Paraplegia - 5 Nursing Diagnosis and Interventions

Nursing Care Plan for Paraplegia

Paraplegia is the loss of movement and sensation in the lower extremities and all or part of the body as a result of injury to the thoracic or medulla. Lumbar or sacral spinal nerve roots. (Smeilzer, Suzanne C., et al. 2001: 2230).

Nursing Diagnosis and Interventions for Paraplegia
Nursing Diagnosis 1. : Impaired physical mobility related to neurons damage, sensory and motor function.
Goal: Improving mobility.
Expected outcomes: Maintaining the position of the function evidenced by the absence of contractures, foot drop, increasing the strength of the sick body / compensation, demonstrate techniques / behaviors enabling reenact activities.
Interventions:

• Assess the functions of sensory and motor patients every 4 hours.


• Change the patient's position every two hours by taking into account the stability and comfort of the patient's body.


• Give retaining board on the patient's foot.


• Use muscle orthopedic, circulation, hand splints.


• Perform passive ROM after 48-72 after injury 4-5 times / day.


• Monitor pain and fatigue in patients.


• Consult physiotherapy to exercise and muscle use as splints.

Rationale:

• Assigning capabilities and limitations of the patient every 4 hours.


• Preventing pressure sores.


• For prevent drop.


• Prevent contractures.


• Increase stimulation and prevent contractures.


• Showed the presence of excessive activity.


• Provide appropriate inducement.

Nursing Diagnosis 2. Risk for Impaired skin integrity related to decrease in immobility, decreased sensory function.
Goal: Maintaining the integrity of the skin.
Expected outcomes: The state of the patient's skin intact, free of redness, free from infection on the location of the distressed.
Interventions:

• Assess risk factor for impaired skin integrity.


• Assess the patient's condition every 8 hours.


• Use a special bed.


• Change positions every two hours with anatomical position.


• Maintain the cleanliness and dryness bed and the patient's body.


• Perform special massage / soft over a bony area every two hours with a circular motion.


• Assess the patient's nutritional status and give food with high protein.


• Perform maintenance on the area of ​​skin abrasions / broken every day.

Rationale:

• One of them is immobilization, loss of sensation, incontinence bladder / bowel.


• Earlier prevent the occurrence of pressure sores.


• Reducing the pressure, thereby reducing the risk of pressure sores.


• Depressed area will lead to hypoxia, a change of position improves blood circulation.


• Humid and dirty facilitate the occurrence of skin damage.


• Improve blood circulation.


• Maintain the integrity of the skin and the healing process.


• Accelerate the healing process.

Nursing Diagnosis 3. : Urinary retention related to an inability to urinate spontaneously, interruption spinothalamicus pathways.
Goal: Increased urinary elimination.
Expected outcomes: The patient can maintain bladder emptying without residues and distension, clear urine, urine culture is negative, fluid intake and output balance.
Interventions:

• Assess for signs of urinary tract infection.


• Assess fluid intake and output.


• Do the catheter according to the program.


• Instruct the patient to drink 2-3 liters every day.


• Check the patient's bladder every 2 hours.


• Check urinalysis, culture and sensibility.


• Monitor body temperature every 8 hours.

Rationale:

• The effects of the ineffectiveness of the bladder is a urinary tract infection.


• Knowing inadequate kidney function and effective bladder.


• The effects of spinal cord injury is the reflex micturition disorders that need assistance in urine output.


• Prevent urine more concentrated which resulted in the onset of infection.


• Knowing the residue as a result of autonomic hyperreflexia.


• Knowing infection.


• Increased temperature indication of the presence of infection.

Nursing Diagnosis 4. : Constipation related to the atony intestine as a result of autonomic disturbances, interruption spinothalamicus pathways.
Goal: Improving bowel function.
Expected outcomes: The patient is free of constipation, stool softening circumstances, shaped.
Interventions:

• Assess the pattern of bowel elimination.


• Give drink 1800 - 2000 ml / day if there are no contraindications.


• Auscultation bowel sounds, assess for abdominal distension.


• Avoid using oral laxatives.


• Mobilize if possible.


• Evaluation and record bleeding at the time of elimination.


• Give suppository according to the program.


• Provide high-fiber diet.

Rationale:

• Determining a change of elimination.


• Prevent constipation.


• Determine the peristaltic movement of the bowel.


• Habitual use of laxatives will occurs dependence.


• Increase the peristaltic movement.


• The possibility of bleeding due to irritation.


• Stool softeners making it easier elimination.


• Fiber increases stool consistency.

Nursing Diagnosis 5. Chronic pain related to treatment, long immobility, psychic injury.
Goal: To provide a sense of comfort: pain.
Expected outcomes: Reported decrease pain / discomfort, identify ways to cope with pain, demonstrate the use of the skills of relaxation and entertainment activities, according to individual needs.
Interventions:

• Assess for the presence of pain, help the patient identify and quantify pain, such as the location, the type of pain intensity on a scale of 0-1.


• Give comfort measures, for example, a change in position, massage, warm compresses / cold as indicated.


• Encourage the use of relaxation techniques, for example, guidance imagination visualization, deep breathing exercises.


• Collaboration administration of drugs according to indications, muscle relaxants, analgesics; anti-anxiety.

Rationale:

• Patients usually report pain above the level of injury, for example; chest / back or the possibility of a headache than a tool stabilizer.


• Alternative actions to control pain.


• Refocused attention, increase the sense of control, and can improve coping skills.


• Needed to relieve spasms / muscle pain or to eliminate-anxiety and increase the rest.

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