NANDA-Nursing Plan 00123 Unilateral neglect

Note: This article was translated from Japanese using translation software. Please use at your own risk, as there may be unnatural points in the content or differences in content due to cultural differences.

Area 5 Perception/Cognition
Human processing systems, including attention, orientation, sensation, perception, cognition, and communication
Category 1 Attention Mental readiness to notice and observe

00123Unilateral neglect

Nursing diagnosis: 00123 Unilateral neglect
Definition: Impaired sensory and motor responses to the body and associated environment, mental representation, and spatial attention.


Characterized by inattention to one side and excessive attention to the other. Left hemi-neglect is more severe and prolonged than right hemi-neglect.

Thank you for always watching.
Half-ignored this time. What was half-neglect like?
Let’s review.

1. What is unilateral neglect (unilateral spatial neglect)?

1) Overview
Hemi-neglect is called ‘hemi-spatial neglect’ and is a type of ‘agnosia’. Agnosia is a type of higher brain dysfunction.
Unilateral spatial neglect is a symptom/sign.

In order to know higher brain dysfunction, it is necessary to look back on higher brain function.
See ★1★1 for higher brain functions and functional localization of the cerebrum.

2) Cause
Cerebrovascular disorder (cerebral infarction, cerebral vasospasm, cerebral hemorrhage, subarachnoid hemorrhage), brain tumor, cerebral cortex damage due to head trauma

3) Symptoms
Damage to the cerebral hemispheres results in failure to perceive stimuli from the contralateral side of the injured hemisphere.
Disorders along the functional localization of the cerebral cortex appear. Unless we know which part of the cerebral cortex controls which function, we cannot understand it. ★Reflect on functional localization in 1.
Looking at the functional localization,
The parietal association area in the right hemisphere is responsible for spatial awareness.
Not only the right hemisphere but also the left hemisphere controls part of the constructive function, which is part of the spatial recognition function.
Therefore,
Left hemi-spatial neglect is mostly caused by damage to the right hemisphere.
but,
Since the left hemisphere also functions partially, sometimes right hemisphere spatial neglect due to left hemisphere disturbance can also occur.
There is a language area (Broca’s area) in the left hemisphere. When the left hemisphere is damaged, aphasia comes to the fore, making it difficult to see symptoms of unilateral spatial neglect.

However, since “spatial recognition” in the right hemisphere is the main,
“Left hemi-spatial neglect” due to damage to the right hemisphere increases.
In the case of left hemisphere disorder, the “spatial awareness ability” in the right hemisphere is preserved, so spatial neglect is less likely to occur.

In aphasia, both Wernicke’s area (sensory language) and Broker’s area (motor language) are located in the left hemisphere.
Even if the right hemisphere is damaged, the language area in the left hemisphere is intact, so speech is possible.

4) Specific symptoms (in case of left hemi-spatial neglect)
・When the food tray is placed in front, the left side is left uneaten.
・Collision without realizing there is an obstacle on the left side of the player.
・Does not notice people on the left and only looks to the right

Now you understand about half-neglect (hemi-spatial neglect).
Next, let’s take a look at the target of half-ignorance.

★ 1 Higher brain dysfunction and cerebral cortical function localization

It’s hard to understand with difficult words.
Let’s understand it little by little.
First, from the functional localization of the cerebral cortex.

1. Cerebral cortex functional localization

1) What is functional localization?

・The cerebrum is divided into four large parts (lobes) by grooves called “furrows”.
・ Four lobes: frontal lobe, parietal lobe, temporal lobe, and occipital lobe
・The grooves form even finer “turns”.
・The role given to each leaf is different.
A specific part of the leaf has a specific function = “functional localization”

2) Frontal lobe functions and disorders

① Frontal association area (located in the right and left frontal areas):
Function: Mental activity, decision-making, discrimination and suppression of behavior
When impaired: social behavior disorder, attention disorder, executive dysfunction
② Broker’s area (left frontal area)
Function: Motility language (speaking)
When impaired: Broker’s aphasia (unable to speak)
③ Primary motor area (left and right frontal areas)
Function: Voluntary movement
When impaired: pyramidal tract disorder, motor apraxia

3) Functions and disorders of the parietal lobe

① Primary somatosensory area (left and right parietal lobes)
Function: somatosensory
When impaired: pyramidal tract disorder, limb motor apraxia, sensory disturbance
② Superior parietal lobule (right and left parietal lobes)
Function: unconscious control of actions
When impaired: visual ataxia
③Inferior parietal lobule (left)
Functions: Object recognition based on sensory and visual information, reading, writing and calculation
When impaired: conductive aphasia, dyslexia, agraphia
④ Parietal association area (②-③ association area)
Function: integration of sensory information, cognition, visuospatial cognition
When impaired: hemispatial neglect (mainly right hemisphere impairment), clothed apraxia, configuration disorder

4) Temporal lobe functions and disorders

① Auditory cortex (left and right)
Function: Hearing
If you are disabled: Hearing impairment
② Wernicke’s field (left)
Function: sensory language
When impaired: Wernicke’s aphasia (cannot understand language)
③ Temporal association area (left and right)
Function: visual perception
Right disability: prosopagnosia
Left obstacle: Object agnosia

5) Functions and disorders of the occipital lobe

① Visual cortex (left and right)
Function: Visual
When impaired: hemianopia

In terms of functional localization, you can see that the role played by each part is different.
Next, let’s understand higher brain dysfunction.

2. higher brain dysfunction

1) What is higher brain function?

The ability to integrate, interpret, and judge primary sensations such as somatosensory, visual, and auditory sensations.
Refers to functions such as language, behavior, attention, and decision-making.

2) What is higher brain dysfunction?

①A state in which higher brain functions are impaired.
Those with aphasia, apraxia, agnosia, memory disorder, and attention disorder.

★This nursing plan, “hemilateral neglect,” is classified as “agnosia” in higher brain dysfunction.

2. Target of hemi-neglect

・ Extensive brain damage due to cerebrovascular disease, brain tumor, or brain trauma.
・Does not recognize either the left or right half
・Insufficient self-care due to lack of recognition of half
Risk of falls and injuries due to unawareness of one half.

Cerebrovascular disease ranks as the fourth leading cause of death in 2020 data.
7.5% of the total. (albeit still less than 1/3 of the cancer mortality rate)
Considering this, it can be said that it is a disease that is often encountered in clinical practice.
By the way, 1st place is malignant neoplasm 27.6%, 2nd place is heart disease 15.0%, 3rd place is senility 9.6%, 4th place is cerebrovascular disease 7.5%, 5th place is pneumonia 5.7%, 6th place is false. 3.1% for aspiration pneumonia.
Now that we’ve digressed, let’s get back to nursing planning, and now let’s plan.

3. aim setting

1) Indicators based on linkage

・Attention to the affected area (0918)
(Definition: An individual’s behavior of recognizing, protecting, and cognitively integrating the affected body part into the self)
・Adaptation to physical disabilities (1308)
(Definition: An individual’s behavior to adapt to significant functional challenges posed by a physical disability)
・Self-care: ADL (0300)
(Definition: Independent behavior of individuals performing most basic physical tasks and self-care, regardless of the use of assistive devices)
・Self-care status (0313)
(Definition: Behavior of individuals performing basic personal care and instrumental activities of daily living)

2) Goal

The goal is to make the patient the subject.
Instead of saying “Nurses can do XX”,
For example, “The patient will be able to do ○○.”

・Be able to describe one’s own disability and points to consider in life due to the disability.
・Able to deal with obstacles.
・The living environment can be prepared according to the disability.
・To describe how to prevent falls.

*Nurse goals include:

・Support for acceptance of functional disorders caused by brain disorders and establishment of a lifestyle according to the disorders.
・Prevent falls.
・Prevent physical disorders such as injuries.
・Provide information (education) to individuals and their families who support their home life so that they can provide care based on the characteristics of agnosia.

3. nursing plan

1) Observation plan 《OP》・

・vital signs
・Awareness level
・Cognitive impairment (Hasegawa score of 20 or less, MMSE score of 21 or less)
・Disease: Cerebrovascular disease, brain tumor, brain trauma
・Treatment course of the disease
・Pre-injury ADL, IADL
・Pre-injury care level, current care level
・Symptoms due to brain damage: agnosia (hemiplegia, etc.), apraxia, aphasia
・Presence or absence of paralysis, site, type (spastic paralysis, flaccid paralysis)
・MMT (Manual Muscle Test)
・Joint range of motion
・Use of self-help tools
・Gait condition (wiggly gait, shuffling gait, rushing gait, small stride gait, spastic gait, dragging gait)
・Range of joint movement that can be done by oneself
・Daily life independence of elderly with dementia before and after injury
・Independence in daily life of disabled elderly before and after injury
・Presence or absence of family members living together, ability to provide nursing care
・Activity/living area (only around the bed, only indoors, etc.)
・Clothing (yukata, pajamas, clothes), footwear (not slippers)
・Environment at home (is it barrier-free with handrails, slopes, etc.)
・Bedroom at home (bed or futon)
・Recognition of disabilities (disabilities such as paralysis and agnosia)
・Motivation and vitality
・Changes in body image
・Negative behavior, lethargy, anxiety
・Stage of disability acceptance process: whether changes in behavior and speech are observed
・Available welfare services
・Presence and relationships of care managers and social workers

2) Action plan 《TP》

① Fall prevention and injury prevention
・Improve the environment with a focus on safety, comfort, and independence.
・Choose clothes and footwear that are easy to move around in.
・Arrange the bed so that the door is on the healthy side so that people can recognize the comings and goings.
・Speak from Ken’s side. Then speak to the patient. (Suddenly speaking from the affected side, they are surprised.)
(By talking to the patient from the affected side, it is possible to have them recognize that there is space even in places they cannot see.)
・Explain repeatedly so that students can recognize that there are objects and obstacles even in places they cannot see or feel as though there is nothing.
・Help the patient touch an object on the affected side with the fingers of the unaffected side.
For example, ask the patient to touch the bed rail on the affected side.
② Consideration for the paralyzed side
・When lying down, the paralyzed side should not be placed under the body.
・When transferring to a wheelchair, always place the paralyzed side on the abdomen to prevent dislocation.
・Periodically observe the circulation and skin condition on the paralyzed side because the circulation is poor.
・I don’t feel pain, so I’m careful about injuries.
・If a decrease in the amount of food is observed, evaluate the oral condition, abdominal symptoms, food form, swallowing function, etc., and adjust the amount of food to increase. Changes in diet, dental intervention, addition of supplements, etc.
③ Support self-care
・Ascertain self-care that cannot be done. What can be done to what extent, what cannot be done from where,
Think about how you can do that.
・Collaborate with doctors and rehabilitation workers to prepare necessary self-help tools. Understand how to use it and use it correctly.
Check if it is being used correctly and call out as appropriate.
– Help with things that cannot be done with self-help devices. Not all help.
・Collaborate with rehabilitation workers to share information such as the contents of rehabilitation, progress, and precautions in daily life, and incorporate them into recuperation life.
④ Support the process of accepting disability.
– Provide assistance according to the process while watching over the process until the person can accept the disability.
Disability acceptance process: shock → denial → anger → escape → acceptance (* partly quoted from Healthy Longevity Net)
• Incorporate recreational activities.
⑤ Support recurrence prevention.
・If dietary therapy and exercise therapy are included in the treatment plan, continue at home and support to prevent recurrence.

3) Education plan 《EP》

①Provide education on fall prevention and injury prevention.
・Tell them not to put unnecessary things around the bed by improving the environment.
・It is necessary to explain how to choose clothes and footwear that are easy to move around in.
・Explain that the bed should be placed so that the door is on the healthy side so that people can recognize the comings and goings.
・Speak from Ken’s side. Then speak to the patient. (Suddenly speaking from the affected side, they are surprised.)
(By talking to the patient from the affected side, it is possible to have them recognize that there is space even in places they cannot see.)
・Explain repeatedly so that students can recognize that there are objects and obstacles even in places they cannot see or feel as though there is nothing. Ask your family to help you repeat until you get used to it.
・Explain to the family members how to help them touch an object on the affected side with the finger on the unaffected side.
For example, ask the patient to touch the bed rail on the affected side. Tell your family how.
② Explain how to consider the paralyzed side.
・When lying down, the paralyzed side should not be placed under the body.
・When transferring to a wheelchair, always place the paralyzed side on the abdomen to prevent dislocation.
・Periodically observe the circulation and skin condition on the paralyzed side because the circulation is poor.
・I don’t feel pain, so I’m careful about injuries.
・Explain that if you feel choked or find it difficult to eat, immediately consult with your child.
③ Explain that you can help with self-care that you can’t do.
– Help with things that cannot be done with self-help devices. Not all help. Tell things.
In addition, the same explanation is given to the family members, and they understand that doing what they can do will lead to the maintenance of ADL.
④ Explain the acceptance process for disability.
・Explain the process of accepting the disability to the family members who support the patient’s life at home, and explain that they should provide support according to the process while watching over them.
Disability acceptance process: shock → denial → anger → escape → acceptance (* partly quoted from Healthy Longevity Net)
・Tell them to talk to you if your family is unable to respond.
⑤ Explain the treatment plan for recurrence prevention.
・If dietary therapy and exercise therapy are included in the treatment plan, continue at home and support to prevent recurrence.
・Instruct the patient not to discontinue taking the oral medicine without permission and to follow the dosage and administration instructions.
⑥Others
・If you have a problem, explain to call the nurse.

References

T. Heather Hardman Shigemi Kamitsuru. (2016). NANDA-I Nursing Diagnosis Definition and Classification 2015-2017. Igaku Shoin.
T. Heather Hardman, Shigemi Kamitsuru, Camila Takao Lopez. (July 1, 2021). NANDA-I Nursing Diagnosis – Definition and Classification 2021-2023 Original 12th Edition. Igaku Shoin Co., Ltd.
Linda J. Calpenito. (2014.1.1). Nursing Diagnosis Handbook. Igaku Shoin Co., Ltd.
Okaniwa, Yutaka. (2012). Review book for nurses and nursing students. Medic Media Co., Ltd.
Yutaka Okaniwa. (2019.3). Year Note 2020. Medic Media Co., Ltd.
Yuko Kuroda (Translation). (2015). Nursing Outcome Classification (NOC) Original 5th Edition Indicators and Measurement Scales for Measuring Outcomes. Elsevier Japan K.K.
Yamaguchi Toru, Kitahara Mitsuo, Fukui Tsuguya. (2012). Today’s treatment guidelines.
Toyoaki Yamauchi. (Date unknown). Physical Assessment Guidebook. Igaku Shoin.

Thank you for your hard work (*゚▽゚*)
If you have any opinions, impressions, or questions, please let us know from the comment section below m(_)m

投稿者 FlorenceMYM

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