Nursing Care Plans for Neuromuscular

Diseases

Jessica Urtecho

Perla Arevalo

Mirlande

Reginale Joseph

INEFFECTIVE BREATHING PATTERN R/T RAPIDLY PROGRESSIVE WEAKNESS AND IMPENDING RESPIRATORY FAILURE

GOAL: Patient will establish normal/effective breathing pattern. Be free of cyanosis and other signs of hypoxia with ABG’s within patients normal/acceptable range.

Interventions

- Obtain medical history and ask if any viral infection within 1-4 weeks?

- Assess/monitor changes in vital signs

-Assess respiratory rate, character, and use of accessory muscle

-Assess/review of ABG, pulse Ox

- Asses for pain/discomfort that may restrict or limit respiratory effort

- Assist with necessary testing (chest x-ray, spinal tap)

-Elevate HOB

-Suction if necessary to clear any secretions

- Monitor for changes in vital capacity- not enough air in lungs (working too hard)

- Monitor for negative inspiratory force (helps determine the need of early intervention)

- Promote the use of incentive spirometer and slower/deeper respirations, use of pursed lip technique

- Chest physiotherapy- to loosen secretions

-Provide patient with comfortable environment and teach relaxation techniques

- Administer oxygen as ordered

- Administer medications as ordered

-Teach patient about disease process

INEFFECTIVE AIRWAY CLEARANCE R/T WEAKNESS OF THROAT MUSCLES AEB DISPHAGIA, PULMONARY SECRETIONS, DECREASED BREATH SOUNDS.

GOAL: Patients will have an effective airway clearance within 15-30 minutess as evidence by clear lung sounds, respiratory rate 12-20, pulse 60-100 bpm, BP 120/80, ABG’S within normal

range

Interventions

- Auscultate heart and lung sounds every 5-10 min, to serve as a baseline.- Assess LOC every 5-10 min, Increasing confusion, restlessness, and irritability are signs of cerebral hypoxia.- Assess vital signs every 5-10 min, Tachycardia and hypertension may be related to increased work of breathing or hypoxia. Fever may develop in response to retained secretions or atelectasis.- Monitor arterial blood gases and pulse oximetry continuously, Increasing PaCO2 and decreasing PaO2 and pulse oximetry readings are signs of respiratory failure.- Administer IVF/oral fluids as indicate, helps to mobilized secretions.- Suction the patient as ordered to ensure an airway clearance. Have intubation tray at bedside.- Apply oxygen as ordered to ensure perfusion.- Position the pt in fowler’s position to avoid aspiration and to facilitate breathing.- Give meds as per MD orders.

Altered Nutritional status, less than body requirement related to dyphagia

Patient will improved nutritional status during the hospital stay.

Interventions

- Assess ability to swallow, chew, and taste

- Assess weight daily- Assess bowel sounds- Monitor intake and output- Review indicated lab data (serum

albumin, glucose, electrolytes)- Maintain IV’s TPN, or tube Feelings as

ordered- Resume oral feeding gradually

Impaired physical mobility R/T muscles weakness

Goal: Patient will demonstrate improved mobility during the hospital stay with the help of medication and collaborative care

Interventions

- Assess gait to determine pt balance

- Assess weakness to determine the degree of weakness

- Administer Baclofen to decrease muscle spasm as per MD order

- Refer to PT/OT to evaluate pt needs

- Repositioning a pt every 2 hrs. to prevent skin breakdown

- Promote range of motion to prevent muscle rigidity

- Teach pt about disease process/S/S of meds to increase compliance and knowledge