Nursing process in a patient with lumbar spondylosis and myelopathy

Abstract

Introduction: The Nursing Process is a scientific methodology that strengthens the quality of care and the autonomy of nurses, and is essential in the management of conditions such as spondylosis with lumbar myelopathy and systemic arterial hypertension. These pathologies have a significant impact on the patient's quality of life due to their physical and functional limitations. Methodology: This is a descriptive study, an experience report type, carried out in a medical clinic unit. Data collection included medical records, anamnesis and physical examination, using the NANDA-I, NIC and NOC systems for diagnosis, planning and implementation of care. Results and Discussion: a 66-year-old female patient diagnosed with lumbar myelopathy presented mobility limitations, constipation and anxiety, in addition to systemic arterial hypertension. Diagnoses were identified; interventions aimed at improving mobility, pain relief, constipation management and emotional support were implemented; and expected results were listed. The evolution allowed monitoring of the patient's responses and adjustment of the care plan as necessary. Conclusion: Myelopathy requires a comprehensive and humanized approach to meet the patient's biopsychosocial needs.