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West Visayas State University COLLEGE OF NURSING

N U R SIN G C AR E PLAN
Name of Patient: A.M. Age: 19 Attending Physician: Dr. S. Impression/Diagnosis: Potts Disease

Ward/Bed Number: OSW/Bed 9

Clustered Cues

Nursing Diagnosis

Rationale
(Scientific Basis)

Objectives of Care/ Outcome Criteria


(Subject + Verb + Condition + Criteria + Target Time)

Nursing Interventions

Rationale
(Scientific Basis)

Evaluation

July 22, 2011; 5:00 PM Indi ako kahulag sang maayo kay indi ko mahulag akon hawak padalum, as verbalized by AM. Difficulty turning absent range of motion of lower extremities Impaired sensory and motor function in lower extremities Kyphotic posture

Impaired physical mobility related to inability to move lower extremities

Impaired physical mobility is the limitation in independent, purposeful physical movement of the body or of one or more extremities.
Source: , Doenges, M.,Moorhouse, M., Murr, A., Nurses Pocket Guide 11th Edition (2008), F.A. Davis Company, Pennnsylvania, p.457

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

Assess the client.

To determine the factors that may contribute to client's immobility.

-not evaluated

Observe clients movement when is unaware. Plan activities to provide uninterrupted rest periods. Encourage participation in selfcare. Support affected body parts using pillows, foot support. Perform passive ROM exercise on lower

To note any incongruencies with reports of abilities. Prevents fatigue.

Enhances self-concept and sense of independence To maintain position of function and reduce risk of pressure ulcers. Enhances circulation, restores or maintains muscle tone and

Spinal cord is a major component of the central nervous system and conducts sensory and motor impulses to and from the brain and

controls many reflexes. Extrapulmonary tuberculosis is TB that occurs anywhere outside the lungs. Pulmonary TB is the most common form of the disease, but after initial invasion, tubercle bacilli can spread throughout the body via the blood and lymph. The spine (40% of cases, especially the thoracic and lumbar vertebrae) followed by knees and hips are most common sites of skeletal involvement. Severe destruction of vertebrae frequently results in permanent compression fractures that produce severe scoliotic or kyphotic deformities and neurologic deficits secondary to spinal cord and nerve compression.

extremity, using slow and smooth movements. Encourage adequate intake of fluids and nutritious foods. Inspect skin daily. Assess for pressure areas, and provide meticulous skin care. Observe proper body alignment when positioning the client. Change clients position, as ordered.

joint mobility, and prevents disuse contractures and muscle atrophy. Promotes well-being and maximizes energy production. Loss of sensation and paralysis potentiate pressure sore formation. To prevent contractures and promote good circulation.

To prevent formation of pressure ulcers and pulmonary complication.

Source: Mosbys Pocket Dictionary of Medicine, Nursing and Health Professions, 5th Edition (2006), Elsevier Singapore, p. 1290 Black, J., Hawks, J.,Medical Surgical Nursing Clinical Management for Positive Outcomes,8th Edition (2009), Elsevier Singapore, Vol. 2, p. 1608-1609. Kumar, V., Abbas, B., Fausto, N., Aster, J., Robbins and Cotran Pathological Basis of Disease, 8th Edition(2010),Saunders Elsevier China, p.12221223.