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West Visayas State University COLLEGE OF NURSING La Paz, Iloilo City


Name of Patient: MGO Age: 41 years old Clustered Cues Attending Physician: Dr. Soriaso Ward/Bed Number: OSW Bed 8 Nursing Diagnosis Ineffective peripheral tissue perfusion related to blood vessel trauma Rationale Impression / Diagnosis: Spinal Cord Injury C5 and C6 in spinal shock secondary to fall s/p application of Gardner Wells Tongs Outcome Criteria Nursing Interventions Rationale Evaluation

Date and Time: February 15, 2013; 9:00am o Apical pulse = 42 bpm o Brachial pulse (left): 42 bpm (right): 47 bpm o Radial pulse = (left): 42 bpm (right): 46 bpm o Dorsalis pedis pulse = (left): 43 bpm (right): 46 bpm o BP = 90/50 mmHg o Conjunctiva pale o Capillary refill of less than 2

Definition: Decrease in blood circulation to the periphery that may compromise health

The patient will be able to: o Demonstrate increased perfusion as Rationale: individually appropriately A spinal cord injury such as: skin usually begins with a warm and dry, sudden, traumatic blow peripheral pulses to the spine that present and fractures or dislocates strong, free of vertebrae. The damage pain and begins at the moment discomfort. of injury when o Demonstrate displaced bone behaviors to fragments, disc improve material, circulation such or ligaments bruise or as engage in tear into spinal cord ROM exercises tissue. Axons are cut off o Verbalize or damaged beyond understanding of repair, and neural cell present condition membranes are broken. and disease

Assess vital signs and neurovital signs

For baseline data and provides comparison to current findings To promote circulation or venous drainage

Elevate head of the bed (10-30 degrees) and maintain head or neck in midline Identify changes related to systemic and or peripheral alterations in circulation Encourage to increase fluid intake Instruct, demonstrate and encourage deep

To assess or determine causative or contributing factors

To replenish fluid volume deficit To decrease metabolic conserves

Date and Time: February 15, 2013; 2:30pm Goal partially met as manifested by: o Naintindihan ko man, gin exlain man na sang doctor sa akon kag kinahanglan guid ako operahan para makahulag liog ko kag amat2 lawas ko patient verbalized. o Patient

seconds o Pale and cool to touch sole of feet and palm of hands o Paralysis of left leg and fingers

management Blood vessels may after 4-5 hours of rupture and cause nursing heavy bleeding in the interventions. central grey matter, which can spread to other areas of the spinal cord over the next few hours. Within minutes, the spinal cord swells to fill the entire cavity of the spinal canal at the injury level. This swelling cuts off blood flow, which also cuts off oxygen to spinal cord tissue. Blood pressure drops, sometimes dramatically, as the body loses its ability to self-regulate. As blood pressure lowers even further, it interferes with the electrical activity of neurons and axons. All these changes can cause a condition known asspinal shock that can last from several hours to several days.

breathing exercises and promote a quiet and restful environment Instruct and assist to do passive and active exercises

tissue O2 demands

To enhance circulation return to unaffected extremities To decrease tension levels

Demonstrate and encourage relaxation techniques Discuss factors and potential outcomes of the disease condition

relaxation techniques such as deep breathing and coughing exercises o Performs passive and active exercises o Skin in right extremities is warm to touch

Information necessary for client to make informed choices and commit to lifestyle changes as appropriate To increase circulation of blood. Dopamine has a positive inotropic effect thus increasing blood volume and strengthening contraction.

Administer medications needed and to report any sign of adverse reactions. Administer dopamine as prescribed by the physician.

Reference: (1) Doenges, M. et al

(2010) Nurses Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales; 12th edition, pages 586-591, (2) Ignativicus, and Workman (2011) Medical-Surgical Nursing, patient centered collaborative care; 6th edition, pages 990-1100; Saunders Elsevier, st. Louis Missouri. (3) http://www.medicinene y_treatments_and_reha bilitation/page10.htm Students Name: BSN3B RLE Group 4 Clinical Instructor: Sheryll B. Javellana, R.N.