NURSING CARE PLAN

ASSESSMENT NURSING SCIENTIFIC PLANNING INTERVENTIO RATIONALE EVALUATION

DIAGNOSI RATIONALE NS
S

SUBJECTIVE: -Acute pain -the bones of the STG: -perform a -to rule out worsening -patient may have
related to spinal column or comprehensive of underlying different levels of
P-unilateral back trauma to vertebrae, run down -after 8 hours of assessment of pain condition or pain every time pain
pain intervertebral the back connecting nursing intervention each time pain development of is assessed.
-pain from disk. the skull to the pelvis. , patient will be able occurs. complications.
movement of neck. These bones protect to report relieved or -patient may show
Q- compressing nerves as they exit the controlled pain. -note patients locus -individual with locus of control
pain. brain and travel down of control. external locus of aggravating pain if its
R- radiating to butt the back and then to LTG: control may take little identifiable by the
T- pain aggravated the entire body. -observe for or no responsibility for patient.
when coughing, -after 2 weeks of nonverbal cues. pain management.
sneezing, bending HNP usually occurs in nursing intervention -patient may show
and doing vulsulva a posterior or patient will be able -monitor vital signs. -observations may or grimacing, guarding
maneuver posterolateral fashion, to demonstrate may not be congruent behavior.
-pain suddenly compressing the use of relation -provide comfort with verbal reports
subsides for few spinal cord and or techniques or skills measures. indicating need for -patient may elicit
days. nerve roots causing and diversional further evaluation. increase in vital signs.
-pain when raising pain and neurologic activities as -encourage use of
leg. symptoms. indicated for relaxation exercise. -vital signs usually -provided comfort
individuals situation. altered in acute pain. measures such as
-encourage back rub, change of
diversional -to provide non position.
OBJECTIVE: activities. pharmacologic pain
management. -patient used relation
-limited ability to -administer technique such as
bend forward analgesics as -to divert attention of focused deep
-tenderness in indicated to maximal the patient to the breathing.
affected area upon dosage as needed. activity rather than the
palpation. pain. -patient achieved
- encourage adequate minimal tolerable
- (+) lasegue’s sign. restperiods. -to maintain acceptable level of pain.
-muscle atrophy of level of pain.
affected area. -patient was able to
-to prevent fatigue. have adequate rest.
 PATHOPHYSIOLOGY

Mechanical stress
( compression,
fusion, HPN,
rotational forces.) Aggravated by age -Decreased fluid in
due to degenerative Decreased in the annulus.
changes thus protein contents -Dehydration of the
resulted in weak (oncotic agents) annulus.
muscles. -weakening of the
annulus, thus less
Men gender are elastic, thus prone to
mostly predisposed to tearing.

-Increased uptake of
fluid in the nucleus
pulposus.
Erosion of vertebral body by -Increase pressure in
bulging disk teared annulus. the nucleus pulposus.

Irritated pain fibris

Stimulation of new
Local bone growth PAIN
tenderness accompanied by
vertebral spasm.
 Ligament Accompanied by:
Increased thicken Autonomic responses:
tension -inc. v/s
-papillary dilatation
-diaphoresis
Calcification

Replacement of
nucleus

Results in neutral
obstruction

Decrease flow of
blood in the
affective area

Compression of Numbness occurs

spinal nerve

Impaired
mobility