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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