Outcomes (NOC)	Interventions (NIC) and Rationales
Pain Control	Pain Management
• Describes causal factors _____ • Uses diary to monitor symptoms over time _____ • Uses preventive measures _____ • Uses nonanalgesic relief measures _____ • Uses analgesics as recommended _____ • Reports pain controlled _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity or severity of pain, and precipitating factors to determine appropriate interventions. • Use appropriate assessment method that allows for monitoring of change in pain and that will assist in identifying actual and potential precipitating factors (e.g., flowsheet, daily diary) to provide patient some control in identifying and controlling factors that may precipitate headaches. • Teach the use of nonpharmacologic techniques (e.g., biofeedback, relaxation, guided imagery, music therapy, distraction, and massage) before pain occurs or increases, and along with other pain relief measures, to provide sense of control over pain. • Provide the person optimal pain relief with prescribed analgesics to reduce pain. • Evaluate the effectiveness of the pain control measures used through ongoing assessment of the pain experience to assess efficacy and identify adverse drug effects. • Consider referrals for patient, family, and significant others to support groups and other resources to increase ability to manage pain and reduce stress.

eNursing Care Plan 59-2 Patient With Seizure Disorder or Epilepsy

Nursing Diagnosis*

Ineffective breathing pattern related to neuromuscular impairment secondary to tonic-clonic status epilepticus and/or postictal fatigue as evidenced by altered respiratory rate, rhythm, and/or depth

Patient Goal

Experiences breathing pattern adequate to meet oxygen needs

Outcomes (NOC)	Interventions (NIC) and Rationales
Respiratory Status: Ventilation	Airway Management
• Respiratory rate _____ • Respiratory rhythm _____ • Depth of inspiration _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range	• Monitor respiratory and oxygenation status to determine presence and extent of breathing problem and to initiate appropriate interventions. • Position patient (side-lying) to maximize ventilation potential and decrease risk of aspiration. • Identify patient requiring actual/potential airway insertion to facilitate intubation as necessary. • Perform endotracheal or nasotracheal suctioning to maintain airway. Seizure Management • Loosen clothing to prevent restricted breathing. • Apply oxygen as appropriate to maintain oxygenation and prevent hypoxia. • Monitor postictal period duration and characteristics because neurologic damage can affect postictal breathing pattern.

Nursing Diagnosis

Risk for injury related to loss of consciousness during seizure activity and postictal physical weakness

Patient Goal

Experiences no seizure-related injury

Outcomes (NOC)	Interventions (NIC) and Rationales
Seizure Control	Seizure Precautions
• Describes precipitating seizure factors _____ • Avoids seizure triggers/risk factors _____ • Uses medications as prescribed _____ • Obtains medical attention immediately if seizure frequency increases _____ • Implements safety practices in environment _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Monitor compliance in taking antiseizure medications to determine risk for seizures. • Remove potentially harmful objects from the environment. • Keep suction, Ambu bag, oral or nasopharyngeal airway at bedside to maintain airway and oxygenation if needed. • Use padded side rails to prevent injury during a seizure. • Instruct patient to carry medication alert card to provide information in case of emergency. Seizure Management • Remain with patient during seizure to protect patient from injury. • Guide movements to prevent injury during a seizure. • Monitor neurological status to identify any deficits resulting from seizure. • Record seizure characteristics: body parts involved, motor activity, and seizure progression. • Monitor postictal period duration and characteristics to plan appropriate interventions as needed.

Nursing Diagnosis

Ineffective coping related to perceived loss of control and threat to physical and social well-being as evidenced by denial of diagnosis, lack of truth-telling regarding seizure frequency, noncompliant behavior

Patient Goals

1. Expresses acceptance of seizure disorder by admitting presence of epilepsy and maintaining compliant behavior

2. Maintains therapeutic levels of antiseizure medications

Outcomes (NOC)	Interventions (NIC) and Rationales
Seizure Control	Coping Enhancement
• Maintains positive attitude toward seizure disorder _____ • Maintains role performance _____ • Maintains social relationships _____ Acceptance: Health Status • Recognizes reality of health situation _____ • Copes with health situation _____ • Adjusts to change in health status _____ • Reports sense of life being worth living _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Appraise patient’s adjustment to changes in body image. • Appraise impact of patient’s life situation on roles and relationships to determine extent of problem and to plan appropriate interventions. • Appraise and discuss alternative responses to situation. • Provide factual information concerning diagnosis, treatment, and prognosis to clarify changes required. • Encourage verbalization of feelings, perceptions, and fears to enable patient to deal with emotional responses to seizure disorder. • Assist the patient to identify positive strategies to deal with limitations and manage needed lifestyle or role changes. • Arrange situations that encourage patient’s autonomy to promote effective coping by providing correct information. Teaching: Disease Process • Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process. • Describe possible chronic complications. • Describe rationale behind management/treatment recommendations.

Nursing Diagnosis

Ineffective self-health management related to lack of knowledge about management of seizure disorder as evidenced by verbalization of lack of knowledge, inaccurate perception of health status, noncompliance with prescribed health behavior

Patient Goals

1. Describes factors involved in effective management of seizure disorder

2. Makes decisions about health and lifestyle modifications necessary for management of seizure disorder

Outcomes (NOC)	Interventions (NIC) and Rationales
Knowledge: Disease Process	Teaching: Disease Process
• Specific disease process _____ • Precautions to prevent complications of disease _____ • Available support groups _____ Measurement Scale 1 = No knowledge 2 = Limited knowledge 3 = Moderate knowledge 4 = Substantial knowledge 5 = Extensive knowledge	• Appraise the patient’s current level of knowledge related to specific disease process to establish learning needs. • Discuss lifestyle changes (e.g., avoidance of precipitating factors, driving restrictions, wearing medical ID tags, moderation in drinking and eating, exposure to stress, and avoidance of hazardous activities) that may be required to prevent future complications and/or control the disease process. • Discuss therapy/treatment options and describe rationale behind management/treatment options so patient and family can make lifestyle modifications to manage a chronic disease.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 59-3 Patient With Multiple Sclerosis

Nursing Diagnosis*

Impaired physical mobility related to muscle weakness or paralysis and muscle spasticity as evidenced by inability to ambulate and painful, intermittent muscle spasms

Patient Goals

1. Maintains or improves muscle strength and mobility

2. Uses assistive devices appropriately for ambulation and mobility

Outcomes (NOC)	Interventions (NIC) and Rationales
Mobility	Exercise Therapy: Ambulation
• Balance _____ • Coordination _____ • Muscle movement _____ • Joint movement _____ • Walking _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	• Apply/provide assistive device (e.g., cane, walker, or wheelchair) for ambulation if the patient is unsteady to decrease fatigue and enhance independence, comfort, and safety. • Encourage independent ambulation within safe limits to maintain mobility and promote independence. Exercise Therapy: Joint Mobility • Instruct patient/caregiver how to systematically perform passive, assisted, or active ROM exercises, as indicated, to prevent contractures and minimize muscle atrophy. Exercise Promotion: Stretching • Instruct patient to slowly extend muscle/joint to point of full stretch (or reasonable discomfort) and hold for specified time and slowly release the stretched muscles to relieve spasms and contracted muscles.

Nursing Diagnosis

Impaired urinary elimination related to sensorimotor deficits as evidenced by post-urination residual volume >50 mL, bladder distention, dribbling, urgency, frequency

Patient Goals

1. Maintains urinary continence

2. Experiences post-urination residual urine volume <50 mL

3. Uses intermittent catheterization to maintain urinary function if necessary

Outcomes (NOC)	Interventions (NIC) and Rationales
Urinary Continence	Urinary Elimination Management
• Maintains predictable pattern of voiding _____ • Recognizes urge to void _____ • Responds to urge in timely manner _____ • Gets to toilet between urge and passage of urine _____ • Voids >150 mL each time _____ • Ingests adequate amount of fluid _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Teach patient to drink 8 oz of liquid with meals, between meals, and in early evening to dilute urine and reduce risk of UTI. • Instruct patient to monitor for signs and symptoms of UTI to ensure early identification and treatment. • Monitor for signs and symptoms of urinary retention to provide early intervention. • Identify factors that contribute to incontinence episodes to plan interventions. • Instruct patient to respond immediately to urge to void to prevent incontinence. • Assist patient with development of toileting routine to help ensure adequate bladder function. Urinary Retention Care • Monitor degree of bladder distention by palpation and percussion to assess urinary retention. • Implement intermittent catheterization to prevent distention or dribbling. • Provide Credé’s maneuver as an alternative method of emptying the bladder. • Stimulate the reflex bladder by applying cold to the abdomen, stroking the inner thigh, or running water to assist in emptying the bladder.

Nursing Diagnosis

Interrupted family processes related to changing family roles, shift in health status of a family member, potential financial problems, and fluctuating physical condition as evidenced by strained family relations, ineffective communication, verbalization of financial concerns

Patient Goals

1. Maintains open communication within the family

2. Utilizes financial, social, and health services to maintain family processes

Outcomes (NOC)	Interventions (NIC) and Rationales
Family Coping	Family Process Maintenance
• Confronts family problems _____ • Manages family problems _____ • Involves family members in decision making _____ • Expresses feelings and emotions freely among members _____ • Maintains financial stability _____ • Uses available family support system _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Identify effects of role changes on family processes. • Assist family members to implement normalizing strategies for their situation. • Assist family members to use existing support mechanisms to enable the family to handle the issues of long-term illness. • Design schedules of patient home care activities that minimize disruption of family routine. Family Support • Facilitate communication of concerns/feelings between patient and family or between family members. • Provide assistance in meeting basic needs for family, such as shelter, food, and clothing, to provide additional help in coping with a chronic debilitating disease. • Assist family to acquire necessary knowledge, skills, and equipment to sustain their decision about patient care as lack of knowledge about multiple sclerosis affects ability to cope with its effects.

Nursing Diagnosis

Ineffective self-health management related to knowledge deficit regarding management of multiple sclerosis, complexity of therapeutic regimen, and expressed powerlessness and inability to care for self as evidenced by verbalization of lack of knowledge, expressed feelings of inability to care for self

Patient Goals

1. Describes activities required to manage the disease process

2. Makes decisions about health and lifestyle modifications necessary for management of multiple sclerosis

Outcomes (NOC)	Interventions (NIC) and Rationales
Multiple Sclerosis Self-Management	Teaching: Disease Process
• Performs treatment regimen as prescribed _____ • Identifies symptoms of disease progression _____ • Identifies ways to cope with functional changes _____ • Reports symptoms of worsening disease _____ • Adjusts life routine for optimal health _____ Measurement Scale 1 = Never demonstrated 2 = Rarely demonstrated 3 = Sometimes demonstrated 4 = Often demonstrated 5 = Consistently demonstrated	• Appraise the patient’s current level of knowledge related to specific disease process to determine learning needs. • Explore with patient what she or he has already done to manage the symptoms to increase patient’s self-efficacy. • Explain the pathophysiology of the disease and how it relates to the anatomy and physiology to increase knowledge of disease process. • Describe the rationale behind management/therapy/treatment recommendations. • Discuss lifestyle changes that may be required to prevent future complications and/or control the disease process so patient can plan for the future. • Instruct the patient on measures to prevent/minimize side effects of treatment for the disease. • Refer the patient to local community agencies/support groups for long-term assistance. Decision-Making Support • Assist patient to clarify values and expectations that may assist in making critical life choices. • Facilitate patient’s articulation of goals for care to support treatment decisions. • Provide information requested by patient to facilitate informed decision making.

ROM, Range of motion.

^*Nursing diagnoses listed in order of priority.

eNursing Care Plan 59-4 Patient With Parkinson’s Disease

Nursing Diagnosis*

Impaired physical mobility related to rigidity, bradykinesia, and akinesia as evidenced by difficulty in initiation of purposeful movements, deterioration of spontaneity of movement

Patient Goals

1. Performs physical exercise appropriately to deter muscle atrophy and joint contractures

2. Uses assistive devices appropriately for ambulation and mobility

Outcomes (NOC)	Interventions (NIC) and Rationales
Mobility	Exercise Therapy: Ambulation
• Balance _____ • Coordination _____ • Gait _____ • Walking _____ Coordinated Movement • Smooth movement _____ • Steadiness of movement _____ • Control of movement _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised	• Assist patient to use footwear that facilitates walking and prevents injury. • Assist patient with initial ambulation to determine degree of impairment and prevent injury. • Consult physical therapist about ambulation plan to facilitate activities of daily living and safe ambulation. • Apply/provide assistive device (cane, walker, or wheelchair) for ambulation, if the patient is unsteady. Exercise Promotion: Stretching • Assist to develop an exercise plan that incorporates an orderly sequence of stretching movements, increments in the duration of the hold phase of the movement, and increments in number of repetitions for each slow-stretch-hold movement, consistent with level of musculoskeletal fitness or presence of pathology, to reduce rigidity. Exercise Therapy: Balance • Assist patient to stand (or sit) and rock body from side to side to stimulate balance mechanisms and decrease akinesia. • Encourage patient to maintain wide base of support to prevent shuffling gait and loss of balance.

Nursing Diagnosis

Imbalanced nutrition: less than body requirements related to inability to ingest food as evidenced by weight loss, poor muscle tone, and/or reports food intake less than recommended daily allowance (RDA)

Patient Goals

1. Maintains nutritional intake adequate for metabolic needs

2. Maintains body weight within normal parameters

Outcomes (NOC)	Interventions (NIC) and Rationales
Nutritional Status	Nutrition Therapy
• Nutrient intake _____ • Food intake _____ • Fluid intake _____ • Energy _____ • Weight/height ratio _____ • Muscle tone _____ Measurement Scale 1 = Severe deviation from normal range 2 = Substantial deviation from normal range 3 = Moderate deviation from normal range 4 = Mild deviation from normal range 5 = No deviation from normal range	• Determine, in collaboration with dietitian as appropriate, number of calories and type of nutrients needed to meet nutrition requirements. • Determine patient’s ability to meet nutritional needs to plan interventions. • Ensure that diet includes foods high in fiber content to prevent constipation. • Teach patient how to keep a food diary to evaluate nutritional intake. • Provide needed nourishment within limits of prescribed diet to maintain nutritional needs. • Monitor recorded intake for nutritional content and calories. • Weigh patient at appropriate intervals to monitor status.

Nursing Diagnosis

Impaired swallowing related to neuromuscular impairment (e.g., decreased or absent gag reflex and/or decreased strength or excursion of muscles involved in mastication as evidenced by observed evidence of difficulty in swallowing, slow bolus formation, lack of chewing, stasis of food in oral cavity, coughing, choking and/or drooling)

Patient Goals

1. Experiences safe passage of fluids and/or solids from the mouth to the stomach

2. Performs actions to prevent the passage of fluid and solid particles into the lung

Outcomes (NOC)	Interventions (NIC) and Rationales
Swallowing Status	Swallowing Therapy
• Maintains food in mouth _____ • Handles oral secretions _____ • Chewing ability _____ • Timely bolus formation _____ • Ability to clear oral cavity _____ • Timely swallow reflex _____ Measurement Scale 1 = Severely compromised 2 = Substantially compromised 3 = Moderately compromised 4 = Mildly compromised 5 = Not compromised • Choking _____ • Coughing _____ • Increased swallow effort _____ Measurement Scale 1 = Severe 2 = Substantial 3 = Moderate 4 = Mild 5 = None	• Explain rationale of swallowing regimen to patient/family to promote understanding of therapy. • Assist patient to sit in an erect position (as close to 90 degrees as possible) for feeding/exercise to promote swallowing. • Assist patient to position head in forward flexion in preparation for swallowing (“chin tuck”) because this position facilitates swallowing. • Monitor patient’s tongue movements while eating to evaluate patient’s level of impairment and minimize risk of aspiration. • Provide rest periods before eating/exercise to prevent excessive fatigue. • Instruct patient/caregiver how to check for pocketed food after eating because this is a frequent happening. • Instruct patient/caregiver on emergency measures for choking to prevent and manage aspiration. Only gold members can continue reading. Log In or Register to continue Share this: Click to share on Twitter (Opens in new window) Click to share on Facebook (Opens in new window) Related Related posts: Introduction Nursing Management: Sexually Transmitted Infections Nursing Management: Integumentary Problems Nursing Management: Musculoskeletal Problems Stay updated, free articles. Join our Telegram channel Tags: Medical-Surgical Nursing Assessment and Management of Clinical P Nov 17, 2016 \| Posted by admin in NURSING \| Comments Off on Nursing Management: Chronic Neurologic Problems Full access? Get Clinical Tree Get Clinical Tree app for offline access Get Clinical Tree app for offline access

Outcomes (NOC)

Interventions (NIC) and Rationales

Swallowing Status

Swallowing Therapy

• Maintains food in mouth _____

• Handles oral secretions _____

• Chewing ability _____

• Timely bolus formation _____

• Ability to clear oral cavity _____

• Timely swallow reflex _____

Measurement Scale

1 = Severely compromised