NURSING CARE PLAN

CUES NURSING INFERENCE NURSING NURSING RATIONALE EVALUATION

DIAGNOSIS GOAL INTERVENTION

SUBJECTIVE: Impaired physical Spinal compression After 8 hours of  Continually assess motor  Evaluates status of After 8 hours of
mobility related to is the act of exerting nursing intervention function by requesting patient individual situation nursing
- “Jak maigaraw neuromuscular an abnormal the patient will to perform certain actions for a specific level of intervention the
toy duwa ng impairment amount of pressure demonstrate injury, affecting type patient was able
sakak ading” (I on the spinal cord. techniques or and choice of to demonstrate
cannot move both Spinal compression behavior that treatment techniques or
of my feet) as may, for instance, enable resumption  Provide means to summon  Enables patient to behavior that
verbalized by the be due to of activity. help have sense of enable
patient a fracture of the control and reduces resumption of
spine or fear of being left activity.
OBJECTIVE: a tumor pressing on alone
the spinal cord  Assist in range of motion  Enhances
 Paralysis exercises on all extremities circulation, restores
 Cooperative https://www.medicin and joints, using slow and or maintains muscle
 Vital signs taken enet.com/ smooth movements tone and joint
as follows: script/main/art.asp? mobility and prevent
BP: 110/90 articlekey=39889 disuse contractures
mmHg  Plan activities to provide and muscle atrophy
RR: 24 cpm uninterrupted rest periods.  Prevent fatigue,
PR: 88 bpm Encourage involvement within allowing opportunity
T: 36.4°C individual tolerance or ability for maximal efforts
or participations by
 Reposition periodically even the patient
when sitting in chair. Teach  Reduces pressure
patient how to use weight- areas, promotes
shifting techniques peripheral circulation

 Inspect skin daily. Observe

for pressure areas and
provide meticulous skin care
 Altered circulation,
loss of sensation,
and paralysis
potentiate pressure
sore formation
 NURSING CARE PLAN
CUES NURSING INFERENCE NURSING NURSING RATIONALE EVALUATION
DIAGNOSIS GOAL INTERVENTION

SUBJECTIVE: Risk for impaired skin Spinal compression After 8 hours of  Inspect all skin areas, noting  Skin is especially After 8 hours of
integrity is the act of exerting nursing intervention capillary blanching and refill, prone to breakdown nursing
- none an abnormal the patient will: redness, swelling. because of changes intervention the
amount of pressure a. Identify in peripheral patient was able
OBJECTIVE: on the spinal cord. individual risk circulation, inability to:
Spinal compression factors to sense pressure, a. Identify
 Paralysis may, for instance, b. Verbalize immobility, altered individual risk
 Cooperative be due to understanding temperature factors
 Vital signs taken a fracture of the of treatment regulation b. Verbalize
as follows: spine or needs  Encourage continuation of  Stimulates understandin
BP: 110/90 a tumor pressing on c. Participate to regular exercise program circulation, g of
mmHg the spinal cord level of ability to enhancing cellular treatment
RR: 24 cpm prevent skin nutrition and needs
PR: 88 bpm https://www.medicin breakdown oxygenation to c. Participate to
T: 36.4°C enet.com/ improve tissue level of ability
script/main/art.asp? health to prevent
articlekey=39889  Elevate lower extremities  Enhances venous skin
periodically, if tolerated return. Reduces breakdown
edema formation
 Massage and lubricate skin  Enhances circulation
with bland lotion or oil. and protects skin
Protect pressure points by surfaces, reducing
use of heel or elbow pads, risk of ulceration.
lamb’s wool, foam padding,
 Reposition frequently,  Improves skin
whether bed or in sitting circulation and
position. Place in prone reduces pressure on
position periodically bony premises
 Provide kinetic therapy or  Improves systematic
alternating-pressure mattress and peripheral
as indicated circulation an
decreases pressure
on skin, reducing
risk of breakdown
 NURSING CARE PLAN
CUES NURSING INFERENCE NURSING NURSING RATIONALE EVALUATION
DIAGNOSIS GOAL INTERVENTION

SUBJECTIVE: Deficient knowledge Spinal compression After 8 hours of  Discuss injury process,  Provide common After 8 hours of
related to lack of is the act of exerting nursing intervention current prognosis and future knowledge base nursing
- “awan pay ammo exposure as an abnormal the patient will: expectations necessary for intervention the
toy sakit ko evidenced by amount of pressure a. Verbalize making informed patient was able:
ading” (I have no statement of on the spinal cord. understanding choices and a. Verbalize
idea regarding misconception Spinal compression of condition, commitment to the understandi
my illness) may, for instance, prognosis and therapeutic regimen. ng of
be due to trearment  Encourage frequent change  Promotes condition,
OBJECTIVE: a fracture of the b. Correctly of positions slowly and circulation; reduces prognosis
spine or perform tolerable by the patient tissue pressure and and
 Paralysis a tumor pressing on necessary risk of complications trearment
 Cooperative the spinal cord procedures  Encourage use of pillows,  Keeps spine aligned b. Correctly
 Vital signs taken and explain supports, splints and prevents or perform
as follows: https://www.medicin reasons for the limits contractures, necessary
BP: 110/90 enet.com/ actions thus improving procedures
mmHg script/main/art.asp? c. Initiate function and and explain
RR: 24 cpm articlekey=39889 necessary independence. reasons for
PR: 88 bpm lifestyle the actions
T: 36.4°C changes and c. Initiate
participate in necessary
treatment lifestyle
regimen changes and
participate in
treatment
regimen
 NURSING CARE PLAN
CUES NURSING INFERENCE NURSING NURSING RATIONALE EVALUATION
DIAGNOSIS GOAL INTERVENTION

SUBJECTIVE: Acute pain related to Spinal compression After 8 hours of  Assess for presence of pain.  Patient usually After 8 hours of
physical injury is the act of exerting nursing intervention Help patient identify and reports pain above nursing
- “Nasakit deng an abnormal the patient will: quantify pain (location, type of the level of injury. intervention the
ken Jak amount of pressure a. Report relief pain, intensity on a scale of 1- After spinal shock patient was able
maigaraw toy on the spinal cord. of 10) phase, patient may to:
duwa ng sakak Spinal compression pain/discom also report muscle a. Report
ading” (it hurts may, for instance, fort spasm and radicular relief of
and I cannot be due to b. Identify pain, described as a pain/disc
move both of my a fracture of the ways to burning or stabbing omfort
feet) as spine or manage pain b. Identify
verbalized by the a tumor pressing on pain  Evaluate increased irritability,  Nonverbal cues ways to
patient the spinal cord c. Demonstrat muscle tension, restlessness, indicative of pain manage
e use of unexplained vital sign and discomfort pain
OBJECTIVE: https://www.medicin relaxation changes requiring c. Demonstr
enet.com/ skills and intervention ate use of
 Paralysis script/main/art.asp? diversion  Provide comfort measures  Alternative relaxation
 Cooperative articlekey=39889 activities as (position changes, massage, measures of pain skills and
 Facial grimace individually ROM exercises, warm or cold control are desirable diversion
 Guarding indicated. packs, as indicated) for emotional activities
behaviour benefit, in addition as
 Vital signs taken reducing pain individuall
as follows: medication need y
BP: 110/90 indicated.
mmHg
RR: 24 cpm
PR: 88 bpm
T: 36.4°C