Nursing Care Plan

In Partial Fulfillment of the

PERCEPTION AND COORDINATION NURSING RLE

Submitted to:

Gemshe Santos, RN

Clinical Instructor

Submitted by:

Anikka Melisse B. Dumandan, StN

BSN3E- Group 1
MAY 2022
 SAN PEDRO HOSPITAL

Name of the Patient: G.C._______ _ Age: 27____ Sex: F____ Admission Date: May 12, 2022__________

Chief Complaint: Right-sided weakness and doubling of vision________________ Ward: __________ Room/Bed #: _______________

Diagnosis: Myasthenia gravis___________________ Physician: ______________________

Date/ Cues Needs Nursing Patient Outcome Nursing Interventions Imple Evaluation
Time Diagnosis ment
ation

M Subjective cues: A Fatigue related to After 1 week of May 19, 2022 3:00
Independent:
nursing PM
A - “grabe kaayo C muscle weakness
interventions, the 1. Monitor physiological
akong kaluya as evidenced by
Y T patient will be response to activity, such as 1
nurse ay wala jud verbalization of
able to: changes in BP, respiratory GOAL MET
koy kusog,” as I overwhelming
rate, or heart rate.
verbalized by the tiredness and 1. improve
12, V
patient impaired ability to muscle strength R: Activity tolerance varies After 1 week of
I maintain usual and endurance in greatly and when there is
Objective cues: interventions, the
routines. ambulation; weakness, the patient tends to
2022 T patient was able to:
- ptosis (right eye) exert more effort in doing
Y 2. explain energy
simple activities that can lead 1. improve muscle
conservation and
R: Fatigue is strength and
restoration plan to
7:00 - With a score of 8 - highly prevalent in to elevated vital signs.
offset the fatigue, endurance in
AM out of 10 on the ocular myasthenia
E and; ambulation as
fatigue scale (1 gravis although the
evidenced by being
being not fatigued X pathophysiology of 3. verbalize 2. Assess severity of fatigue
able to fully abduct
at all and 10 being it is unknown since increased energy on a scale of 0 to 10,
E arms without
total fatigue and it can be hard to and improved frequency of fatigue (number
difficulties and
exhaustion) R measure and it is vitality. of days per week and time of
assistance as well
merely an day), activities and
Interpretation: very C 2 as being able to
experience felt by symptoms associated with
fatigued move around the
I the person and it is increased fatigue, and the
room feeling weak,
still unsure why ability to perform ADLs.
S lastly a score of 0
myasthenia gravis
- With a score of 2 R: Results from this out of 10 (no fatigue
E can only affect one
out of 5 on the assessment helps in at all) in the fatigue
side of the body
muscle power formulating the best care plan scale;
than the other.
grading scale (0 for the day and helps in
P Fatigue is one of 2. explain energy
being no muscle assessing the severity of the
the hallmark signs conservation and
contraction and 5 A fatigue.
of myasthenia restoration plan to
being active
T gravis and is offset the fatigue as
movement against
T caused by the loss evidenced by
gravity with full Collaborative:
of muscle verbalization of
resistance)
E contraction due to “kung ako nalang
Interpretation: R the autoimmune 3. Refer to physical and/or
gani isa sa balay
active movement processes of the occupational therapy.
N pwede man na
only with gravity acetylcholine and
R: Programmed daily exercises magpahulay sako
eliminated the muscle
and activities help client gikan ug trabaho
receptors that
maintain or increase strength para kusgan ko inig
causes the
and muscle tone and enhance maka relax na ug
- unable to lift right neuromuscular
sense of well-being. kung kanus a gani
arm over the head weakness.
na murag maluya
(abduction)
nasad ko pwede
4. Start administering man ko magpa
(Ruiter, A.,
pyridostigmine PO. 3 deliver nalang ug
- Requires Verschuuren, J., &
pagkaon or grocery
assistance to Tannemaat, M., R: The anticholinesterase drug
pero kabalo nako
ambulate 2020) can improve muscle strength.
na importante na ag
exercise gihapon ko
ug inom atong
INDEPENDENT:
tambal nako”, and;

5. Provide a safe
environment for the patient 3. verbalize

such as removing objects increased energy

out of the way, securing side and improved

rails. Encourage a clean dry 4 vitality as
floor and a lit room. evidenced by
verbalization of “dili
R: This is to help the patient
na kaayo luya
see better and avoid injuries
akong lawas nurse
when doubling of vision is
makaya na nako
present.
ilihok-lihok akong
tuo na kamot, hay
salamat naulian
6. Provide assistance to the
nako”.
client while performing self-
care and as her activity level 5
increases as indicated.

R: Prevents severe
deconditioning and may
Anikka Dumandan,
conserve strength,
StN
increase stamina, and enable
client to become more active.

7. Encourage the patient to

perform ROM exercises in all
extremities, as prescribed.

R: To improve muscle strength

and stamina while preventing
muscle stiffness. taas
6

8. Teach deep breathing

exercises and relaxation
techniques and provide
adequate ventilation in the
room.

R: To allow the patient to relax

while at rest and to provide
adequate oxygen in the room
and in the body.

9. Recommend scheduling
activities for periods when
7
client has most energy and
plan care to allow for rest
periods while involving the
family in planning.

R: Planning allows client to be

active during times when
energy level is higher, which
may restore a feeling of well-
being and a sense of control.
Frequent rest periods are 8
needed to restore or conserve
energy. Number 9

10. Refer to community

resources, such as grocery
delivery, Meals on Wheels,
house cleaning or home
maintenance services,

or home-care agency

R: Provides assistance in areas

of individual need as ability to
care for self becomes more
difficult. 9
10
Clustering of Cues

CLUSTERED DATA NURSING DIAGNOSIS PRIORITY

(Diagnostic Label)

HEALTH PERCEPTION / MANAGEMENT

 “abi namog na stroke nani siya” Deficient Knowledge Low Priority

NUTRITIONAL-METABOLIC

 N/A N/A N/A

ELIMINATION

 N/A N/A N/A

ACTIVITY-EXERCISE

 Right arm weakness (2 out of 5 on the Fatigue High Priority

muscle power grading scale)
 Fatigue (8 out of 10 on the fatigue scale)
 unable to lift right arm over the head
 Requires assistance to ambulate

SLEEP-REST
 N/A N/A N/A

COGNITIVE-PERCEPTUAL

 Doubling of vision Risk for Injury Medium Priority

 ptosis

ROLES-RELATIONSHIP

 N/A N/A N/A

SEXUALITY-REPRODUCTIVE

 N/A N/A N/A

COPING-STRESS TOLERANCE

 N/A N/A N/A

VALUES-BELIEFS

 N/A N/A N/A

References:

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nursing care plans: Guidelines for individualizing client care across the life span. FA
Davis. Retrieved on May 11, 2022
Herdman, H. T., & Kamitsuru, S. (Eds.). (2017). NANDA international nursing diagnoses: definitions & classification 2018-2020. Thieme.
Retrieved on May 11, 2022
Ruiter, A., Verschuuren, J., & Tannemaat, M., (2020). Fatigue in patients with myasthenia gravis. A systematic review of the literature.
Retrieved May 11, 2022 from https://www.nmd-journal.com/article/S0960-8966(20)30160-7/fulltext
Swearingen, P. (2016). ALL-IN-ONE NURSING CARE PLANNING RESOURCE Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental
Health. Retrieved on May 11, 2022