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N U R SIN G C AR E PLAN
Name of Patient: A.M. Age: 19 Attending Physician: Dr. S. Impression/Diagnosis: Potts Disease
Clustered Cues
Nursing Diagnosis
Rationale
(Scientific Basis)
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 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.
-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
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.
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.