Introduction:

A spinal cord injury (SCI) is a damage to any part of the spinal cord or nerves at the
end of the spinal canal. The condition often causes permanent changes in strength,
sensation and other body functions below the site of the injury.
Motor vehicle accidents, acts of violence, and sporting injuries are the common causes
of spinal cord injury (SCI). The mechanism of injury influences the type of SCI and the
degree of neurological deficit. Spinal cord lesions are classified as a complete (total loss
of sensation and voluntary motor function) or incomplete (mixed loss of sensation and
voluntary motor function).
Physical findings vary, depending on the level of injury, degree of spinal shock, and
phase and degree of recovery, but in general, are classified as follows:

C-1 to C-3: Tetraplegia with total loss of muscular/respiratory function.

C-4 to C-5: Tetraplegia with impairment, poor pulmonary capacity, complete

dependency for ADLs.

C-6 to C-7: Tetraplegia with some arm/hand movement allowing some

independence in ADLs.
C-7 to T-1: Tetraplegia with limited use of thumb/fingers, increasing

independence.
T-2 to L-1: Paraplegia with intact arm function and varying function of

intercostal and abdominal muscles.

L-1 to L-2 or below: Mixed motor-sensory loss; bowel and bladder dysfunction.

Learning Objective:

After completing this case study, the learner will be able to:
Describe the pathophysiology and clinical manifestations of acute cervical spinal
cord injury (SCI) and outline essential assessment parameters.
Explain the impact of neurogenic shock following acute SCI.
list nursing interventions to facilitate patient adaptation following an injury to the cervical
spinal cord.
Collaborate with members of the health care team to provide appropriate care to
the patient with an acute SCI.
Outline a nursing care plan to prevent/minimize potential complications in a
patient with an acute SCI.
Identify the clinical manifestations of autonomic dysreflexia and describe nursing
measures to counteract adverse effects.

Patient Profile
Demographic profile
Name: Mr. RASJ
Age: 12 y/o
Date of birth: 12-jul-2003
Gender: Male
Civil status: single
Religion: Roman Catholic
Address: Nueva Vizcaya
Nationality: Filipino
Date of Admission: 09/29/15 (5:25AM)
Physician: Dr. Abay
Hospital no.: 87-92-37
Final Diagnosis: Spinal Cord Injury Incomplete SL due to Lytic process L1-L3

History of Present Illness

Two years and three months prior to admission, the patient fell from bicycle. After
one week patient complained of weakness on the inguinal area, they consulted with
MD, x-ray done, given antibiotics, progression of weakness of bilateral extremity onset.
2nd week of July, two weeks after the accident, they consult at Veterans Hospital Nueva
Vizcaya, patient was admitted for two weeks, consulted for TB, given anti-TB drugs, and
then discharged.
One month prior to admission, August 2013, 3rd consultation with different doctor,
advised biopsy done, allegedly, negative for malignancy transferred to POC.

History of Past Illness

(-) hypertension
(-) diabetes mellitus
Surgical: none
Accident: none

medication: none
Allergy: no known food & drugs allergies

Social History
Industry vs Inferiority
During this stage, often called the Latency, we are capable of learning, creating
and accomplishing numerous new skills and knowledge, thus developing a sense of
industry. This is also a very social stage of development and if we experience unresolved
feelings of inadequacy and inferiority among our peers, we can have serious problems in
terms of competence and self-esteem.
As the world expands a bit, our most significant relationship is with the school and
neighborhood. Parents are no longer the complete authorities they once were, although
they are still important.

GORDONS HEALTH ASSESSMENT

PATTERN

DEFINITION

ACTUAL

ANALYSIS/

HEALTH

Data collection is

FINDINGS
Patient perceives himself

INTERPRETATION
According to Erik

PERCEPTION

focused

as not a healthy kid. He

Eriksons Stages of

AND HEALTH

on the persons

considers himself as a kid

Development, there will

who needs to get well

be a conflict about

MANAGEMENT perceived level of

health and well- being, soon because his

competence, Industry vs.

on practices for

perception of a healthy

Inferiority. This is a very

maintaining health.

person at his age is the

social stage of

Habits that maybe

one who goes to school

development and if

detrimental to health

every day. He is expecting

unresolved, feelings of

are also evaluated,

to recover from his present

inadequacy and inferiority

including smoking,

condition with the help of

among peers will occur

alcohol and drug used.the health care providers

leading to a very serious

Actual or potential

attending to his needs. All

problem about the childs

problems related to

of the medications

competency and self

safety

prescribed to patient are

esteem.

and health

available. Currently he is

management maybe

taking Rifampicin,

evaluated.

Isoniazid, Paracetamol

and Pediasure.
NUTRITION AND Focused on the patternDuring hospitalization, the
patient in on Diet As
METABOLISM
of food and fluid
Tolerated. Health care
consumption relatively
providers include in his diet
to metabolic
the BRAT Banana, Rice,
rate. The adequacy of Apple/Applesauce and
Toast. He also has loss of
local nutrient supplies
appetite because of
is evaluated, actual or uncomfortable feeling.
potential problem

An individuals health status

greatly affects eating habits and
nutritional status (Fundamentals
of Nursing by Kozier p. 1178).
The patient eats what the
doctor, nurses and parents told
him to eat, but he always dont
finishes his meals because of

related to

the uncomfortable feeling of

fluid balance, tissue

hospitalization.

integrity
and host defense
maybe identified as
well as problems
with gastrointestinal
ELIMINATION

system.
Data collection is

Bowel

focused on excretory Patient defecates once a

patterns (Bowel,
day but not every day.
bladder, skin)ExcretoryStool is soft, is minimal in
amount and is brown in
problem such as
color.
incontinence,
Bladder
constipation, diarrhea,
and urinary retention Patient voids 3-4 times a
day without pain and
maybe identified.
discomfort.

Focused on the
activities of
ACTIVITY AND

daily living requiring

EXERCISE

energy expenditure,
including self-

Patients activities in the

hospitals are deep
breathing exercise, taking
a bath or personal hygiene
and Range of Motion
Exercises.

care activities,
exercise and leisure
activities. The status of
major body system
involved with activity
and exercise is

Bowel
There was a change in the
frequency, consistency and
amount of stool.

Bladder
Urine color is yellow and
hazy. According to laboratory
results, there is presence of
Pseudomonas Aeruginosa
which is the causative agent
of TB.

During Patients confinement

in the hospital, there is
limitation in his activities of
daily living and a disruption in
his leisure and recreation
pattern.

evaluated including
respiratory,
cardiovascular, and
musculoskeletal
systems.
SLEEP AND
REST

Focused on the

Patients sleeps well everyday,Illness that causes pain or

persons sleep rest
7 to 9 hours a day because physical distress can result in
sleep problems. People who
And relaxation
he cannot ambulate most of
are ill require more sleep than
practices.
the time and just stay most of normal and the normal
rhythm and wakefulness is
Dysfunctional sleep the time in his bed.
often disturbed.
patterns,
(Fundamentals of Nursing, 7th
Fatigue and responses
ed by Barbara Kozier, et al, p.
1117). There is disruption of
to sleep deprivation
the sleep-wake cycle because
may be identified
of the patients condition

SELF-

Focused on persons Patient knows how to read

PERCEPTION

attitude towards self, and write because before

There was discontinuance in the

AND SELF

including identity, body hospitalization he was in

progress of his cognitive and

CONCEPT

image and sense of

his 4th grade in school.

perceptual pattern in terms of

self worth. The person

reading, writing because he

level of self- esteem

stopped in school due to his

and response to treats

condition.

to his/her self-concept
ROLES AND

maybe identified
Focused on persons

RELATIONSHIPS role in the

Patient is the youngest of all. The patient wants to be healthy

He knows that all of his

world and relationship siblings cares for him and

with others.
Satisfaction with roles,
role strain or

know his condition.

again and go back to school.

Dysfunctional
relationship may
further evaluated

SEXUALITY AND

Focused on the

REPRODUCTION

persons satisfaction

The patient don't perform sexualThe patient is too young to

or dissatisfaction with activity.

engage in sexual

sexuality patterns and

activities.

reproductive functions.
Concerns with
sexuality may be
identified.
COPING AND

Focused on the

STRESS

persons perception

TOLERANCE

Due to his condition, patient RB According to Folkman

and Lazaruz, coping is
of stress and on his or does not have any outlet to
the cognitive and
her coping strategies divert his feelings unlike before
behavioral effort to
support system are
he can watch television, or
manage specific
evaluated and
diverting it through playing his external and/or internal
demands that are
symptoms of stress
toys.
appraised as taxing or
are noted. The
exceeding the
resources of the
effectiveness of
person(Fundamentals
personscoping
Of Nursing by Kozier P.
strategies in terms
1020).
stress tolerance
maybe further
evaluated

VALUES AND BELIEFFocused on the

persons values and

According to the patient, there After what happened,

Beliefs including

are no practices that affect his patient is now seeking for

(spiritual beliefs) or

hospitalization. He follow

medical assistance.

goals that guide his or therapeutic regimen and a

Religious effort is still a

her choice of

strong faith to God accounts for part of patients life.

decisions.

his fast progress that was

thought to him by his parents.

PHYSICAL ASSESSMENT (INSPECTION, PALPATION, PERCUSSION,

AUSCULTATION)
AREA

TECHNIQUE

NORMAL FINDINGS

ACTUAL
FINDINGS

Inspection,
Palpation

Hair is fine clean and

equally distributed
Brown hair no
presence of lies or
lesion Scalp is clean
and moist. No
dandruff.

N/A

HAIR

Inspection,
Palpation

Round
shape,erect,and in
midline, no lesion
Head should be held
still upright
Face is symmetrical
with round oval
elongated or square
appearance
No abnormal
movements noted

HEAD AND
FACE

ANALYSIS/
INTERPRETATION
Normal Findings

Normal Findings
N/A

Temporal atery id
elastic and not tender
Inspection,
Use of
penlight
Palpation

Round eyes ,pupils

equally round
reactive to light and
accommodation, no
tenderness on
lacrimal apparatus,
fine eyebrows and
normal eyelashes

Pale
eyelid,pale
palpebral
conjunctiva

OPTIC

Inspection

Client can see and

identify
Object

N/A

OCCULO
MOTOR

Inspection

Client was able to

follow with eyes
moving finger
superiorly, inferiorly
and laterally

EYES

ABDUCENS

Inspection
Client was able to
follow with eyes
moving fingers
superiorly, inferiorly,
and laterally

TROCH-LEAR

Inspection

Client was able to

follow with eyes
moving fingers
superiorly and
laterally.

Pale eyelid, pale

palpebral conjunctiva and
increase platelet count
indicates the signs and
symptoms of anemia as
seen on the patient
present condition and
laboratory result.

Normal Findings

EARS

Inspection,
Use of
penlight,
Palpation

Small ears, equal in

size bilaterally,
auricle align within
the corner of the
eyes .Positive
hearing

Presence of
yellow
discharge
on the right
ear and
black
cerumen
(earwax) on
the left ear

Foul smelling, sticky

discharge-otitis external
or impacted foreign body
bloody, purulent
discharge- otitis media
with ruptured tymphanic
membrane.
Blood watery drainage
(cerebrospinal fluid- skull
trauma)
Impacted cerumen
blocking the view of the
eternal canal ear canalconductive hearing loss
as seen on patient ears.

NOSE

Inspection
Use of
penlight
Palpation

Nasal structures is
smooth and
symmetrical
Frontal and maxillary
sinuses are non
tenderness to
palpation

.N/A

Normal Findings

MOUTH AND
THROAT

Inspection
Use of
penlight
Palpation

No presence of
lesions or sore
No inflammation,
pink gums, pink lips.
Mouth open and
close smoothly.
Complete 10
temporary teeth
Glossopharengeal:
Exhibit gag reflex
Vagus :The client
ovula move forward
when she open her
mouth.
Hyphoglossal:
Tongue
move side by side

NECK AND
SHOULDER

Inspection
Palpation

Symmetrical with
head centered
without bulging
masses
No palpable
lympnodes carotid
and jugular artery
can be palpated
No lumps or lesions
No tenderness
Accessory: Patient
was able to
shruggles and turn
around her head
laterally

ARMS

Inspection
Palpation

10 fingers(left and
right) hands are
symmetrical, nontender and without
Nodules, no pain or
tingling sensation
and with normal
range of motion
Elbows are wrist are
symmytric without

N/A

Normal Findings

N/A

Normal Findings

Arms are
Impaired mobility may
smaller than often leads to muscle
usual.
atrophy and decrease
muscle tone.

deformities,
nontender without
nodules.
Nails are short firm
and and clean, nail
plate firmly attached
to nailbed
Pink tone returns
immediately to
blanced nail beds
when pressure is
release.
Good capillary refill

NAILS (arms
and feet)

Inspection
Palpation

SKIN

Inspection
Palpation

Fair complexion,
good skin tugor.
Soft and warm to
touch. No lesion ,skin
is intact with no
reddened areas.

CHEST

Inspection
Auscultation

No presence of
retraction
Symmetrical chest
expansion,no
presence of
adventious, sound
Normal respiratory
rate.

Inspection
Palpation

Cervical and lumbar

spine are concave,
thoracic fine is
straight (when
observed from
behind).
Nontender spinous
processes well
developed, soft and
smooth, nontender
paraverteberal
muscles. No muscles
spasm.
Flexion of cervical
spine is 45 degrees.
Extension of the
cervical spine is 45

Back

N/A

Normal Findings

Pallor, (loss
of skin
color) pale
skin eyelid.

One of the present

condition of the patient is
malnutrion and also the
decreace of hematocrit
indicates pallor and pale
eyelid that possible to
anemia deficiency.

N/A

Normal Findings

Visible
abscess at
the lumbar
area,
swollen and
painful to
touch.

Spinal cord injury often

results in inflammation at
the affected area.

ABDOMEN

GENETALIA
AND ANUS

LEGS( Lower
ExtremeTies)

degrees.
Buttocks are equally
sized; iliac crest are
symmetric in height.
Hips are stable,
nontender, without
crepitus.
Inspection
Abdominal skin is
Auscultation
pale and smooth
(use of
,free from rashes or
stethoscope) lesion
Palpation(Slig Umbilicus is midline
ht)
at lateral line
Percussion

Inspection
Palpation

No lesions, bleeding,
or rashes on her
genital.
Vaginal wall feel
smooth, pink, moist
and no irritation
The rectal mucusa is
normally soft,smooth,
non tender and free
from nodules

Inspection
Palpation

ANATOMY AND PHYSIOLOGY:

Abdomen is
asymmetric
al or bulge,
slow bowel
sound(peris
talsis
movement).

The patient had poor

elimination pattern (once
every 10 days)that
causes bulging of
abdomen ; slow bowel
sound and decrease fluid
intake which result to
constipation upon
assessment.

Presence of
skin rashes
in the rectal
area

Improper hygiene of
changing diaper
and cleaning may cause
diaper rash especially for
children.

Legs are
Impaired mobility may
smaller than often leads to muscle
usual.
atrophy and decrease
muscle tone.

The Spine
More than two dozen bones stacked
upon one another form the spine.
The bone closest to the head is
called the atlas because it carries the
weight of the skull.
Individual bones are grouped
together and include from top to bottom:
Seven neck bones (C, for
cervical)
12 chest-level bones (T, for
thoracic)
Five lower back bones (L,
for lumbar)

Anatomy and Physiology of the Spine

The spinal column also known as the
spine or backbone protects the delicate
nerve tissue of the spinal cord.

Four fused bones forming

the sacrum (S)
The tailbone (coccyx)

The Vertebrae
Each bony unit of the spine is called a vertebra; vertebrae is the plural form of the

word.

A vertebra is made up of the body and the arch. The arch aligns and form the
spinal canal when the vertebrae are stacked.

There are cushions between each vertebra; these intervertebral disks are made
up of cartilage, collagen fibers, and water.

Ligaments hold the vertebrae and the intervertebral disks together.

Damage to the vertebrae

Vertebrae can be crushed by force pushing on it and making a fracture; it is the

same mechanism that happens when someone breaks an arm or a leg.

Vertebrae can also be damaged when the ligaments that hold them together
break; this makes the stacked vertebrae fall out of alignment.
Both falling out of alignment and breaks can injure the spinal cord. Injuries can range
from a bruised spinal cord or, in a worst-case scenario, a crushed and interrupted spinal
cord.

Spinal Cord
The spinal cord is composed of many nerve fibers that run from the base of the
brain to the small of the back. It is the most important way for the brain to communicate
with the rest of the body.
Spinal nerves:

Exit from the spinal cord to send and receive signals from muscles, skin, and
other organs.

The nerves exit the bony canal through passageways, called foramen, between
the vertebrae.

Nerves exiting near the:

Neck and upper back send and receive signals from the arms

Chest area are in charge of internal organs

Lower back control the legs and the genital area

The spinal cord runs within the spinal canal.

The spinal cord and the spinal canal are of equal lengths before birth.

The spinal cord stops growing earlier than the spinal canal that covers it.

In an adult, the spinal cord ends in the spinal canal in the small of the back,
around the level of the second lumbar vertebrae (L2).

The rest of the spinal canal only contains spinal nerves and not the spinal cord

itself.

LABORATORY TEST

10/09/2015 - Chest X-ray

RESULT OF EXAMINATION:

CHEST:
> Lungs are clear
> Heart is not enlarged
> Diaphragm & Sulci are intact
Incidental note of suspicious left humeral neck cortical areas.

IMPRESSION:
> Normal Chest
> Suggest views of the Elbow is warranted

LUMBOSACRAL SPINE
> Lytic osseous changes are seen in the posterior elements of L1-L3 vertebral
Body with a soft tissue component.
> Vertebral bodies of L1 & L2 are Partially involved posteriorly
> There is relative preservation of the intervertebral space.
> The rest of the vertebral body heights, pedicles, posterior elements &
Intervertebral spaces

IMPRESSION:

CONSTELLATION OF BRIDGING MAY RELATE TO AN INFECTIOUS PROCESS

SUGGEST HISTOPATHOLOGIC CORRELATION FOR BETTER EVALUATION

MRI OF THE LUMBOSACRAL SPINE

Impression:

1. Large nodular solid tumor masses involving the erector spinae.

Musculature as well as the right and left psoas muscle from L1 down to L4
with accompanying tumor extension into the intraspinal region at T12 down to
L3 vertebrae; Soft tissue sarcoma is the main consideration.
Potts disease process unlikely.
2. Marrow edema of L1, L2 and L3 vertebrae with gibbus deformity also noted at
the above levels.

3. Degenerative fatty atrophy of the rest of the lower erector spinae musculature.
4. Repeat Biopsy recommended for mor definitive histologic evaluation.

CLINICAL MICROSCOPYY
Urinalysis

PHYSICAL CHARACTERISTICS:
Color
=
Yellow
Transparency
=
HAZY
Reaction
=
7
Specific Gravity = 1.015

CHEMICAL TEST;
Sugar =
Negative
Protein =
Negative
MICROSCOPIC FINDINGS:
CELLS:
RBC
=
0-1/HPT
PUS Cells
=
2-4/HPT
Epithelial Cells
=
Few
Bacteria
=
Few
Mucus Threads
=
Few

INTERPRETATION:
Presence of bacteria which is Pseudomonas Aeruginosa. A bacteria that causes
Tuberculosis.

09/30/2015- CLINICAL CHEMISTRY

TEST

SI

CONVENTIONAL

Blood Urea Nitrogen

Creatinine
Albumin
Total Protein
Globulin
A/G Ratio
Sodium
Potassium
Chloride

1.7 - 8.3
36.3 L 71 - 115
38 - 51
97.3 H 60-83
52.97 H 22 - 32
0.84 L 1.50 - 3.1
135-148
3.5 - 5.3
98 - 107

15-41 mg/dl
0.59 mg/dL
4.52 g/dL
3.18 g/dL
141 mEq/L
4.1 mEq/L
98 mEq/L

4.76 - 23.2
0.49 - 1.30
3.8 - 5.1
2.8 - 3.6
135 - 148
3.5 - 5.3
98 -107

INTERPRETATION:
Clinical chemistry shows normal results but slightly high, this means that there may be a
presence of bacteria through infection may not be seen.

9/30/15 - HEMATOLOGY

COMPONENT:
Hemoglobin Mass
Hematocrit
COAGULATION STUDIES:

97
0.30

Prothrombin Time
RH Typing

16.3
POSITIVE

Normal Range
Male 140 - 180 g/L
0.37 - 0.57

11 - 15 seconds

INTERPRETATION:
Laboratory hematology shows normal results but slightly low , this means there may be
a presence of bacteria though infection may not be seen

10/07/2015 - PROTHROMBIN TIME:

PROTIME
PT % of Activity

15.1
73.6%

11.00 - 15.00

I.N.R.
APTT
SECONDS

1.23
37.1

22.00 - 45

INTERPRETATION:
CHEMISTRY SHOWS NORMAL RESULTS THIS IS AFTER ANTIBIOTIC TREATMENT
MEANING THAT TUE BODY IS RESPONDING FOR TREATMENT REGIMEN.

DRUG STUDY
NAME OF
DRUG

Generic Name:

DOSAGE

CLASSIFICAT
ION

MECHANISM OF
ACTION

ADVERSE
REACTION

NURSIN
CONSID

5.00 ml

Antituberculoti

The

Cardiovascular:

ORAL:

pharmacologic

Rifampicin

OD
AC

Brand Name
Rifadin

effects of enalapril may

be decreased, resulting
in
a
decrease
in
antihypertensive control.
Monitor BP; consider an
alternative
antihypertensive if BP
remains uncontrolled.

Rofac
(Canada)

Hypotension;shock
CNS:
Behavioral
changes;dizziness;dro
wsiness,
fatigue,generalized
numbness,
headache;inability to
concentrate,
mental
confusion.
Dermatologic:
Flushing,
pruritus,
rash
EENT
Conjunctivitis;
disturbance.

visual

GI:
Anorexia,
cramps,
diarrhea,
epigastric
distress,
gas,
heartburn,
nausea,
sore
mouth
and
tongue, vomiting.
Hematologic:
Decreased
Hgb,
eosinophilia,
hemolytic
anemia,
leukopenia

NAME OF
DRUG

Generic
Name

* Admin
after 2
full glas

*If pat
swallow
lower d
liquid s
compou
manufa
for prep

*Shake
prepare

INJECT
*For IV
or subc

*Follow
instruct
product
diluent,
If adde
adminis

*Incomp
Physica
diltiazem

DOSAGE

CLASSIFICATION

MECHANISM OF
ACTION

ADVERSE
REACTION

NURS
CONS

5ML

Antituberculotic

This medication is used

with other medication

Pheripheral
neuropathy

History
Allergy

OD
AC
Isoniazid
Brand Name
Niazid

to
Treat
active
tuberculosis
(TB)
infections or alone to
prevent those who
have positive TB test
from
developing
symptoms
of
TB.
Isoniazid belogs
To a class of drugs
known
As antibiotics that are
active
against
tuberculosis.
Interferes with lipid and
nucleic
acid
biosynthesis in
Actively growing in
active growing tubercle
bacilili.

Nausea and vomitting

Thrombocytopenia
Local irritation at IM
site.
Epigastric distress
Elevated AST

Can ca
Neurop
Manife
sensat
can b
use of
B6 (py

Physic
T; orien
Reflex
sensiti
streng
examin

Give in
hr be
meals.
food if

Give in
Revers
patient
medica
Decrea
tyramin
patient

NAME OF DRUG

DOSAGE

CLASSIFICATION

GENERIC NAME:

250mg/5ml
Q4hrs
Temp.
>38C

Antipyretic
(feverreducing) and analgesic
(pain relieving) medicine

Paracetamol

MECHANISM OF
ACTION

ADVERSE
REACTION

Unknown. Thougt to
produce analgesic by
blocking pain impulses
by inhibiting synthesis of
prostaglandin in the CNS
or of other substances
that
sensitize
pain

Hematologic:
Hemolytic
anemia,
neutropenia,
leukopenia,
pancytopenia.
Hepatic:

receptors to stimulation.
The drug may relieve
fever through central
action
in
the
hypothalamic
heatregulating center.

NAME OF DRUG

Pediasure

DOSAGE

1 glass /day
(full glass)

CLASSIFICATION

Nutritional
replacement

Jaundice
Metabolic:
Hypoglycemia
Skin:
Rash
Urticaria.

MECHANISM OF
ACTION

ADVERSE
REACTION

Enternal
nutritional
formulas are indicated to
provide
nutritioanal
support for individuals
with impaired digestion or
specialized
nutritional
support for individuals
with special nutritional
needs,

Not meant for kids who

are easily drinking milk
twice a day or even
once.

Not meant for kids who

are eating roti, bread,
puri, parantha,
Pasta or noodles

Not meant for kids who

finish off their breakfast,
lunch, snacks or dinner
with a little bit of
coaxing.
Not meant to be a taste
and protein enhancer
for generally healthy

kids

NCP
Assessment

Subjective:
"Hindi ako gaano
makagalaw galaw"
as verbalized by the
patient
Objective:
Decreased
muscle control/
strength
limited ROM
Inability
to
purposefully
more within the
physical
environment

Diagnosis

Impaired physical
mobility related to
neuromascular
impairment.

Planning

Intervention

Rationale

Within the duration Continually

Evaluates status
of duty, the patient
asses
motor
of
individual
will
maintain
function
by
situation (motorposition of function
requesting
sensory
and skin integrity by
patient
to
impairment may
absence of foot
perform certain
be mixed and/
drops, contractures
actions.
or not clear) for
and decubitus ulcer
specific level of
injury, affecting
type and choice
of intervention.

Provide means
to
summon
help.

Enables patient
to have sense of
control,
and
reduces fear of
being left alone.

Assist in range
of
motion

Enhance
circulation,
restores
or
maintains
muscle tone and

exercises on all
extremities and
joints,
using
slow,
smooth
movements.

Assessment

Diagnosis

Planning

Intervention

joint
mobility,
and
prevent
disuse
contractures
and
muscle
atrophy.

Rationale

Subjective:
Mabilis akong
mapagod
kaya
natutulog na lang
ako
Objective:
Needs
assistance
in
repositioning
Inability to do
his ADLs

Activity intolerance
r/t neuromuscular
impairment

Within the duration

of duty, the patient
will demonstrate a
decrease
in
physiologic sign of
intolerance

Evaluated clients
actual
and
perceive
limitations/ degree
of deficit in light of
usual status

Noted
clients
report
of
weakness, fatigue,
pain and difficulty
accomplishing his
task.
Ascertained ability
to move about and
degree
of

assistance
necessary use of
equipment

To
provide
comparative
baseline
and
provide information
about
needed
education/
intervention
regarding quality of
life
Symptoms
results
contribute
intolerance
activity

may
of/or
to
of

To
determined
current status and
needs associated
with participation in
Encouraged
needed
desired
expression
of activities.
To assist the client
feelings
contributing to his to
deal
with
condition
contributing factors
and
manage
activities
within
individual limits
Assist
with
activities
and To protect from
provide/
monitor injury
clients
use
of
assistive devices
Promote
comfort
measures
and To enhanced the
provide relief of ability to participate
pain
in activities
Repositioning
every 2 hours

To prevent bedsore
and to maintain
body alignment all
the time.
To prevent bedsore

 Made repositioning
schedule and post
at bedside and
educated
the
patients S.O in
proper turning the
patient

and to promote
circulation.

DISCHARGE PLANNING.

MEDICATION:
Rifampicin 5ml OD AC
Isoniazid 5ml OD AC
Paracetamol 250mg/5ml for pain

ENVIRONMENT AND EXERCISE:

Encourage patient to do:

Proper nutrition

Deep breathing

TREATMENT:
Handwashing
Daily wound care
HEALTH TEACHING:
Explain to the the family the importance of the following:

Handwashing

Proper nutrition

General health measures ( like maintain clean environment, wound

dressing, adequate sleep)

Teach the proper way of preparing the medication of the patient after
discharged.

OUT PATIENT:
Follow up check up as instructed upon discharged from the hospital.
Encourage family member to have multivitamins supplement provided for patient.

DIET:
Diet as Tolerated
Pediasure 1 full glass a day

PROGNOSIS:
Prognosis is very good if the swelling mass treated promptly by Incision and
drainage ( or surgical procedure) and continuous anti-biotic medication until the
bacterial infection threaten.