NCLEX: Physiological Integrity: Nursing Care of the Adult Client

Physiological Integrity: Nursing Care of the Adult Client: NEUROMUSCULAR SYSTEM

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

MULTIPLE SCLEROSIS: progressive neurological disease, common in northern climates, characterized by demyelination of brain and spinal cord leading to degenerative neurological function; chronic remitting and relapsing disease; cause unknown. Visual problems are often the first indication of multiple sclerosis. Classifications of multiple sclerosis: relapsing-remitting, primary progressive, secondary progressive, and progressive-relapsing. Exacerbations aggravated by fatigue, chilling, and emotional distress.

A. Pathophysiology: multiple foci (patches) of nerve degeneration throughout brain, spinal cord, optic nerve, and cerebrum cause nerve impulses to be interrupted (blocked) or distorted (slowed). Researchers suggest that, in genetically susceptible people, the disease results from an abnormal autoimmune response to some agent, perhaps a virus or environmental trigger.

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Northern climate.
  • Onset age: 20 to 40 years.
  • Two to three times more common in women than men.

Physiological Integrity: Nursing Care of the Adult Client

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Extremities: weak, numb, decreased sensation.

b. Emotional: instability, apathy, irritability, mood swings, fatigue.

c. Eyes: diplopia (double vision), spots before eyes (scotomas), potential blindness.

d. Difficulty in swallowing.

e. Pain.

  • Objective data:

a. Nystagmus (involuntary rhythmic movements of eyeball) and decreased visual acuity.

b. Inappropriate outbursts of laughing or crying (sometimes related to ingestion of hot food).

c. Disorders of speech.

d. Susceptible to infections.

e. Tremors to severe muscle spasms and contractures.

f. Changes in muscular coordination; gait: ataxic, spastic.

g. Changes in bowel habits (e.g., constipation).

h. Urinary frequency and urgency.

i. Incontinence (urine and feces).

j. Sexual dysfunction.

k. Cognitive changes/depression.

l. Laboratory tests: cerebrospinal fluid has presence of gamma globulin IgG.

m. Diagnostic tests:

(1) Neurological examination.
(2) Positive Lhermitte’s sign (electric shock–like sensation along spine on flexion of the head).
(3) Positive Babinski reflex.
(4) MRI detects plaques.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Impaired physical mobility related to changes in muscular coordination.
  • Self-esteem disturbance related to chronic, debilitating disease.
  • Altered health maintenance related to spasms and contractures.
  • Risk for impaired skin integrity related to contractures.
  • Constipation related to immobility.
  • Impaired swallowing related to tremors.
  • Visual sensory/perceptual alteration related to nystagmus and decreased visual acuity.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: maintain normal routine as long as possible.

a. Maintain mobility—encourage walking as tolerated; active and passive ROM; splints to decrease spasticity.

b. Avoid fatigue, infections.

c. Frequent position changes to prevent skin breakdown and contractures; position at night: prone, to minimize flexor spasms of knees and hips.

d. Bowel/bladder training program to minimize incontinence.

e. Avoid stressful situations.

  • Goal: decrease symptoms—medications as ordered:

a. Methylprednisolone (high dose, IV) plus sodium succinate, followed by gradual tapering of steroids to treat at initial diagnosis.

b. Methylprednisolone (Solu-Medrol), prednisone (Deltasone), and dexamethasone (Decadron) used to treat acute relapses.

c. Methotrexate (Rheumatrex) (low dose) used to delay progression of impairment.

d. Interferon beta-1b (Betaseron) reduces number of lesions and frequency of relapses.

e. Glatiramer (Copaxone) to reduce number of relapses.

f. Baclofen (Lioresal) for alleviating spasticity 5 mg three times daily, increased by 5 mg every 3 days; not to exceed 80 mg/day (20 mg four times daily). Optimal effect between 40 and 80 mg; sudden withdrawal of medication may cause hallucinations and rebound spasticity.

g. Diazepam (Valium), dantrolene (Dantrium) to relieve muscle spasm.

h. Carbamazepine (Tegretol) or amitriptyline HCl (Elavil) for dysesthesias or neuralgia.

i. Ciprofloxacin (Cipro) to treat bladder dysfunction.

j. Psyllium hydrophilic mucilloid (Metamucil) to treat bowel dysfunction.

k. Phenytoin (Dilantin) to treat sensory symptoms.

l. Analgesics to treat pain.

  • Goal: health teaching to prevent complications.

a. Signs and symptoms of disease; measures to prevent exacerbations.

b. Teach to monitor respiratory status to prevent infections.

c. Referral: importance of physical therapy to prevent contractures.

d. Referral: possible counseling or community support group for assistance in accepting long-term condition.

e. Teach special skin care to prevent decubitus ulcers.

f. Teach use of assistive devices to maintain independence.

  • Goal: provide psychosocial support.

a. Answer questions of client and family members.

b. Provide referrals to appropriate agencies.

c. Monitor for signs of suicide (higher incidence of suicide in clients with MS than the general population).

d. Encourage communication.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Establishes daily routine; adjusts to altered lifestyle.
  • Injuries prevented; no falls.
  • Urinary and bowel routines established; incontinence decreased.
  • Infections avoided.
  • Symptoms minimized by medications.

MYASTHENIA GRAVIS: chronic neuromuscular disease characterized by weakness and easy fatigability of facial, oculomotor, pharyngeal, and respiratory muscles. The muscle weakness increases during periods of activity and improves after periods of rest.

A. Pathophysiology: inadequate acetylcholine or excessive or altered cholinesterase, leading to impaired transmission of nerve impulses to muscles at myoneural junction.

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Possible autoimmune reaction.
  • Thymus tumor.
  • Young women and older men, but can occur at any age.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Diplopia (double vision).

b. Severe generalized fatigue.

  • Objective data:

a. Muscle weakness: hands and arms affected first.

b. Ptosis (drooping of eyelids), expressionless facies.

c. Hypersensitivity to narcotics, barbiturates, tranquilizers.

d. Abnormal speech pattern, with high-pitched nasal voice.

e. Difficulty chewing/swallowing food.

f. Decreased ability to cough and deep breathe, vital capacity.

g. Positive Tensilon test (administration of edrophonium chloride, 10 mg IV, produces relief of symptoms within 30 seconds).

h. Positive Prostigmin test (1.5 mg subcutaneous neostigmine methylsulfate, produces relief of symptoms within 15 minutes; increased muscle strength within 30 minutes).

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Ineffective breathing pattern related to weakness.
  • Risk for injury related to muscle weakness.
  • Activity intolerance related to severe fatigue.
  • Bathing/dressing self-care deficit related to progressive disease.
  • Impaired physical mobility related to decrease in strength.
  • Anxiety related to physical symptoms and disease progression.
  • Knowledge deficit (learning need) related to medication administration and expected effectiveness.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: promote comfort.

a. Passive and active ROM, as tolerated, to increase strength.

b. Mouth care: before and after meals.

c. Diet: as tolerated, soft, pureed, or tube feedings.

d. Skin care to prevent decubiti.

e. Eye care: remove crusts; patch affected eye prn.

f. Monitor respiratory status—suction airway prn.

  • Goal: decrease symptoms.

a. Administer medications as ordered:

(1) Anticholinesterase (neostigmine [Prostigmin], pyridostigmine [Mestinon]) to elevate concentration of acetylcholine at myoneural junction.
(2) Give before meals to aid in chewing, with milk or food to decrease GI symptoms; may be given parenterally.

  • Goal: prevent complications.

a. Respiratory assistance if breathing pattern not adequate.

b. Monitor for choking/increased oral secretion.

c. Avoid: narcotics, barbiturates, tranquilizers.

  • 4. Goal: promote increased self-concept.

a. Encourage independence when appropriate.

b. Encourage communication; provide alternative methods when speech pattern impaired.

  • Goal: health teaching.

a. Medication information:

(1) Adjust dosage to maintain muscle strength.
(2) Medication must be taken at prescribed time to avoid:

(a) Myasthenic crisis (too little medication).
(b) Cholinergic crisis (too much medication).

b. Signs and symptoms of crisis: dyspnea, severe muscle weakness, respiratory distress, difficulty in swallowing.

c. Importance of avoiding upper respiratory infections.

d. Determine methods to conserve energy, to maintain independence as long as possible, while avoiding overexertion.

e. Refer to Myasthenia Gravis Foundation and other community agencies for assistance in reintegration into the community and plans for follow-up care.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Independence maintained as long as possible.
  • Respiratory arrest avoided.
  • Infection avoided.
  • Medication regimen followed and crisis avoided.

PARKINSON’S DISEASE: progressive disease of the brain occurring generally in later life; characterized by stiffness of muscles and by tremors.

A. Pathophysiology: depigmentation of the substantia nigra of basal ganglia → decreased dopamine (neurotransmitter necessary for proper muscle movement) → decreased and slowed voluntary movement, masklike facies, and difficulty initiating ambulation. Decreased inhibitions of alpha-motoneurons → increased muscle tone → rigidity of both flexor and extensor muscles and tremors at rest.

B. Risk factors:

  • Age older than 40; most often 50 to 60 years.
  • Affects men and women equally.
  • Cause unknown; possibly connected to arteriosclerosis or viral infection.
  • Drug-induced parkinsonian syndromes have been linked to:

a. Phenothiazines.

b. Reserpine (Serpasil).

c. Butyrophenones (haloperidol).

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Insomnia.

b. Depression.

c. Defects in judgment related to emotional instability; dementia (memory loss).

  • Objective data:

a. Limbs, shoulders: stiff, offer resistance to passive ROM.

b. Loss of coordination, muscular weakness with rigidity.

c. Shuffling gait: difficulty in initiating gait, then propulsive, trunk bent forward.

d. Tremors: pill-rolling of fingers, to-and-fro head movements.

e. Loss of postural reflexes.

f. Weight loss, constipation.

g. Difficulty in maintaining social interactions because of impaired speech, lack of facial affect, drooling.

h. Facies: wide-eyed, decreased eye blinking, decreased facial expression.

i. Akinesia (abnormal absence of movement).

j. Excessive salivation, drooling.

k. Speech: slowed, slurred.

l. Judgment defective (e.g., poor decision making); intelligence intact.

m. Heat intolerance.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Impaired physical mobility related to loss of coordination.
  • Altered health maintenance related to defective judgment.
  • Risk for injury related to altered gait.
  • Dressing/grooming self-care deficit related to muscular rigidity.
  • Sleep pattern disturbance related to insomnia.
  • Body image disturbance related to tremors and drooling.
  • Social isolation related to altered physical appearance.
  • Altered nutrition, less than body requirements, related to lack of appetite.
  • Impaired swallowing related to excessive drooling.
  • Constipation related to dietary changes.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: promote maintenance of daily activities.

a. ROM exercises, skin care, physical therapy.

b. Encourage ambulation; discourage sitting for long periods.

c. Assist with meals—high-protein, high-calorie; soft diet; small, frequent feedings; encourage increased fluids.

d. Encourage compliance with medication regimen:

(1) Dopamine agonists:

(a) Levodopa: given in increasing doses until symptoms are relieved; given with food to decrease GI symptoms. Side effects: nausea, vomiting, anorexia, postural hypotension, mental changes, cardiac arrhythmias. Levodopa (L-Dopa) helps restore dopamine deficiency in striated muscles: 500 to 1,000 mg/day in divided doses; increase by 100 to 750 mg/day every 3 to 7 days until response reached; usual maintenance dose should not exceed 18 gm/day.
(b) Carbidopa-levodopa (Sinemet): 25/250 mg/day in 3 to 4 divided doses. Limits the metabolism of levodopa peripherally and provides more levodopa for the brain.

(2) Anticholinergics: effective in lessening muscle rigidity.

(a) Benztropine mesylate (Cogentin): 0.5 to 6 mg/day in 1 to 2 divided doses.
(b) Biperiden (Akineton): 2 mg 3 to 4 times daily, not to exceed 16 mg/day.
(c) Trihexyphenidyl (Artane): 1 to 2 mg day; increased by 2 mg every 3 to 5 days; usual maintenance dose: 5 to 15 mg/day in 3 to 4 divided doses.

(3) Antihistamines: have mild central anticholinergic properties.

  • Goal: protect from injury.

a.Monitor BP, side effects of medications (e.g., orthostatic hypotension).

b.Monitor for GI disturbances.

c. Avoid pyridoxine (vitamin B6): it cancels effect of levodopa.

d. Levodopa contraindicated with:

(1) Glaucoma (causes increased intraocular pressure).
(2) Monoamine oxidase (MAO) inhibitors (causes possible hypertensive crisis).

  • Goal: health teaching.

a. Teach client and family about medications: dosage range, side effects, not discontinuing medications abruptly.

b. Exercise program to maintain ROM and normal body posture; also to get adequate rest to prevent fatigue.

c. Dietary adjustment and precautions regarding cutting food in small pieces to prevent choking, taking fluid with food for easier swallowing.

d. Importance of adding roughage to diet to prevent constipation.

e. Assist client and family to adjust to this chronic debilitating illness.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Activity level maintained.
  • Symptoms relieved by medications; no drug interactions.
  • Complications avoided.

AMYOTROPHIC LATERAL SCLEROSIS (ALS; Lou Gehrig’s disease): progressive degeneration of motor neurons within the brain, spinal cord, or both, leading to death within 2 to 7 years, usually from infection (pneumonia) or consequences of respiratory or bulbar paralysis. There are three types of ALS: classic sporadic, familial, and Mariana Islands (Guam).

A. Pathophysiology: myelin sheaths destroyed, replaced by scar tissue; involves lateral tracts of spinal cord, eventually medulla and ventral tracts.

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Affects men more than women.
  • Usually in middle age.
  • Viral infection possible causal agent.
  • Possible familial or genetic component.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Early symptoms: fatigue, awkwardness.

b. Dysphagia, dysarthria; speech slurred—may sound drunk.

c. Alert, no sensory loss.

  • Objective data:

a. Symptoms depend on which motor neurons affected.

b. Decreased fine finger movement.

c. Progressive muscular weakness, atrophy, especially lower limbs at onset of disease; later arms, hands, and shoulders.

d. Spasticity of flexor muscles; one side of body becomes more involved than other.

e. Progressive respiratory difficulties →diaphragmatic paralysis.

f. Progressive disability of upper and lower extremities.

g. Fasciculations (muscle twitching visible under skin).

h. Diagnostic tests:

(1) Electromyography (EMG).
(2) Nerve conduction velocities (NCVs).

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Ineffective airway clearance related to difficulty in coughing.
  • Ineffective breathing pattern related to progressive respiratory difficulties and eventually respiratory paralysis.
  • Altered health maintenance related to inability to perform self-care activities.
  • Impaired physical mobility related to progressive muscular weakness.
  • Self-care deficits: bathing/hygiene and dressing/grooming.
  • Powerlessness related to lifestyle of progressive physical helplessness.
  • Impaired swallowing related to disease progression.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: maintain independence as long as possible.

a. Assistance with ADLs; splints, prosthetic devices to support weak limbs and maintain mobility.

b. Skin care to prevent decubiti.

c. Soft/liquid diet to aid in swallowing, prevent choking; suction prn; head of bed elevated when eating.

d. Respiratory assistance as needed; ventilators as disease progresses and diaphragm becomes involved.

e. Arrange long-term care arrangements if home maintenance no longer feasible.

f. Emotional support, when client is alert; continue involving client in decisions regarding care.

g. Medications: riluzole (Rilutek) has some effect in reducing disease progression; other drugs offer temporary relief of symptoms.

  • Goal: health teaching.

a. Skin care to prevent decubitus ulcer.

b. Explain ramifications of disease so client and family can make decisions regarding future care, whether client will remain at home as disease progresses or enter a long-term care facility.

c. How to use suction apparatus to clear airway.

d. Care of nasogastric or gastrostomy feeding tube.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Obtains physical and emotional support.
  • Complications avoided in early stage of disease.
  • Remains in control of ADLs as long as possible.
  • Skin breakdown avoided.
  • Peaceful death.

GUILLAIN-BARRÉ SYNDROME: an uncommon, acquired autoimmune disease resulting in demyelination of the cranial and peripheral nerves and a progressive ascending paralysis that is usually reversible; develops in hours or up to 10 days. Also known as acute inflammatory polyradiculoneuropathy; incidence 1.6/100,000. Client is often completely paralyzed, yet sensation and mentation remain intact.

A. Pathophysiology: macrophages attack normal myelin of the peripheral nerves → demyelination and blocked conduction of impulses to muscles → progressive symmetrical and bilateral muscle weakness from distal lower extremities to proximal upper extremities, trunk, and neck.

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Viral infection 1 to 3 weeks before paralysis in 50% of cases.
  • Gastroenteritis.
  • Immunizations.
  • May be linked to cytomegalovirus and Epstein-Barr virus.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Pain, tingling in legs and back (paresthesias).

b. Reports falling.

c. Dyspnea.

  • Objective data:

a. Footdrop; unable to walk.

b. Gradual, progressive facial weakness; dysphagia; dysarthria.

c. Flaccid paralysis; absent superficial and deep tendon reflexes (DTRs).

d. Respiratory muscle paralysis → respiratory failure.

e. Postural hypotension; arterial hypertension, heart block, tachycardia.

f. Laboratory data: ↑ CSF protein.

g. Diagnostic tests: lumbar puncture; electrophysiologic studies (EEG: abnormal; EMG: slowed neural conduction).

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Impaired physical mobility related to progressive muscular weakness.
  • Ineffective breathing pattern related to progressive respiratory difficulties and eventual respiratory paralysis.
  • Anxiety related to disease progression.
  • Self-care deficits: bathing/hygiene and dressing/grooming.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: prevent complications during recovery from paralysis.

a. Respiratory:

(2) Prepare for mechanical ventilation if needed.
(3) Tracheostomy care and ventilator weaning as indicated.

b. Prepare for IV plasma exchanges.

(1) 2 to 3 hours daily over 4 to 5 days; 200 to 250 mL/kg body weight of albumin exchanged.
(2) Monitor for: hypotension, arrhythmias, vascular access problems.

c. IV immune globulin also may be given. Complications include: hypotension, dyspnea, fever, transient hematuria.

  • Goal: monitor for signs of autoimmune dysfunction.

a. Acute periods of ↑ BP alternating with ↓ BP.

b. Arrhythmias: give antiarrhythmic medications.

  • Goal: prevent tachycardia.

a. Medication: propranolol.

b. ECG monitoring (continuous) to detect alteration in cardiac rate and pattern.

  • Goal: assess cranial nerve function.

a. Check gag and swallowing reflex.

b. Check ability to clear secretions.

c. Check voice.

  • Goal: maintain adequate ventilation.

a. Monitor respiratory rate and depth.

b. Perform serial vital capacities and ABGs.

c. Observe for ventilatory insufficiency.

d. Prevent pneumonia, atelectasis.

  • Goal (in acute phase): check for progression of muscular weakness—check individual muscle groups q2h.
  • Goal: maintain nutrition.

a. NG tube—balanced liquid diet; mouth care.

b. Check gag and swallowing reflex before starting soft, pureed foods.

  • Goal: prevent injury and complications.

a. Eye care: artificial tears or ointment, due to lack of blinking or poor eyelid closure.

b. Mobility:

(1) ROM.
(2) Prevent DVT, contractures: use splints, high-top sneakers, footboards, heel and elbow protectors.
(3) Antiembolic stockings.

c. Elimination:

(1) Observe for urinary retention and constipation.
(2) Avoid enemas if possible (prevent further autonomic response).

  • Goal: support communication.

a. Develop two methods:

(1) To indicate immediate needs.
(2) For basic conversation.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Complete reversal of paralysis.
  • Complications avoided: maintains respiratory function, able to swallow, no complications from immobility.
  • After onset and plateau period, recovery may take 3 to 12 months.

SPINAL CORD INJURIES: trauma from hyperextension, hyperflexion, axial compression, lateral flexion, or shearing of the spine.

A. Types:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • C1 and C2 injury level—resulting deficit:

a. Phrenic nerve involvement.

b. Diaphragmatic paralysis.

c. Respiratory difficulties (require permanent ventilatory support).

d. Possible quadriplegia.

e. Possible death.

  • C4 through T1 injury level—resulting deficit: possible quadriplegia.
  • Thoracic-lumbar injury level—resulting deficit: possible paraplegia.

B. Pathophysiology: trauma → vertebral dislocation or fractures → cord trauma, compression, or severance of the cord.

C. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Motor vehicle accidents.
  • Diving, surfing, contact sports.
  • Falls.
  • Gunshot wounds.

D. Assessment:

  • Subjective data:

a. Pain at the level of injury.

b. Numbness/weakness, loss of sensation below level of injury.

c. Psychological distress related to severity of injury and its effects.

  • Objective data:

a. Symptoms depend on extent of injury to spinal cord/spinal nerves.

b. Paralysis: motor, sphincter.

(1) Initially a period of flaccid paralysis and loss of reflexes, called spinal or neural shock.

(2) Incomplete injuries may lead to loss of voluntary movement and sensory deficits below injury level (symptoms vary depending on injury).

(3) Complete injury leads to loss of function and all voluntary movement below level of injury.

c. Respiratory distress.

d. Alterations in temperature control.

e. Alterations in bowel and bladder function.

f. Involved muscles become spastic and hyperreflexic within days or weeks.

E. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Ineffective breathing pattern related to high-level injury.
  • Impaired physical mobility related to injuries affecting lower limbs.
  • Fear related to uncertain future health status.
  • Anxiety related to loss of control over own activities of daily living.
  • Bathing/hygiene self-care deficit related to injuries above T1.
  • Impaired home maintenance management related to possible quadriplegia and paraplegia.
  • Risk for altered body temperature related to absence of sweating below level of injury.
  • Risk for injury related to equipment necessary for daily activities.
  • Tactile sensory/perceptual alterations related to injury level.
  • Body image disturbance related to permanent change in physical status.

F. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: maintain patent airway.

a. Suction, cough, tracheostomy care, prn.

b. Oxygen, ventilator care.

c. Monitor blood gas levels.

  • Goal: prevent further damage.

a. Immobilize spine.

b. Firm mattress, Stryker frame, Foster frame, CircO-electric bed, traction, braces.

c. Skeletal traction via tongs: Crutchfield, Gardner-Wells.

d. Halo traction.

  • Goal: relieve edema: anti-inflammatory medications, corticosteroids.
  • Goal: relieve discomfort: analgesics, sedatives, muscle relaxants.
  • Goal: promote comfort:

a.Maintain fluid intake: PO/IV, I&O.

b. Increase nutritional intake.

c. Prevent contractures and decubiti.

d. Assist client to deal with psychosocial issues (e.g., role changes).

e. Begin rehabilitation plan.

  • Goal: prevent complications.

a. Monitor for spinal shock during initial phase of injury.

b. Monitor for hyperreflexia with severed spinal cord injuries.

  • Goal: health teaching.

a. Self-care techniques for highest level of independence; include significant others in teaching.

b. How to use ambulation assistive devices (battery-operated wheelchair controlled by mouthpiece or hand controls, depending on level of paralysis).

c. Identify community resources for follow-up care and career counseling.

d. Signs and symptoms of autonomic hyperreflexia.

e. Methods to prevent skin breakdown, infections of respiratory, urinary tract.

f. Bowel, bladder program.

G. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Complications avoided.
  • Accomplishes self-care to greatest level for injury.
  • Participates in rehabilitation plan.
  • Grieves over loss and begins to integrate self into society.

SPINAL SHOCK: temporary flaccid paralysis and areflexia following a severe injury to the spinal cord.

A. Pathophysiology: squeezing or shearing of the spinal cord due to fractures or dislocation of vertebrae; interruption of sensory tracts; loss of conscious sensation; interruption of motor tracts; loss of voluntary movement; loss of facilitation; loss of reflex activity; loss of muscle tone; loss of stretch reflexes, leading to bowel and bladder retention. If injury between T1 and L2, leads to loss of sympathetic tone and decrease in blood pressure. Afferent impulses are unable to ascend from below the injured site to the brain, and efferent impulses are unable to descend to points below the site.

B. Risk factors:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Automobile/motorcycle accidents.
  • Athletic accidents (e.g., diving in shallow water).
  • Gunshot wounds.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Subjective data:

a. Loss of sensation below level of injury.

b. Inability to move extremities.

c. Pain at level of injury.

  • Objective data:

a. Neurological examination:

(1) Absent: pinprick, pressure, and vibratory sensations below level of injury; reflexes below level of injury.

(2) Muscles: flaccid.

b. Vital signs:

(1) BP decreased (loss of vasomotor tone below level of injury).
(2) Bradycardia.
(3) Elevated temperature.
(4) Respirations: may be depressed; possible respiratory failure if diaphragm involved.

c. Absence of sweating below level of injury.

d. Urinary retention.

e. Abdominal distention: retention of feces, paralytic ileus.

f. Skin: cold, clammy.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Decreased cardiac output related to loss of vasomotor tone below level of injury.
  • Ineffective breathing pattern related to injuries involving diaphragm.
  • Impaired physical mobility related to loss of voluntary movement of limbs.
  • Urinary retention related to loss of stretch reflexes.
  • Fear related to serious physical condition.
  • Risk for injury related to potential organ damage if shock continues.

E. Nursing care plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Goal: prevent injury related to shock.

a. Maintain patent airway: intubation and mechanical ventilation may be necessary with cervical spinal injuries due to involvement of diaphragm.

b. Monitor vital signs; profound hypotension and bradycardia are most dangerous aspects of spinal shock.

c. Administer blood/IV fluids as ordered.

d. Nutrition and hydration:

(1) NPO in acute stage: maintain nutrition by IV infusions as ordered.
(2) When allowed to eat: high-protein, high-calorie, high-vitamin diet.

e. Maintain proper position to prevent further injury.

(1) Backboard is necessary to transport from place of injury.
(2) Support head in neutral alignment and prevent flexion.
(3) Skeletal traction will be applied once diagnosis is made.

f. Monitor urinary output q1h; may have Foley catheter while in shock; later, intermittent catheterization will be used as needed.

g. Relieve bowel distention; use lubricant containing anesthetic, as necessary, when checking for or removing impaction.

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

  • Complications are avoided.
  • Body functions are maintained.
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AUTONOMIC DYSREFLEXIA (autonomic hyperreflexia): a group of symptoms in which many spinal cord autonomic responses are activated simultaneously. This may occur when cord lesions are above the sixth thoracic vertebra; it is most commonly seen with cervical and high thoracic cord injuries; may occur up to 6 years after injury.

A. Pathophysiology: pathological reflex condition, which is an acute medical emergency characterized by extreme hypertension and exaggerated autonomic responses to stimuli.

B. Risk factors:

1. Distention of bladder or rectum.

2. Stimulation of skin (e.g., decubitus ulcers, wrinkled clothing).

3. Stimulation of pain receptors.

C. Assessment:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Subjective data:

a. Severe, pounding headache.

b. Blurred vision; sees spots in front of eyes.

c. Nausea.

d. Restlessness.

e. Feels flushed.

2. Objective data:

a. Severe hypertension (systolic BP may reach 300 mm Hg).

b. Bradycardia (30 to 40 beats/min); fever.

c. Profuse diaphoresis above level of injury.

d. Flushing of skin above level of injury.

e. Pale skin below level of injury.

f. Pilomotor spasm (gooseflesh); chills.

g. Nasal congestion.

h. Distended bladder, bowel.

i. Skin breakdown.

j. Seizures.

D. Analysis/nursing diagnosis:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Dysreflexia related to high spinal cord injury.

2. Risk for injury related to complications of hypertension, stroke.

3. Visual sensory/perceptual alteration related to blurred vision.

4. Urinary retention related to inability to empty bladder due to spinal injury.

5. Constipation related to inability to establish successful bowel training program.

6. Impaired skin integrity related to immobility.

E. Nursing plan/implementation:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. Goal: decrease symptoms to prevent serious side effects.

a. Elevate head of bed; this lowers BP in persons with high spinal cord injuries.

b. Identify and correct source of stimulation if possible; notify physician.

c. Monitor vital signs (BP) q15 min and prn; uncontrolled hypertension can lead to stroke, blindness, death.

d. Give medications as ordered: nitrates, nifedipine (Procardia), or hydralazine (Apresoline).

2. Goal: maintain patency of catheter.

a. Monitor output; palpate for distended bladder.

b. Check for tubing kinks; irrigate catheter prn.

c. Insert new catheter immediately if blocked. Do not use Credé’s maneuver or tap the bladder; it could exacerbate the response.

d. Culture if infection suspected.

3. Goal: promote regular bowel elimination.

a. Bowel training program.

b. Administer suppository/enemas/laxatives as ordered and prn.

c. When checking for and removing impaction, first use anesthetic ointment (e.g., dibucaine [Nupercainal] ointment) to decrease irritation.

4. Goal: prevent decubitus ulcers.

a. Meticulous skin care.

b. Position change q1–2h.

c. Flotation pads, alternating pressure mattress on bed and wheelchair.

5. Goal: health teaching.

a. How to recognize risk factors that could initiate this condition.

b. Methods to prevent situations that increase risk (e.g., bowel program, bladder program, skin care, position change schedule).

F. Evaluation/outcome criteria:

Focus topic: Physiological Integrity: Nursing Care of the Adult Client

1. BP remains within normal limits.

2. No complications occur.

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