Ncp
This document was uploaded by user and they confirmed that they have the permission to share it. If you are author or own the copyright of this book, please report to us by using this DMCA report form. Report DMCA
Overview
Download & View Ncp as PDF for free.
More details
- Words: 439
- Pages: 2
Student Nurses’ Community NURSING CARE PLAN – Spinal Cord Injury ASSESSMENT SUBJECTIVE: “Hindi ako makagalaw” (I can’t move) as verbalized by the patient. OBJECTIVE:
Paralysis Muscle atrophy Irritability V/S taken as follows: T: 37.3 P: 92 R: 19 BP: 120/80
DIAGNOSIS Impaired physical mobility related to neuromascular impairment.
INFERENCE Spinal cord injury may result from trauma, vascular disruption, infection, tumor, and other insults. The injury may be partial or complete and vary from a mild cord concussion with transient numbness to complete cord transaction causing immediate and permanent tetraplegia. The most common sites of injury are the cervical areas C5, C6, and C7, and the junction of the thoracic and lumbar vertebrae, T12 and L1. Clinical manifestations vary with the location and severity of cord damage. In general, complete transaction
PLANNING After 8 hours of nursing interventions, the patient will demonstrate techniques or behaviors that enable resumption of activity.
INTERVENTION Independent: • Continually asses motor function (as spinal shock or edema resolves) by requesting patient to perform certain actions.
RATIONALE •
Evaluates status of individual situation (motor-sensory impairment may be mixed and/ or not clear) for a specific level of injury, affecting type and choice of intervention.
•
Provide means to summon help.
•
Enables patient to have sense of control, and reduces fear of being left alone.
•
Assist in range of motion exercises on all extremities and joints, using slow, smooth movements.
•
Enhances circulation, restores or maintains muscle tone and joint mobility, and prevent disuse contractures and muscle atrophy.
•
Plan activities to provide uninterrupted rest periods. Encourage involvement within individual tolerance or ability. Reposition periodically even when sitting in chair. Teach patient how to use weightshifting techniques.
•
Prevents fatigue, allowing opportunity for maximal efforts or participations by patient.
•
Reduces pressure areas, promotes peripheral circulation.
•
EVALUATION After 8 hours of nursing interventions, the patient was able to demonstrate techniques or behaviors that enable resumption of activity.
Student Nurses’ Community causes loss of all function below the level of lesion, and incomplete cord damage results in a variety of regional deficits. Complications include shock, respiratory or cardiac arrest, thromboembolism , infections, and autonomic dysreflexia.
•
Inspect the skin daily. Observe for pressure areas, and provide meticulous skin care.
Collaborative: • Consult with physical or occupational therapist.
•
Administer muscle relaxants or antispasticity as prescribed.
•
Altered circulation, loss of sensation, and paralysis potentiate pressure sore formation.
•
Helpful in planning and implementing individualized exercise program and identifying or developing assistive devices to maintain function, enhance mobility and independence.
•
May be useful in limiting or reducing pain associated with spasticity
Paralysis Muscle atrophy Irritability V/S taken as follows: T: 37.3 P: 92 R: 19 BP: 120/80
DIAGNOSIS Impaired physical mobility related to neuromascular impairment.
INFERENCE Spinal cord injury may result from trauma, vascular disruption, infection, tumor, and other insults. The injury may be partial or complete and vary from a mild cord concussion with transient numbness to complete cord transaction causing immediate and permanent tetraplegia. The most common sites of injury are the cervical areas C5, C6, and C7, and the junction of the thoracic and lumbar vertebrae, T12 and L1. Clinical manifestations vary with the location and severity of cord damage. In general, complete transaction
PLANNING After 8 hours of nursing interventions, the patient will demonstrate techniques or behaviors that enable resumption of activity.
INTERVENTION Independent: • Continually asses motor function (as spinal shock or edema resolves) by requesting patient to perform certain actions.
RATIONALE •
Evaluates status of individual situation (motor-sensory impairment may be mixed and/ or not clear) for a specific level of injury, affecting type and choice of intervention.
•
Provide means to summon help.
•
Enables patient to have sense of control, and reduces fear of being left alone.
•
Assist in range of motion exercises on all extremities and joints, using slow, smooth movements.
•
Enhances circulation, restores or maintains muscle tone and joint mobility, and prevent disuse contractures and muscle atrophy.
•
Plan activities to provide uninterrupted rest periods. Encourage involvement within individual tolerance or ability. Reposition periodically even when sitting in chair. Teach patient how to use weightshifting techniques.
•
Prevents fatigue, allowing opportunity for maximal efforts or participations by patient.
•
Reduces pressure areas, promotes peripheral circulation.
•
EVALUATION After 8 hours of nursing interventions, the patient was able to demonstrate techniques or behaviors that enable resumption of activity.
Student Nurses’ Community causes loss of all function below the level of lesion, and incomplete cord damage results in a variety of regional deficits. Complications include shock, respiratory or cardiac arrest, thromboembolism , infections, and autonomic dysreflexia.
•
Inspect the skin daily. Observe for pressure areas, and provide meticulous skin care.
Collaborative: • Consult with physical or occupational therapist.
•
Administer muscle relaxants or antispasticity as prescribed.
•
Altered circulation, loss of sensation, and paralysis potentiate pressure sore formation.
•
Helpful in planning and implementing individualized exercise program and identifying or developing assistive devices to maintain function, enhance mobility and independence.
•
May be useful in limiting or reducing pain associated with spasticity
