Escolar Documentos
Profissional Documentos
Cultura Documentos
I. Acknowledgement
II. Introduction
III. Assessment
I. Personal data
II. Medical History
A. History of present illness
B. Past Medical History
C. Family Medical History
D. Personal and Social history
IV. Physical assessment
V. Anatomy and Physiology
VI. Pathophysiology
VII. Nursing Care Plan
VIII. Drug Study
IX. Discharge Planning
ACKNOWLEDGEMENT
INTRODUCTION
THEORETICAL FRAMEWORK
For the theoretical framework, I used the “21
nursing problems” according to Faye Glenn Abdellah.
She defined nursing as broadly grouped into the 21
nursing problem areas to guide care and promote the
use of nursing judgement. She also said that nursing is
a service that is based on the art and science and aims
to help people, sick or well, cope with their health
needs.
ASSESSMENT
I. Personal Data:
Name: B.P.
Address: Novaliches Quezon City
Age: 28 years old
Sex: Female
Civil status: Married
Religion: Roman Catholic
Birthday: November 19, 1978
Birthplace: Manila
Attending Physician: Dr. Adrian Catbagan
Admitting Diagnosis: Spinal cord compression on T/3
level
Chief complaint: weakness of lower extremities
( - ) HPN
( - ) DM
( - ) asthma
( - ) allergy
B. Family Medical History:
( - ) HPN
( - ) DM
( - ) CA
( - ) asthma
ANATOMY
The vertebral column provides structural support for the
trunk and surrounds and protects the spinal cord. The
vertebral column also provides attachment points for
the muscles of the back and ribs. The vertebral disks
serve as shock absorbers during activities such as
walking, running, and jumping. They also allow the
spine to flex and extend.
MEDICAL/SURGICAL INTERVENTIONS
Drug Study
PATHOPHYSIOLOGY
Pulmonary tuberculosis
Spread of mycobacterium tuberculosis from other
site
Extrapulmomary tuberculosis
Vertebral narrowing
Vertebral collapse
Spinal damage
POTT’S DISEASE
O- rthopedic center
T- imely manner
S- ight any symptoms other than the usual and report it to the physician
PHYSICAL ASSESSMENT
N/A
Legs and Inspection Pinkish in color and Normal
Extremities intact.
Grossly normal.
Absence of No edema.
deformities and good No cyanosis.
ROM. Absence of
Respiratory Auscultation edema and Normal
system ecchymosis.
Clear breath sounds. No
retractions.
No unusual sounds
should be heard; RR
should range
from normal
Cardiovascular Auscultation and effortless Normal
system respiration.
Adynamic
precordium,normal
Regular rhythm, no rate,regular rhythm,No
heart murmurs. murmur
NURSING CARE PLAN
Cues Nursing Diagnosis Planning Implementation Rationale Evaluation
Independent:
SUBJECTIVE: Disturbed body GOAL: Evaluate
“Ayoko ng image related to 1) Determine >To assess response to
ganito. trauma/ injury to After 1 day of nursing whether causative/ interventions,
Mahirap. spinal cord as intervention, the condition is contributing teachings and
Inaasa nalang evidenced by patient will recognize permanent/ no factors actions
lahat sa iba.. verbal reports of and incorporate body hope for performed.
Wala naman negative feelings image change into self- resolution
din ako about body concept in accurate 2) Evaluate level of > To assess * The patient
magawa dahil (feelings of manner without clients causative/ was able to
hindi ko naman helplessness and negating self-esteem. knowledge of contributing incorporate
kaya, “ as powerlessness) and anxiety factors body image
verbalized by EXPECTED OUTCOME: related to change into
the patient. The patient will: situation. self-concept
1) Verbalize Observe without
OBJECTIVE: acceptance of emotional negating self-
- patient has self in situation. changes. >To asses esteem.
been bedridden 2) Verbalize relief 3) Have client causative/ The goal was
ever since she of anxiety and describe self , contributing met.
was adaptation to noting what is factors
hospitalized actual/altered positive and
body image. what is negative.
3) Acknowledge Beware of how
self as an client believes
individual who others see self.
has 4) Note signs of >To evaluate
responsibility for grieving/indictor needs for
self. s of depression counseling and
5) Identify medication
previously used >To determine
coping coping
strategies and its skills/capabilities
effectiveness.
6) Establish > To assist
therapeutic client/SO(s) to
nurse-client deal with/accept
relationship issues of self-
conveying an concept related to
attitude of caring body image.
and developing a
sense of trust. >To enhance
7) Provide capabilities
assistance with
self care needs/
measures as
necessary while
promoting
individual
abilities/indepen
dence