About
Injury to spinal cord causing partial or complete paralysis permanently or reversible depending on severity of injury.
Assess
Airway, breathing, level of injury, increased or decreased sensation, constipation, immobility, pressure ulcers, incontinence, paralysis, bradycardia, hypotension
Complications
Mechanical ventilation
Neurogenic shock; autonomic dysreflexia; pressure ulcers
Ineffective coping
Diagnosis
- Ineffective coping related to chronic rehabilitation
- Impaired urinary elimination related to impaired muscle control
- Impaired mobility related to paralysis
- Ineffective airway clearance related to lack of effective cough
- Risk for injury related to paralysis
Goals
- The client will remain free from injury.
- The client will adapt to mobility alterations using adaptive techniques.
Interventions
- Monitor circulation to extremities ( presence of ulcers, redness, erythema, decreased pulses, pallor, pain, decreased sensation, etc.).
- Monitor urinary output, insert catheter or perform intermittent straight catheterization as ordered.
- Monitor for autonomic dysreflexia ( bradycardia, hypertension, flushing, headache); notify physician immediately and plan to catheterize.
- Perform range of motion exercises, encourage client to participate.
- Maintain clutter-free environment free from physical barriers.
- Assist client with ADL's, as needed.
- Encourage active participation in ADL's as much as the client is able to tolerate.
- Encourage active participation in physical therapy and/ or occupational therapy.
- Encourage high fiber to promote peristalsis.
- Encourage client to verbalize concerns, fears, and feeling regarding injury.
- Initiate plans for continued rehabilitation, physical therapy, occupational therapy, etc as indicated.
- Monitor for signs/ symptoms of complications.
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