NURSING CARE PLAN

ASSESSMENT NURSING GOALS AND NURSING INTERVENTIONS RATIONALE EVALUATION

DIAGNOSIS OBJECTIVES

Subjective: Altered physical NOC: Self-Care: NIC: Joint Mobility GOAL MET
-65-year-old mobility related to Activities of Daily Living
Male neuromuscular (ADLs) The patient was able to
damage secondary engage in activities on
- Patient suddenly to Guillain- Barre GOAL: his own or within the
felt numbness of Syndrome The patient will parameters of his health
the limbs. demonstrate the use of state, and his endurance
adaptive equipment to and performance in the
- Symptoms increase mobility, afflicted limbs have
progress to body demonstrate increased improved. He also
weakness with endurance and demonstrated how to use
blurring of vision performance in the adaptive equipment to
and deafness afflicted limbs, and increase mobility.
despite of having engage in activities on his
good nutritional own or within the
intake parameters of the health
condition.
Objective:
- Patient is OBJECTIVE:
conscious and
coherent, but with OBJECTIVE: After 8 hours of nursing
minimal intervention,
stuttering After 8 hours of nursing
intervention the patient
- Complained of will, Examine mobility talents in the This is a good tool for the
difficulty of sequence listed below: assessment criteria and care Patient can now move
swallowing.  Sitting with and without plan for safe patient handling around with minimal
Determine if a client assistance and movement. assistance.
- Patient was requires both patient’s  Walking and standing
given 9 vials of safety and rehabilitation exercises
IgG daily for 5 due to reduced mobility,
consecutive days functional challenges, and Assess motor Interventions can subsequently
cognitive impairment. strength or functional be designed to target weak
- Patient was level of mobility. areas and therefore help
extubated after reduce the risk of immobility
manifesting and dependence (Rikli &
ability to move Jones, 2012)
the lower and
upper extremities. The patient's dietary needs should Proper nutrition to client
be closely monitored since they supplies the energy needed to Patient shows adherence
are related to a reduction or participate in his various in the dietary plan and
Adhere self-care activities
alteration in his mobility. physical or rehabilitation was able to consult to a
to improve lifestyle
activities. therapist.
Bony prominences, such as the It is less likely that pressure
elbows and heels, should be ulcers will develop if the
padded. Additionally, if extremities are kept in their
necessary, perform dynamic, and normal posture. It therefore
relaxing range-of-motion encourages joint mobility,
exercises. encourages oxygenation, and
boosts muscle strength.

Consult with To develop individual

physical/occupational
therapist as indicated.
Raise the bed side rails and
always lower the bed.
Maintain a safe and
comfortable position.
exercise/mobility program and
identify appropriate adjunctive
devices.
The patient verbalized,
It ensures patient’s safety.
“I feel more comfortable
 Provide a quiet environment and
practice deep breathing and
perform other relaxation methods
like listening to calm music,
reading, and watching podcast.
now. The methods of
Comfortable and peaceful relaxation too were very
environment promotes effective for me”.
relaxation to client condition.

Assess home environment for

Cooperate and learn the
factors that create barriers to
factors that affect his GBS
physical mobility. Refer to
condition.
occupational therapy services if
needed to assist the client in
restructuring home environment
and daily living patterns.
Develop a treatment plan that
includes specialized
interventions to promote
muscular strength and retrain
patients to conduct daily
activities (ADLs).
The patient cooperated
and able to assess the
barrier in his home and
was able to train with an
physical therapist.

Refer to physical therapy for gait

training, strengthening, and
balance training. Physical
therapists can provide direct
interventions as well as assess
need for assistive devices (e.g.,
cane, walker)
Altered mobility decreases
circulation to dependent areas.
Decreased circulation and
shearing place the client at
risk for skin breakdown.

Anticipate that the client can walk

Long-term altered physical
independently, encourage the
mobility may weaken his
client to start an exercise regimen
muscle. Exercising with S/O
or go for a stroll with a buddy.
will improve his mobility.
Provide support to the client and
family/caregivers during long- To support continued
term impaired. independent living.

Adhere to pharmacologic Administer medications as The patient received IgG

These are given  to help stop
regimen and non- prescribed: the harmful antibodies vials and oxygen 2LPM
pharmacologic regimen to  9 Vials IgG damaging your nerves. and no side effects were
address Guillain- Barre observed or reported. He
Syndrome. also verbalized “I feel
To avoid hypoxemia and much better now”.
Provide supplemental oxygen at dysrhythmia, additional
2LPM via nasal cannula oxygen must be maintained at
a saturation level greater than
90%.

Medications can cause side

Monitor medications for side effects or adverse effects which
effects. can worsen the client
condition. It is important to
monitor the drugs taken to
avoid complications

Illustrate adherence to Teach the client's family member Patient and Family
understanding instruction. how to use a wheelchair or other Mobility can be improved and member was able to
the risk of falling can be grasp the teachings and
mobility aids to promote
decreased with the proper use was able to enhance
movement, such as a cane,
of wheelchairs, canes, transfer their knowledge
walker, gait belt, weighted vest,
bars, and other assistive regarding on the
or crutches (Yeom et al, 2009).
equipment. patient’s condition

Work with the client using self-

Use of self-efficacy-based
efficacy interventions using
interventions resulted in
single or multiple methods. Teach
increased exercise (Resnick et
client and family members to
al, 2009).
assess fear of falling and develop
strategies to mitigate its effect on
mobility progression.