X. PROBLEM LIST Actual problems Problems 1. Acute pain related to nerve compression and muscle spasm. 2.

. Impaired mobility related to pain on the lower back. Long Term Objective: After the implementation of planned medical and nursing regimen, the patient will be able to attain optimum level of functioning as manifested by wellness and harmony of the different aspects of his health: physically, mentally, emotionally, socially, psychologically, and spiritually. Date Identified Date Resolved

XI. NURSING CARE PLAN #1 Acute pain related to nerve compression and muscle spasm. Date and time: Cues Nursing interventions Evaluation >Assessed characteristics STO: of pain and vital signs. S> Masakit po iyong likod ko lalo na kapag After 8 hours of Goal fully met: After >Noted non-verbal cues nai-stretch. collaborative 8 hours of of pain. Nababawasan po kapag interventions, collaborative umiinom ako ng patients pain scale nursing additional gamot. will decrease from >Provided interventions the pillows for comfort. 5/10 to 3/10. patients pain scale Rated pain as 5/10 decreased from >Scheduled activities to characterized as 5/10 to 3/10 provide adequate and intermittent pain undisturbed rest periods. confined on the lower back aggravated by >Administered pain engaging in strenuous medication as prescribed activities. and monitored for side O> grimacing noted > guarding behavior on the lower back
effects. > Accompanied to Rehab section for physical therapy. > Instructed about nonpharmacological treatment for pain like listening to music, deep breathing exercise and guided imagery. > Instructed to assume position of comfort, to observe proper body mechanics, and to refrain from engaging in strenuous activities. > Instructed to report unusual signs and symptoms like sudden increase in pain, dizziness and weakness. >Encouraged to verbalize any concerns regarding his health.

Objectives STO:

NURSING CARE PLAN #2 Impaired physical mobility related to pain on the lower back. Date and time: Cues Objectives Nursing Interventions Evaluation STO: S>My back hurts more especially when I engage in activities involving the use of my back. STO: > Assessed vital signs and extent of mobility. Goal fully met. The patient > Noted functional ability. was able to maintain > Promoted safety environment. strength and function of his > Seen and checked at intervals and lower back. attended to needs.
pain medication as

>After implementation of medical and nursing regimen within shift, patient will O>With minimal maintain or movement in bed increase strength and function of > Limited range of affected body >Administered prescribed. motion part. >Needs minimal assistance in doing ADLs

> Accompanied to Rehab section for physical therapy. > Instructed to assume position of comfort, to observe proper body mechanics, and to refrain from engaging in strenuous activities. > Encouraged range of motion exercises as tolerated. >Encouraged to verbalize concerns.