NCP

Cues Nursing Diagnosis Rationale Goals/Outcome Criteria Nursing Interventions Rationale Evaluation
1. Subjective Ineffective In high cervical Goal: Independent Breathing may no longer be a At the end of 15 mins,
‘Medyo d ko ka Breathing Pattern spine injuries, After 15 mins, patient will be A. Assist patient in “taking totally voluntary activity but patient was able to:
ginhawa’ r/t spinal cord able to control” of respirations as require conscious effort, a. Verbalize ease of
as verbalized by impairment of innervation to the Maintain adequate ventilation indicated. Instruct in and depending on level of injury breathing.
the patient . innervation of phrenic nerve w/c as evidenced by absence of encourage deep breathing, and involvement of b.Demonstrate relaxation
2. Objective diaphragm(lesion stimulates the respiratory distress and ABGs focusing attention on steps respiratory muscles. skill.
-Drowsy C6) as evidence by diaphragm is lost. within acceptable limits. of breathing. B..Hypoxemia may result C. Demonstrate
- RR: 32bpm weak cough, and (Brunner, 2010 p. Outcome Criteria: B. Monitor oxygen from impaired gas exchange appropriate behaviors to
- chest X-ray : mild pulmonary 1936) With injuries At the end of 15 mins, patient saturation. and from the buildup of support respiratory
decreased lung edema to the cervical and will be able to: C. Provide the opportunity secretions and bronchial -Goal met
expansion upon upper thoracic a. verbalize ease of breathing. for exercise and physical constriction
inhalation, mild spinal cord, b. Demonstrate relaxation therapy. C.Exercise supports the goal
pulmonary edema innervation to the skill. D. Elevate the head of the of airway clearance by
major accessory C. Demonstrate appropriate bed and assist the patient to loosening the mucus and
muscles of behaviors to support assume semi-Fowler’s facilitating effective coughing.
respiratory is lost respiratory position. It also improves overall
and respiratory physical conditioning and
problems develop. Dependent recovery.
These include E. Administer 100% of D..Head elevation and proper
decrease vital oxygen by appropriate positioning help improve the
capacity, retention method (nasal prongs, mask, expansion of the lungs,
of secretions, intubation, ventilator). enabling the patient to
increase PaCo2, breathe more effectively.
decrease oxygen Collaborative E.Method is determined by
levels, respiratory Refer to a respiratory level of injury, degree of
failure and therapist/ chest respiratory insufficiency, and
pulmonary edem physiotherapist as needed. amount of recovery of
respiratory muscle function
after spinal shock phase.
To provide specialized
respiratory care to the
patient.
Cues Nursing Rationale Goals/Outcome Criteria Nursing Interventions Rationale Evaluation

Diagnosis
Subjective Acute pain rt to Extreme pain Goal: Independent A.Alternative measures for At the end of 1 day, patient
‘Masakit akun liog’ as Physical injury causes neurogenic After 1 hour of nursing a..Provide comfort measures pain control are desirable able to:
verbalized by the as evidence by shock by intervention the patient will (position changes, massage, for emotional benefit, in Identify ways to manage
patient severe pain at overexciting the be able to Report relief or ROM exercises, warm or cold addition to reducing pain pain.
Objective the parasympathetic control of pain/discomfort. packs, as indicated). medication need and Report relief or control of
-Cervical Spine: nervous system Outcome Criteria: b. Encourage use of undesirable effects on pain/discomfort
Unstable C6 At the end of 1 day, patient relaxation techniques (guided respiratory function. Demonstrate use of
Compression Fracture will be able to: imagery, visualization, deep- relaxation skills and
or Axial Loading Injury breathing exercises) B..Refocuses attention, diversional activities as
(Burst Fracture) Report relief or control of Dependent promotes sense of control, individually indicated.
-CT Spine: some blood pain/discomfort. C..Administer medications as and may enhance coping
evident at C5-6 with Identify ways to manage pain. indicated: muscle relaxants abilities. -Goal met
bone fragments in the Demonstrate use of and antianxiety agent C. May be desired to
Spinal Canal. relaxation skills and Collaborative relieve muscle spasm and
diversional activities as Refer to the physician about pain associated with
individually indicated the client if the pain is still spasticity or to alleviate
severe after interventions anxiety and promote rest.
To plan another
intervention in order to
relieve the pain.
Cues Nursing Rationale Goals/Outcome Criteria Nursing Interventions Rationale Evaluation

Diagnosis
Subjective Impaired Patient with lesions Goal: Independent Enhances circulation, At the end of 2 hours,
‘I couldn’t feel my physical mobility above the mid- After 8 hours, patient will be Perform/assist with full ROM restores/maintains muscle patient able to: will
arms and legs’ as related to thoracic level have able to Maintain position of exercises on all extremities and tone and joint mobility and maintain position of
verbalized by the neuromuscular loss of sympathetic function as evidenced by joints, using slow smooth prevents disuse contractures function as evidenced by
patient impairment as control of absence of contractures, foot movements.Hyperextend hips and muscle atrophy absence of contractures,
evidence by peripheral drop.. periodically Prevents frozen shoulder foot drop, and increase
unable to move vascoconstrictor Outcome Criteria: Position arms at 90 degree at Construction. strength of
Objective his arm and legs. activity, leading to At the end of 4 hours, patient regular intervals. Prevents foot drop and unaffected/com
-laboratory hypotension. will be able to!maintain Maintain ankles at 90 degree with external rotation of hips. pensatory body parts
revealed Contractures can position of function as footboard. Place trochanter rolls F. May be useful for reducing -Goal met
abnormality develop rapidly evidenced by: along thighs when in bed pain associated with
- Could not with immobility and absence of contractures, foot Dependent spasticity. Note: Baclofen may
localize touch or muscle paralysis drop, D. Administer medication as be delivered via implanted
describe texture increase strength of indicated Baclofen (Lioresal) 10 intrathecal pump on a long
with any unaffected/com pensatory mg/tab TID as ordered by the term basis as appropriate
consistency at the body parts physician
area. . -orthopedic doctor is a board-
Collaborative certified
Assist with orthopedic

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What are some nursing interventions for ineffective breathing pattern?

What are some nursing interventions for acute pain?

Cues Nursing Diagnosis Rationale Goals/Outcome Criteria Nursing Interventions Rationale Evaluation

Cues Nursing Rationale Goals/Outcome Criteria Nursing Interventions Rationale Evaluation

Cues Nursing Rationale Goals/Outcome Criteria Nursing Interventions Rationale Evaluation

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