Acute Pain and Ineffective Breathing Pattern - NCP for Scoliosis
Scoliosis is a medical condition in which a person's spine is curved from side to side. Although it is a complex three-dimensional deformity, on an X-ray, viewed from the rear, the spine of an individual with scoliosis can resemble an "S" or a "?", rather than a straight line.
People having reached skeletal maturity are less likely to have a worsening case. Some severe cases of scoliosis can lead to diminishing lung capacity, putting pressure on the heart, and restricting physical activities.
The signs of scoliosis can include:
- Uneven musculature on one side of the spine
- A rib prominence or a prominent shoulder blade, caused by rotation of the ribcage in thoracic scoliosis
- Uneven hips, arms or leg lengths
- Slow nerve action (in some cases)
Scoliosis is typically classified as either congenital (caused by vertebral anomalies present at birth), idiopathic (cause unknown, sub-classified as infantile, juvenile, adolescent, or adult, according to when onset occurred), or secondary to a primary condition.
Nursing Diagnosis and Interventions
1. Acute Pain related to the position of lateral body tilt.
Goal : Pain is reduced or lost
Interventions :
- Assess the type, intensity and location of pain. Rational: Influencing choice / control the effectiveness of Interventions can influence the level of anxiety to pain.
- Teach relaxation and distraction techniques. Rational: To divert attention, thereby reducing pain.
- Teach and Encourage use of the brace. Rational: To Reduced pain during activity
- Collaboration in the provision of analgesia. Rational: To relieve pain.
2. Ineffective Breathing Pattern related to the suppression of pain.
Goal : The pattern of breathing Effectively.
Interventions :
- Assess respiratory status every 4 hours.
- Help and teach the patient to breath in any one hour. Rationale: Increasing the maximum ventilation and oxygenation.
- Adjust bed semi-Fowler position to improv lung expansion. Rational: Sitting height allowing Easier breathing and lung expansion.
- Monitor vital signs every 1 hour. Rational: general indicators, circulation status and adequacy of perfusion.
