Question

The patient is a 23-year-old man who sustained a C7 fracture during a ski accident. He is being transferred from the medical-surgical unit to the inpatient rehabilitation unit. He has family in the area, and they have been supportive throughout his hospital stay. His mother has spent many hours at the bedside and expresses a willingness to take him home and continue his care once his hospital and rehab treatments are completed. The patient has lost approximately 18lbs. during the hospital stay and demonstrates a weak nonproductive cough. He had been actively participating with physical therapy and occupational therapy, but he is currently discouraged and withdrawn.

Q1. Identify at least five priority problems for this patient and family.

Q2. Why is this patient at risk for pneumonia, and what nursing interventions could be used to help prevent this complication?

Q3. What are the major complications of prolonged immobility?

Q4. Identify the major areas of education for the patient with an SCI.

Q5. What kinds of interventions would the nurse use to assist the patient with SCI with psychosocial adaption and successful rehabilitation?

Second part leads into question 6: On the first day in the rehabilitation unit, the physical therapist is working with the patient, and observes that the right leg appears to be larger than the left leg. The nurse is notified, and upon assessment of the bilateral lower extremities, the nurse notes that the right lower leg is swollen, a pale pinkish red color, and feels warmer than the left leg.

Q6. Using the ISBARR format, how would the nurse communicate these findings to the appropriate health care provider?

Answer 1

ANSWER 1.

Five priority problems for this patient and family are as follows;

1. Acute Pain

2. Impaired Physical Mobility

3. Impaired Skin Integrity

4. Deficient Knowledge

5. Self-Care Deficit

ANSWER 2.

THIS PATIENT IS AT HIGHER RISK OF DEVELOPING PNEUMONIA DUE TO

1. Patient is confined to bed

2. Patient has loss of body weight

3.Patient has weak non productive cough

4. Patient is under depression

ANSWER 3.

These nursing interventions, if implemented appropriately, would prevent the patient from resulting in the complications of pneumonia.

To improve airway patency:

• Removal of secretions. Secretions should be removed because retained secretions interfere with gas exchange and may slow recovery.
• Adequate hydration of 2 to 3 liters per day thins and loosens pulmonary secretions.
• Humidification may loosen secretions and improve ventilation.
• Coughing exercises. An effective, directed cough can also improve airway patency.
• Chest physiotherapy. Chest physiotherapy is important because it loosens and mobilizes secretions.

To promote rest and conserve energy:

• Encourage avoidance of overexertion and possible exacerbation of symptoms.
• Semi-Fowler’s position. The patient should assume a comfortable position to promote rest and breathing and should change positions frequently to enhance secretion clearance and pulmonary ventilation and perfusion.

To promote fluid intake:

• Fluid intake. Increase in fluid intake to at least 2L per day to replace insensible fluid losses.

To maintain nutrition:

• Fluids with electrolytes. This may help provide fluid, calories, and electrolytes.
• Nutrition-enriched beverages. Nutritionally enhanced drinks and shakes can also help restore proper nutrition.

To promote patient’s knowledge:

• Instruct patient and family about the cause of pneumonia, management of symptoms, signs, and symptoms, and the need for follow-up.
• Instruct patient about the factors that may have contributed to the development of the disease.

ANSWER 3.

The major complications of prolonged immobility

• Contractures. ...
• Strength deficiencies. ...
• Skeletal mass loss. ...
• Negative nitrogen balance. ...
• Constipation. ...
• Weakness and tightness. ...
• Alterated ventilation/perfusion. ...
• Decreased carbohydrate tolerance

ANSWER 4.

The major areas of education for the patient with an SCI

ANSWER 5.

NURSING INTERVENTINS ARE AS FOLLOWS

Nursing Interventions	Rationale
Assess respiratory function by asking patient to take a deep breath. Note presence or absence of spontaneous effort and quality of respirations (labored, using accessory muscles).	C-1 to C-3 injuries result in complete loss of respiratory function. Injuries at C-4 or C-5 can lead to variable loss of respiratory function, depending on phrenic nerve involvement and diaphragmatic function, but generally cause decreased vital capacity and inspiratory effort. For injuries below C-6 or C-7, respiratory muscle function is preserved; however, weakness or impairment of intercostal muscles may impair effectiveness of cough and the ability to sigh, deep breathe.
Auscultate breath sounds. Note areas of absent or decreased breath sounds or development of adventitious sounds (rhonchi).	Hypoventilation is common and leads to accumulation of secretions, atelectasis, and pneumonia (frequent complications). Note: Respiratory compromise is one of the leading causes of mortality, especially during the acute stage as well as later in life.
Note strength or effectiveness of cough.	Level of injury determines the function of intercostal muscles and ability to cough spontaneously or move secretions.
Observe skin color for developing cyanosis, duskiness.	May reveal impending respiratory failure, need for immediate medical evaluation and intervention.
Assess for abdominal distension and muscle spasm.	Abdominal fullness may impede diaphragmatic excursion, reducing lung expansion and further compromising respiratory function.
Monitor and limit visitors as indicated.	General debilitation and respiratory compromise place patient at increased risk for acquiring URIs.
Monitor diaphragmatic movement when phrenic pacemaker is implanted.	Stimulation of phrenic nerve may enhance respiratory effort, decreasing dependency on mechanical ventilator.
Elicit concerns and questions regarding mechanical ventilation devices.	Acknowledges reality of situation.
Provide honest answers.	Future respiratory function needs will not be totally known until spinal shock resolves and acute rehabilitative phase is completed. Even though respiratory support may be required, alternative devices and techniques may be used to enhance mobility and promote independence.
Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated.	Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient airway.
Assist patient in “taking control” of respirations as indicated. Instruct in and encourage deep breathing, focusing attention on steps of breathing.	Breathing may no longer be a totally voluntary activity but require conscious effort, depending on level of injury and involvement of respiratory muscles.
Assist with coughing as indicated for level of injury (have patient take deep breath and hold 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 patient exhales (quad cough).	Adds volume to cough and facilitates expectoration of secretions or helps move them high enough to be suctioned out. Note: Quad cough procedure is generally reserved for patients with stable injuries once they are in the rehabilitation stage.
Suction as necessary. Document quality and quantity of secretions.	If cough is ineffective, suctioning may be needed to remove secretions, enhance gas exchange, and reduce risk of respiratory infections. Note: “Routine” suctioning increases risk of hypoxia, bradycardia (vagal response), tissue trauma. Therefore, suctioning needs are based on inability to move secretions.
Reposition and turn periodically. Avoid and limit prone position when indicated.	Enhances ventilation of all lung segments, mobilizes secretions, reducing risk of complications such as atelectasis and pneumonia. Note: Prone position significantly decreases vital capacity, increasing risk of respiratory compromise and failure.
Encourage fluids (at least 2000 mL per day).	Aids in liquefying secretions, promoting mobilization and expectoration.
Measure or graph:
Vital capacity (VC), tidal volume (VT), inspiratory force;	Determines level of respiratory muscle function. Serial measurements may be done to predict impending respiratory failure (acute injury) or determine level of function after spinal shock phase and while weaning from ventilatory support.
Serial ABGs and pulse oximetry.	Documents status of ventilation and oxygenation, identifies respiratory problems such as hypoventilation (low Pao2 and elevated Paco2) and pulmonary complications.
Administer oxygen by appropriate method (nasal prongs, mask, intubation, ventilator).	Method is determined by level of injury, degree of respiratory insufficiency, and amount of recovery of respiratory muscle function after spinal shock phase.
Assist with use of respiratory adjuncts (incentive spirometer, blow bottles) and aggressive chest physiotherapy (chest percussion).	Preventing retained secretions is essential to maximize gas diffusion and to reduce risk of pneumonia.
Refer and consult with respiratory and physical therapists.	Helpful in identifying exercises individually appropriate to stimulate and strengthen respiratory muscles and effort. For example, glossopharyngeal breathing uses muscles of mouth, pharynx, and larynx to swallow air into lungs, thereby enhancing VC and chest expansion.

ANSWER 6.