Cues and Clues Observation: y Needs assisstance in walking y Irritable, weakness y Grimace especially in moving, Pain scale 10 out

of 10 y Increase in BP from 120/70 to 130/80 y Limited body movements Subjective: y Reported severe pain radiating to thighs and legs y Reporting tingling and numbing sensation on the right leg y Reported an increase in pain while walking y Verbalized nahihirapan ako lumakad, sobrang sakit ngayon y Confined to bed, expresses the disire to rest

Nursing Diagnosis

Scientific Rationale

Expected Outcome After 2 to 3 days of nursing intervention the client will able to: 1. Verbalizepain tolerance during activity and will preform self care with out the need of assistance for atleast 2 to 3 hours. After 3 to 5 hours of nursing intervention the client will able to: 2. To verbalize decrease in pain with a pain scale of 7-8 out of 10, and will able to tolerate the pain during small activities like standing and walking. 3. Have an adequate rest for about 3 to 4 hours. y y

Nursing Intervention Monitor the patient s vital signs. Assess for the precipitating factors that contributes to weakness and fatigue, such as pain, disease, age, insomnia, fear, monotony. Assess the level of mobility, especially the activities of daily living. y y

Rationale To provide baseline data. Personal factors can influence the client s actual and perceived ability to participate in activity.

Evaluation After 2 to 3 days of nursing intervention the client 1. Verbalized pain tolerance during activity and preformed self care with out the need of assistance for atleast 3 hours. After 3 to 5 hours of nursing intervention the client 4. To verbalized decrease in pain with a pain scale of 8 out of 10, and will able to tolerate the pain during small activities like standing and walking. 5. Have an adequate rest for about 3 to 4 hours.

Activity intolerance related to low back pain radiating to right thigh and leg.

Lumbosacral Radiculopathy is a disease cause by herniated disc or bulging of disc. Large protrusion on the L4-5 level compressing the nerve root causes pain, tingling sensation and numbness. Pain may alter the activity of the patient, especially when it was severe. Also tinggling and nubning sensation may alter the mobility. Due to nerves compression it also alters the transmission of impulses on the affected body especially the motor impulses.

Plan care to carefully balance rest periods with activities. Assist with self care activity and ADL s, as necessary. Provide rest periods to facilitate comfort, sleep and relaxation. Encourage to move his his right leg while on bed rest.

Administered analgesic as ordered

This aids in defining what patient is capable of, which is necessary before setting realistic goals. This will reduce fatigue. To promote energy conservation and recovery. Assisting the patient with self care activities and ADL s allows for conservation of energy. This will help the patient to enhanced ability to participate in activities. To increase blood circulation on the affected body area, that will promote tissue oxygenation. Analgesic have the ability to block the

-check for the doctor s order before administering. -check for dosage and frequency. Check for 5R s.

Advise to do exercise appropriate for his disease as precribed by his PT, if tolerated.

prostaglandins production, thus reduces pain and inflammation. This will also enhance the patient s capability to participate in the activities. This improves muscle s strength and circulation, and promotes wellness.