ASSESSMENT NURSING DIAGNOSIS INFERENCE PLAN OF CARE INTERVENTIONS RATIONALE EVALUATION

Subjective: Impaired physical A spinal cord injury (SCI) Short Term:  Continue assess motor  Evaluates status of Short Term:
“hindi ko mobility related to is damage to any part of function by requesting individual situation for a
magalaw paa ko” neuromuscular the spinal cord or nerves After 2 hours of nursing patient to perform specific level of injury, After 2 hours of nursing
as verbalized by impairment at the end of the spinal interventions, the certain actions affecting type and interventions, the patient
the patient secondary to spinal canal. The condition patient will verbalize choice of interventions verbalized understanding of
injury often causes permanent understanding of  Provide means to  Enables patient to have individual factors that
Objective: changes in strength, individual factors that summon help a sense of control, and contribute to the injury
VS: sensation, and other contribute to the injury reduces fear of being
T – 36.5 C body functions below left alone Long Term:
P – 76bpm the site of the injury. Long Term:  Perform and assist with  Enhances circulation,
R – 16bpm full ROM exercises on all restores and maintains After 2 days of nursing
BP – 140/80 After 2 days of nursing extremities and joints muscle tone and joint interventions, the patient
interventions, the mobility demonstrate techniques
(+) paralysis patient will  Reposition periodically  Reduces pressure areas, that enable to resume
(+) altered demonstrate even when sitting in promotes peripheral activities such as ROM
mobility techniques that enable chair. Teach patient how circulation exercises and weight-shift
(+) fall history to resume activities to use weight-shifting technique
techniques
 Encourage use of  Reduces muscle tension
relaxation techniques. and fatigue, may help
limit pain of muscle
spasms, spasticity
 Consult with physical and  Helpful in planning and
occupational therapists implementing
and rehabilitation team individualized exercise
program and developing
assistive devices to
maintain function,
enhance mobility and
independence
 NURSING
ASSESSMENT INFERENCE PLAN OF CARE INTERVENTIONS RATIONALE EVALUATION
DIAGNOSIS
Subjective: Acute pain related to A spinal cord injury (SCI) Short Term:  Assess for presence of  Patient usually reports Short Term:
“ang sakit ng physical injury is damage to any part of pain. Help patient pain above the level of
buong likod ko” as secondary to motor the spinal cord or nerves After 1 hour of nursing identify and quantify injury such as the chest After 1 hour of nursing
verbalized by the acciddent at the end of the spinal interventions, the pain. and back or headache interventions, the patient
patient canal. The condition patient will be able to possibly from stabilizer expressed a decrease in
often causes permanent achieve a sense of  Assist patient in  Burning pain and muscle pain and discomfort with
Objective: changes in strength, comfort from pain identifying precipitating spasms can be pain scale of 6/10
VS: sensation, and other factors precipitated and
T – 36.6 C body functions below aggravated by multiple
P – 80bpm the site of the injury. Long Term: factors Long Term:
R -16bpm  Provide comfort  Alternative measures for
BP – 130/80 After 3 days of nursing measures pain control are desirable After 3 days of nursing
interventions, the for emotional benefit interventions, the patient
 Encourage use of
Pain scale 8/10 patient will be able to  Refocuses attention, identified ways to cope to
identify ways to cope relaxation techniques pain and demonstrated
promotes sense of
to pain, demonstrate Provide diversional use of relaxation
control, and may enhance
use of relaxation activities as appropriate techniques in relieving
coping abilities
techniques in relieving  May be desired to relieve pain
 Administer medications
pain muscle spasm and pain
as indicated: muscle
associated with spasticity
relaxants