12 Ncp Spinal Cord Injury

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NCP: Patient with A Spinal Cord Injury (Asuhan Keperawatan pada pasien Cedera Tulang Belakang) Ineffective breathing related to respiratory muscle fatigue, neuromuscular paralysis, and retained seretion as evidenced by decreased vital capacity, alterations in depth of breathing, decreased tidal volume, decreased minute ventilation, poor cough, diminished breath sounds (Pola nafas tidak efektif berhubungan dengan kelemahan otot pernafasan, kelumpuhan neuromuskular, adanya tahanan seresi ditandai dengan penurunan tanda-tanda vital, perubahan nafas, penurunan tidal volum, penurunan ventilasi, batuk, suara nafas berkurang) 1. Maintains adequate ventilation (Pertahankan ventilasi yang adekuat). 2. Demonstrates no signs of respiratory distress (demonstrasikan tidak adanya tanda-tanda gangguan pernafasan) Patient goals Intervetion Outcome Respiratory Monitoring (Pemantauan Pernafasan) Respiratory Status :Ventilation  Monitor rate, rhythm, depth, and effort of repirations to note  Respiratory rate....... baseline and changes in status.(Pantau laju, irama,  Respiratory rhythm..... kedalaman, danusaha nafasserta perubahan status)  Depth of respiration...........  Monitor for diaphragmatic muscle fatigue (parodoxic motion).(Pantau kelemahan otot diafragma) Respiratory Status  Auscultate breath sounds, noting areas of decreased/absent  Auscultated breath sounds........... ventilation and presence of adventitious sounds.(Auskultasi  Oxygen saturation....... suara nafas, catat area yg mengalami penurunan/ventilasi  Pulmonary function tests...... dan adanya suara adventif)  Note changes in SaO2, SvO2, end-tidal CO2, and ABG Measurement Scale values. (Catat perubahan di SaO2, SvO2, tidal CO2, dan 1= Severe deviation from normal range nilai ABG) 2= Substantial deviation from normal range  Monitor PFT values, particularly vital capacity, maximal 3= Moderate deviation from normal range inspiratory force and forced expiratory volume, to identify 4= Mild deviation from normal range hypoventilation requiring mechanical ventilation.(Pantau 5= No deviation from normal range nilai PFT, khususnya kapasitas vital, kekuatan inspirasi dan ekspirasi maksimal, untuk mengidentifikasi terjadinya hipoventilasi)  Monitor patient’s ability to cough effectively to identify need for suctioning (Pantau kemampuan pasien dalam batuk efektif untuk kebutuhan tindakan suction)

Nursing diagnosis

NCP: Spinal Cord Injury

Page 2 of 7 Airway Management (Penatalaksaan jalan napas)  Identify patient requiring actual/potential airway insertion to ensure timely intervention (Identifikasi kebutuhan aktual/potensial jalan napas pasien untuk memastikan tindakan intervensi selanjutnya)  Perform endotracheal or nasotracheal suctioning to stimulate coughing and to clear respiratory secretions.(Lakukan suction endotracheal atau nasotracheal untuk menstimulasi batuk dan untuk membersihkan sekresi napas)

Nursing diagnosis

Patient goal

Impaired skin integrity related to skull tong placement, imobility, and purtissue perfusion as evidenced by reddened skin over bony prominences and open tong sites (Gangguan integritas kulit berhubungan dengan penempatan tengkorak, imobilisasi, dan perfusi jaringan yang buruk ditandai dengan kemerahan) 1. Demonstrates no signs of infection at skull tong sites (Demonstrasikantidak adanya tanda infeksi di tengkorak) 2. Maintains intact skin over bony prominences (Pertahankan keutuhan tulang)

Intervention Skin Surveillance (Surveilans Kulit)  Monitor for sources of pressure and friction to identify areas at risk for breakdown (Pantau tekanan dan gesekan untuk mengidentifikasi resiko kerusakan)  Monitor for infection at open tong sites to promote early detection and treatment.(Pantau tanda infeksi pada area yang terbuka untuk membantu deteksi dini dan terapi)

Outcome Tissue Integrity :Skin and Mucous Membrane  Skin lessions.....  Erythema....  Necrosis......  Induration........  Blanching .........

Infection Control (Pengendalian Infeksi)  Ensure appropriate wound care technique to prevent bacterial colonization at tong sites. (Pastikan kesesuaian perawatan luka untuk mencegah masuknya bakteri)

Measurement Scale 1= Severe 2= Substantial 3= Moderate 4= Mild 5= None

NCP: Spinal Cord Injury

Page 3 of 7 Pressure Management (Penatalaksanaan Penekanan)  Monitor skin for areas of redness and breakdown so that interventions can be initiated promptyl if a problem develops.(Catat adanya kemerahan pada area kulit  Place on an appropriate therapeutik mattress/bed to relieve pressure.  Use appropriate devices to keep heels and bony prominences off the bed.  Facilitate small shiftss of body weight to relieve pressure without disrupting traction.  Monitor the patient’s nutritional status to maintain healthy skin resistant to breakdown.

Nursing diagnosis

Patient goal

Constipation: related to neurogenic bowel, inadequate fluid intake, diet low in roughage , and immobility as evidenced by lack of bowel, movement formore than 2 days, decreased bowel sounds, palpable impaction, hard stool, or stool incontinence. 1. Establishes a bowel management program based on neurologic function and personal preference 2. Maintains a bowel meovement every other day

Intervention (NIC)

Outcome (NOC)

Bowel Management Bowel Elimination  Monitor bowel movements, including frequecy, consistency,  Elimination pattern...... shape, volume, and color, to establish baseline function  Control of bowel movements.......  Monitor bowel sounds to determine if peristalsis is present  Stool soft and formed.............  Instruct patient on foods high in fiber because bulk and fiber  Ease o stool passage............. are necessery to the success of a bowel program  Initiate a bowel training program to establish a bowel routine Measurement Scale as quickly as possible 1= Severely compromised

NCP: Spinal Cord Injury

Page 4 of 7 2= Substantially compromised 3= Moderately compromised 4= Mildly compromised 5= Not compromised

Nursing diagnosis

Impaired urinary elimination related to spinal injury and limited fluid intake as evidenced by urinary retention, bladder distension, involuntary emptying of bladder (after spinal shock)

Patient goal

Establish a bladder management program based on neurologic function, caregiver status, and lifestyle choices

Intervention Urinary Retention care  Monitor intake and output to evaluate fluid balance.  Monitor degree of bladder distension by palpation and percusion because loss of autonomic and reflex control of bladder and sphincter can cause urinary retention.  Insert urinary catheter to relief urinary retention in spinal shock  Implement intermitten catherterization postacute phase of spinal cord injury to maintain bladder tone and avoid infection associated with long term use of indwelling catheter.

outcome Urinary Elimination  Urinary retention............  Urinary incontinence.............. Measurement Scale

1= Severe 2= Substantial 3= Moderate 4= Mild 5= None

NCP: Spinal Cord Injury

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Refer to urinary continence specialist to establish long term bladder management program.

Risk for autonomic dysreflexia related to reflex stimulation of sympathetic a nervous system after spinal shock resolves

Nursing diagnosis Patient goals

1. Experiences no episodes of dysreflexia 2. Describes causes, prevention, symptoms, and management od dysreflexia

Intervention Dysreflexia management  Identify and minimize stimui that may precipitate dysreflexia: bladder distention, renal calculi, infection, fecal impaaction, rectal examination, suppository insersion, skin breakdown, and constrictive clothing or bed linen.  Monitor for signs and symptoms of autonomic dysreflexia: paroxysmal hypertension, bradycardia, tachycardia, diaphoresis above the level of injury, facial flushing, palor below the level of injury, headache, nasal congestion, engorgement of temporal and neck vessel, conjuctival congestion, chills without fever, pilomotor erection, and

outcome Neurologic Status: Autonomic  Apical herat rate............  Systolic blood pressure...............  Diastolic blood pressure..............  Bowel elimination pattern.................  Urinary elimination pattern.................. Measurement Scale 1= Severely compromised 2= Substantially compromised 3= Moderately compromised

NCP: Spinal Cord Injury

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chest pain. Investigate and treat or remove offending cause (e.g., distended bladder, fecal impaction, skin lessions, and constrictinhg bedclothes). Place head of bed in upright position if hyperreflexia occurs to reduce blood pressure by allowing blood to pool in the lower extremities. Stay with patient and monitor status every 3-5 min if hyperreflexia occurs Administer antihypertensive agents intravenously as ordered to reduce blood pressure. Instruct patient and caregiver about causes, symptoms, treatment, and prevention of dysreflexia to reverse occurence and prevent occurence of status epilepticus, stroke, and possible death.

Nursing diagnosis Patient goals

4= Mildly compromised 5= Not compromised  

Headaches................ Dysreflexia................

Measurement Scale

1= Severe 2= Substantial 3= Moderate 4= Mild 5= None

Ineffective coping related to loss of control over bodily functions and altered lifestyle secondary to paralysis as evidenced by ation of inability to cope, expression of anger or other negative feelings, refusal to discuss changes in function and participate in social contacts 1. Reports ability to cope with effects of spinal cord injury 2. Expresses feelings of grief in adapting to losses related to chronic condition

Intervention Coping Enhancement  Appraise patient’s adjusment to changes in body images  Appraise impact of patient’s life situation on roles and relationships.  Provide and atmosphere of acceptance.  Encourage verbalizaton of feelings, perceptions, and fears to aid patient in clarifying feelings.  Provide factual information concerning diagnosis, treatment, and prognosis because knowledge of expectations can help patient cope with the future.

Outcome Coping  Identifies effective coping patterns................  Identifes ineffective coping patterns.............  Verbalizes sense of control..................  Verbalizes acceptance of situation...................  Modifies lifestyle as needed...............  Uses personal support system.................  Uses effective coping strategies...................  Reports decrease in negative feelings...................

NCP: Spinal Cord Injury

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Provide patient with realistic choices about certain aspect of care. Support use of appropriate defense mechanisms Assist patient to identify positive strategies to deal with limitations and manage needed lifestyle or role changes to prevent patient from practicing ineffevtive behaviors such as smoking, drinking, or angry outburst. Encourage family involvement to enhance patient’s sense of worth and value as a person. Assist patient to grieve and work through the losses of chronic illness and/or disability because spinal cord injury results in a real loss, requires adjustment through grieving.

Measurement Scale 1= never demonstrated 2= rarely demonstrated 3= sometimes demonstrated 4= often demonstrated 5= consistently demonstrated

NCP: Spinal Cord Injury