NURSING PROCESS: THE PATIENT WITH QUADRIPLEGIA OR PARAPLEGIA
Assessment focuses on the patient’s general condition, complica-tions, and how the patient is managing at that particular point in time. A head-to-toe assessment and review of systems should be part of the database, with emphasis on the areas prone to prob-lems in this population. A thorough inspection of all areas of the skin for redness or breakdown is critical. It is also important to review with the patient the established bowel and bladder pro-gram, because the program must continue uninterrupted. Patients with quadriplegia or paraplegia have varying degrees of loss of motor power, deep and superficial sensation, vasomotor control, bladder and bowel control, and sexual function. They are faced with potential complications related to immobility, skin break-down and pressure ulcers, recurring UTI, contractures, and psychosocial disruptions. Knowledge about these particular issues can further guide the assessment in any setting. Nurses in all settings, including home care, must be aware of these potential complications in the lifetime management of these patients.
An understanding of the emotional and psychological responses to quadriplegia or paraplegia is achieved by observing the responses and behaviors of the patient and family and by listening to their concerns (see Chart 63-10 for a discussion of ethical issues). Documenting these assessments and reviewing the plan with the entire team on a regular basis provide insight into how both the pa-tient and the family are coping with the changes in lifestyle and body functioning. Additional information frequently can be gath-ered from the social worker or psychiatric/mental health worker.
It takes time for the patient and family to comprehend the magnitude of the disability. They may go through stages of grief, including shock, disbelief, denial, anger, depression, and accep-tance. During the acute phase of the injury, denial can be a pro-tective mechanism to shield patients from the overwhelming reality of what has happened. As they realize the permanent na-ture of paraplegia or quadriplegia, the grieving process may be prolonged and all-encompassing because of the recognition that long-held plans and expectations may be interrupted or perma-nently altered. A period of depression often follows as the patient experiences a loss of self-esteem in areas of self-identity, sexual functioning, and social and emotional roles. Exploration and as-sessment of these issues can assist in developing a meaningful plan of care.
Based on the assessment data, the major nursing diagnoses of the patient with quadriplegia or paraplegia may include the following:
· Impaired physical mobility related to loss of motor function
· Risk for disuse syndrome
· Risk for impaired skin integrity related to permanent sen-sory loss and immobility
· Urinary retention related to level of injury
· Constipation related to effects of spinal cord disruption
· Sexual dysfunction related to neurologic dysfunction
· Ineffective coping related to impact of dysfunction on daily living
· Deficient knowledge about requirements for long-term management
Based on all the assessment data, potential complications of quad-riplegia or paraplegia that may develop include:
· Infection and sepsis
The goals for the patient may include attainment of some form of mobility, maintenance of healthy, intact skin, achievement of bladder management without infection, achievement of bowel control, achievement of sexual expression, strengthening of coping mechanisms, and absence of complications.
The patient requires extensive rehabilitation, which is less dif-ficult if appropriate nursing management has been carried out during the acute phase of the injury or illness. Nursing care is one of the key factors determining the success of the rehabilitation program. The main objective is for the patient to live as inde-pendently as possible in the home and community.
The unaffected parts of the body are built up to optimal strength to promote maximal self-care. The muscles of the hands, arms,shoulders, chest, spine, abdomen, and neck must be strengthened in the paraplegic patient because he or she must bear full weight on these muscles to ambulate. The triceps and the latissimus dorsi are important muscles used in crutch walking. The muscles of the abdomen and the back also are necessary for balance and for maintaining the upright position.
To strengthen these muscles, the patient can do push-ups when in a prone position and sit-ups when in a sitting position. Extending the arms while holding weights (traction weights can be used) also develops muscle strength. Squeezing rubber balls or crumbling newspaper promotes hand strength.
With encouragement from all members of the rehabilitation team, the paraplegic patient can develop the increased exercise tolerance needed for gait training and ambulation activities. The importance of maintaining cardiovascular fitness is stressed to the patient. Alternative exercises to increase the heart rate to target levels must be designed within the patient’s abilities.
When the spine is stable enough to allow the patient to assume an upright posture, mobilization activities are initiated. A brace or vest may be used, depending on the level of the lesion. A pa-tient whose paralysis is due to complete transection of the cord can begin weight-bearing early because no further damage can be incurred. The sooner muscles are used, the less chance there is of disuse atrophy. The earlier the patient is brought to a stand-ing position, the less opportunity for osteoporotic changes to take place in the long bones. Weight-bearing also reduces the possibility of renal calculi and enhances many other metabolic processes.
Braces and crutches enable some paraplegic patients to ambu-late for short distances. Ambulation using crutches requires a high expenditure of energy. Motorized wheelchairs and specially equipped vans can provide greater independence and mobility for patients with high-level SCI or other lesions. Every effort should be made to encourage the patient to be as mobile and active as possible.
Patients are at high risk for developing contractures as a result of disuse syndrome due to the musculoskeletal system changes (atrophy) brought about by the loss of motor and sensory functions below the level of injury. Range-of-motion exercises must be pro-vided at least four times a day, and care is taken to stretch the Achilles tendon with exercises (Hickey, 2003). The patient is repositioned frequently and maintained in proper body align-ment whether in bed or in a wheelchair (Hickey, 2003).
Because these patients spend a great portion of their lives in wheel-chairs, pressure ulcers are an ever-present threat. Contributing factors are permanent sensory loss over pressure areas; immobil-ity, which makes relief of pressure difficult; trauma from bumps (against the wheelchair, toilet, furniture, and so forth) that cause unperceived abrasions and wounds; loss of protective function of the skin from excoriation and maceration due to excessive per-spiration and possible urinary and fecal incontinence; and poor general health (anemia, edema, malnutrition), leading to poor tis-sue perfusion.
The person with quadriplegia or paraplegia must take respon-sibility for monitoring (or directing) his or her skin status. This involves relieving pressure and not remaining in any position for longer than 2 hours, in addition to ensuring that the skin receives meticulous attention and cleansing. The patient is taught that ul-cers develop over bony prominences exposed to unrelieved pres-sure in the lying and sitting positions. The most vulnerable areas are identified. The paraplegic patient is instructed to use mirrors, if possible, to inspect these areas morning and night, observing for redness, slight edema, or any abrasions. While in bed, the patient should turn at 2-hour intervals and then inspect the skin again for redness that does not fade on pressure. The bottom sheet should be checked for wetness and for creases. The quadriplegic or paraplegic patient who cannot perform these activities is en-couraged to direct others to check these areas and prevent ulcers from developing.
The patient is taught to relieve pressure while in the wheelchair by doing push-ups, leaning from side to side to relieve ischial pres-sure, and tilting forward while leaning on a table. The caregiver for the quadriplegic patient will need to perform these activities if the patient cannot do so independently. A wheelchair cushion is prescribed to meet individual needs, which may change in time with changes in posture, weight, and skin tolerance. A referral can be made to a rehabilitation engineer, who can measure pressure levels while the patient is sitting and then tailor the cushion and other necessary aids and assistive devices to the patient’s needs.
The diet for the patient with quadriplegia or paraplegia should be high in protein, vitamins, and calories to ensure minimal wast-ing of muscle and the maintenance of healthy skin, and high in fluids to maintain well-functioning kidneys. Excessive weight gain and obesity should be avoided because they limit mobility.
The effect of the spinal cord lesion on the bladder depends on the level of injury, the degree of cord damage, and the length of time after injury. A patient with quadriplegia or paraplegia usually has either a reflex or a nonreflex bladder (see Chaps. 11 and 44). Both bladder types increase the risk of UTI.
The nurse emphasizes the importance of maintaining an ade-quate flow of urine by encouraging a fluid intake of about 2.5 L daily. The patient should empty the bladder frequently so there is minimal residual urine and should pay attention to personal hygiene, because infection of the bladder and kidneys almost always occurs by the ascending route. The perineum must be kept clean and dry and attention given to the perianal skin after defe-cation. Underwear should be cotton (more absorbent) and changed at least once a day.
If an external catheter (condom catheter) is used, the sheath is removed nightly; the penis is cleansed to remove urine and is dried carefully, because warm urine on the periurethral skin pro-motes the growth of bacteria. Attention also is given to the col-lection bag. The nurse emphasizes the importance of monitoring for indications of UTI: cloudy, foul-smelling urine or hematuria (blood in the urine), fever, or chills.
The female patient who cannot achieve reflex bladder control or self-catheterization may need to wear pads or waterproof undergarments. Surgical intervention may be indicated in some patients to create a urinary diversion.
The objective of a bowel training program is to establish bowel evacuation through reflex conditioning. If a cord injury occurs above the sacral seg-ments or nerve roots and there is reflex activity, the anal sphincter may be massaged (digital stimulation) to stimulate defecation. If the cord lesion involves the sacral segment or nerve roots, anal massage is not performed because the anus may be relaxed and lack tone. Massage is also contraindicated if there is spasticity of the anal sphincter. The anal sphincter is massaged by inserting a gloved finger (which has been adequately lubricated) 2.5 to 3.7 cm (1 to 1.5 in) into the rectum and moving it in a circular motion or from side to side. It soon becomes apparent which area triggers the defecation response. This procedure should be performed at the same time (usually every 48 hours), after a meal, and at a time that will be convenient for the patient at home. The patient also is taught the symptoms of impaction (frequent loose stools; constipation) and cautioned to watch for hemorrhoids. A diet with sufficient fluids and fiber is essential to a successful bowel training program, avoiding constipation, and decreasing the risk of autonomic dysreflexia.
Many paraplegic and quadriplegic patients can have some form of meaningful sexual relationship, although some modifications will be necessary. The patient and partner benefit from counsel-ing about the range of sexual expression possible, special techniques and positions, exploration of body sensations offering sensual feelings, and urinary and bowel hygiene as related to sexual ac-tivity. For men with erectile failure, penile prostheses enable them to have and sustain an erection. Sildenafil (Viagra) is an oral smooth muscle relaxant that causes blood to flow into the penis, resulting in an erection.
Sexual education and counseling services are included in the rehabilitation services at spinal centers. Small-group meetings in which the patients can share their feelings, receive information, and discuss sexual concerns and practical aspects are helpful in producing effective attitudes and adjustments (Sipski & Alexander, 1997).
The impact of the disability and loss becomes marked when pa-tients return home. Each time something new enters their lives (eg, a new relationship, going to work), they are reminded anew of their limitations. Grief reactions and depression are common.
To work through this depression, patients must have some hope for relief in the future. Thus, the nurse can encourage them to feel confident in their ability to achieve self-care and relative independence. The role of the nurse ranges from caretaker during the acute phase to teacher, counselor, and facilitator as patients gain mobility and independence.
The patient’s disability affects not only the patient, but also the entire family. In many cases, family therapy is helpful to help work through issues as they arise.
Adjustment to the disability leads to the development of re-alistic goals for the future, making the best of the abilities that are left intact and reinvesting in other activities and relation-ships. Rejection of the disability causes self-destructive neglect and noncompliance with the therapeutic program, which leads to more frustration and depression. Crises for which interven-tions may be sought include social, psychological, marital, sexual, and psychiatric problems. The family usually requires counsel-ing, social services, and other support systems to help them cope with the changes in their lifestyle and socioeconomic status.
A major goal of nursing management is to help patients over-come their sense of futility and to encourage them in the emo-tional adjustment that must be made before they are willing to venture into the outside world. However, an excessively sympa-thetic attitude on the part of the nurse may cause patients to develop an overdependence that defeats the purpose of the entire rehabilitation program. Patients are taught and assisted when necessary, but the nurse should avoid performing activities that patients can do for themselves with a little effort. This approach to care more than repays itself in the satisfaction of seeing a com-pletely demoralized and helpless patient become independent and find meaning in a newly emerging lifestyle.
Muscle spasticity is one of the most problematic complications of quadriplegia and paraplegia. These incapacitating flexor or ex-tensor spasms, which occur below the level of the spinal cord le-sion, interfere with both the rehabilitation process and activities of daily living. Spasticity results from an imbalance between the facilitatory and inhibitory effects on neurons that exist normally. The area of the cord distal to the site of injury or lesion becomes disconnected from the higher inhibitory centers located in the brain. Facilitatory impulses, which originate from muscles, skin, and ligaments, thus predominate.
Spasticity is defined as a condition of increased muscle tone in a muscle that is weak. Initial resistance to stretching is quickly followed by sudden relaxation. The stimulus that precipitates spasm can be either obvious, such as movement or a position change, or subtle, such as a slight jarring of the wheelchair. Most patients with quadriplegia or paraplegia have some degree of spasticity. With SCI, the onset of spasticity usually occurs from a few weeks to 6 months after the injury. The same muscles that are flaccid during the period of spinal shock will develop spas-ticity during recovery. The intensity of spasticity tends to peak around 2 years after the injury, after which the spasms tend to regress.
Management of spasticity is based on the severity of symptoms and the degree of incapacitation. Antispasmodic medications such as diazepam (Valium), baclofen (Lioresal), and dantrolene (Dantrium) are frequently effective in controlling spasm but cause drowsiness, weakness, and vertigo in some patients. Passive range-of-motion exercises and frequent turning and reposition-ing are helpful because stiffness tends to increase spasticity. These activities also are essential in the prevention of contractures, pres-sure ulcers, and bowel and bladder dysfunction.
Contractures can complicate day-to-day care, increasing the difficulty with positioning and decreasing mobility. A number of surgical procedures have been tried with varying degrees of suc-cess. These techniques are used if more conservative approaches fail. The best treatment is prevention.
Patients with quadriplegia and paraplegia are at increased risk for infection and sepsis from a variety of sources: urinary tract, res-piratory tract, and pressure ulcers. Sepsis remains a major cause of death and complications in these patients. Prevention of in-fection and sepsis is essential through maintenance of skin in-tegrity, complete emptying of the bladder at regular intervals, and prevention of urinary and fecal incontinence. The risk of respira-tory infection can be decreased by avoiding contact with people with symptoms of respiratory infection, performing coughing and deep-breathing exercises to prevent pooling of respiratory se-cretions, receiving yearly influenza vaccines, and giving up smok-ing. A high-protein diet is important in maintaining an adequate immune system, as is avoiding factors that may reduce immunesystem function (eg, excessive stress, drug abuse, excessive alcohol intake).
If infection occurs, the patient requires thorough assessment and prompt treatment. Antibiotic therapy and adequate hydra-tion, in addition to local measures (depending on the site of infection), are initiated immediately.
UTIs are minimized or prevented by:
· Aseptic technique in catheter management
· Adequate hydration
· Bladder training program
· Prevention of overdistention of the bladder and stasis
Skin breakdown and infection are prevented by:
· Maintenance of a turning schedule
· Frequent back care
· Regular assessment of all skin areas
· Regular cleansing and lubrication of the skin
· Passive range-of-motion exercise to prevent contractures
· Pressure relief, particularly over broken skin areas, bony prominences, and heels
· Wrinkle-free bed linen
Pulmonary infections are managed and prevented by:
· Frequent coughing, turning, and deep-breathing exercises and chest physiotherapy
· Aggressive respiratory care and suctioning of the airway if a tracheostomy is present
· Assisted coughing
· Adequate hydration
Infections of any kind can be life-threatening. Therefore, ag-gressive nursing interventions are key to their prevention and management.
Patients with quadriplegia or paraplegia are at risk for complica-tions for the rest of their lives. Thus, a major aspect of nursing care is teaching patients and their families about these complica-tions and about strategies to minimize this risk. UTIs, contractures, infected pressure ulcers, and sepsis may necessitate hospitaliza-tion. Other late complications that may occur include lower ex-tremity edema, joint contractures, respiratory dysfunction, and pain. To avoid these and other complications, the patient and a family member are taught skin care, catheter care, range-of-motion exercises, breathing exercises, and other care techniques. Teaching is initiated as soon as possible and extends into the rehabilitation or long-term care facility and home.
Referral for home care is often appropriate for assessment of the home setting, patient teaching, and evaluation of the patient’s physical and emotional status. During visits by the home care nurse, teaching about strategies to prevent or minimize potential complications is reinforced. The home environment is assessed for adequacy for care and for safety. Environmental modifications are made and specialized equipment is obtained, ideally before the patient goes home.
The home care nurse also assesses the patient’s and the family’s adherence to recommendations and their use of coping strategies. The use of inappropriate coping strategies such as drug and alco-hol use is assessed and referrals to counseling are made for the patient and family. Appropriate and effective coping strategies are reinforced. The nurse reviews previous teaching and deter-mines the need for further physical or psychological assistance. The patient’s self-esteem and body image may be very poor at this time. Because people with high levels of social support often re-port feelings of well-being despite major physical disability, it is beneficial for the nurse to assess and promote further develop-ment of the support system and effective coping strategies of each patient.
The patient requires continuing, life-long follow-up by the physician, physical therapist, and other rehabilitation team mem-bers because the neurologic deficit is usually permanent and new deficits and complications can develop. These require prompt at-tention before they take their toll in additional physical impair-ment, time, morale, and financial costs. The local counselor for the Office of Vocational Rehabilitation works with the patient with respect to job placement or additional educational or voca-tional training.
The nurse is in a good position to remind patients and family members of the need for continuing health promotion and screening practices. Referral to accessible health care providers and imaging centers is important in health promotion.
Expected patient outcomes may include:
a) Attains some form of mobility
b) Contractures do not develop
c) Maintains healthy, intact skin
d) Achieves bladder control, absence of UTI
e) Achieves bowel control
f) Reports sexual satisfaction
g)Shows improved adaptation to environment and others
h) Exhibits reduction in spasticity
i) Reports understanding of the precipitating factors
ii) Reports understanding of measures to reduce spasticity
i) Describes long-term management required
j) Exhibits absence of complications
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