Nursing Care Plan

Louise O. Reponte BSN-3C

DATE

CUES

N x

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

does not want to talk much

P A husky voice T T does not E respond R immediately N when asked uses nonverbal communicat ion (such as nodding of the head to signify "yes" instead of saying her answer)

Rationale: Myasthenia Gravis is a disease characterized by extreme skeletal muscle weakness and easy fatigability. The muscle groups most commonly affected are those involved in the eye movements, breathing, head control, chewing swallowing and speeech.

reduces feeling of tiredness uses eye contact

express of meaningful verbal or nonverbal communica tion

2.) Monitor vital sign R: For baseline data, to assess fluid status and cardiopulmonary response to activity 3.) Identify physical/neurolo gic conditions impacting speech such as neuromuscular weakness R: to assess causative or contributing factors

reduces feeling of tiredness uses eye contact express of meaningf ul verbal or nonverbal communic ation like patient uses nodding

DATE

CUES

Nx

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

R O di kayo ko L ka isturya E tarong gang, hinay pa R gamay E As L verbalized A 11, by patient T I 2012 Objective: O Weakness N @ S Irritable H 3-11 I Shift Absence of P eye contact difficulty speaking

N O V E M B E R

Subjective:

Impaired Verbal Communicat ion related to weakened speech muscles secondary to Myasthenia Gravis

Within 8 hours span of care patient will be able to establish method of communica tion in which needs can be expressed as evidenced by:

1.) Establish rapport with client like initiating eye contact and meet family members present, ask simple questions and smile. R: Helps establish trusting relationship with client and family, demonstrating about the client as a person

Within 8 hours span of care patient was able to establish method of communic ation in which needs can be expressed as evidenced by:

DATE

CUES

Nx

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

Vital signs of T: 36.4 RR: 20 cpm PR: 81bpm CR: 83 bpm BP: 130/90 mmhg MEDS: Mestinol

Laryngeal involvement produces dysphonia (voice impairment) in the form of nasal sound of the voice or difficulty in articulation

Vital signs within normal range T: 36.4 RR: 16-20 cpm PR: 70-80 bpm CR: 7080bpm BP: 120/80 mmhg

4.) Identify dominant language spoken R: Knowing the language spoken is important in understanding. They may still have limited understanding of the language,

and also answers our question when having interview

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CUES

Nx

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

Bibliography: Smutzer. Bane (2010) . 9th edition. Smutzer & Bane of Medical Surgical Nursing . Philadelphia| : Elsevier Saunders

especially the language of healthcare professionals and may have difficulty answering questions, describing symptoms, or following directions

Vital signs within normal range T: 36.3 RR: 16-20 cpm PR: 78 bpm CR: 80bpm BP: 120/80 mmhg

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CUES

Nx

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

5.) Determine cultural factors affecting communication such as beliefs concerning touch and eye contact R: Certain cultures may prohibit client from speaking directly to healthcare provider.

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CUES

Nx

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

Asians are may shout and gesture when excited; silence and tone of voice has various meanings, and slang words can cause confusion/unders tandings

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CUES

Nx

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

6.) Determine emotional barriers such as depression or anxiousness R: This can affect expressing of thoughts and feelings of patient

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CUES

Nx

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

7.) Observe body language, eye movement and behavioral clues. R: To know patients reaction to certain needs like when in pain patient react with tears, grimacing etc.. 8.) Point to objects or demonstrate desired actions when patient has difficulty of language

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CUES

Nx

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

R: Speakers own body language can be used to assist patients understanding 9.) Validate meaning of nonverbal communication; dont make assumptions, because they may be wrong. Be honest if you dont understand seek assistance from others

DATE

CUES

Nx

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

R: To make sure that patients needs or wants are appropriately given 10.) Provide comfortable environment (non-stimulating environment) R: To have adequate rest and sleep

DATE

CUES

Nx

Nursing Diagnosis

Objective of Care

Nursing Intervention

Evaluation

Collaborative: 11.) Administer prescribed drugs as ordered (Mestinol) R: To treat conditions that causes patients verbal communication impairment (Myasthenia Gravis)