Nursing Care Plan (Pre-op)

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Alteration in After 15 minutes of nursing  Placed patient in a  Aids in relieving pain
 back pain comfort: Pain intervention, the patient comfortable position and discomfort
 spinal mass related to spinal will be able to report appropriate for
 paraplegia compression relieve from pain and pain disease condition
 worsening of secondary to Pott’s scale will be diminished to
pain on disease <4.  Fixed bed in a firm  Helps to stabilize the
movement mattress and placed patient from moving
 Facial grimace pillow on both sides to reduce pain

 Kept patient remain  To lessen the pain

still on bed rest from movement

 Encouraged use  It may promote rest,

of relaxation redirects attention
techniques such as and may enhance
deep breathing coping
exercises.

 Encouraged to listen  To divert attention

to music or talk to SO

 Administered pain  To relieve pain

medication as
ordered.
 Nursing Care Plan (Pre-op)

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Impaired physical After the shift of nursing  Raised side rails of bed  To promote safety
 Paraplagia mobility r/t interventions, the patient
 Gibbus musculoskeletal will be able to gradually  Supported body parts  To maintain position
(kyphosis) impairment regain strength and using pillows
 Body weakness secondary to Pott’s mobilize the affected body
 limited ROM disease parts. As manifested by:  Assisted turning side to  To promote circulation
 postural  elevate head of bed side at intervals to all tissues and to
instability without pain appropriate to her relieve pressure
 pain upon  can turn side to side condition
movement
 Elevated lower  Prevent hypotension,
extremities at intervals thrombus formation
by placing pillow on and for mobilization
feet or adjust bed

 Inspected skin daily.  Loss of sensation and

Observed for pressure paralysis potentiate
areas and provided pressure sore
meticulous care. formation.

 Perform passive ROM

exercises to  To gradually mobilize
extremities the body parts

 Emphasized the
importance of using  To support and
the KT brace stabilize the vertebral
part of the body
 Nursing Care Plan (Pre-op)

Assessment Diagnosis Planning Intervention Rationale Evaluation

Objective: Activity intolerance After the shift of nursing  Positioned  Aids in relieving
 limited ROM related to weakness interventions, the patient appropriately in a discomfort
 appears weak and immobility will be able to enhance comfortable position
 reports of secondary to Pott’s activity tolerance
discomforts disease appropriate to her disease  Raised side rails and  To provide safety
 slowed condition. As manifested placed pillows on sides
movement by:
 Paraplagia  can manage to sit and  Assisted in sitting on  To gradually mobilize
 Gibbus walk gradually bed and can slowly perform
(kyphosis)  can perform gradually daily activities
 Body weakness her daily routine
 limited ROM  Facilitated passive  To promote circulation
 postural exercises of extremities and for mobilization
instability in a gradual time

 Assisted proper  To promote self-care

hygiene such as fixing
hair and sponge bathe

 Organized nursing  To regain strength

activities and provided
adequate rest periods
in between.
 Nursing Care Plan (Pre-op)

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Body Image After 2 hours of  Helped to identify changes  To evaluate her capacity
“napansin kong Disturbance nursing interventions, in activities of daily living. on doing her daily routines
nagkuba ang likod related to spinal the patient will be able
ko” as verbalized by deformity to accept the body  Encouraged verbalization of  It is worthwhile to
the patient. secondary to Pott’s image state and gain positive or negative feelings encourage the patient to
disease self-esteem. As about actual change. separate feelings about
Objective: manifested by: changes in body structure
 Gibbus  Have the ability to and/or function from
(Kyphosis) look at, talk about, feelings about self-worth.
 Change in shape and care for altered
of the back and body part or  Assisted patient in  Opportunities for positive
alignment of the function. incorporating actual feedback and success in
spinal column  Verbalize changes into ADLs, social social situations may
acceptance of body life, interpersonal hasten adaptation
image state until it relationships, and
will be normalize occupational activities.
after surgical
management  Taught about the normalcy  To compensate for actual
of body image disturbance changed body structure
and the grief process. and function.

 Taught patient adaptive

behavior such use of  Help to have positive
adaptive equipment that attitude to her condition
enhances body part or
function
 Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: “medyo Ineffective airway After 2 hours of nursing  Positioned or elevated  To maintain open
nahihirapan akong clearance related to intervention, the patient head up to 45 degrees airway
huminga”as retained secretions will be able to improve appropriate to the
verbalized by the in the lower airway airway clearance as patient
patient. of the respiratory evidenced by:
tract secondary to  Diminish crackle sound  Encouraged to
Objective: disease process upon auscultation increased fluid intake  Helps to liquefy viscous
 (+) Crackles  Effective excretion of atleast 2500 ml. secretions
upon copious secretions
auscultation  Normal respirations  Suction nasal or oral  help the patient
 RR= 24 cpm secretions as indicated. breathe easier

 Assisted deep  To mobilize secretions

breathing and
coughing exercises

 Administered  To loosen secretions

bronchodilator
medication as ordered

 Administered  To loosen and

mucolytic medication expectorate secretions
as ordered
 Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Sleep pattern After shift of nursing  Organized nursing  To promote minimal
"hindi ako disturbance related interventions, the patient care interruption in sleep
makatulog ng to interruptions will be able to report or rest.
maayos, naiistorbo secondary hospital improvement of sleep, will  Performed monitoring  Allows for longer
ako sa ibang regimen be able to increase the and care activities periods of
pasyente at sa mga number of hours of sleep without waking uninterrupted sleep
nurse palagi.” as and will feel rested on patient as possible.
verbalized by the awakening.
patient. As manifested by:  Provided bedside care  To promote comfort
>Increased number such as straightening
Objective: of hours of sleep: to 7-8 bed linens
 Decreased hours  Minimized the  To provide an
number >Verbalization of feeling environmental noise environment
of hours of rested and maintain conducive for sleeping
sleep= from 6- comfortable
8 hours to 4 temperature and
hours proper ventilation as
 Yawning much as possible

 Assisted patient in  To promote relaxation

performing bed time
rituals and provide
sleeping aids such as
pillow
 Encouraged patient to  To reduce need
limit fluid intake for voiding during the
before bedtime night.
 Nursing Care Plan

Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Deficient After an hour of nurse-  Defined Pott’s  Gives information
“Hindi ko alam na knowledge related patient interaction, disease, it’s origin and clarifies
may ganitong sakit to unfamiliarity of the patient will be able to and explained its misconceptions
at aabot sa ganito the disease verbalize understanding of effect to the other
ang sakit ko” as secondary to Pott’s her condition, parts of the body
verbalized by the Disease disease process and
patient. treatment. As manifested  Identified risk factors  To avoid or eradicate
by: like smoking and factors that might
Objective:  repeats and exposed to TB worsen her condition
 Frequently summarizes patients
asking questions information about the  Information can clear
about her disease process  Provided patient’s queries and
condition and  Approve and follows explanations and ease anxiety
treatment the medical and reasons for the
 Multiple nursing management patient’s questions
questions about the disease
 Misconceptions process

 Explained the  To encourage patient

importance of to cooperate and for
adhering to faster recovery
treatment regimen
and follow up check-
ups