Nursing Diagnosis |
Risk for self care deficit relating to neuromuscular impairment, intolerance to activity and motor impairment.
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Nursing Intervention |
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Desired Outcome |
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Risk for Activity Intolerance
May be related to fatigue, medications, emotional demands and
pain/discomfort
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§ Identify and review factors affecting
ability to be active: temperature extremes, inadequate food intake, insomnia,
use of medications, time of day
§ Determine need for walking aids. Provide
braces, walkers, or wheelchairs. Review safety considerations
§ Assist with physical therapy. Increase
patient comfort with massages and relaxing baths
§ Administer medications as ordered
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Risk for Self-Care Deficit
May be related to neuromuscular
impairment, decreased strength and endurance, motor impairment, memory loss,
pain/discomfort, fatigue and depression
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§ Encourage patient to perform self-care to
the maximum of ability as defined by patient. Do not rush patient
§ Assist according to degree of disability;
allow as much autonomy as possible
§ Provide assistive devices and aids as
indicated: shower chair, elevated toilet seat with arm supports
§ Reposition frequently when patient is
immobile (bed or chair bound). Provide skin care to pressure points, such as
sacrum, ankles, and elbows. Position properly and encourage to sleep prone as
tolerated
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Impaired Urinary Elimination
May be related to neuromuscular impairment
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§ Note reports of urinary frequency,
urgency, burning, incontinence, nocturia, and size or force of urinary
stream. Palpate bladder after voiding
§ Review drug regimen, including prescribed,
over-the-counter (OTC), and street as a side effect may be due to use
§ Encourage adequate fluid intake, avoiding
caffeine and use of aspartame, and limiting intake during late evening and at
bedtime
§ Promote continued mobility
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Common Symptoms:
