In: Nursing
A nurse is caring for a quadriplegic patient who is unable to perform any self-care activities and has a Foley urinary catheter. What risk diagnosis should the nurse document for this patient? How should the nurse prioritize the risks?
Quadriplegic means paralysis of both arms and legs that condition is called Quadriplegic.Quad comes from latin word means four and Plegia comes from latin word means inability to move.
Severity of paralysis depends on what part of spinal cord is injured and at what extend of damage.With complete Quadriplegic patient is unable to move any part of the body below neck but some have unability to move neck also.
Causes...
*Serious spinal cord injury
*Cerebral palsy and strokes cause similar paralysis.
spinal cord and brain are two main parts of nervous system that send signals thriughout the body to perform various functions but when spinal cord is injured brain cannot communicate properly that is why sensations and movements impaired.
Risk diagnosis or complications.....
It cause many complication or risk which need proper and careful management....
#Pressure sores--In Quadriplegia patient has great risk of pressure sores because patient can not shift body weight by own and when patient is immobilize body for long time With pressure from the weight of the body can cause skin to develop sores.
~Prevention of pressure sores...
*once injuries are stable nurses and team of hospital will turn patient at regular interval.
*keep skin dry and clean.
*use special mattresses or air mattress and cushion that helps to preevent pressure sores.
#Blood clots...
In this patient have much slower blood circulation.Anticoagulation therapy helps to prevent thrombophlebitics.
#Spastic muscles...some patient develop muscle spasm that can cause hand and leg muscles to jerk uncontrollably or stiffening of muscle.
management...
*Oral medicines to relax muscles
*Physical exercises or stretching
* braces..helps to hold muscles in normal position
#Respiratory problems...The nerve signals to chest and diaphragm may disturbed with spinal cord injuries that make difficulty in breathing.
*Prioritize the respiratory risk..special pacemakers used to stimulate the nerves of diaphragm and allow patient to breath without aany ventilator.
*In paralytic patients higher risk of pneumonia and other respirtaory problems.
prevention...medicines and respiratory exercises used to treat or prevent respiratory problems.
#Loss of bladder and bowel movements that lead Urinary tract infections and constipation In this condition various degree of loss on this area because spinal nerves controls the function of bladder and bowel.
Prevention....Patient already has foley catheter so health care team help patient to deal with bladder and bowel control.Also need to clean the around foley cather twice a day with soap and water and afterward dry area with towel so patient will not develop any kind of infection.