3 Spinal Cord Injury Nursing Care Plan 6qe1i

Nursing Problems with cues

Nursing Diagnosis With Rationale

SMART

Nursing Interventions

Rationale for Interventions (with reference)

Problem 1:

Ineffective Breathing Pattern r/t impairment of innervation of diaphragm (lesion SL C5)

Within the 8 hour shift of nursing interventions, patient will maintain adequate ventilation as evidenced by absence of respiratory distress, ABG within normal limits, and pulse oximetry maintained at 90% or greater.

Independent: Note client’s level of injury when assessing respiratory function. Note presence or absence of spontaneous effort and quality of respiration. (e.g. labored, using accessory muscles)

Injuries at C5 can result in variable loss of respiratory function, depending on the phrenic nerve involvement and diaphragmatic function but generally cause decreased vital capacity and inspiratory effort. (Doenges, N p.274)

Auscultate breath sounds. Note areas of absent or decreased breath sounds or development of adventitious sounds.

Hypoventilation is common and leads to accumulation of secretions, atelectasis and pneumonia. (Deonges, et al.)

Maintain client airway: keep head in neutral position, elevate head of bed slightly if tolerated, and use airway adjunct as indicated.

Clients with high cervical injury and impaired cough reflex needs assistance in preventing aspiration/maintaining patent airway. (Doenges, et al.)

Assist client in taking control of respirations as indicated. Instruct and encourage deep breathing focusing attention on steps of breathing.

Breathing may no longer be a totally involuntary activity but require conscious effort, depending on level of injury/involvement of respiratory muscles. (Doenges, et al.)

Difficulty of breathing Date: Subjective: “She can’t breathe well especially during episodes of spasms” as verbalized by patient’s significant others. Patient reported shortness of breath, “air hunger” during muscle spasms

Objective: Vital Signs Range: HR: 110-125

Rationale: In high cervical spine injuries, spinal cord innervation to the phrenic nerve w/c stimulates the diaphragm is lost. (Brunner, 2010 p. 1936) With injuries to the cervical and upper thoracic spinal cord, innervation to the major accessory muscles of respiratory is lost and respiratory problems develop. These include decrease vital capacity, retention of secretions, increase PaCo2, decrease oxygen levels, respiratory failure and pulmonary edema.

After 30 minutes of health teaching and nursing care patient will demonstrate appropriate behaviors to respiratory

RR:25-36 Exhibits labored and using of accessory muscles Minimal nasal flaring is noted Breath soundsCrackles on both bases Reduced voice and tactile fremitus O2 saturation92-94%

effort such as focused deep breathing during muscle spasms and establish a normal or effective respiratory pattern with ABGs on acceptable range.

Maintain a calm attitude, assisting client to Assist client to dela with the physiologic “take control” by using slower/deeper effects of hypoxia which may be respirations. manifested as anxiety and fear. (Doenges, N p. 153)

Assist with coughing as indicated for level of injury; e.g have client take deep breath for 2 sec. before coughing, or inhale deeply then cough at the end of a slow exhalation. Alternatively assist by placing hands below diaphragm and pushing upward as client exhales.

Reposition/turn periodically. Avoid/limit prone position when indicated.

(Example of diagnostic and blood test results) Date: ________ MRI of cervical spine- Spinal cord compression at C3 to C4 level. Date:_________

Encourage patient to fluids (at least 2000ml/day).

Adds volume to cough and facilitates expectoration of secretions or help move them high enough to be suctioned out. (Doenges, et al.)

Enhances ventilation of all lung segments, mobilizes secretions, reducing risk of infection. Note: prone position significantly decreases vital capacity, and increase risk of resp. compromise failure. (Doenges, et al.)

Aids liquefying secretions, promoting mobilization and expectoration. (Doenges, et al.)

Chest X-rayInterstitial pneumonitis, both bases Date:_________ ABGs- Partially compensated respiratory alkalosis, with adequate oxygenation

Assist with use of respiratory adjuncts: incentive spirometer

Collaborative: ister oxygen by appropriate method. (Nasal cannula)

Check serial ABGs.

Preventing retained secretions is essential to maximize gas diffusion. (Doenges, et al.)

Method determine by level of injury, degree of respiratory insufficiency. (Doenges, et al.)

Document status of ventilation and oxygenation, identifies respiratory problems. (Doenges, et al.)

Nursing Problems with cues Problem 2: Inability to move Subjective: “She can’t move on her own” as verbalized by the patient’s significant other. Objective: Examples of diagnostic procedure results: Date:___________ MRI of cervical spineSpondylodiskiti s at C3-C5 with subluxation at C3-C4 and extensive paravertebral collection from

Nursing Diagnosis With Rationale

SMART

Impaired physical mobility r/t neuromuscular impairment.

After 3 hours of nursing care and health teaching the patient will maintain position of function as evidenced by absence of contractures, foot drop, and increase strength of unaffected/com pensatory body parts.

Rationale: Patient with lesions above the midthoracic level have loss of sympathetic control of peripheral vascoconstrictor activity, leading to hypotension. Contractures can develop rapidly with immobility and muscle paralysis. (Brunner and Suddarth’s Medical Surgical Nursing, p. 1939)

Nursing Interventions Independent: Continually assess motor function by requesting client to perform certain actions (e.g, shrug shoulders, spread fingers, release/squeeze examiner’s hands)

Perform/assist with full ROM exercises on all extremities and ts, using slow smooth movements. Hyperextend hips periodically.

Rationale for Interventions (with reference) Evaluates status of individual situation (motor-sensory impairment may be mixed and or not clear) for a specific level of injury, affecting type and choice of interventions.

Enhances circulation, restores/maintains muscle tone and t mobility and prevents disuse contractures and muscle atrophy.

Expected Outcomes

Evaluation

The patient will maintain position of function as evidenced by absence of contractures, foot drop, and increase strength of unaffected/compensatory body parts.

Goal met. After 3 hours of nursing care and health teaching the patient was able to maintain position of function as evidenced by absence of contractures, foot drop, and increase strength of unaffected/compensatory body parts.

C2 to T1. Spinal cord compression at C3 to C4 level. Date:__________ Cervical Spine APL- Posterior dislocation/retr opulsion of C5 in relation to C4 (Grade 4 Retrolisthesis)

Position arms at 90 degree at regular intervals.

Maintain ankles at 90 degree with footboard. Place trochanter rolls along thighs when in bed.

Assess skin daily. Observe for pressure areas and provide meticulous skin care.

Assess for redness, swelling/muscle tension of calf tissues. Record calf and thigh measurements as indicated.

Prevents frozen shoulder contractures.

Prevents foot drop and external rotation of hips.

Altered circulation, loss of sensation, and paralysis potentiate pressure sore formation.

In a high percentage of clients with cervical cord injury, thrombi develop because of altered peripheral circulation, immobilization, and flaccid paralysis. Greatest during 2

weeks but persist throughout life span.

Investigate sudden onset of dyspnea, cyanosis, and other signs of resp. distress.

Development of pulmonary emboli may be silent because pain is altered and DVT is not easily recognized.

Collaborative: ister medication as indicated Baclofen (Lioresal) 10 mg/tab TID as ordered by the physician.

May be useful for reducing pain associated with spasticity. Note: Baclofen may be delivered via implanted intrathecal pump on a long term basis as appropriate.

Nursing Problems with cues Problem 3: Risk for Complication of Autonomic Dysreflexia (No signs and symptoms)

Nursing Diagnosis With Rationale Risk for Autonomic Dysreflexia related to altered nerve function (C3-C4) Rationale: Autonomic Dysreflexia occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after the spinal shock subsided. The sudden increase in blood pressure may cause rupture of one or more cerebral blood vessels or lead to increase I.

SMART

Nursing Interventions

During 4 hours of nursing care and health teaching the patient will not manifest episodes of autonomic dysreflexia.

Assessment Identify/monitor precipitating risk factors; e.g, bladder/bowel distention or manipulation; bladder spams, stones, infection; skin/tissue pressure areas, prolonged sitting position, temperature extremes/drafts.

Patient will not manifest symptoms such as pounding headache with paroxysmal hypertension, profuse diaphoresis, nausea, nasal congestion, and bradycardia.

Observe for signs/symptoms of syndrome: e.g changes in VS, paroxysmal hypertension, tachycardia/bradycardia; autonomic responses: sweating, flushing above level of lesion; pallor below injury, chills, goose flesh, piloerection, nasal stuffiness, severe pounding headache, especially in occiput and frontal regions. Note associated symptoms: chest pains, blurred vision, nausea, metallic taste, Horner’s syndrome

Rationale for Interventions (with reference)

Visceral distention is the most common cause of autonomic dysreflexia which is considered an emergency. Treatment of acute episode must be carried out immediately (removing stimulus, treating unresolved symptoms), the interventions must be geared toward prevention.

Early detection and immediate intervention is essential to prevent serious consequences/complications. Note: Average systolic BP in tetraplegic client after spinal shock has resolved is 120; therefore readings of 140+ are considered high.

Expected Outcomes

Evaluation

The patient will not experience episodes of autonomic dyreflexia.

Goal met. During 4 hours of nursing care and health teaching the patient was not able to experience episodes of autonomic dysreflexia.

(contraction of pupil, partial stasis of eyelid, enophthalmos (recession of eyeball into the orbit), and sometimes loss of sweating over one side of the face).

Independent Monitor BP frequently (every 3-5) during acute autonomic dysreflexia and take action to eliminate stimulus. Continue to monitor BP at intervals after symptoms subside.

Aggressive therapy/removal of stimulus may drop BP rapidly resulting in a hypotensive crisis, especially in those clients who routinely have low BP. In addition autonomic dysreflexia may recur, particularly if stimulus is not eliminated.

Removing noxious stimulus

usually terminated episode and may prevent more serious autonomic dysreflexia. Correct/eliminate causative stimulus as able; e.g., bladder, bowel, skin pressure (including loosening tight leg bands/clothing, removing abdominal binder/elastic stockings; temperature extremes.

Inform client/SO of warning signals and how to avoid onset of symptoms; e.g goose flesh, sweating, piloerection may indicate full bowel; sunburn may precipitate episode.

This lifelong problem can largely controlled by avoiding pressure from over distention of visceral organs or pressure on the skin.