Nursing Interventions For Left Hemiplegia, Respiratory Failure, Neglect, And Malnutrition

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Actual problem

Left hemiplegia

dysphagia

Respiratory failure

aphagia

Potential problem

Neglect

malnutrition

Love and belonging

hypertension

Actual/potential problem

Patient problem

1. 1^st Priority

Left hemiplegia

· Impaired physical mobility (Mr. Robertson cannot stand on his own and he is immobile)

· Disuse syndrome, due to shifted weight to the affected side

· Inability to self-care due to paralysis of the limbs and the left side of the body

· Difficult in communication

· Difficulty in swallowing

· Pain

· Ataxia

· Mr. Robertson is inactive

· Injury risks

· Lack of self-care

2. 2^nd Priority

Respiratory failure

· Low oxygen saturation (Sp02 94% RA

· Irregular breathing patterns

· Irregular respiratory rates (RR is 24 bpm

· Decreased levels of consciousness

· Smoking can lead to lung problems (15/day)

3. 3^rd Priority

Neglect

· Social interaction limitations like communication, his sons do not attend to him he stays with his wife alone.

4. 4^th Priority

Malnutrition

·  Mr. Robertson has aphagia

· Mr. Robertson is immobile

· Mr. Robertson has dysphagia (unable to swallow certain foodstuffs)

· Lack of muscle coordination, he suffers from stroke as it is manifested by his left hemiplegia condition, so he cannot feed himself alone

· Due to paralysis of the limbs and the left side of the body

Patient problem

Planning

1

Left hemiplegia

Impaired physical mobility

Ø Assess the degree of the physical immobility and explore possible alternatives to aid in recovery

Ø Monitor thromboplebitis symptoms

Ø Observe the left side for changes in colour and oedema

Difficult in communication

Ø Determine the degree of aphasia and the levels at which the patient can express themselves

Ø Determine the levels of brain involvement

Ø Monitor receptive aphasia on pupil response

Ø Monitor expressive aphasia

Ø Monitor articulation of simple sounds

Ø Monitor levels of mental well-being like depression and frustration

Pain

Ø monitor any possible instances of pain and stiffness in the shoulders and the left cheek

Ø assess the possibilities of pain and sensory abnormalities

Ø monitor the patient’s physical expression of feeling pain either by palpation, restlessness, or moaning

Ø monitor the extent of laceration on the chin sustained after falling

Ø use the wong backers scale to measure the extent of pain

Ø investigate further signs and symptoms related to pain

Inability to self-care

Ø assess and determine the levels of the inability of the patient to meet personal needs

Ø assess the patient’s ability to communicate when they need to attend to washrooms

Ø determine the significance levels of bowel load

Difficulty in swallowing

Ø monitor the patient’s ability to swallow by monitoring tongue movements, teeth movements and sound, coughing patterns

Ø maintain and monitor proper calories limits

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Respiratory failure

Poor breathing

Ø to monitor breathing rates after every four hours to detect any alteration in the breathing system

Ø monitor oxygen saturation levels and factors affecting it

Ø monitor breathing patterns like breath cessations, deep breathing, intermittent breathing, shallow or quick breath, labored or unlabored breath, increased depth of breathing and rapid or shallow breath

Ø monitor breathing sounds like wheezing, constant sounds or musical sounds

Ø monitor any instances of shortness of breath

Ø monitor any example of using accessory muscles to facilitate breathing

Ø monitor diaphragm movements while breathing

Ø monitor nostrils movements and contractions while breathing

Ø monitor breathing positions of the patient, whether difficult or breathes at ease

Ø monitor nasal secretions amount and colour

Ø monitor anxiety and consciousness levels

Ø monitor for instances of abdominal or chest pains while breathing

3

Neglect

Risk of neglect from his immediate family

Ø assess and determine the patient’s possible signs of neglect by his family or caregivers like clothing and hygiene

Ø monitor sitting and sleeping positions

Ø monitor feeding patterns

Ø monitor head movements

Ø monitor response to external environments from the neglected side

Ø monitor grooming on the neglected side

Ø monitor the ability to move body parts of the neglected side

4

Malnutrition

Poor access to nutrition

Ø determine the patient’s weight

Ø monitor the patients feeding environments and the frequency of feeding

Ø monitor physical and noticeable evidence of malnutrition

Ø determine the living environments of the patient

Ø determine the patients’s sensory abilities in taste

Ø determine appropriate types of equipment for therapies, especially on physically challenged patients or immobile patients

Ø determine the swallowing capacity of the patient on various foods

Ø assess the patient’s other vital signs that manifest as malnutrition

Ø assess food volumes consumed by the patient against wastes

Ø determine on available options in cases of nausea and vomiting

Ø assess proper renal functions

Patient problem

Nursing intervention

Rationale

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Left hemiplegia

Impaired physical immobility

Ø Change sleeping positions frequently.

Ø Inspecting the affected side regularly and provide massage to any affected swollen or reddened parts and offer soft surfaces for sleeping

Ø To reduce instances of tissue damage and injuries.

Ø To enhance blood circulation on the pressurized parts of the lower side.

Difficult in communication

Ø Provide alternative means of communication, for instance, the use of a sign or body language

Ø Referring a patient to specialized professionals like a therapist

Ø To ease communication and information delivery.

Ø To assess communication gaps and needs of the patient and recommend possible alternatives.

Pain

Ø Assist the patient when changing the position to ensure minimum pain is inflicted

Ø Proper positioning of the shoulders when the patient is sleeping

Ø Use of appropriate method when shoulders and arms to reduce pain

Ø Ensure proper inclinement of

Ø the scapula and scapula joints

Inability to self-care

Ø Only chip in when necessary and promote patient independence in performing duties

Ø Give feedback to the patient on progress and subsequent improvements

Ø To promote self-esteem and speedy recovery

Ø Form of encouragement and it provides the patient with a sense of self-worth

Difficulty in swallowing

Ø Suggest alternative feeding methods

Ø Provide food and water at desired temperatures

Ø To meet body fluids and nutritional needs

Ø lukewarm temperatures impairs salivation

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Respiratory complications

Poor breathing

Ø ensure the patient’s posture and position does not affect in any way the breathing pattern

Ø determine the impact of introducing an inspiration muscle training model

Ø To allow enough space for the abdominal cavity movements to enhance breathing

Ø To facilitate unwarranted movement of  respiratory muscles and enhance their strength for efficient breathing

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Neglect

Risk of neglect from his immediate family

Ø Promote the patient’s ability to accept, manage and cope with neglect. Show them alternative options for self-help

Ø Initiate and promote fall associated risks management and interventions like outlining underlying factors that cause falls like mental health, gait and imbalances, cognitive and sensory challenges

Ø Promote self-acceptance, worthiness and fast healing

Ø Reduce the dangers associated with fall risks as a result of involuntary or unwarranted fall downs

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Malnutrition

Poor nutrition

Ø Include and collectively involve the patient’s family and caregivers in decision making, create awareness and explore possible alternatives for enhanced nutrition programs for the patient

Ø Advise the patient and the family on the available option for laxatives and diuretics

Ø To promote a healthy feeding regime for the patient

Ø Reduce the advanced feeling of self-unworthy and acceptance to minimise vomiting and enhance fluid balance in the body.

Nursing intervention

Evaluation

1

Left hemiplegia

Ø Change of sleeping positions frequently

Ø Inspecting the affected side regularly and provide massage to any affected swollen or reddened parts and offer soft surfaces for sleeping

Ø Improvement of blood circulation and reduced instances of damaged tissues or swollen and reddened parts  

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Respiratory complications

Ø Ensure the patient’s posture and position does not affect in any way the breathing pattern

Ø Determine the impact of introducing an inspiration muscle training model

Ø Enhanced voluntary and unlabored breathing patterns.

Ø The patient breathing is at ease; breathing rate, heart rate and oxygen concentrations are at the required levels

3

Neglect

Ø Promote the patient’s ability to accept, manage and cope with neglect. Show them alternative options for self-help

Ø Initiate and promote fall associated risks management and interventions like outlining underlying factors that cause falls like mental health, gait and imbalances, cognitive and sensory challenges

Ø Decreased instances of fall risk effects like death and physical injuries and

Ø improved sense of self-acceptance, reliance and appreciation of the patient’s condition and the ability to perform some tasks on their own or with less assistance from the carers

4

Malnutrition

Ø Include and collectively involve the patient’s family and caregivers in decision making, create awareness and explore possible alternatives for enhanced nutrition programs for the patient

Ø Advise the patient and the family on the available option for laxatives and diuretics

Ø Collective response in ensuring nutritional requirements for the patient are met both in quality and quantity.

Ø Improved feeding patterns, environment, patient weight and general body condition.

Ø Improved electrolytes and fluid balance in the patient’s body