Peplaus theory application nursing process:

The nursing process for Mrs. JL based on Peplaus theory is as follows:

Mrs. JL

27 years

Diagnosis: Inter vertebral disc prolapse

Assessment
(Orientation phase)

Mrs. JL is on pelvic
traction and she is
restricted to bed.
The need for bed rest
and restriction was
discussed.

Nursing
diagnosis

Impaired physical
mobility related to
the presence of
pelvic traction.

Planning (Identification phase)

Goal setting was done along with patient

Implementation (Exploitation
phase)

Carried out plans mutually agreed

upon.

Patient will have improved physical mobility as

evidenced by participating in self care within the
limits.
Provide active and passive exercises to all the
extremities to improve the muscle tone and
strength.
Make the patient to perform the breathing
exercises which will strengthen the respiratory
muscle.

(Resolution
phase)

Mrs. JL was free to express problems

regarding difficulty in mobilizing.

She expressed satisfaction when able

to move without difficulty.
Provided active and passive
exercises to all the extremities

Made the patient to perform

breathing exercises

Massaged the upper and lower

Massage the upper and lower extremities which
extremities
help to improve the circulation.
Provide articles near to the patient and
encourage doing activities within limits.

Evaluation

Provided article within the reach of

the patient

Provide positive reinforcement for even a small Provided positive reinforcement to

improvement to increase the frequency of the the patient
desired activity.

Assessment (Orientation phase) Nursing diagnosis

Planning (Identification phase)

Implementation (Exploitation
phase)

Evaluation
phase)

Mrs. JL expresses pain in the low

back region.

Goal setting was done along with

patient

Carried out plans mutually agreed

upon.

Mrs. JL was free to express problems

of pain.

Provide non-pharmacological
measures for pain relief such as
diversional activity which diverts
the patients mind.

Provided non pharmacological

measures like diversion, massaging,
and pelvic traction.

Expressed that she got slight relief

from pain.

Give the client a neutral position

Provided supine position to the client

Supported the back during position
change

Regarding pain, discussion was

made to assess the severity and
the type and duration of pain. Also
the measures to reduce pain were
discussed.

Pain related to the

degenerative
changes in the
lumbar region.

(Resolution

Mrs. JL will have reduction in pain

as evidenced by her verbalisation
of reduction in pain responses.

Always use back support while

turning the patient that reduces the Used pillows to support the back.
strain on the back.
Support the areas with extra pillow
to allow the normal alignment and
to prevent strain.
Administer analgesics as
prescribed by the physician.

Administered Tab. Hifenac P and Cap.

Myoril 4mg as prescribed.

Provide pelvic traction to the

patient

Given pelvic traction and explained the

need for traction

Assessment (Orientation Nursing diagnosis Planning (Identification phase)

phase)

Implementation (Exploitation
phase)

Evaluation
phase)

Mrs. JL expresses that she Self care deficit

need assistance to get
related to the
down from bed.
presence of pelvic
traction.

Carried out plans mutually agreed

upon.

Mrs. JL was free to express problems

of self care.

Regarding self care

discussion was done and
discussed regarding the
measures to solve the
problems.

Goal setting was done along with patient

Client will achieve and maintain self care
activities with assistance of caregiver or
within her limits.
Keep all the articles within the reach of the
patient.
Provide a call bell to the patient to call in
any emergency
Frequently visit the patient and enquire for
any needs.
Assist the patient in doing her self care
activities.
Remove the weight of the traction as
needed by the patient.

(Resolution

She used to call for the needs and all

her needs were met appropriately
Kept the articles within t he reach of
the client

Frequently visited the patient and

enquired for any needs
Assisted the client in doing her self
care activities
Removed the weight as and when
needed.

She achieved and maintained self

care activities within her limits

Assessment
(Orientation phase)

Nursing diagnosis

Mrs. JL is enquiring
about the disease
condition, its outcome
and need for surgery

Anxiety related to hospital Goal setting was done along with patient Carried out plans mutually agreed
admission as evidenced
upon.
by verbalisation and client Client will have reduced feeling of anxiety
& family appearing
as evidenced by
withdrawn
asking fewer questions

Discussed with the client

regarding the disease
process and the findings
in the client

Planning (Identification phase)

Implementation (Exploitation
phase)

Teach the family and client regarding the

disease process.
Taught the family regarding the
Explain in simple understandable
disease process in simple Kannada
language of the client.

Evaluation
phase)

Mrs. JL was free to express problems

of self care.
She asked her doubts regarding the
illness and the diagnostic procedures
She verbalized that her anxiety has
reduced to some extent.

Allow and encourage the client and family

to ask questions. Allow the client and
Allowed the client and family members
family to verbalize anxiety.
to ask questions
Stress that frequent assessment are
routine and do not necessarily imply a
deteriorating condition.

She and her husband expressed their

anxiety

Allow the family members to visit the

client frequently

Allowed the family members to

frequently visit the client

Assessment
(Orientation phase)

Nursing diagnosis

Planning (Identification
phase)

Implementation (Exploitation Evaluation

phase)

(Resolution

(Resolution phase)

Mrs. JL is enquiring
about the disease
condition, its outcome
and need for surgery
Discussed with the client
regarding the disease
process and the need for
follow up

Deficient knowledge
related to the
treatment measures to
be continued even
after the discharge.

Goal setting was done along

with patient

Carried out plans mutually

agreed upon.

She expressed acquisition of knowledge regarding the

disease and the signs of aggravation of illness

Patient will acquire adequate

knowledge regarding the
treatment and home care.
Explain the treatment
measures to the patient and
their benefits
Explain to the client the signs
of aggravation of illness
Use simple and
understandable terms

Explained treatment measures

and the need for follow up
Explained regarding the signs
of aggravation of disease
Used simple and
understandable terms for
explaining
Clarified her doubts

Clarify all the doubts of the

patient of importance.
Repeat the information
whenever necessary to
reinforce learning.

Mrs. JL was free to express problems of self care.

Repeated the information