West Visayas State University College of Nursing

NURSING CARE PLAN

Name of Patient: A.M. Age: 19 y.o. Clustered Cues Nursing Diagnosis Rationale (Scientific Basis) Ward/Bed Number: OSW/ 9
Objectives of Care/Outcome Criteria (Subject+Verb+ Condition+Criteria+ Target Time)

Attending Physician: Dr. S Impression/Diagnosis: Potts disease Rationale (Scientific Basis) To determine the factors that may contribute to client's immobility. Evaluation

Nursing Interventions

July 22, 2011; 5:00 PM

Impaired physical mobility Indi ako related to kahulag sang inability to maayo kay indi move lower ko mahulag akon extremities hawak padalum, as verbalized by AM. Difficulty turning absent range of motion of lower extremities

Impaired physical mobility is the limitation in independent, purposeful physical movement of the body or of one or more extremities.

The client will be able to maintain skin integrity, function of affected and unaffected body parts, and absence of contractures by July 29, 2011 at 7:00 AM.

Assess the client.

-not evaluated

Observe clients movement when he is unaware.

To note any incongruencies with reports of abilities.

Plan activities to provide Prevents fatigue. uninterrupted rest periods. Enhances self-concept and sense of Encourage participation independence in self-care. Support affected body parts using pillows, foot support. Perform passive ROM exercise on lower extremity, using slow and smooth movements. To maintain position of function and reduce risk of pressure ulcers. Enhances circulation, restores or maintains muscle tone and joint mobility, and prevents disuse contractures and muscle atrophy.

 Impaired sensory and motor function in lower extremities Kyphotic posture

Encourage adequate intake of fluids and nutritious foods.

Reference: Doenges, M.,Moorhouse, M., Murr, A., Nurses Pocket th Guide 11 Edition (2008),

Promotes well-being and maximizes energy production.

Inspect skin daily. Assess for pressure areas, and Loss of sensation and provide meticulous skin paralysis potentiate care. pressure sore formation. Observe proper body alignment when positioning the client. Change clients position, as ordered. To prevent contractures and promote good circulation. To prevent formation of pressure ulcers and pulmonary complication.

Students Name: Clinical Instructor:

West Visayas State University College of Nursing

NURSING CARE PLAN

Name of Patient: A.M. Age: 19 y.o. Clustered Cues Nursing Diagnosis Rationale (Scientific Basis) Ward/Bed Number: OSW/ 9
Objectives of Care/Outcome Criteria (Subject+Verb+ Condition+Criteria+ Target Time)

Attending Physician: Dr. S Impression/Diagnosis: Potts disease Rationale (Scientific Basis) Evaluation

Nursing Interventions

Disturbed body image related to Nasubuan gid the ko kay damu deformities gasunlog sa akun brought about nga bugtot ,as by the disease verbalized by condition. A.M Sang-una kaya ko pa mag ubra sang damu nga bagay subong gasalig nalang ko sa iban as verbalized by A.M kyphotic posture

7/22/11: 5:30pm

Confusion and/or dissatisfaction in mental picture of one's physical self. Pott's disease or tuberculous spondylitis is a rare grave form of tuberculosis caused by the invasion of Mycobacterium tuberculosis into the spinal vertebrae. The intervertebral disks may be destroyed resulting in the collapse and wedging of affected vertebrae and the shortening and angulation of the spine causing deformities. Deformity refers to the distortion, disfigurement,flaw,or

The client will be able to verbalize understanding of changes in the body and identify feelings and methods for coping with negative perception of self by 7/23/11.

Discuss the disease according to clients level of understanding. Support and encourage client; provide care with a positive and friendly attitude.

To increase awareness and understanding

Not evaluated

Caregivers sometimes allow judgmental feelings to affect the care of client and need to make every effort to make client feel valued as a person. To assist client to deal with issues of self concept related to body image.

Provide assistance with self care needs while promoting individual abilities or independence.

malformation that affects the body in general or any part of it.Any perceived change in structure or function of a body part can lead to disturbed body image.

Encourage client and significant others to verbalize feelings to each other. Discuss concerns about fear of rejection when client is facing poor outcome of illness. Encourage client to touch affected body parts.

To address realities and provide emotional support. To incorporate changes to body image.

Source: Doenges,
M.,Moorhouse, M., Murr, A., Nurses Pocket Guide th 11 Edition (2008), F.A. Davis Company, Pennnsylvania,p 115

Mosbys Pocket Dictionary of Medicine, Nursing and Health Professions, 5th Edition (2006), Elsevier Singapore, p,187,385,1409
Students Name: Clinical Instructor:

Sources: Doenges, M.,Moorhouse, M., Murr, A., Nurses Pocket Guide 11th Edition (2008), F.A. Davis Company, Pennnsylvania,p,117-120