Nursing

Problems with
cues

Nursing Diagnosis
With Rationale

SMART

Nursing Interventions

Rationale for Interventions

(with reference)

Problem 1:

Ineffective Breathing Pattern r/t

impairment of innervation of
diaphragm
(lesion SL C5)

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)

Injuries at C5 can result in variable loss of

respiratory function, depending on the
phrenic nerve involvement and
diaphragmatic function but generally
cause decreased vital capacity and
inspiratory effort. (Doenges, NCP p.274)

Auscultate breath sounds. Note areas of

absent or decreased breath sounds or
development of adventitious sounds.

Hypoventilation is common and leads to

accumulation of secretions, atelectasis
and pneumonia. (Deonges, et al.)

Maintain client airway: keep head in

neutral position, elevate head of bed
slightly if tolerated, and use airway adjunct
as indicated.

Clients with high cervical injury and

impaired cough reflex needs assistance in
preventing aspiration/maintaining patent
airway. (Doenges, et al.)

Assist client in taking control of

respirations as indicated. Instruct and
encourage deep breathing focusing
attention on steps of breathing.

Breathing may no longer be a totally

involuntary activity but require conscious
effort, depending on level of
injury/involvement of respiratory
muscles. (Doenges, et al.)

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)

Assist with coughing as indicated for level

of injury; e.g have client take deep breath
for 2 sec. before coughing, or inhale
deeply then cough at the end of a slow
exhalation. Alternatively assist by placing
hands below diaphragm and pushing
upward as client exhales.

Reposition/turn periodically. Avoid/limit

prone position when indicated.

(Example of
diagnostic and
blood test
results)
Date: ________
MRI of cervical
spine- Spinal
cord compression
at C3 to C4 level.
Date:_________

Encourage patient to fluids (at least

2000ml/day).

Adds volume to cough and facilitates

expectoration of secretions or help move
them high enough to be suctioned out.
(Doenges, et al.)

Enhances ventilation of all lung segments,

mobilizes secretions, reducing risk of
infection. Note: prone position
significantly decreases vital capacity, and
increase risk of resp. compromise failure.
(Doenges, et al.)

Aids liquefying secretions, promoting

mobilization and expectoration.
(Doenges, et al.)

Chest X-rayInterstitial
pneumonitis,
both bases
Date:_________
ABGs- Partially
compensated
respiratory
alkalosis, with
adequate
oxygenation

Assist with use of respiratory adjuncts:

incentive spirometer

Collaborative:
Administer oxygen by appropriate
method. (Nasal cannula)

Check serial ABGs.

Preventing retained secretions is essential

to maximize gas diffusion. (Doenges, et
al.)

Method determine by level of injury,

degree of respiratory insufficiency.
(Doenges, et al.)

Document status of ventilation and

oxygenation, identifies respiratory
problems. (Doenges, et al.)

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

The patient will maintain

position of function as
evidenced by absence of
contractures, foot drop,
and increase strength of
unaffected/compensatory
body parts.

Goal met. After 3 hours of

nursing care and health
teaching the patient was
able to maintain position
of function as evidenced
by absence of
contractures, foot drop,
and increase strength of
unaffected/compensatory
body parts.

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 skin daily.

Observe for
pressure areas
and provide
meticulous skin
care.

Assess for
redness,
swelling/muscle
tension of calf
tissues. Record
calf and thigh
measurements
as indicated.

Prevents frozen
shoulder
contractures.

Prevents foot drop

and external
rotation of hips.

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

weeks but persist

throughout life
span.

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.

May be useful for

reducing pain
associated with
spasticity.
Note: Baclofen may
be delivered via
implanted
intrathecal pump
on a long term
basis as
appropriate.

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.

Patient will not

manifest
symptoms such
as pounding
headache with
paroxysmal
hypertension,
profuse
diaphoresis,
nausea, nasal
congestion, and
bradycardia.

Observe for signs/symptoms

of syndrome:
e.g changes in VS,
paroxysmal hypertension,
tachycardia/bradycardia;
autonomic responses:
sweating, flushing above
level of lesion; pallor below
injury, chills, goose flesh,
piloerection, nasal
stuffiness, severe pounding
headache, especially in
occiput and frontal regions.
Note associated symptoms:
chest pains, blurred vision,
nausea, metallic taste,
Horners syndrome

Rationale for Interventions

(with reference)

Visceral distention is the most

common cause of autonomic
dysreflexia which is considered
an emergency. Treatment of
acute episode must be carried
out immediately (removing
stimulus, treating unresolved
symptoms), the interventions
must be geared toward
prevention.

Early detection and immediate

intervention is essential to
prevent serious
consequences/complications.
Note: Average systolic BP in
tetraplegic client after spinal
shock has resolved is 120;
therefore readings of 140+ are
considered high.

Expected
Outcomes

Evaluation

The patient will

not experience
episodes of
autonomic
dyreflexia.

Goal met. During

4 hours of
nursing care and
health teaching
the patient was
not able to
experience
episodes of
autonomic
dysreflexia.

(contraction of pupil, partial

stasis of eyelid,
enophthalmos (recession of
eyeball into the orbit), and
sometimes loss of sweating
over one side of the face).

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.

Removing noxious stimulus

usually terminated episode and

may prevent more serious
autonomic dysreflexia.
Correct/eliminate causative
stimulus as able; e.g.,
bladder, bowel, skin
pressure (including
loosening tight leg
bands/clothing, removing
abdominal binder/elastic
stockings; temperature
extremes.

Inform client/SO of warning

signals and how to avoid
onset of symptoms; e.g
goose flesh, sweating,
piloerection may indicate
full bowel; sunburn may
precipitate episode.

This lifelong problem can largely

controlled by avoiding pressure
from over distention of visceral
organs or pressure on the skin.