NURSING CARE PLAN

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION

INDEPENDENT:
SUBJECTIVE: ♦ Impaired ♦ Kyphosis ♦ After 8 hours ♦ Continually assess ♦ Evaluates status ♦ After 8 hours of
physical (Greek - of nursing motor function by of individual nursing
“Nanghihina ako, mobility kyphos, a interventions, requesting patient situation, interventions,
pakiramdam ko related to hump), in the patient to perform certain affecting type the patient was
hindi ko kayang neuro- general terms, will actions like and choice of able to
gumalaw” (I feel mascular is a curvature of demonstrate shrugging interventions. demonstrate
weak, I can’t move) impairment. the upper techniques or shoulders, techniques or
as verbalized by spine. It can be behaviors that spreading fingers. behaviors that
the patient. either the result enable enable
of bad posture resumption of ♦ Assist with full ♦ Enhances resumption of
OBJECTIVE: or a structural activity. range of motion circulation, activity.
anomaly in the exercises in all restores muscle
♦ Paralysis. spine. In the extremities and tone and joint
♦ Muscle sense of a joints using slow, mobility.
atrophy. deformity, it is smooth
♦ V/S taken as the pathological movements.
follows: curving of the
spine, where ♦ Position arms at ♦ Prevents frozen
T: 37.1 parts of the 90-degree angle shoulder
P: 89 spinal column at regular contractures.
R: 20 lose some or all intervals.
BP: 110/90 of their lordotic
profile. This ♦ Elevate lower ♦ Loss of vascular
causes a extremities at tone and muscle
bowing of the intervals when in action results in
back, seen as a chair or raise foot pooling of blood
slouching or bed when and venous
posture. permitted in stasis in the
Symptoms of individual lower abdomen
kyphosis, that situation. and lower
may be present extremities, with
or not, increased risk of
depending on hypotension and
the type and thrombus
extent of the formation.
deformity,
include mild
back pain, ♦ Plan activities to ♦ Prevents fatigue,
fatigue, provide allowing
appearance of uninterrupted rest opportunity for
round back and periods. maximal efforts
breathing Encourage or participation
difficulties. involvement within by the patient.
Severe cases individual
can cause great tolerance or
discomfort and ability.
even lead to
death. ♦ Encourage use of ♦ Reduces muscle
relaxation tension, may
techniques. limit pain of
muscle spasm.

♦ Inspect skin daily. ♦ Altered

Observe for circulation, loss
pressure areas of sensation, and
and provide paralysis
meticulous care. potentiate
pressure sore
formation.

COLLABORATIVE:

♦ Consult with ♦ Helpful in

physical therapist. planning and
implementing
individualized
exercise program
and identifying
assistive devices
to maintain
function,
enhance mobility
and
independence.