D& T F E B R U A R Y

CUES S: Kagabii, nikalit kog kalipong ug kawala ako panan-aw human gipangmugn aw ko. Busog man unta ko, wala pud naglabad akong ulo. Paghigda lang jud nako nalipong kog kalit na murag nituyok akong palibot. O:

NEED H E A L T H P E R C E P T I O

NURSING DIAGNOSIS Risk for injury: Fall related to impaired dorsal column. Rationale: Risk for injury is a state in which the individual is at risk of injury as a result of environmental conditions interacting with the individuals adaptive and defensive resources. Brought by his physical factors of his current

OBJECTIVES OF CARE That within my 8-hour span of care, patient will be free from injury as evidenced by:

NURSING INTERVENTIONS 1. Observe individuals general health status. Rationale: noticing factors that might affect safety, such as chronic or debilitating conditions, use of multiple medications, recent trauma. 2. Assess muscle strength, gross and fine motor coordination. Review history of past or current physical injuries (e.g., musculoskeletal injuries; orthopedic surgery)

EVALUATION February 05, 2013 @ 3 PM GOAL MET! After my 8 hour-span of care, patient was free from injury as evidenced by: a. Demonstrated safety measures such as asking for assistance in performing activities, sitting and standing properly. b. Absence of fall noted c. wala man naga sakit akong likod maong comfortable kayo

a. Demonstrate safety measures; b. free from fall;

05, 2 0 1 3

c. verbalization for any unusualities experienced, Rationale: altering coordination, gait, and; and balance. d. vital signs within normal range. 3. Reassess vital signs

Rationale: Serve as a baseline data or to check for complications 4. Enumerate ways or safety measures to prevent injury such as a) Ask for assistance in changing position-to

> (+) Rombergs

sign 7:0 0A M >(+) nystagmus > lumbosacral instability > easily gets dizzy especially if eyes closed > readily cannot maintain balance when standing on one feet > Vital signs BP: 120/80 T: 36.2 RR: 19 cpm CR: 85 bpm PR: 84 bpm

P A T T E R N

condition, there is an increase risk for injury or fall because of the probable injury to clients dorsal column that is responsible for position and movement. A positive Rombergs test and nystagmus is suggestive of damage to this area.

avoid injury ( fall). b) Instructed how to sit, stand, lie down and lifting objects properlyto avoid further complication of the condition. c) Organize the activitiesto avoid confusion and to anticipate needs or assistance.

ko mag lihok og hinay2 ra pod as verbalized by the patient d. Vital signs within normal range BP-110/70 Temp-36.5 CR-84 bpm

5. Assess for factors known to PR-82 bpm increase level of fall risk such as disease- related symptoms RR-20 cpm Rationale: There is increase incidence of falls to persons who are weak or with fatigue. 6. Monitor results of laboratory studies (hemoglobin and hematocrit) Rationale: Hemoglobin and hematocrit may be contributing factors for injury if the patient has its low levels of the said laboratory studies.

7. Encourage to perform safety measures such as changing position slowly,used side rails if necessary, bed must be free from clutter Rationale: To prevent the risk of injury and promote a conducive environment 8. Provide a conducive environment such as free from noise, room temeperature. Rationale: That may alleviate pain and patient will feel comfortable. 9. Provide information regarding the disease or condition that may result in increase risk of injury Rationale: To assist patient caregiver to reduce the risk factors.

10. Position the patient in his desirable manner. Rationale: To feel patient comfortable. 11. Patients are encouraged to switch activities lying, sitting and walking around for a long time. Rationale: To avoid muscle spasms and low or poor blood circulation in the body.

DATE AND TIME F E B R U A R Y

CUES

NEED

NURSING DIAGNOSIS Acute pain: Lower back r/t lumbosacral nerve root compression.

OBJECTIVES OF CARE

NURSING INTERVENTIONS

EVALUATION

Subjective: sakit lagi akong likod maam oy sa baba banda mao mag lisod kog lihok2 -As verbalized by the patient

C O G N I T I V E

05, Objective: 2 0 -pain at lower back -pain scale

P E

Within my 5 hours span of care, my patient will be able to demonstrate relief and control of pain Rationale: as evidenced In a lumbosacral by: instability, compression of a. Verbalize effective pain neural management structures strategies; results from excessive or b. Demonstrate inappropriate methods to movement at L7 alleviate pain; - S1. This may cause c. maintain

1. Reassess the pain (location, weight, duration, nature, propagation and associated leg weakness) Rationale- to have a baseline data and to determine underlying factors. 2. Encourage to have adequate rest and modify body position. Rationale: To reduce pain nurses can encourage patients to bed rest and modification of the position is determined to improve lumbar flexion.

February 05, 2013 @ 12pm GOAL MET After my 5 hours span of care, my patient was able to demonstrate relief and control of pain as evidenced by: a. Verbalization of effective pain management strategies- ma wala2x na ang sakit pag dili kayo ko mag kalit og lihok og

3. Enumerate ways to minimize pain

1 3

of 6/10 -pain is present even when resting or lying down -pain is aggravated with movement or positioning -diagnosis: lumbosacral instability -facial grimace Vital Signs: - BP: 120/80 T: 36.2 RR: 19 cpm CR: 85 bpm

R C E P T

7:00AM

U A L

compression of neural tissues due to dorsal protrusion of the intervertebral disk into the spinal canal often results in pain.

vital signs within normal range, and; c. Absence of facial grimace

such as: a. Massage the soft tissue- is very useful for reducing muscle spasms, improve circulation and reduce the damming and reduce pain. b. heat application- heat reduces pain through improved blood flow to the area through reduction of pain flexes. c. progressive relaxation, imagery, and music- these are centrally acting techniques for pain management work through reducing muscle tension and stress. d. Encourage diversional activities (TV/radio, socialization with others, imagery)to divert the attention

mag hinay2 pag lingkod As verbalized by the patient.

Reference: (Gould, B. (2007) Pathophysiology for Health Professionals)

b. Demonstrated methods to alleviate pain such as performing massage on soft tissue, use of warm compress and performing deep breathing exercise. c. maintained vital signs within normal range.

P A T T E R N

BP: 110/70 T: 36.5 RR: 20 cpm CR:84 bpm PR: 82 bpm d. Absence of

PR: 84 bpm

towards pain. 4. Instructed to avoid sudden position change Rationale: to minimize occurrence of pain and trauma to site. 5. Encourage patient to do deep breathing exercises Rationale- To assist in muscle and generalized relaxation. 6. Watch out for any changes in pain Rationale- May indicate a new physical condition 7. Encourage right-brain stimulation with activities such as love, laughter, and music Rationale- to help in release of endorphins enhancing sense of well-being. 8. Monitor patients vital signs and record Rationale-To monitor for changes,

facial grimace

any fluctuations may indicate complications or other new physical condition.

9. Administer analgesic or narcotic drugs as ordered Rationale- Pharmacological agents are the best way to decrease pain faster 10. Assess for side effects, dependency and tolerance for pain of medication. Rationale- to abruptly intervene the patient and to avoid complication.