Far Eastern University
Institute of Nursing Submitted by: Dimla, Roma E. Section: BSN 142 Group 166A Name & Age of patient: Lenita Patalud/49 Final Medical diagnosis: Spinal cord compression NURSING CARE PLAN Nursing Problems Cues Subjective: “masakit ang likod at tiyan ko” Patient is 49 years old. “mahirap din kumilos dahil ramdam ko na sasakit yung mga binti ko pag igalaw ko.” Nursing Goal and Diagnosis objectives Acute pain Goal: After the nursing related to neuromusc intervention, the client’s will be ular able to feel her disorder. pain is controlled and relieved. Objectives: 1. The etiology of the client’s current health status will be able to be identified. 1. Assess for referred pain as appropriate. 1. To help determine possibility of underlying condition or organ dysfunction requiring treatment. 1. The etiology of the client’s current health status was identified. Interventions Rationale Evaluation
Objective: GCS: Motor response is 4. (withdraws from pain) The client has controlled gestures to avoid feel of pain. Have expressive behavior through moaning and restlessness. Have reduced interaction with people and environment. 2. The client’s response to pain will be able to be evaluated. 2a. Obtain client’s assessment to pain. Reassess each time pain occurs. Note any changes from previous reports. 2b. Accept client’s description of pain. Acknowledge the pain experienced and convey acceptance of client’s response to pain. 2c. Monitor skin color/ temperature and vital signs. 2a. to include 2. The client’s location, response to characteristics, pain was onset/duration, evaluated. frequency, quality, intensity and precipitating factors. 2b. To know client’s subjective experience of pain which is not felt by the others.
2c. To determine alterations in acute pain.
3. The client will be able to be assisted in exploring methods for pain control.
3a. Determine factors in client’s lifestyle. (E.g. smoking, drug abuse.)
3a. To know the responses to analgesics or choice of interventions for pain management. 3b. To medicate prophylactically, as appropriate 3c. To promote nonpharmacological pain management. 3d. To distract attention and reduce tension.
3. The client was successfully assisted in exploring methods for controlling pain.
3b. Note when pain occurs. 3c. Provide comfort measures. (E.g. touch, repositioning.) 3d. instruct use of relaxation technique such as focused breathing. 3e. Administer analgesics as indicated
3e. To maintain “acceptable” level of pain.
4. The client’s wellness will be promoted 4b. provide for even after her individualized hospitalization. physical therapy or exercise that can be continued by client after discharge.
4a. Encourage adequate rest periods.
4a. To prevent fatigue 4b. to promote active role and enhance sense of control.
4. There was a promoted wellness of the client after hospitalizatio n.
Far Eastern University
Institute of Nursing Submitted by: Dimla, Roma E. Section: BSN 142 Group 166A Name & Age of patient: Lenita Patalud/33 Final Medical diagnosis: Spinal cord compression NURSING CARE PLAN Nursing Problems Cues Subjective: “masakit ang likod kaya ayoko nang nagagalaw” “Masakit din ang mga binti ko pag ikinikilos ko” Objective: Impaired ability to turn to sides; move Nursing Goal and Diagnosis objectives Goal: Impaired After the nursing bed intervention, the mobility client’s will be related to neuromusc able participate in repositioning to ular impairmen increase strength and to prevent t. having bedsores. Objectives: 1. The causative or contributing factors of the client will be able to be identified. 1. Determine diagnoses that contribute to immobility of the client. 1. To be 1. Proper aware of the interventions complication for the client and proper current health intervention situation were for the client’s identified and Interventions Rationale Evaluation
from supine to sitting position. GCS: Motor response is 4. (withdraws from pain)
current health situation. 2. The client’s level of function will be able to be increased and patient’s complications will be prevented. 2a. Observe skin for reddened areas. Provide appropriate pressure relief. 2b. Administer medications prior to activity as needed for pain relief.
applied.
2a. To 2. The client’s promote level of mobility and optimal health enhance was promoted environmental and client’s safety. risks on different 2b. to reduce complications friction, were maintain safe prevented. skin pressure and wick away moistures. 2c. to prevent maximal effort/ involvement in activity. 2d. to adjust care as indicated.
2c. Assist on and off bed and into sitting position. 2d. observe for changes in strength to do more or less self-care.
3. The client’s wellness will be promoted after hospitalization.
3a. Involve client in determining activity schedule. 3b. Encourage continuation of exercises.
3a. to promote 3. The client has commitment promoted to plan, wellness after maximizing hospitalization outcomes. . 3b. To maintain or enhance gains in strength or muscle control.
Far Eastern University
Institute of Nursing Submitted by: Dimla, Roma E. Section: BSN 142 Group 166A Name & Age of patient: Lenita Patalud/49 Final Medical diagnosis: Spinal cord compression NURSING CARE PLAN Nursing Problems Cues Selffeeding deficit. Inability to: -Handle utensils and bring food from a receptacle to mouth. Uses straw for drinking water instead of glass cup. Hygiene Nursing Goal and Diagnosis objectives Self – Goal: At the end of care nursing deficit related to interventions, the weakness client will be ; pain and motivated to give discomfo attention or her own care habits rt. and will also be able to verbalize knowledge of healthcare practices Objectives: Interventions Rationale Evaluation
deficit. Inability to: -wash body and access bathroom. Groomin g deficit. Inability to: -put clothing on body Client is inserted with folley catheter. Client is assisted by her husband in self-care at all times.
1. The contributing factors of the client to her self care deficit will be identified. 2. The client will be able to be assisted in correcting or dealing with situation.
1. Determine age/ developmental issues.
1. To identify what affects ability of individual to participate in own care. 2a. Enhances commitment to plan, optimizing outcomes and supporting recovery or health promotion. 2b. To discover barriers to participation and to work on problem solution. 2c. To recognize that today’s success is as important as any long term goal.
1. Client’s view on commitment to plan was enhanced through optimizing outcomes. 2. Client was successfully assisted on dealing and correcting her current situation.
2a. Promote client’s participation in problem identification and desired goals and decision making. 2b. Plan time for listening to client’s feeling and concerns.
2c. Practice and promote short term goal setting and
achievement. 3. The client will be able to be promoted and maintained even after hospitalization. 3a. Review or modify program periodically to accommodate changes in client’s abilities. 3b. review safety concerns. Modify activities and environment. 3c. Give family information about other care options. 3a. to assist client in adhering to plan of care to full extent. 3. The client’s wellness was promoted and maintained even after hospitalizati on.
3b. To reduce risks of injury and promote successful community functioning. 3c. to allow them free time away for the care situation to renew themselves.