Paraplegia, characterized by paralysis affecting the lower half of the body, predominantly the legs, stems primarily from spinal cord damage. This condition not only impacts motor function but also sensation and autonomic functions, necessitating comprehensive nursing care. Understanding the nuances of Nursing Diagnosis For Paraplegia is crucial for healthcare professionals to deliver effective patient care and improve outcomes.
Understanding Paraplegia
Paraplegia’s severity and impact are categorized into distinct types:
Complete Paraplegia: Marked by a total loss of motor and sensory function. Patients experience a complete inability to move their legs, accompanied by loss of sensation, and impaired bladder and bowel control.
Incomplete Paraplegia: Involves partial loss of function. Individuals might retain some movement in one leg or sensation below the injury level, indicating some neural pathways remain intact.
The level of spinal injury significantly dictates the symptoms. Thoracic spine injuries can compromise abdominal and respiratory muscles, leading to breathing and coughing difficulties. Lumbar spine injuries typically spare chest and abdominal muscles but may still affect bowel and bladder control. Sacral injuries are more prone to result in incomplete paraplegia, potentially allowing patients to ambulate with aids, though bowel and bladder dysfunction may persist.
Beyond paralysis, paraplegia manifests in various symptoms including:
- Phantom pain or sensations
- Sexual dysfunction
- Bowel and bladder incontinence
- Depression
- Chronic pain
- Autonomic dysreflexia, causing fluctuations in vital signs, sweating, and temperature
Common causes of paraplegia include traumatic spinal cord injuries from motor vehicle accidents, falls, penetrating injuries, and medical conditions such as spinal tumors, infections, stroke, ischemia, and inflammatory diseases like multiple sclerosis. Diagnosis involves imaging techniques like X-rays, CT scans, or MRIs, alongside neurological examinations and electromyography to assess nerve and muscle function.
Nursing Process and Paraplegia Care
Management of paraplegia emphasizes preventing secondary complications and further injury. Prompt medical intervention is critical to mitigate the progression from partial to complete paraplegia. Rehabilitation and physical therapy are cornerstones of treatment, aimed at muscle strengthening and pain management. Nurses play a pivotal role in empowering patients through education and support for lifestyle adjustments, promoting active and productive living.
Nursing care plans, derived from identified nursing diagnoses for paraplegia, are essential tools for prioritizing assessments and interventions. These plans guide both immediate and long-term care strategies. The following sections detail examples of nursing care plans relevant to paraplegia.
Autonomic Dysreflexia Nursing Care Plan
Autonomic dysreflexia is a critical concern in paraplegia, particularly with spinal cord injuries at or above the T6 level. It’s characterized by an exaggerated autonomic nervous system response to noxious stimuli below the injury level, leading to dangerous hypertension.
Nursing Diagnosis: Autonomic Dysreflexia
Related Factors:
- Constipation
- Skin irritation
- Tissue injury
- Constricting clothing
- Positioning
- Bladder distention
- Urinary tract infection
- Sexual intercourse
- Painful stimuli below the level of injury
Evidenced By:
- Blurred vision
- Severe headache
- Bradycardia or Tachycardia
- Chest pain
- Nasal congestion
- Paresthesia
- Diaphoresis above the injury level
- Pallor below the injury level
Expected Outcomes:
- Patient will maintain stable vital signs within acceptable limits.
- Patient and caregivers will articulate understanding of autonomic dysreflexia triggers and preventive measures.
Nursing Assessment and Interventions:
- Monitor for Symptoms: Headache, especially severe and sudden, can be an initial sign. Immediately assess blood pressure if reported.
- Identify Triggers: Engage with the patient to identify known triggers. If unknown, collaboratively investigate potential causes to tailor a preventative care plan.
- Vital Signs Monitoring: Closely monitor blood pressure due to the risk of severe hypertension and stroke.
- Upright Positioning: Immediately elevate the patient to a high-Fowler’s position with legs dangling to help lower blood pressure.
- Remove Constrictive Items: Loosen or remove any tight clothing, shoes, compression stockings, or binders. Ensure no pressure from IV lines or catheters.
- Bladder and Bowel Assessment: Check for catheter kinks or bladder distention. Obtain a urinalysis to rule out UTI. Assess for fecal impaction if urinary issues are ruled out.
- Skin Assessment: Inspect skin for pressure ulcers, wounds, or ingrown toenails if bladder and bowel are not the cause.
- Antihypertensive Administration: Administer prescribed antihypertensive medications like nitroglycerin paste or nifedipine as per protocol.
- Continuous Blood Pressure Monitoring: Reassess blood pressure every 3-5 minutes during an episode and regularly for up to 2 hours post-episode.
- Detailed Documentation: Document each episode, including precipitating factors and interventions.
- Patient and Caregiver Education: Educate on autonomic dysreflexia, its causes, symptoms, and emergency responses to prevent complications.
Impaired Physical Mobility Nursing Care Plan
Paraplegia inherently leads to impaired physical mobility, significantly impacting a patient’s independence and quality of life.
Nursing Diagnosis: Impaired Physical Mobility
Related Factors:
- Neuromuscular dysfunction
- Decreased muscle control and strength
- Joint stiffness
- Pain
Evidenced By:
- Inability to move purposefully
- Decreased gross motor skills
- Paralysis
- Postural instability
- Limited range of motion
- Muscle atrophy and spasticity
Expected Outcomes:
- Patient will effectively utilize assistive devices for mobility.
- Patient will actively participate in prescribed rehabilitation and physical therapy programs.
Nursing Assessment and Interventions:
- Assess Immobility Degree: Determine if paraplegia is complete or incomplete to tailor interventions.
- Identify Underlying Causes: Explore physical, psychological, or motivational barriers to mobility.
- Address Patient Feelings: Assess for depression or negative emotions towards immobility, as these can affect therapy adherence and motivation.
- Environmental Modifications: Recommend home modifications like ramps and car adaptations for wheelchair accessibility.
- Alternative Therapies: Suggest acupuncture, massage, or chiropractic care to alleviate pain and improve comfort during movement.
- Prepare for Surgical Interventions: If applicable, prepare patient for surgeries aimed at improving mobility, such as tumor removal.
- Physical Therapy Referral: Ensure referral to physical therapy for ongoing rehabilitation and exercise programs.
- Encourage Exercise: Promote activities like swimming, yoga, and seated aerobics to maintain muscle strength, prevent atrophy, and improve respiratory function.
Impaired Sitting, Standing, and Transfer Ability Nursing Care Plan
Difficulty in sitting, standing, and transferring is a direct consequence of paralysis and sensory loss in the lower body associated with paraplegia.
Nursing Diagnosis: Impaired Physical Mobility (specifically related to sitting, standing, and transfer)
Related Factors:
- Disease process (paraplegia)
- Immobility
- Paralysis
- Insufficient muscle strength
- Loss of sensation in lower extremities
Evidenced By:
- Difficulty adjusting lower limbs on uneven surfaces
- Knee flexion/extension difficulties
- Torso balance issues
- Hip flexion difficulties
- Postural balance instability
- Challenges in bed-to-chair transfers or standing
- Difficulty with shower transfers
- Ambulation difficulties
- Stair climbing difficulties
Expected Outcomes:
- Patient will achieve maximum possible independence in sitting, standing, and transferring within their physical limitations.
- Patient will demonstrate proper use of assistive devices for sitting, standing, and transfers.
Nursing Assessment and Interventions:
- Functionality Level Assessment: Evaluate the patient’s current ability in sitting, standing, and transferring based on their spinal injury level.
- Muscle Strength and Tone Assessment: Assess muscle strength, tone, range of motion, balance, and coordination to understand physical capabilities.
- Bedside Mobility Assessment Tool Utilization: Employ standardized tools like the Bedside Mobility Assessment Tool to objectively evaluate mobility status and assistance needs.
- Range of Motion Exercises: Implement and assist with range of motion exercises to improve circulation, prevent contractures and muscle atrophy, and maintain muscle tone.
- Occupational and Physical Therapy Referral: Refer to occupational and physical therapists for tailored exercise programs and recommendations on assistive equipment.
- Mobility and Transfer Device Training: Instruct on the use of mobility aids such as slide boards, lifts, walkers, wheelchairs, and canes to facilitate safe movement and transfers.
- Braces and Orthotics Consideration: Discuss and arrange fitting for braces or orthotics to stabilize joints and aid in movement.
Impaired Urinary Elimination Nursing Care Plan
Neurogenic bladder, resulting from disrupted nerve signals between the brain and bladder, is common in paraplegia, leading to impaired urinary elimination.
Nursing Diagnosis: Impaired Urinary Elimination
Related Factors:
- Disease process (neurological damage)
- Bladder dysfunction (neurogenic bladder)
- Involuntary sphincter relaxation
- Weakened bladder muscles
Evidenced By:
- Dysuria
- Nocturia
- Urinary hesitancy and urgency
- Urinary retention and incontinence
- Recurrent urinary tract infections
Expected Outcomes:
- Patient will verbalize understanding of urinary infection symptoms.
- Patient will demonstrate correct urinary catheter care, if applicable.
Nursing Assessment and Interventions:
- Urinary Elimination Pattern Assessment: Monitor and document patterns, including incontinence, infections, nocturia, and emptying difficulties.
- Bladder Distention Assessment: Palpate for bladder distention, which can indicate retention and increase infection risk. Perform post-void residual volume measurement.
- Diagnostic Review: Review urinalysis and urodynamic test results to identify dysfunction and causative factors.
- Encourage Fluid Intake: Promote adequate fluid intake to maintain renal function and prevent UTIs, counteracting the tendency to restrict fluids to avoid incontinence.
- Urine Characteristics Evaluation: Monitor urine color, odor, and presence of abnormal components like blood or pus, which may indicate complications.
- Credé Maneuver Instruction: Teach the Credé maneuver to aid bladder emptying in neurogenic bladder.
- Urinary Catheter Management: Manage intermittent or indwelling catheters as needed, considering suprapubic catheters for long-term management.
- Anticholinergic Administration: Administer prescribed anticholinergic medications to improve bladder capacity and reduce pressure.
- Botulinum Toxin Education: Educate on Botox as a treatment option to increase bladder capacity and reduce incontinence.
Risk for Injury Nursing Care Plan
Due to sensory and motor deficits, patients with paraplegia are at heightened risk for various types of injuries.
Nursing Diagnosis: Risk for Injury
Related Factors:
- Altered psychomotor performance
- Neuromuscular injury
- Spinal cord injury
- Muscle weakness
- Immobility of lower extremities
- Sensory disruption
Evidenced By:
- (Risk diagnoses are not evidenced by signs and symptoms but by risk factors.)
Expected Outcomes:
- Patient will remain free from falls, injuries, and skin breakdown.
- Patient will consistently use safety equipment and adhere to safety protocols.
Nursing Assessment and Interventions:
- Risk Factor Assessment: Evaluate individual risk factors such as mobility limitations and sensory loss that predispose to injury.
- Environmental Hazard Assessment: Assess the patient’s environment for potential hazards and modify as needed to ensure safety.
- Support System Evaluation: Determine the availability of caregivers or support persons needed for assistance with mobility, ADLs, and injury prevention.
- Assist with Transfers and Ambulation: Provide assistance during transfers and ambulation using gait belts, walkers, or other aids as appropriate. Ensure competent assistance for non-ambulatory patients.
- Skin Breakdown Prevention: Implement pressure injury prevention strategies, including frequent repositioning and keeping pressure off bony prominences. Regularly check skin integrity, especially in insensate areas.
- Encourage Self-Care within Limits: Promote independence in self-care activities using adaptive equipment where necessary, focusing on what the patient can safely manage.
- Rehabilitation Program Referral: Refer to comprehensive rehabilitation programs to enhance strength, teach safe maneuvering techniques, and promote independence.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Lewis’s Medical-Surgical Nursing. 11th Edition, Mariann M. Harding, RN, Ph.D., FAADN, CNE. 2020. Elsevier, Inc.
- Paraplegia. Beth Israel Lahey Health Winchester Hospital. 2023. From: https://www.winchesterhospital.org/health-library/article?id=230663
- Spinal cord injury. Mayo Clinic. Reviewed: October 02, 2021. From: https://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/symptoms-causes/syc-20377890
- What is paraplegia? The University of Alabama. 2023. From: https://www.uab.edu/medicine/sci/faqs-about-spinal-cord-injury-sci/what-is-paraplegia
