercises that can help stimulate paralyzed legs. FlintRehab. Retrieved last November 18, 2022, from
https://www.flintrehab.com/paraplegic-exercises/
McCallum, K. (2021). Why do I get dizzy and lightheaded when standing up? Methodist. Retrieved last November 19, 2022, from
https://www.houstonmethodist.org/blog/articles/2021/oct/why-do-i-get-dizzy-lightheaded-when-standing-up/
Medtronic. (2020). About Severe Spasticity. Retrieved last November 18, 2022, from https://www.medtronic.com/us-en/patients/conditions/severe-spasticity.html
Melinosky, C. (2021). Spasticity. WebMD. Retrieved last November 18, 2022, from https://www.webmd.com/pain-management/pain-management-spasticity
Swearingen, P. L. (2016). All-in-one nursing care planning resources: medical-surgical, pediatric, maternity, and psychiatric-mental health. Elsevier, pp (251-
252).