Incomplete Spinal Cord Injury

Nursing Care Plan (ACTUAL)

Patient’s Name: Alvarez,Marcelo Age: 59y.o. Sex: M Address: Bacolod City
Pathophysiologic/ Nursing
Assessment Cues Nursing Diagnosis Desired Outcome Rationale Evaluation
Schematic Diagram Intervention
Subjective Cues: After 8 hours of Independent After 8 hours of
Predisposing factors:
“Ganiwang na Imbalance Nursing Interventions: Nursing
*Occupational/repetitive
pasyente namon nutrition:less than Intervention the *Assess patient’s *To have baseline Intervention:
activities
kay wala sa kaon” body requirements patient will be general condition data in
*59 years old
as verbalized by r/t NPO status able to; identification of
* Arthritis
the significant problem 1. Patient’s
others Definition: 1. Have adequate *Monitor input *To promote nutritional needs
Imbalance supply of and output nutritional was addressed
Precipitating Factors:
Nutrition: Less nutritional needs balance by through NGT
*Unhealthy diet
than Body through comparing the feeding. Goal
*Alcohol abuse
Requirements - A parenteral *Encourage intake and output met.
*Motor vehicle
Objective Cues: condition in which administration patient to comply *To optimize
accidents
-Ongoing IVF @L Intake of nutrients in complete bed recovery 2. Patient’s
arm is insufficient to rest safety was
PLR1L 80cc/hr meet metabolic 2. Have good and *To decrease provided by
Vital signs: needs Initial force applied safe environment *Facilitate and body temperature putting side rails
T:36.9 C
o to spinal cord while in complete monitor NGT *To supply up and soiled
PR:80 Source: bed rest feeding adequate linens were
RR:30 Spinal cord *Monitor IV site nutritional needs change to provide
BP: 100/70 NANDA contusion/laceration IV drip rate *To stabilize IV good
GCS:11 fluid environment.Goal
E-4 met
Incomplete Spinal Cord Injury

V-1 Petechial *Instruct SO to

M-6 hemorrhage follow the *To
-eyes responds formation doctor’s order for
spontaneously After 4 day of series of
-no verbal Nursing laboratory test *To alleviate After 4 day of
response Axonal shearing Intervention the patient’s anxiety Nursing
-responsive motor patient will be Intervention the
response able to *Record and *To note if there patient was able
-small body Vascular disruption demonstrate monitor fluid and is imbalance fluid to demonstrate
weight (behind progressive electrolyte status and electrolyte progressive
normal BMI) Loss of weight gain status weight gain
consciousness, towards desirable towards desirable
partial loss of weight. weight AEB
sensory and motor current BMI of
function, weakness Dependent 19.Goal met
of extremities Interventions:
*Administer
PLR1L 80cc/hr as
ordered
Inability to meet *Medication will
nutritional needs by *Give provide specific
mouth medications as function for
prescribed, such treatment
as antibiotic:
Imbalanced *To asses
nutrition, less than *Refer for further patient’s
Incomplete Spinal Cord Injury

body requirements evaluation and improvement

related to NPO laboratory test base from
status laboratory results.
Incomplete Spinal Cord Injury

Nursing Care Plan (POTENTIAL)

Patient’s Name: Alvarez,Marcelo Age: 59y.o. Sex: M Address: Bacolod City
Pathophysiologic/ Nursing
Assessment Cues Nursing Diagnosis Desired Outcome Rationale Evaluation
Schematic Diagram Intervention
Subjective Cues: After 8 hours of Independent After 8 hours of
Predisposing factors:
“Way gid sa Potential for Nursing Interventions: Nursing
*Occupational/repetitive
gasabat istoryahon compromised Intervention the *Assess patient’s *To have baseline Intervention:
activities
kag daw kapoy family coping r/t patient will be general condition data in
*59 years old
inchindi kung ano unresponsiveness able to; identification of
* Arthritis
nabatyag ya” as and prolonged problem
verbalized by the recovery period *Monitor input *To promote
significant others 1. Attain comfort and output nutritional 1. Patient
Precipitating Factors:
, while in complete *Encourage balance by attained comfort
*Unhealthy diet
Definition: bed rest patient to comply comparing the while in complete
*Alcohol abuse
Potential for in complete bed intake and output bed rest AEB no
*Motor vehicle
Objective Cues: compromised 2. Takes in rest skin lesions or
accidents
-Ongoing IVF family coping - prescribed *Assessed *To decrease pain.Goal met.
PLR1L 80cc/hr risk for a situation medication patient’s skin for body temperature
Vital signs: in which a usually ulceration or pain 2. Patient was
T:36.9 C
o
supportive 3. Attain safety *Administer able to take
PR:80 primary person is Initial force applied medication as prescribed
RR:30 providing to spinal cord prescribed medication at
BP: 100/70 insufficient or *facilitate and right time. Goal
GCS:11 ineffective support Spinal cord monitor NGT *To alleviate met.
E-4 and contusion/laceration feeding patient’s anxiety 3. Patient
Incomplete Spinal Cord Injury

V-1 encouragement to *Monitor IV site attained safety

M-6 the patient IV drip rate AEB no further
-eyes responds Petechial *Put side rails up *to provide injuries. Goal
spontaneously Source: hemorrhage patient’s safety met.
-no verbal formation After 4 day of *Educate SO
response NANDA Nursing about the * To relive After 4 days of
-responsive motor Intervention the neurological anxiety and Nursing
response Axonal shearing patient will be condition of the provide emotional Intervention
-small body able to patient support patient was able
weight (behind demonstrate *Encourage to demonstrate
normal BMI) Vascular disruption positive attitude significant others positive attitude
towards treatment to provide towards treatment
Loss of necessary support AEB patient’s
consciousness, for the patient willingness to
partial loss of * Orient patient to *To facilitate treatment and
sensory and motor Date and place mental status progressive
function, weakness improvement recovery.Goal
of extremities met.
Dependent
Interventions:
*Administer
Inability to respond PLR1L 80cc/hr as
and communicate ordered
verbally to
significant others *Give *Medication will
medications as provide specific
Incomplete Spinal Cord Injury

prescribed, such function for

as antibiotic: treatment

Potential for *Refer for further *To asses

compromised family evaluation and patient’s
coping r/t laboratory test improvement
unresponsiveness base from
and prolonged laboratory results.
recovery period