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.
- 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.
- 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.
- 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.
- 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.
