Avoids injury
o Shows lessening agitation and restlessness
o Is oriented to time, place, and person
Maintains normal body temperature
o Absence of fever
o Absence of hypothermia
Demonstrates intact skin integrity
o Exhibits no redness or breaks in skin integrity
o Exhibits no pressure ulcers
Shows improvement in cognitive function and improved memory
Demonstrates normal sleep/wake cycle
Demonstrates absence of complications
o Exhibits normal vital signs and body temperature, and increasing
orientation to time, place, and person
o Demonstrates normal or reduced ICP
Experiences no posttraumatic seizures
o Takes antiseizure medications as prescribed
o Identifies side effects/adverse effects of antiseizure medications
Family demonstrates adaptive family processes
o Joins support group
o Shares feelings with appropriate health care personnel
o Makes end-of-life decisions, if needed
Participates in rehabilitation process as indicated for patient and family
members
o Takes active role in identifying rehabilitation goals and participating in
recommended patient care activities
o Prepares for dischargeNursing Process
The Patient with Acute Spinal Cord InjuryAssessment
The breathing pattern is observed, the strength of the cough is assessed, and the lungs
are auscultated, because paralysis of abdominal and respiratory muscles diminishes
coughing and makes clearing of bronchial and pharyngeal secretions difficult. Reduced
excursion of the chest also results.
The patient is monitored closely for any changes in motor or sensory function and for
symptoms of progressive neurologic damage. In the early stages of SCI, determining
whether the cord has been severed may be impossible, because signs and symptoms of
cord edema are indistinguishable from those of cord transection. Edema of the spinal
cord may occur with any severe cord injury and may further compromise spinal cord
function.
Motor and sensory functions are assessed through careful neurologic examination.
These findings usually are recorded on a flow sheet so that changes in the baseline
neurologic status can be monitored closely and accurately. The ASIA classification is
commonly used to describe level of function for SCI patients. Chart 63-7 gives
examples of the effects of altered spinal cord function. At the minimum: