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Problems with
cues
Nursing Diagnosis
With Rationale
SMART
Nursing Interventions
Problem 1:
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 clients level of injury when assessing
respiratory function. Note presence or
absence of spontaneous effort and quality
of respiration. (e.g. labored, using
accessory muscles)
Difficulty of
breathing
Date:
Subjective:
She cant
breathe well
especially during
episodes of
spasms as
verbalized by
patients
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
support
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,
NCP p. 153)
(Example of
diagnostic and
blood test
results)
Date: ________
MRI of cervical
spine- Spinal
cord compression
at C3 to C4 level.
Date:_________
Chest X-rayInterstitial
pneumonitis,
both bases
Date:_________
ABGs- Partially
compensated
respiratory
alkalosis, with
adequate
oxygenation
Collaborative:
Administer oxygen by appropriate
method. (Nasal cannula)
Nursing
Problems with
cues
Problem 2:
Inability to
move
Subjective:
She cant move
on her own as
verbalized by
the patients
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
Suddarths 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
examiners
hands)
Perform/assist
with full ROM
exercises on all
extremities and
joints, 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
joint mobility and
prevents disuse
contractures and
muscle atrophy.
Expected Outcomes
Evaluation
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 for
redness,
swelling/muscle
tension of calf
tissues. Record
calf and thigh
measurements
as indicated.
Prevents frozen
shoulder
contractures.
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
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:
Administer
medication as
indicated
Baclofen
(Lioresal) 10
mg/tab TID as
ordered by the
physician.
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 ICP.
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.
Expected
Outcomes
Evaluation
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.