Student Nurses’ Community NURSING CARE PLAN – Spinal Cord Injury ASSESSMENT
SUBJECTIVE: “Hindi ako makagalaw” (I can’t move) as verbalized by the patient. OBJECTIVE: Paralysis Muscle atrophy Irritability V/S taken as follows: T: 37.3 P: 92 R: 19 BP: 120/80
DIAGNOSIS
Impaired physical mobility related to neuromascular impairment.
INFERENCE
Spinal cord injury may result from trauma, vascular disruption, infection, tumor, and other insults. The injury may be partial or complete and vary from a mild cord concussion with transient numbness to complete cord transaction causing immediate and permanent tetraplegia. The most common sites of injury are the cervical areas C5, C6, and C7, and the junction of the thoracic and lumbar vertebrae, T12 and L1. Clinical manifestations vary with the location and severity of cord damage. In general, complete transaction
PLANNING
After 8 hours of nursing interventions, the patient will demonstrate techniques or behaviors that enable resumption of activity.
INTERVENTION
Independent: • Continually asses motor function (as spinal shock or edema resolves) by requesting patient to perform certain actions. •
RATIONALE
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 intervention. Enables patient to have sense of control, and reduces fear of being left alone. Enhances circulation, restores or maintains muscle tone and joint mobility, and prevent disuse contractures and muscle atrophy. Prevents fatigue, allowing opportunity for maximal efforts or participations by patient. Reduces pressure areas, promotes peripheral circulation.
EVALUATION
After 8 hours of nursing interventions, the patient was able to demonstrate techniques or behaviors that enable resumption of activity.
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Provide means to summon help.
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Assist in range of motion exercises on all extremities and joints, using slow, smooth movements. Plan activities to provide uninterrupted rest periods. Encourage involvement within individual tolerance or ability. Reposition periodically even when sitting in chair. Teach patient how to use weightshifting techniques.
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Student Nurses’ Community
causes loss of all function below the level of lesion, and incomplete cord damage results in a variety of regional deficits. Complications include shock, respiratory or cardiac arrest, thromboembolism , infections, and autonomic dysreflexia. • Inspect the skin daily. Observe for pressure areas, and provide meticulous skin care. • Altered circulation, loss of sensation, and paralysis potentiate pressure sore formation. Helpful in planning and implementing individualized exercise program and identifying or developing assistive devices to maintain function, enhance mobility and independence. May be useful in limiting or reducing pain associated with spasticity
Collaborative: • Consult with physical or occupational therapist.
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Administer muscle relaxants or antispasticity as prescribed.
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