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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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