Nursing Care Process: The Patient with Quadriplegia or Paraplegia

Assessment

Activity/ RestMay exhibit:

Paralysis of muscles (flaccid during spinal shock) at/below level of lesion

Muscle/generalized weakness (cord contusion

CirculationMay report:

Palpitations Dizziness with position changes

May exhibit: Low BP, postural BP changes,

bradycardia Cool Pale extremities Absence of perspiration in

affected area

Elimination:May exhibit:

Incontinence of bladder and bowel

Urinary retention Abdominal distension; loss of

bowel sounds Melena, coffee-ground

emesis/hematemesis

Ego Integrity:May report:

Denial, misbelieve, sadness, anger

May Exhibit: Fear, anxiety, irritability,

withdrawal

Food/Fluid:May exhibit:

abdominal distension; loss of bowel sounds (paralytic ileus)

Hygiene:May exhibit:

Variable level of dependence in ADLs

NeurosensoryMay report:

Absence of sensation below area of injury, or opposite side sensation

Numbness, tingling, burning, twitching of arms/legs

May Exhibit: Flaccid Paralysis Loss of sensation Loss of Muscle/vasomotor tone Loss of asymmetrical reflexes,

including deep tendon reflexes Changes in pupil reaction, ptosis

of upper eyelid Loss of sweating in affected area

Pain/DiscomfortMay report:

Pain/ tenderness in musclesMay exhibit:

Vertebral tenderness, deformity

RespirationMay report:

Shortness of breath, “air hunger”, inability to breath

May Exhibit: Shallow/labored respirations;

periods of apnea Diminished breath sounds,

rhonchi Pallor, cyanosis

Safety May exhibit: Temperature

fluctuations

Sexuality:

May report: Expression of concern about

return to normal functioning

May Exhibit: Uncontrolled erection (priapism) Menstrual irregularities

Possible Nursing Diagnosis:

Risk for ineffective Breathing PatternRelated to: impairment of innervations of

diaphragm at or above C-5 Complete or mixed loss of

intercostals muscle function reflex abdominal Spasms; gastric

distention

Risk for TraumaRelated to: Temporary weakness/ instability

of spinal column

Impaired Physical MobilityRelated to: Neuromuscular Impairment Immobilization by traction

As evidence by: Inability to purposefully move;

paralysis Muscle Atrophy

Disturbed Sensory PerceptionRelated to: Destruction of sensory tracts with

altered sensory reception, transmission, and integration

Reduced environmental stimuli Psychological stress

As manifested by: Measured change in sensory

acuity, including position of body parts/ proprioception

Change in usual response to stimuli

motor incoordination Anxiety, disorientation, bizarre

thinking, exaggerated emotional responses

Acute PainRelated to:

Physical injury Traction Apparatus

As manifested by: Hyperesthesia immediately

above level of injury Burning Pain below level of

injury Muscle spasms/spasticity Phantom pain; headaches

Anticipatory GrievingRelated to:

Perceived/ actual loss of physiopsychosocial well-being

As manifested by: Altered communication patterns Expression of distress, choked

feeling, e.g. denial, guilt, fear, sadness, altered affect

Alteration in sleep patterns

Situational Low Self-EsteemRelated to:

traumatic injury, situational crisis; forced crisis

As manifested by: verbalization of forced change in

lifestyle Fear of rejection/reaction by

others

Focus on past strengths, function, or appearance

negative feelings about body feeling of helplessness,

hopelessness or powerlessness Actual change in structure and/or

function lack of eye contact change in physical capacity to

resume role confusion about self, purpose, or

direction of life

Bowel Incontinence/ConstipationRelated to:

Disruption of innervation to bowel and rectum

Perceptual impairment altered dietary and fluid intake change in activity level

As manifested by: loss of ability to evacuate bowel

voluntarily Constipation Gastric dilation, ileus

Impaired Urinary EliminationRelated to:

Disruption in bladder innervation bladder atony

As manifested by:

bladder distention; incontinence/overflow, retention

Urinary Tract infection Bladder, kidney stone formation Renal dysfunction

Risk for Impaired Skin Integrity:Risk factor:

Altered/inadequate peripheral circulation; sensation

Presence of Edema; tissue pressure

Altered metabolic state immobility; traction apparatus

Deficient KnowledgeRelated to:

Lack of exposure/recall information misinterpretation Unfamiliarity with information

resources

As manifested by: Questions; statement of

misconceptions; request for information

Inadequate follow-through instruction

inappropriate or exaggerated behaviors, e.g. hostile, agitated, apathetic

Development of preventable complication

Planning/ Goal:1. Maximize Respiratory Function2. Prevent further injury to Spinal Cord3. Promote mobility/ independence4. Maintenance of healthy intact skin5. achievement of bowel control6. achievement of sexual expression7. prevent or minimize complications8. strengthening of coping mechanisms9. support psychological adjustment of patient/ SO

10. Provide info about injury, prognosis & expectations, TX needs, complications

Nursing Interventions:1. Increasing Mobility Exercise

-push up while in prone position-Traction- extending the harms while holding the weight

Mobilization (if spine is stable enough)-brace or vest may be used, depending on level of lesion.-weight bearing for px whose paralysis is due to complete trasection of the cord-braces and crutches enable some paraplegic patient to ambulate for short

distances-Motorized wheelchair and specially equipped vans can provide greater

independence and mobility for PX with high-level SCI or other lesions

2. Preventing Disuse Syndrome-ROM exercises at least 4 times a day-Patient should be reposition frequently and maintained in proper body alignment

whether in bed or in a wheelchair.

3. Promoting Skin Integrity-Monitor skin status-turning every 2 hours-meticulous attention and cleansing of skin-teach about how ulcer develops over bony prominences. The most vulnerable areas are identified-paraplegic px is instructed to use mirrors, if possible, to inspect these areas morning and night, observing for redness, slight edema, or any abrasions-bottom should be checked for wetness and for creases.-for quadriplegic or paraplegic who cannot perform such activities is encouraged to direct others to check these areas and prevent ulcers from developing.-In wheelchair- ask to do push-ups, leaning form side to side to relieve ischial pressure-wheelchair cushion-diet: high protein, vitamins and calories to ensure minimal wasting of muscles and the maintenance of healthy skin-high in fluids to maintain well-functioning kidneys-prevent excessive weight gain and obesity, they may limit mobility.

4. Improving Bladder Management-encourage a fluid intake of about 2.5 L daily.-instruct patient to empty bladder frequently so there is minimal residual urine and should pay attention to personal hygiene.-perineum must be kept clean and dry and attention given to the perianal skin after defecation.

-underwear should be cotton (more absorbent) and changed at least once a day.-if an external catheter is used, the sheath is removed nightly; penis is cleansed to remove urine and is dried carefully, warm urine on the periurethral skin promotes growth of bacteria.-emphasize the importance of monitoring for indications of UTI.-Female- who cannot achieve reflex bladder control or self-catheterization may need to wear pads or waterproof undergarments.

5. Establishing Bowel Control-Reflex conditioning –to establish bowel evacuation.-massage anal sphincter to stimulate defecation.-teach px symptoms of impaction and cautioned to watch for hemorrhoids.-diet with sufficient fluids and fibers

6. Counseling on Sexual Expression-Counseling about the range of sexual expression possible, special techniques and positions, exploration of body sensations offering sensual feelings, and urinary and bowel hygiene as related to sexual activity.-for men, with erectile failure, penile prostheses enable them to have and sustain an erection.-Sildenafil (Viagra) is an oral smooth muscle relaxant that causes blood to flow into the penis, resulting in an erection.-small group meetings in which the patient can share their feelings, receive information, and discuss sexual concerns and practical aspects are helpful in producing effective attitudes and adjustments.

7. Enhancing Coping Mechanisms-encourage px to feel confident in their ability to achieve self-care and relative independence.-family therapy is helpful to help work thru issues in the family.-family may require counseling, social services, and other support systems to help them cope with the changes in their lifestyle and socio-economic status.-help patient overcome their sense of futility and to encourage them in the emotional adjustment that must be made before they are willing to venture into the outside world.-teach-patient are taught and assisted when necessary, nurse should avoid doing activities that px can do for themselves with a little effort.

Evaluation:Expected patient outcomes may include:

1. Attain some form of mobility2. contractures do not develop3. maintains healthy intact skin4. achieve bladder control, absence of UTI5. Achieve bowel control

6. Reports sexual satisfaction7. shows improved adaptation to environment and others8. Exhibits Absence of complications