Concept Map Spinal Cord Injury

Key Problem/ND #4: Key Problem/ND # 3: Risk for infection related to urinary catheterization as evidenced by decreased sensation in the bilateral lower extremities. Risk for pressure injury related to bladder incontinence as evidenced by need for urinary catheterization. Key Problem/ND #5: Risk for pressure injury related to decreased mobility as evidenced by inability to move. Objective Assessment Data: Key Problem/ND #2: Knowledge deficit related to emotional state affecting learning as evidenced by lack of selfdemonstration. BP: 124/82 mmHg Respirations: 20 Pulse: 90 bpm Oxygen Saturation: 96% Temperature: 98*F / 38.6*C Pain: 0/10 B/L upper extremity strength: +4 B/L lower extremity strength: 0 Key Problem/ND #6: Risk for falls and injury related to inability to ambulate as evidenced by decreased sensation in the bilateral lower extremities. Subjective Assessment Data: “I can’t live normally anymore.” Key Problem/ND #1: Impaired urination related to inability to urinate as evidenced by T8 spinal cord injury. Medical Diagnosis/Surgical Procedure: Patient Initials: KJ Age: 28 Police officer injured on the job Paraplegia d/t T8 spinal cord injury caused by a low-velocity gunshot wound to her back; Urinary catheterization Key Problem/ND #7: Risk for altered self-esteem status related to the inability to cope as evidenced by the statement “I can’t live normally anymore.” Problem #1/ND: Impaired urination related to inability to urinate as evidenced by T8 spinal cord injury. General Goal: Patient will be able to place urinary catheter and urinate without impairment by the time of discharge. Expected Outcome: Patient will be able to use the urinary catheter without hesitation. She will demonstrate the ability to perform urinary selfcatheterization insertion and intermittent catheterization every 4 hours. Maintain proper bladder management by keeping bladder volume under 500mL to prevent overdistention of the bladder. Nursing Interventions: Rationale: - Monitor labs (CBC, BUN, creatinine) - Used to assess kidney function and can promote early detection of infection (Potter et. al, 2021) - Perform intermittent catheterization every 4 hours and keep - Performing frequent urinary catheterization will decrease bladder bladder volume under 500mL volume and risk for bladder distention and patient discomfort - Use the bladder scanner prior to each catheterization - Ensures visualization of bladder volume procedure - Ensure there are no kinks or twists in the catheter tubing - Twists and kinks may cause the patient to feel the urge to urinate or have increased bladder pressure (Potter et. al, 2021) - Monitor and record intake and output - Promotes proper urination volume, bladder emptying, fluid balance, and ensures proper kidney function (Potter et. al, 2021) - Educate patient on urinary self-catheterization using clean - Shows the patient is able to perform the skill upon discharge and technique using the teach-back method decreases risk for infection; makes patient aware of importance of maintaining proper urinary health (Nurselabs, 2021) - Educate patient on proper bladder management - Emptying the bladder frequently avoids overdistention of the bladder and maintains urinary comfort of the patient - Monitor urine for darkness, cloudiness or odor - Malodorous, cloudy and/or dark urine may indicate sign of urinary infection (Nurselabs, 2021) - Educate patient on signs and symptoms related to urinary - Early UTI detection can decrease the infection from advancing tract infections and to report immediately if present - Encourage fluid intake during the day and limit fluid intake - Proper hydration ensures urination, promotes bladder function and during evening and nighttime prevents infection (Potter et. al, 2021) Evaluation: - Patient understands the importance of using clean technique for urinary self-catheterization - Patient demonstrates the skill of urinary self-catheterization using clean technique during teach-back opportunities - Intake and output values are balanced showing fluid balance, normal bladder and kidney function - Patient verbalizes signs and symptoms of possible UTI and agrees to report them promptly - Urine is clear and non-odorous, urinary frequency is normal without pain Problem #2/ND: Knowledge deficit related to emotional state affecting learning as evidenced by lack of self-demonstration. General Goal: Patient will have knowledge regarding new skills, such as urinary self-catheterization, transitions, and wheelchair ambulation for a paraplegic lifestyle by performing proper self-demonstration by the time of discharge. Expected Outcome: Patient will properly demonstrate urinary self-catheterization, transitions, and wheelchair ambulation. She will have a positive attitude about learning and maintaining her new lifestyle. She will feel emotionally ready to perform these tasks independently and demonstrate a positive learning experience. Nursing Interventions: Rationale: - Assess the willingness of patient to learn - This will help the nurse and patient perform a trusting relationship and give the nurse insight on where and how to begin patient education (Nurselabs, 2021) - Provide the patient with short, but clear explanations - Educating the patient with short and clear explanations promotes patient learning and avoids patient losing interest in information - Minimize distractions during interventions and patient - Promotes patient learning so the patient is focused on the given teaching intervention and education information (Potter et. al, 2021) - Comfort and provide the patient with emotional support - The patient may be more inclined to learn and perform selfdemonstration methods when calm and comfortable - Educate the client on the use of positive coping mechanisms - Strategies that promote positive emotional states can help the patient (Potter et. al, 2021) - Use different and effective educational techniques, including - Offering the patient a variety of learning methods may help the teach-back method promote successful learning and avoid patient frustration - Provide patient with positive feedback or constructive - Patients will feel more confident in their ability to complete the comments related to skill learning skill and are also able to be corrected and learn the skill properly rather than fixing their wrong learning (Nurselabs, 2021) - Encourage taking part in daily exercise routines or programs - Promotes a healthy lifestyle and a healthy mindset; helps the patient to feel confident in their abilities (Nurselabs, 2021) Evaluation: - Patient expressed adequate interest in learning her new lifestyle modifications such as urinary self-catheterization, transitions, and wheelchair ambulation - Patient understood teaching methods and explanations regarding such criteria - Patient was not distracted during patient education and actively participated during patient care and demonstrations - Patient feels emotionally supported and is eager to return home to her family upon discharge - Patient has knowledge about her new modifications and understands she will continue to learn throughout the rest of her life - Patient has a positive attitude about performing tasks independently Problem # 3/ND: Risk for infection related to urinary catheterization as evidenced by decreased sensation in the bilateral lower extremities. General Goal: Patient will be able to perform sterile self-catheterization technique by teach-back demonstration by the time of discharge to decrease risk of infection. Expected Outcome: Patient will not acquire an infection as evidenced by normal vital signs, normal urinalysis lab findings and signs and symptoms of infection (fever, chills, painful/frequent urination, malodorous urine). She will follow proper infection prevention guidelines. She will maintain a proper diet and fluid intake to promote immune system function. Nursing Interventions: Rationale: - Perform proper hand hygiene and use of PPE - Reduces the number of microorganisms that may be transmitted to the client and cause infection - Assess vital signs and pain level every 8 hours - Abnormal vital signs may indicate present infection; increase in body temperature is one of the first indicators of infection (Ackley, 2020) - Monitor lab findings (CBC, urinalysis and urine culture) - Presence of bacteria, WBCs, and nitrates in urine indicate urinary tract infection; cloudy urine may indicate infection - Record and monitor intake and output - Increased frequency but low amounts in output may indicate infection (Potter et. al, 2021) - Maintain sterile technique upon catheterization care - Proper sterile technique dramatically reduces risk for infection - Perform intermittent catheterization every 4 hours - Decreases volume of urine in the bladder and decrease risk for infection - Encourage a nutritious diet (especially rich in protein) and - Proper nutrition will support immune system function and ability increased fluid intake to fight infection; fluid will help renal flow and reduce colonization of bacteria (Nurselabs, 2021) - Client education regarding proper hygiene - Reduces the number of microorganisms that may cause infection - Instruct patient to report signs and symptoms of UTI (fever, - Prompt reporting of signs of infection will decrease risk of chills, painful/frequent urination, dark or cloudy urine, spreading throughout the body and prevent serious complications malodorous urine) (Ackley, 2014) Evaluation: - Labs remain clear of infection indicators (absence of bacteria, WBCs, and nitrates) - Vital signs remain normal and stable - INO remains stable, patient produces about 30ml of urine per hour - Patient understands and maintains proper nutrition and has increased their fluid intake - Patient is able to verbalize infection prevention measures and reasoning - Patient is aware of signs and symptoms associated with infection and knows to report them immediately if they occur Problem #4/ND: Risk for pressure injury related to bladder incontinence as evidenced by need for urinary catheterization. General Goal: Patient will be able to perform and maintain self-perineal care regularly to avoid pressure injury from incontinence. Expected Outcome: Patient will not acquire a pressure injury. She will perform proper perineal care and avoid the area from becoming saturated. She will continue to increase fluid intake and consume a nutritious diet to promote skin health and skin integrity. Nursing Interventions: - Use the Braden Scale to assess for pressure injury risk - Assess skin condition and skin integrity - Monitor bony prominence sites - - Assess skin turgor and hydration status by pinching the skin on the back of client’s hand to observe skin return Encourage a nutritious diet (especially rich in protein) and increased fluid intake Perform daily perineal care once per shift or as needed - Inform patient on signs of a developing pressure injury - Rationale: - Objective tools can help measure client’s risk for pressure injury (Malaquias et. al, 2014) - Decreased skin integrity increases the risk for developing a pressure injury; increased skin moisture may decrease skin integrity (Nursing Times, 2020) - Body areas that have a bony prominence are more prone to developing pressure injury (Malaquias et. al, 2014) - Decreased skin turgor may contribute to decreased skin integrity (Malaquias et. al, 2014) - Increased protein and fluid intake will promote healthy skin condition and function (Nurselabs, 2021) - Urine may cause skin erosion and increased skin moisture; maintaining a clean perineal area and free from urine will decrease moisture and risk of pressure injury - Prompt reporting of pressure injury incidence will help the wound from advancing and/or causing infection (Menna et. al, 2016) Evaluation: - Patient understands importance of performing daily perineal care - Patient is able to demonstrate how to effectively clean perineal area - Patient maintains proper nutrition and hydration status by consuming adequate foods with protein and increasing fluid intake - Patient verbalizes her understanding about the signs of a possible pressure injury Problem #5/ND: Risk for pressure injury related to decreased mobility as evidenced by bilateral lower extremity paralysis. General Goal: Patient will be able to change position independently at least every 6 hours by the time of discharge to avoid pressure injury. Expected Outcome: Patient will not acquire a pressure injury as evidenced by immobility. She will change her position at least every 6 hours to remove pressure on high-incidence pressure injury areas (bony part and prominences). She will exhibit knowledge and understanding of plan to prevent pressure injury due to decreased mobility. Nursing Interventions: - Use the Braden Scale to assess for pressure injury risk - Assess skin condition and skin integrity - Monitor bony prominence sites - Assess skin turgor and hydration status by pinching the skin on the back of client’s hand to observe skin return Encourage a nutritious diet (especially rich in protein) and increased fluid intake Assess client’s ability to change position in bed, moving from the bed to the wheelchair Inform patient on signs of a developing pressure injury - Rationale: - Objective tools can help measure client’s risk for pressure injury (Malaquias et. al, 2014) - Decreased skin integrity increases the risk for developing a pressure injury; increased skin moisture may decrease skin integrity (Nursing Times, 2020) - Body areas that have a bony prominence are more prone to developing pressure injury (Malaquias et. al, 2014) - Decreased skin turgor may contribute to decreased skin integrity (Malaquias et. al, 2014) - Increased protein and fluid intake will promote healthy skin condition and function (Nurselabs, 2021) - Changing positions removes pressure on areas of the body that have increased risk for pressure injury - Prompt reporting of pressure injury incidence will help the wound from advancing and/or causing infection (Menna et. al, 2016) Evaluation: - Skin integrity is maintained, no redness or blisters present on the skin - Following a pinch, skin returns to normal position on the back of the hand - Patient understands and maintains proper nutrition and has increased their fluid intake - Patient is able to verbalize and understands the importance of changing position at least every 6 hours - Patient is able to demonstrate the ability to independently change position in bed and move to/from her wheelchair Problem #6/ND: Risk for falls and injury related to inability to ambulate as evidenced by bilateral lower extremity paralysis. General Goal: Patient will be able to use the wheelchair independently to ambulate by the time of discharge. Expected Outcome: Patient will not become injured or fall. Patient will take the proper protocols for changing position or ambulating. She will demonstrate the ability to transfer into the wheelchair and ambulate independently. She will ask for assistance when needed and implement methods to prevent falls and injury. Nursing Interventions: Rationale: - Assess for safety measures and implement fall/injury precautions, use bed rails, keep bed in lowest position, provide ample light - - Place call button and frequently used personal items within arm’s reach - - Orient the patient on their environment - - Use a fall risk wristband - - Instruct patient to ask for help when needed - - Educate the client on proper mechanics for changing position, transfers and using the wheelchair properly Assess patient’s ability to use wheelchair and other assistive devices independently Encourage taking part in daily exercise routines or programs - - - Maintaining a safe environment, decreasing the amount of space from the bed to the floor, increasing visibility (especially at night), and using bed rails appropriately can decrease risk for falls and injury (Nurselabs, 2021) Having objects commonly used close by will keep the patient from reaching for them and getting up more frequently and increasing risk of falling (Potter et. al, 2021) Showing the patient their space can help them become familiar with their area and furniture and decrease risk of injury Make others aware of patient’s fall risk will help promote a safe and helpful environment (Ackley, 2020) Assisting the client when needed can help keep them safe and can promote patient teaching (Potter et. al, 2021) Proper education to the client will promote their confidence in their ability to do such tasks and keep them from becoming injured Ensuring that the patient can utilize assistive devices properly can help the patient from falling and causing injury Increases mobility, muscle strength, bone health, and overall supporting healthy body functions (Nurselabs, 2021) Evaluation: - Patient did not sustain a fall or injury - Patient is well-oriented to her environment - Patient understands fall prevention procedures and importance of maintaining a safe environment in her room and at home - Patient demonstrates the ability to transfer into the wheelchair and ambulate independently while using proper body mechanics - Patient will use her call button and ask for assistance when needed Problem #7/ND: Risk for altered self-esteem status related to the inability to cope as evidenced by the statement “I can’t live normally anymore.” General Goal: Patient will become confident and comfortable with her new lifestyle by the time of discharge. Expected Outcome: Patient will not show signs of depression, aggression, hopelessness, or suicidal tendencies. She will understand that she will still be capable of leading a successful and healthy life but with some lifestyle modifications. She will feel confident and ready to live independently but will know available resources to her. Nursing Interventions: - Monitor for signs of aggression, hopelessness, depression or suicidal thoughts - Allow the patient to share past experiences and concerns regarding treatment and care plan - Assess for misconceptions regarding paraplegia and urinary impairment - Assess the patient’s support system - Offer comfort to the patient - Provide patient with support resources Rationale: - Inhibits the patient from becoming progressively more depressed and keeps them safe from self-harm - Creates an open communication relationship to enhance patient care and comfortability (Nurselabs, 2021) - Clearing up a misunderstanding will promote patient of proper teaching and assist the patient in making positive thoughts - Making sure a patient has an adequate support system to help them maintain a balanced mental status and gives them a sense of encouragement upon discharge - Promotes a positive mentality for the patient to heal physically, mentally, and emotionally (Nurselabs, 2021) - Helps the patient feel important and reassures them that they are a priority with many available resources (Jarvis, 2016) Evaluation: - Patient does not show signs of aggression, hopelessness, depression or have suicidal behaviors - Patient shared openly about her previous life experiences and that she is concerned regarding her new lifestyle modifications regarding urinary abilities and immobility - Patient does not have misconceptions regarding her plan of care and understands her new lifestyle modifications - Patient feels confident that she will be able to perform her new lifestyle habits upon discharge - Patient communicates that she has a large family and a strong support system at home but is also aware of outside resources available - Patient expresses gratitude for her care team and feels comforted throughout her care