Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Ineffective After 2 hours of  Assess  Scoliosis

breathing pattern nursing respiratory status hinders the
“nahihirapan po
related to intervention the every 4 hours. movement of
ako makahinga” as
Decreased lung patient will be able the ribs,
verbalized by the
expansion to maintain an therefore
patient
effective breathing weakens the
pattern, as respiratory
evidenced by muscles
Objective: relaxed breathing at causing an
-increase in normal rate and increase in the
respiratory rate 30 depth and absence work of
cpm. of shortness of breathing
breath during, rest,
-altered chest activity or at
excursion sleep
-use of accessory
muscle in  Auscultate breath  This is to
breathing sound at least detect
every 4 hours. decreased or
-dyspnea adventitious
breath sound.
 Monitor intake  Adequate
and output. hydration
mobilizes
secretions and
prevents
infection.

 Assess oxygen  Pulse oximetry

saturation and is a helpful
pulse rate by tool to detect
using pulse alterations in
oximetry. oxygenation.

 Place the patient  Facilitates

in semi-fowler expansion of
position. the lungs.

 Assist the patient  Deep breathing

in doing deep exercises are
breathing initiated to
exercises. improve lung
function.
  Frequently
reposition the  Promotes lung
patient every 2 field inflation.
hours.

 Administer
oxygen as
needed.  Oxygen
increases
peripheral
oxygen by
95%-100%

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Impaired After 2 hours of  Assess the  Understanding

physical mobility nursing level of the particular
“minsan po nasakit
related to intervention the physical level, guides the
likod ko pag
musculoskeletal patient will be mobility. design of best
natatagalan masyado
impairment, pain able to maintain possible
sa paghiga” as
and discomfort proper body management
verbalized by the
patient. alignment and plan.
progress with
Impaired  Assess
activity as  Severe curvature
Physical patient’s
Objective: ordered by the of the spine
Mobility related description of
physician. creates stress and
o That looks are to postural pain
pressure on the
not the same of imbalance.  Increase including the
the shoulder spinal discs,
physical type,
height muscles, nerves,
o Visible mobility location, and
and ligaments
protrusion of the intensity.
scapula is not that can lead to
the same pain.
o Looks are not
the same hip

 Encourage
the patient to
 Promotes good
perform
circulation, helps
active range-
maintain strength
of-motion
and muscle tone.
exercises.

 Encourage
regular
 postural  These exercises
exercises. may help in
correcting the
posture and
managing the
effects of
 Teach and scoliosis.
encourage
use of brace  The primary
as indicated. purpose of
utilizing a brace
is to prevent or
slow down the
progression of
the spinal curve.
Assessment Diagnosis Planning Intervention Rationale Evaluation

After 2 hours of  Assess the  Provides

Subjective: Disturbed body nursing patient’s information about
image related to intervention the feelings on the status of self
“nung 11 yrs old ako
biophysical and patient will wearing concept and
napansin ko na lang experience
psychosocial brace, long changes in
nag iiba na form ng improved body term appearance.
factors of spinal
katawan ko” as image. treatments,
deformity
verbalized by the restricted
patient. lateral curvature of movements,
the spine 2° to and inability
structural scoliosis to keep up
with peers
Objective: as evidenced by
and
right shoulder is participate in
- 16 yrs. Old girl higher than the left
activities.
- Right shoulder (obvious S-shaped
is higher than  Encourage  Provides an
spine)
the left and verbalization of opportunity to
there is an feelings and
verbalized and
concerns and
obvious S- support child’s limit negative
shaped spine communication feelings on
- Patient s with changes in
significant appearance and
revealed that others and prolong wearing
her mother is peers.
of an appliance.
hurting her
- And the patient  Assist child
verbalized that to adjust to
she is fetching self  Promotes realistic
and carrying perception of perception of
short leg, use appearance and
gallons of
of appliance positive self
water. image.
and effect on
appearance.
 Assist with
the plan for  Promotes
independenc independence and
e in adjustment to the
performing appliance.
ADL
application
and removal
of appliance,
choice of
shoes and
clothing
wear.

 Maintain
positive  Enhances body
environment image and
and confidence, and
encourage promotes trust
activities and respect of the
appropriate child.
to the child.

 Reassure
parents and  Promotes positive
 child that feelings about the
most treatment and
activities are restrictions
permitted created by the
with use of deformity.
appliance.

 Educate the
patient about  Improves
the activity appearance and
restrictions body image.
that include