Nursing Care Process: The Patient with Quadriplegia or Paraplegia

Neurosensory
Assessment May report:
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Activity/ Rest •
May exhibit: May Exhibit:
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Circulation •
May report:
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May exhibit:
Pain/Discomfort
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May report:
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• May exhibit:
Elimination: •
May exhibit: Respiration
• May report:
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• May Exhibit:
• •
Ego Integrity: •
May report: •
• Safety
May Exhibit: • May exhibit:
• Sexuality:
Food/Fluid: May report:
May exhibit: •
• May Exhibit:
Hygiene: •
May exhibit:
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Possible Nursing Diagnosis: Impaired Physical Mobility
Related to:
Risk for ineffective Breathing •
Pattern •
Related to: As evidence by:
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• Disturbed Sensory Perception
Risk for Trauma Related to:
Related to: •
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 • Bowel Incontinence/Constipation
Related to:
As manifested by: •
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• As manifested by:
Acute Pain •
Related to: •
• •
• Impaired Urinary Elimination
As manifested by: Related to:
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• As manifested by:
Anticipatory Grieving •
Related to: •
• •
As manifested by: •
• Risk for Impaired Skin Integrity:
• Risk factor:
• •
Situational Low Self-Esteem •
Related to: •
• •
As manifested by: Deficient Knowledge
• Related to:
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• As manifested by:
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Planning/ Goal:

Nursing Interventions:
1. Increasing Mobility
• Exercise
• Mobilization (if spine is stable enough)
Preventing Disuse Syndrome
3. Promoting Skin Integrity
4. Improving Bladder Management
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5. Establishing Bowel Control
6. Counseling on Sexual Expression
7. Enhancing Coping Mechanisms