Far Eastern University

Institute of Nursing

Submitted by: Dimla, Roma E. Name & Age of patient: Lenita Patalud/49
Section: BSN 142 Group 166A Final Medical diagnosis: Spinal cord compression

NURSING CARE PLAN

Nursing Problems Nursing Goal and Interventions Rationale Evaluation

Cues Diagnosis objectives
Subjective:  Acute pain Goal:
 “masakit related to After the nursing
ang likod at neuromusc intervention, the
tiyan ko” ular client’s will be
disorder. able to feel her
 Patient is pain is controlled
49 years and relieved.
old.
Objectives:
 “mahirap
din kumilos 1. The 1. Assess 1. To help 1. The etiology
dahil etiology of the for referred determine of the client’s
ramdam ko client’s current pain as possibility of current health
na sasakit health status appropriate. underlying status was
yung mga will be able to condition or identified.
binti ko pag be identified. organ
igalaw ko.” dysfunction
requiring
treatment.
Objective:
2. The 2a. Obtain 2a. to include 2. The client’s
 GCS: Motor client’s client’s location, response to
response is 4. response to assessment to characteristics, pain was
(withdraws pain will be pain. Reassess onset/duration, evaluated.
from pain) able to be each time pain frequency,
evaluated. occurs. Note quality, intensity
 The client has any changes and precipitating
controlled from previous factors.
gestures to reports.
avoid feel of
pain. 2b. Accept 2b. To know
client’s client’s
 Have description of subjective
expressive pain. experience of
behavior Acknowledge pain which is
through the pain not felt by the
moaning and experienced and others.
restlessness. convey
acceptance of
 Have reduced client’s
interaction response to
with people pain.
and
environment. 2c. Monitor 2c. To
skin color/ determine
temperature and alterations in
vital signs. acute pain.
 3a. Determine 3a. To know the 3. The client
3. The client factors in responses to was
will be able to client’s analgesics or successfully
be assisted in lifestyle. (E.g. choice of assisted in
exploring smoking, drug interventions for exploring
methods for abuse.) pain methods for
pain control. management. controlling
pain.
3b. To medicate
3b. Note when prophylactically,
pain occurs. as appropriate

3c. To promote
3c. Provide non-
comfort pharmacological
measures. (E.g. pain
touch, management.
repositioning.)
3d. To distract
3d. instruct use attention and
of relaxation reduce tension.
technique such
as focused
breathing.
3e. To maintain
3e. Administer “acceptable”
analgesics as level of pain.
indicated
 4a. Encourage 4a. To prevent 4. There was a
4. The adequate rest fatigue promoted
client’s periods. wellness of
wellness will the client
be promoted 4b. provide for 4b. to promote after
even after her individualized active role and hospitalizatio
hospitalization. physical therapy enhance sense n.
or exercise that of control.
can be
continued by
client after
discharge.
 Far Eastern University
Institute of Nursing

Submitted by: Dimla, Roma E. Name & Age of patient: Lenita Patalud/33
Section: BSN 142 Group 166A Final Medical diagnosis: Spinal cord compression

NURSING CARE PLAN

Nursing Problems Nursing Goal and Interventions Rationale Evaluation

Cues Diagnosis objectives
Subjective:  Impaired Goal:
 “masakit bed After the nursing
ang likod mobility intervention, the
kaya ayoko related to client’s will be
nang neuromusc able participate in
nagagalaw” ular repositioning to
 “Masakit impairmen increase strength
din ang mga t. and to prevent
binti ko pag having bedsores.
ikinikilos
ko” Objectives:

1. The causative 1. Determine 1. To be 1. Proper

Objective: or contributing diagnoses that aware of the interventions
factors of the contribute to complication for the client
 Impaired client will be immobility of and proper current health
ability to turn able to be the client. intervention situation were
to sides; move identified. for the client’s identified and
 from supine to current health applied.
sitting position. situation.
 GCS: Motor
response is 4. 2. The client’s 2a. Observe skin 2a. To 2. The client’s
(withdraws level of for reddened promote level of
from pain) function will areas. Provide mobility and optimal health
be able to be appropriate enhance was promoted
increased and pressure relief. environmental and client’s
patient’s safety. risks on
complications different
will be 2b. Administer 2b. to reduce complications
prevented. medications friction, were
prior to activity maintain safe prevented.
as needed for skin pressure
pain relief. and wick
away
moistures.

2c. Assist on 2c. to prevent

and off bed and maximal
into sitting effort/
position. involvement
in activity.

2d. observe for 2d. to adjust

changes in care as
strength to do indicated.
more or less
self-care.
3. The client’s 3a. Involve 3a. to promote 3. The client has
wellness will client in commitment promoted
be promoted determining to plan, wellness after
after activity maximizing hospitalization
hospitalization. schedule. outcomes. .

3b. Encourage 3b. To

continuation of maintain or
exercises. enhance gains
in strength or
muscle
control.
 Far Eastern University
Institute of Nursing

Submitted by: Dimla, Roma E. Name & Age of patient: Lenita Patalud/49
Section: BSN 142 Group 166A Final Medical diagnosis: Spinal cord compression

NURSING CARE PLAN

Nursing Nursing Goal and Interventions Rationale Evaluation

Problems Cues Diagnosis objectives
 Self-  Self – Goal:
feeding care At the end of
deficit. deficit nursing
Inability to: related to interventions, the
-Handle weakness client will be
utensils and ; pain and motivated to give
bring food discomfo attention or her
from a rt. own care habits
receptacle to and will also be
mouth. able to verbalize
Uses straw knowledge of
for drinking healthcare
water instead practices
of glass cup.
Objectives:
 Hygiene
deficit. 1. The 1. Determine 1. To identify 1. Client’s
Inability to: contributing age/ what affects view on
-wash body factors of the developmental ability of commitment
and access client to her issues. individual to plan was
bathroom. self care deficit to enhanced
 Groomin will be participate through
g deficit. identified. in own care. optimizing
Inability to: outcomes.
-put clothing
on body 2. The client 2a. Enhances 2. Client
 Client is will be able to 2a. Promote commitment to was
inserted with be assisted in client’s plan, optimizing successfully
folley correcting or participation in outcomes and assisted on
catheter. dealing with problem supporting dealing and
 Client is situation. identification recovery or correcting
assisted by and desired health her current
her husband goals and promotion. situation.
in self-care at decision
all times. making.
2b. To discover
2b. Plan time barriers to
for listening to participation and
client’s feeling to work on
and concerns. problem
solution.

2c. To recognize
2c. Practice and that today’s
promote short success is as
term goal important as any
setting and long term goal.
 achievement.

3. The client 3a. to assist

will be able to 3a. Review or client in 3. The
be promoted modify program adhering to plan client’s
and maintained periodically to of care to full wellness was
even after accommodate extent. promoted
hospitalization. changes in and
client’s maintained
abilities. even after
3b. To reduce hospitalizati
3b. review risks of injury on.
safety concerns. and promote
Modify successful
activities and community
environment. functioning.

3c. to allow them

3c. Give free time away
family for the care
information situation to
about other renew
care themselves.
options.