Nursing Process: The Care of the Patient with SCI
Assessment
- Monitor respirations and breathing pattern
- Lung sounds and cough
- Monitor for changes in motor or sensory function; report immediately
- Assess for spinal shock
- Monitor for bladder retention or distention, gastric dilation, and ilieus
- Temperature; potential hyperthermia
Nursing Process: Diagnoses
- Ineffective breathing pattern
- Ineffective airway clearance
- Impaired physical mobility
- Disturbed sensory perception
- Risk for impaired skin integrity
- Impaired urinary elimination
- Constipation
- Acute pain
Collaborative Problems/Potential Complications
- DVT
- Orthostatic hypotension
- Autonomic dysreflexia
Nursing Process: Planning
- Major goals may include improved breathing pattern and airway clearance, improved
mobility, improved sensory and perceptual awareness, maintenance of skin integrity,
promotion of comfort, and absence of complications.
Promotion of Effective Breathing and Airway Clearance
- Monitor carefully to detect potential respiratory failure
- Pulse oximetry and ABGs