Nursing diagnoses

 

Nursing diagnoses

 

When caring for patients with neurologic disorders, certain nursing diagnoses are commonly used. When developing your care plan, keep in mind interventions to prevent the three most common complications in patients with neurologic disorders: respiratory infection, urinary tract infection (UTI), and infected pressure ulcers.

 

Nursing diagnoses: Impaired physical mobility

Impaired physical mobility can occur in ALS, cerebral palsy, stroke, MS, muscular dystrophy, myasthenia gravis, Parkinson’s disease, poliomyelitis, or spinal cord injury.

Expected outcomes

  • The patient will show no evidence of complications, such as contractures, venous stasis, thrombus formation, or skin breakdown.
  • The patient will achieve the highest level of mobility possible.
  • The patient will maintain muscle strength and joint ROM.

Nursing interventions and rationales

  • Have the patient perform ROM exercises at least once every shift, unless contraindicated. Progress from passive to active exercises, as tolerated. This prevents joint contractures and muscular atrophy.
  • Turn and position the dependent patient every 2 hours. Establish a turning schedule, post this schedule at the bedside, and monitor the frequency of turning. Turning prevents skin breakdown by relieving pressure.
  • Place joints in functional positions (use hand splints if needed and available), use a trochanter roll along the thigh, abduct the thighs, use high-top sneakers, and put a small pillow under the patient’s head. These measures maintain joints in a functional position and prevent musculoskeletal deformities.
  • Identify the patient’s level of functioning using a functional mobility scale. Communicate the patient’s skill level to all staff members to provide continuity and preserve a specific level of independence.
  • Encourage mobility independence by helping the patient use a trapeze and side rails to reposition himself; use his good leg to move his affected leg; and perform self-care activities, such as feeding and dressing, to increase muscle tone and build self-esteem.

Declaration of independence

  • If one-sided weakness or paralysis is present, place items within reach of the patient’s unaffected arm to promote independence.
  • Monitor and record evidence of immobility complications (such as contractures, venous stasis, thrombus, pneumonia, skin breakdown, and UTI) each day. The patient with a history of a neuromuscular disorder or dysfunction may be prone to complications.
  • Promote progressive mobilization to the degree possible in light of the patient’s condition (bed mobility to chair mobility to ambulation) to maintain muscle tone and prevent complications.
  • Refer the patient to physical and occupational therapists for development of a mobility regimen to help rehabilitate the patient’s musculoskeletal deficits. Request written mobility plans and use these as references.
  • Teach the patient and his family how to perform ROM exercises, transfers, and skin inspection and explain the mobility regimen to prepare the patient for discharge.
  • Demonstrate the mobility regimen, and have the patient and his caregivers do a return demonstration and note the dates of both. This ensures continuity of care and correct completion.
  • Help identify resources that will help the patient carry out the mobility regimen, such as Stroke-survivors International, the United Cerebral Palsy Associations, and the National Multiple Sclerosis Society, to help provide a comprehensive approach to rehabilitation.
[sociallocker]

Nursing diagnoses: Impaired skin integrity

Impaired skin integrity is a potential (and common) problem for anyone with a lower than normal level of activity. However, it can be deadly for a patient who can’t turn or move by himself. Infected pressure ulcers are one of the primary causes of death in a patient with neurologic disease. Even when not infected, pressure ulcers still cause prolonged distress and adversely affect the patient’s ability to function and his quality of life.

Expected outcomes

  • The patient will maintain intact skin integrity.
  • The patient won’t develop complications, should skin breakdown occur.
  • The patient will maintain the optimal nutrition needed to prevent skin breakdown.

Nursing interventions and rationales

  • Turn and move the patient at least every 2 hours if he’s unable to do so. Teach wheelchair patients to shift position several times each hour; provide help if needed. Pressure reduces skin circulation very quickly, which is a precursor to breakdown.

Steering clear of breakdowns

  • Use appropriate support surfaces, such as 4 convoluted foam mattresses or gelmats. If the patient develops pressure ulcers, consult established guidelines and protocols to determine the proper supportive surfaces for the patient. Repositioning and proper support surfaces reduce pressure on skin and help prevent skin breakdown.
  • Consult with an enterostomal therapist and published guidelines to determine preventive measures and interventions.
  • Encourage optimal food and fluid intake to maintain skin health.

Nursing diagnoses: Impaired urinary elimination

Impaired urinary elimination is another of the major complications affecting patients with neurologic disorders. Many of these patients have bladder spasticity or are unable to empty their bladders fully or properly. UTIs are common and can lead to prolonged hospitalization or even death.

Expected outcomes

  • The patient will empty his bladder completely and regularly.
  • The patient won’t develop a UTI.

Nursing interventions and rationales

  • Use appropriate strategies for assessing adequacy of output and bladder emptying. Although regular emptying is essential to urinary tract health, the patient may be unable to do so or may be unable to sense whether or not he’s completely emptying his bladder.
  • Encourage the patient to drink plenty of fluids each day. Fluid intake is essential to the production of urine to clean the urinary tract and bladder.
  • If the patient can’t empty his bladder alone, use the least invasive strategies to improve bladder emptying. Start with such techniques as Credé’s maneuver, in which the patient bends forward and presses on the bladder while urinating. Intermittent self-catheterization is more invasive, but less likely to cause infection than an indwelling urinary catheter.
  • If the patient voids adequately but is incontinent, a condom catheter will help keep his skin dry, while being less likely than intermittent or indwelling urinary catheterization to cause infection.

Nursing diagnoses: Impaired gas exchange

Impaired gas exchange relates to the third most common complication for patients with neurologic disorders: respiratory infection.

Expected outcomes

  • The patient won’t develop a respiratory infection.
  • The patient will maintain optimal oxygen saturation levels.

Nursing interventions and rationales

  • If the patient is immobile or has impaired respiratory muscle function, encourage the use of incentive spirometry, deep breathing, and coughing several times per day. Deep breathing and coughing help prevent atelectasis, which can become a respiratory infection as secretions accumulate.
  • Encourage fluid intake. Fluids keep respiratory secretions thin and easy to cough up.
  • Discourage smoking and exposure to second-hand smoke that impair respiration and the body’s ability to clear the lungs.
  • Encourage adequate rest, exercise, and nutrition, which will help maintain the strength of respiratory muscles.
[/sociallocker]

FURTHER READING:

Resources: