Medical Surgical Nursing

 Motor ability is tested by asking the patient to spread the fingers, squeeze the

examiner's hand, and move the toes or turn the feet.

 Sensation is evaluated by gently pinching the skin or touching it lightly with an

object such as a tongue blade, starting at shoulder level and working down both

sides of the extremities. The patient should have both eyes closed so that the

examination reveals true findings, not what the patient hopes to feel. The patient

is asked where the sensation is felt.

 Any decrease in neurologic function is reported immediately.

The patient is also assessed for spinal shock, a complete loss of all reflex, motor,
sensory, and autonomic activity below the level of the lesion that causes bladder
paralysis and distention. The lower abdomen is palpated for signs of urinary retention
and overdistention of the bladder. Further assessment is made for gastric dilation and
ileus caused by an atonic bowel, a result of autonomic disruption.
Temperature is monitored, because the patient may have periods of hyperthermia as a
result of alteration in temperature control due to autonomic disruption.

Diagnosis
Nursing Diagnoses
Based on the assessment data, the patient's major nursing diagnoses may include the
following:

 Ineffective breathing patterns related to weakness or paralysis of abdominal and

intercostal muscles and inability to clear secretions

 Ineffective airway clearance related to weakness of intercostal muscles

 Impaired bed and physical mobility related to motor and sensory impairments

 Disturbed sensory perception related to motor and sensory impairment

 Risk for impaired skin integrity related to immobility and sensory loss

 Impaired urinary elimination related to inability to void spontaneously

 Constipation related to presence of atonic bowel as a result of autonomic

disruption

 Acute pain and discomfort related to treatment and prolonged immobility

Collaborative Problems/Potential Complications
Based on the assessment data, potential complications that may develop include:

 DVT

 Orthostatic hypotension

 Autonomic dysreflexia

Planning and Goals
The goals for the patient may include improved breathing pattern and airway clearance,
improved mobility, improved sensory and perceptual awareness, maintenance of skin
integrity, relief of urinary retention, improved bowel function, promotion of comfort,
and absence of complications.

Nursing Interventions

Promoting Adequate Breathing and Airway Clearance
Possible impending respiratory failure is detected by observing the patient, measuring
vital capacity, monitoring oxygen saturation through pulse oximetry, and monitoring