Medical-surgical Nursing Demystified

(^246) Medical-Surgical Nursing Demystified
NURSING DIAGNOSES

• Activity intolerance


• Impaired mobility


• Risk for injury

NURSING INTERVENTION

• Monitor neurological status for changes.


• Monitor respiratory status for changes.


• Encourage self-care, allow patient extra time.


• Encourage exercise; assist with passive ROM if necessary.


• Weigh patient.


• Record food intake.


• Explain to the patient:
  
  
  • Importance of following medication time schedule as well as effects of
    medication wearing off.
  
  
  • Reduce risk of falls at home.
  
  
  
  

Spinal Cord Injury

WHAT WENT WRONG?

Injury to the spinal cord results in compression, twisting, severing, or pulling on the

spinal cord. The damage to the cord may involve the entire thickness of the cord

(complete), or only a partial area of the spinal cord (incomplete). The most com-

mon cause of spinal cord injury is trauma. Any level of the spinal cord may have

been affected by the injury. Loss of sensation, motor control, or reflexes may occur

below the level of injury or within 1 to 2 vertebrae or spinal nerves above the level

of injury. The loss may be unilateral or bilateral. Damage to the vertebrae may

have occurred at the same time as the spinal cord injury. Swelling due to the ini-

tial trauma may make the injury seem more severe than it actually is. When the

initial swelling resolves, the actual degree of permanent injury can be more accu-

rately assessed.

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