- Ineffective Breathing Pattern related to thoracic spinal cord injury and Diaphragm muscle weakness as evidenced by Paradoxical or unequal chest wall movement and Shallow rapid breaths
- Self-Care Deficit related to muscle weakness and impaired mobility as evidenced by inability to perform self-care tasks and unable to use the toilet independently
- Situational Low Self-Esteem related to alteration in body image and functional impairment as evidenced by Poor perception about own body or self and feelings of helplessness
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective data: Difficulty breathing; shortness of breath or dyspnoea Anxiety in relation to breathing Objective data: -Dyspnoea -Abnormal respiratory rate; tachypnoea or bradypnea -Poor oxygen saturation -Abnormal ABG results -Shallow breathing -Pursed-lip breathing -Accessory muscle use when breathing -Nasal flaring -Cough -Restlessness and anxiety -Decreased level of consciousness -Diaphoresis -Abnormal chest x-ray results | Ineffective Breathing Pattern Related to thoracic spinal cord injury and Diaphragm muscle weakness as evidenced by Paradoxical or unequal chest wall movement and Shallow rapid breaths | Patient will demonstrate a respiratory rate and rhythm within expected limits Patient will maintain an oxygen saturation of 95-100% Patient will demonstrate clear breath sounds Patient will demonstrate effective coughing | 1. Relax the respiratory muscles. Help the patient deal with the physiological side effects of hypoxia, which might include anxiety and terror. 2. Maintain patent airway. Keep the head in a neutral posture, raise the head of the bed a little if it is safe to do so, and use an airway device if needed. 3. Prevent pneumonia. Pneumonia and related complications are common causes of death in SCI. Preventing the development of respiratory conditions by suctioning, instructing on deep breathing, and respiratory muscle training can reduce the risk. 4. Consider cough assist and chest physiotherapy. A weak cough is a common finding and can lead to a build-up of secretions. A mechanical cough assist device can apply pressure to stimulate a cough. Chest PT can also assist in clearing the airways. 5. Prepare for tracheostomy or mechanical ventilation. SCI that affects the phrenic nerve at the cervical level causes an impairment in respiration. Long-term tracheostomy and mechanical ventilation may be required. | Patient demonstrated a respiratory rate and rhythm within expected limits Patient maintained an oxygen saturation of 95-100% Patient demonstrated clear breath sounds Patient demonstrated effective coughing |
| Subjective data: Verbalize unable to perform activities Objective data: -Inability to perform self-care tasks -Unable to bathe independently -Unable to dress independently -Unable to eat independently -Unable to use the toilet independently | Self-Care Deficit related to muscle weakness and impaired mobility as evidenced by inability to perform self-care tasks and unable to use the toilet independently | Patient will be able to identify the activities in which they need assistance Patient will be able to verbalize independence in doing an activity Patient will be able to perform self-care activities within their capability | 1. Instruct on ways to preserve self-care despite limitations. Dependence on others for basic care can feel dehumanizing. At the very least, implement ways for the patient to communicate their needs. Recommend devices and equipment that allow the patient to participate. 2. Assist the patient in meeting their needs. While encouraging and integrating self-care independence, assisting with personal care is a necessary component of nursing care. 4. Encourage decision-making. Allow the patient to make any decisions they can, such as choosing what to eat or wear, to encourage independence and participation. 5. Consider home health services. The patient and family may need additional help in the home with ADLs. Refer to case management for assistance with referrals. 6. Refer to rehabilitative services. Rehabilitation will help the patient optimize their ability to perform at their highest capacity. Adaptive services such as wheelchair fitting or creating handicap-accessible transportation can improve the patient’s access to the environment. | Patient identified the activities in which they need assistance Patient verbalized independence in doing an activity Patient performed self-care activities within their capability |
| Subjective data: Express feeling low Alteration in body image Objective data: -Poor perception about own body or self -Feelings of helplessness/uselessness -Loss of interest in care or outcomes -Change in social involvement | Situational Low Self-Esteem related to alteration in body image and functional impairment as evidenced by Poor perception about own body or self and feelings of helplessness | Patient will openly discuss their feelings about their situation Patient will be able to demonstrate self-confidence through goal planning and active participation in care Patient will be able to express positive self-appraisal | 1. Identify the patient’s coping mechanisms. Coping mechanisms boost resilience because they teach how to deal effectively with unpleasant emotions and other adverse circumstances. 2. Listen to the patient’s self-talk. Unconsciously, someone who feels unimportant, incompetent, or out of control frequently speaks negatively about themselves, contributing to a loss of self-esteem. 3. Refer to mental health services. Spinal cord injuries cause loss not only of physical abilities but the potential loss of achievements and future plans. Realization of this can cause immense depression that requires expert mental health support. 4. Encourage support groups. Meeting and developing relationships with others who have experienced an SCI can improve the patient’s self-esteem and remind them that they are not alone. 5. Encourage verbalization of feelings. Expression of one’s own feelings aids in the process of loss and grief. 6. Promote patient involvement. Patients involved in their care are more likely to adhere to treatment regimens, are more knowledgeable about their conditions, and report higher levels of satisfaction with their care. 7. Appreciate the patient’s efforts. Recognize improvement by acknowledging it. Encouragement from others in a positive way encourages perseverance and continued growth. | Patient discussed their feelings about their situation Patient demonstrated self-confidence through goal planning and active participation in care Patient expressed positive self-appraisal |