Manaia Genovia

NURS 360

Concept Map
1. Impaired Physical Mobility
Paraplegia
Impaired sensory perception 3. Infection (UTI)
Pain Flaccid bladder no urge/sensation to
Post-op spinal surgery urinate
BMI 41.8 (obese) 2. Impaired Urinary Elimination Cloudy, hazy, dark-amber colored urine
Pain medication Paraplegia Foul fishy-smelling urine
Physical therapy Flaccid bladder no urge/sensation to UA sent to lab 4. Pain
Occupational therapy urinate Encourage fluid intake 2-3L dailyL10-L3 spinal fusion
Post-op
surgery
8. Disturbed BodyBladder
Image scan q 4-6hr Pain 6/10 to back upon
Straight cath
SCI Paraplegic at 21 years old> 400ml Chief Medical Diagnosis:
movement/increased pressure
Upset during PT & OT saying T12-L1 fx dislocation
to back
this f***** sucks! Paraplegia
Tylenol 650mg QID
Said, Im only 21, I cant Post-op L10-L3 spinal fusion
Gabapentin 600mg TID
believe this, I never dreamed Id w/ hardware surgery
Hydromorphone 2mg q 4-6hr
be paralyzed
Therapeutic communication Priority Assessment: Pain,
Active listening CMS checks, I&O, bladder
Frequent monitoring scan, integumentary, mental
status

7. Constipation 5. Risk for Impaired Skin Integrity

Decreased physical activity Paraplegia
Pain medication BMI 41.8 (obese)
Small, irregular bowel movement 6. Risk for DVT Turn q 2 hr
Encourage fluid intake 2-3L daily Paraplegia Pressure relieving devices
Sennoside/docusate sodium 2tab, BID Decreased physical activity Daily hygiene to keep skin clean and
Lovenox 40mg subcutaneous dry
Bilateral TED Hose
Flowtron intermittent
compression device

Desired Outcome Nursing Interventions

1. Impaired Physical Mobility 1. Assess patients ability to use upper extremities to assist
in transferring and ability to use a wheelchair correctly.
The patient will demonstrate 2. Perform and assist with full ROM exercises on all
proper use of adaptive techniques extremities using slow, smooth movements

that promote transferring.
The patient will demonstrate
proper use of adaptive device:
wheelchair
Goal to be completed: 7 days
2. Impaired Urinary Elimination
The patient will maintain urine
output greater than 30ml/hr with
normal color and free of odor
using straight catheterization
Goal to be completed: by the end
of every shift
3. Infection (UTI)
The patient will be free of UTI
AEB clear, non-foul smelling
urine, normal WBC count, and
absence of fever, chills, and
suprapubic pain.
Goal to be completed: end of abx
therapy 3-10 days
4. Pain
The patient will use
pharmacological and non-
pharmacological methods of pain
relief and report pain less than 3/10
on a rating scale of 0-10.
Goal to be completed: by the end
of every shift
Manaia Genovia
NURS 360
3. Measure and monitor blood pressure before and after
activities
4. Demonstrate appropriate use of assistive device:
wheelchair
5. Assist the patient in accepting limitations. Emphasize
abilities.
6. Provide positive reinforcement during activity
7. Facilitate transfer training by teaching or using
appropriate techniques and devices when transferring to
bed, chair, or stretcher.
8. Encourage the patient to rest between activities that are
tiring. Teach energy-saving techniques.
9. Provide recommendations for nutritional intake for
adequate energy recourses and metabolic requirements
1. Palpate abdomen for bladder distention
2. Monitor and document I&O
3. Assess for sx of UTI: frequency, burning on urination,
elevated temperature, or elevated white blood cell count
4. Assess frequency, amount, and characteristics of urine
5. Perform bladder scan every four to six hours
6. Perform straight catheterization if volume is greater than
400ml using sterile technique
7. Check residual in bladder after performing straight
catheterization
8. Encourage fluid intake of 2-3L daily
1. Assess for sx of UTI: increased frequency, foul-smelling
urine, fever and chills, elevated WBC count, or suprapubic
tenderness.
2. Assess urinalysis for presence of WBC, RBC, or
bacteriuria
3. Encourage patient to drink extra fluid (2-3L daily) and
up to 500-1000mg of cranberry or prune juice daily
4. Perform bladder scans more frequently to avoid urinary
stasis
5. Perform straight catheterization for urine >400ml or
according to orders and be sure to empty bladder of
residual urine
6. Encourage patient to complete full course of antibiotics
7. Monitor characteristics of urine output
8. Administer antibiotics as prescribed
1. Assess characteristics of pain: quality, location, onset,
duration, factors
2. Respond immediately to reports of pain
3. Provide rest periods to facilitate comfort, sleep, and
relaxation
4. Administer pharmacologic pain methods: scheduled and
prn
5. Introduce non-pharmacologic methods: hot/cold,
relaxation techniques, distraction, music, breathing
exercises
6. Determine most effective pain relief method

5. Risk for Impaired Skin
Integrity
The patient will maintain intact
skin AEB no redness over bony
prominences, no skin breakdown
and capillary refill less than 6
seconds over areas of redness
Goal to be completed: by the end
of every shift
6. Risk for DVT
The patient will remain free of
thrombophlebitis and deep vein
thrombosis AEB bilaterally equal
calves and absence of calf pain
Goal to be completed: by the end
of every shift
7. Constipation
The patient will pass soft, formed
stool at a frequency perceived as
normal by the patient
Goal to be completed: by the end
of every shift
8. Disturbed Body Image
The patient will demonstrate
enhanced body image and positive
self-esteem
Manaia Genovia
NURS 360
7. Evaluate effectiveness of pain relief methods
8. Administer pain medication prior to PT/OT to prevent
pain during therapy.
9. Administer Tylenol 650mg QID, gabapentin 600mg TID,
and hydromorphone 2mg every 4-6 hours
1. Assess the patients skin integrity
2. Keep the skin clean and dry
3. Apply moisture barrier lotions/creams as indicated
4. Turn the patient every two hours. Use lift shifts when
repositioning
5. Use pressure relieving devices such as pillows
6. Instruct the patient in a wheelchair to shift positions
every 20-30 min
7. Provide adequate nutritional intake
8. Teach the patient and caregiver to inspect the skin daily.
Provide a long-handled angled mirror for the patient to
perform skin checks independently
1. Assess the legs for swelling, changes in skin color,
temperature, or vein distention in the legs
2. Apply TED hose while in bed
3. Apply flowtron intermittent compression devices
continuous while in bed
4. Encourage cough and deep breathing exercises
5. Administer lovenox 40mg subcutaneous daily
1. Assess the usual pattern of elimination including
frequency and consistency of stool.
2. Assess patients dietary habits, eating schedule and liquid
intake
3. Administer enema if prescribed
4. Encourage fluid intake of 2-3L daily
5. Encourage a minimum of 20g of dietary fiber (raw fruits,
fresh vegetables, whole grains) per day
6. Teach the patient that constipation is a common side
effect for opioid medications therefore laxative/stool
softener will be prescribed
7. Instruct patient to report bowel movements immediately
to staff so they can assist with clean up to maintain skin
integrity
8. Administer sennoside/docusate sodium 2 tab BID. Hold
for loose stool
1. Assess patients perception of dysfunction
2. Assess the patients social support system
3. Acknowledge the normality of the emotional response to
the change in body function. Allow the patient to grieve.
4. Help the patient verbalize feelings regarding impairment.
5. Help the patient identify helpful coping mechanisms
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NURS 360

Goal to be completed: 6 months
1 year+
such as interacting with family and friends, spiritual rituals,
perseverance, or distraction.
6. Actively listen to patients statements about himself
7. Provide an environment conducive to the expression of
feelings
8. Teach the patient methods of healthy coping strategies
9. Encourage patient to participate in daily activities
10. Give positive reinforcement for progress noted in
completing tasks during the day and during PT/OT.

Evaluation

1. Impaired Physical Mobility

The outcome was met.
The patient was able to use his arms to push himself off the bed into a sitting position. He used
his arms to scoot him side to side and to the edge of the bed. He used his arms to lift himself inch
by inch from the bed to the wheelchair using a transfer board. He demonstrated proper use of the
wheelchair and used his arms to roll the wheelchair around the room and down the hall during PT

2. Impaired Urinary Elimination

The outcome was partially met.
The patient had a urine output of 600ml over a six-hour period using straight catheterization. The
urine was cloudy, hazy; dark amber colored and had a foul fishy odor. A urine sample was sent to
the lab and the results were still pending at the end of the shift.

3. Infection
The outcome was not met.
The patients urine showed positive characteristics for a urinary tract infection. It was cloudy,
hazy; dark amber colored and had a foul fishy odor. The patient was informed that antibiotics will
be ordered if the urinalysis shows a positive urinary tract infection.

4. Pain
The outcome was met.
The patient stated pain was 6/10. After 2mg hydromorphone administration, the pain decreased to
a 2/10. The patient was able to actively participate in PT/OT will minimal complaints of pain.
The patient stated that listening to music and watching movies/videos were effective distractions
for pain relief.

5. Risk for Impaired Skin Integrity

The outcome was met.
The patients skin was free of redness with a brisk capillary refill and no areas of breakdown. The
patient stated he likes turning side to side because it comes too hot lying in the same place for
hours. His girlfriend stated she would assist in inspecting his skin daily.

6. Risk for DVT

The outcome was met.
The patient did not show signs and symptoms of a deep-vein thrombosis. The patients TED
hoses and flowtron devices were in place continuously in bed. The patient stated he didnt care to
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NURS 360

have them on because he couldnt feel it but he stated understanding the rationale the
interventions.

7. Constipation
The outcome was met
The patient passed a large, loose stool the previous day therefore the sennoside/docusate sodium
was held. The patient stated being unable to determine if he had a bowel movement therefore the
staff must check for bowel movement and clean the patient to maintain skin integrity.

8. Disturbed Body Image

The outcome was not met.
The patient continued to express feelings of denial, sadness, and hopelessness. The patients
spinal cord injury occurred on March 30, 2017. The patient will meet the outcome over time
when he is ready to accept the reality of his injury and move towards creating realistic goals for
himself.

Discharge Plan / Patient Teaching

The patient will be discharged to Rehab Hospital of the Pacific to continue rehabilitation services.
His support system includes his family, friends and girlfriend. His girlfriend stays with him for
majority of the day and assists him with daily hygiene. He requires maximum assistance to
perform ADLs. He is able to perform activities that involve his arms like brushing his teeth and
feeding himself. His family members and girlfriend can assist with setting up his morning
hygiene and meals. He is unable to move his legs but he has strong-arm strength and is able to
use his arms effectively during transferring. He requires a transfer board to get from the bed to the
wheelchair and to the bedside/toilet commode. He also requires a wheelchair because he is
paraplegic. As of his condition right now, he requires the assistance of trained personnel to assist
with transferring. It is not safe for him to transfer independently or with his girlfriends help until
they are taught the proper technique. The staff at Rehab will determine when it is safe to transfer
independently or with the help of family members. The nursing staff at Rehab hospital will
perform the dressing changes to his surgical site. The patient prefers to learn with visual examples
and by performing the task/skill. He has no barriers to learning. He is very active and engaged in
his medical care and is quick to ask questions when he does not understand. Upon discharge to
Rehab hospital, the patient will need to be taught that his spinal cord injury will be lifelong and
permanent. The nursing staff at Rehab hospital will administer his medications and his assigned
physician will adjust the medications as needed.