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Interdisciplinary practice: Spinal cord injury
CLINICAL DECISIONS Section Editor: Colleen Swartz, RN, MSN, CCRN
Interdisciplinary Practice: Spinal Cord Injury
Q
Dianne Danis, RN, MS, CEN
Q A
What guidelines have other hospitals developed for the acute care of patients with spinal cord injury?
At Beth Israel Deaconess Medical Center in Boston, Massachusetts, a level I trauma center, a multidisciplinary task force developed interdisciplinary practice guidelines that cover expected patient outcomes and interdisciplinary interventions. Although every patient is different and the guidelines never seem to apply exactly, they have been very helpful. They are used in conjunction with a weekly multidisciplinary (eg, trauma and spine service, nursing, social work, case management, physical therapy, occupational therapy) patient conference when a patient with an acute spinal cord injury is admitted. These guidelines describe considerations for the evaluation and management of patients with spinal cord injury. They are not a substitute, replacement, or alternative for independent clinical assessment and judgment with respect to the care and treatment of any patient. They are reprinted on the following pages with permission from Beth Israel Deaconess Medical Center.
Dianne Danis, RN, MS, CEN, is a trauma program manager for Beth Israel Deaconess Medical Center in Boston. Please write Dianne Danis at [email protected] or Colleen Swartz at [email protected] with comments.
64 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Danis
Int J Trauma Nurs 2001;7:64-6. Copyright © 2001 by the Emergency Nurses Association. 1075-4210/2001/$35.00 + 0 65/1/115396 doi:10.1067/mtn.2001.115396
VOLUME 7, NUMBER 2
Table 1. Expected patient outcomes Outcome
Initial admission and stabilization: 48 h
Interim hospitalization and treatment: 48 h to 1 wk
Predischarge and discharge: 1 to 2 wk
Physiologic parameters
VSS Respiratory stability (no aspiration, clear BS, no evidence of retained secretions)
VSS Respiratory stability (no aspiration, clear BS, no evidence of retained secretions, trach if needed)
VSS Respiratory stability (no aspiration, clear BS, no evidence of retained secretions)
BP maintained within prescribed parameters
BP maintained within prescribed parameters
BP maintained within prescribed parameters
U/O > 30 cc/h
U/O > 30 cc/h
U/O > 30 cc/h
No complications of spinal shock
No complications of spinal shock
No complications of spinal shock
Pain managed
Pain managed
Pain managed
Taking adequate calories orally or parenterally Tolerates bowel and bladder program No evidence of skin breakdown
Taking adequate calories orally or parenterally Tolerates bowel and bladder program No evidence of skin breakdown
Bladder and bowel regimen implemented
Able to sit upright > 30 min with an appropriate hemodynamic response
Patient and family demonstrate understanding of medical condition and hospital environment
Family performs ROM/ stretching program with assistance
Able to sit upright > 60 min with an appropriate hemodynamic response No complications of autonomic dysreflexia Functional ROM in all 4 extremities Family is independent with ROM/stretching program
High-dose methylprednisolone implemented according to protocol Spine stabilized Taking adequate calories orally or parenterally
Patient and family education
Family is knowledgeable of proper positioning and pressure relief techniques Patient and family demonstrate understanding of coping skills and the stages of grief and loss Patient and family understand pathophysiology of injury
Form of communication
Readiness for discharge
Patient and staff begin to develop a mode of communication, eg, communication board
Patient is able to manage the following environmental elements with assistance or adaptive device: call light, telephone, television, and bed position Communication mode established with patient, staff, and family Patient and family discuss and explore potential discharge options with physician(s) or staff Staff assist patient and family in preparing for discharge
Family is knowledgeable of proper positioning and pressure relief techniques Patient and family demonstrate understanding of coping skills and the stages of grief and loss Patient and family understand pathophysiology of injury Patient and family are knowledgeable of progression of activity Patient is able to manage the following environmental elements independently or with adaptive device: call light, telephone, television, and bed position
Patient and family complete plan for discharge
Patient and family are knowledgeable of rehabilitation levels of care and the variety of rehabilitation programs available VSS, Vital signs stable; BS, breath sounds; BP, blood pressure; U/O, urine output; ROM, range of motion.
APRIL-JUNE 2001
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Danis 65
Table 2. Interdisciplinary interventions Interventions
Initial admission and stabilization: 48 h
Interim hospitalization and treatment: 48 h to 1 wk
Assessments
VS Neuro check Evaluate need for halo/surgery Bowel and bladder assessment Skin assessment Nutritional status Patient and family comprehension and ability to cope Posttraumatic stress, anxiety, grieving Problem solving, self-directing behaviors, coping skills Identify best communication methods for patient (OT, SLP) Daily assessments by clinical team
VS Neuro check Evaluate need for tracheostomy Bowel and bladder assessment Skin assessment Nutritional status Patient and family comprehension and ability to cope Posttraumatic stress, anxiety, grieving Problem solving, self-directing behaviors, coping skills Identify best communication methods for patient (OT, SLP) Daily assessments by clinical team
Consults
Spine consult PT and CPT OT and splint evaluation Speech (SLP) consult Physiatry consult Rehabilitation nursing Nutrition RT (assess for special needs) Case management SW for psychosocial support APS as indicated Weekly case conference
Physiatry as indicated Referral to Learning Center
Medications
Methylprednisolone according to protocol Pain management Pain management Psychopharmacologic management IV fluids as indicated IV fluids as indicated Pressors to maintain perfusion pressure as ordered DVT prophylaxis DVT prophylaxis
Treatments
Activity and safety
Pulmonary hygiene and airway management as indicated NG/OG tube Urinary catheter OT/PT/CPT Halo traction/vest as indicated Rotating bed as indicated Implement collar care guidelines Develop methods of communication RT DVT prophylaxis ROM Nutrition Immobility precautions Turn q2h CPT q2h
Patient education
Instruct patient and family in: Coping with crisis Pathophysiology of injury Overview of hospital course
Discharge planning
Clarify and verify patient’s insurance benefits Initiate discussion about rehabilitation Apply for insurance, free care, or Medicaid as necessary Financial counseling as indicated
Weekly case conference
Predischarge and discharge: 1 to 2 wk VS Neuro check S&Sx of autonomic dysreflexia Bowel and bladder assessment Skin assessment Nutritional status Patient and family comprehension and ability to cope Posttraumatic stress, anxiety, grieving Problem solving, self-directing behaviors, coping skills Identify best communication methods for patient (OT, SLP) Daily assessments by clinical team
Weekly case conference Pain management IV fluids as indicated
DVT prophylaxis
Bowel program
Bowel program
Bladder program Skin care management
Bladder program Skin care management
Collar care Collar changed to allow OOB Provide pressure-reducing chairpad for patient OT/PT/CPT RT DVT prophylaxis ROM Nutrition Initiate activity/mobilization plan Turn q2h Provide adequate communication system When able to transfer to chair, use appropriate specialty equipment as indicated (ie, Hoyer lift, recliner, wheelchair, seat cushions, etc) Instruct patient and family in: Coping skills and the stages of grief and loss ROM/stretching S&Sx autonomic dysreflexia Proper positioning and pressure relief techniques Discuss what to expect at rehabilitation hospital Rehabilitation screening initiated Patient and family provided with discharge options
RT DVT prophylaxis ROM Nutrition Continue activity/mobilization plan Turn q2h Begin wheelchair mobility as able
Review with patient and family in: Coping skills and the stages of grief and loss ROM/stretching S&Sx autonomic dysreflexia Proper positioning and pressure relief techniques Prepare for discharge to rehabilitation
VS, Vital signs; S&Sx, signs and symptoms; OT, occupational therapy; SLP, speech language pathology; PT, physical therapy; CPT, chest physical therapy; RT, respiratory therapy; SW, social work; APS, acute psychiatry service; IV, intravenous; DVT, deep venous thrombosis; NG/OG, nasogastric/orogastric; OOB, out of bed; ROM, range of motion; q2h, every 2 hours.
66
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Danis
VOLUME 7, NUMBER 2
Interdisciplinary Practice: Spinal Cord Injury
Q
Dianne Danis, RN, MS, CEN
Q A
What guidelines have other hospitals developed for the acute care of patients with spinal cord injury?
At Beth Israel Deaconess Medical Center in Boston, Massachusetts, a level I trauma center, a multidisciplinary task force developed interdisciplinary practice guidelines that cover expected patient outcomes and interdisciplinary interventions. Although every patient is different and the guidelines never seem to apply exactly, they have been very helpful. They are used in conjunction with a weekly multidisciplinary (eg, trauma and spine service, nursing, social work, case management, physical therapy, occupational therapy) patient conference when a patient with an acute spinal cord injury is admitted. These guidelines describe considerations for the evaluation and management of patients with spinal cord injury. They are not a substitute, replacement, or alternative for independent clinical assessment and judgment with respect to the care and treatment of any patient. They are reprinted on the following pages with permission from Beth Israel Deaconess Medical Center.
Dianne Danis, RN, MS, CEN, is a trauma program manager for Beth Israel Deaconess Medical Center in Boston. Please write Dianne Danis at [email protected] or Colleen Swartz at [email protected] with comments.
64 INTERNATIONAL JOURNAL OF TRAUMA NURSING/Danis
Int J Trauma Nurs 2001;7:64-6. Copyright © 2001 by the Emergency Nurses Association. 1075-4210/2001/$35.00 + 0 65/1/115396 doi:10.1067/mtn.2001.115396
VOLUME 7, NUMBER 2
Table 1. Expected patient outcomes Outcome
Initial admission and stabilization: 48 h
Interim hospitalization and treatment: 48 h to 1 wk
Predischarge and discharge: 1 to 2 wk
Physiologic parameters
VSS Respiratory stability (no aspiration, clear BS, no evidence of retained secretions)
VSS Respiratory stability (no aspiration, clear BS, no evidence of retained secretions, trach if needed)
VSS Respiratory stability (no aspiration, clear BS, no evidence of retained secretions)
BP maintained within prescribed parameters
BP maintained within prescribed parameters
BP maintained within prescribed parameters
U/O > 30 cc/h
U/O > 30 cc/h
U/O > 30 cc/h
No complications of spinal shock
No complications of spinal shock
No complications of spinal shock
Pain managed
Pain managed
Pain managed
Taking adequate calories orally or parenterally Tolerates bowel and bladder program No evidence of skin breakdown
Taking adequate calories orally or parenterally Tolerates bowel and bladder program No evidence of skin breakdown
Bladder and bowel regimen implemented
Able to sit upright > 30 min with an appropriate hemodynamic response
Patient and family demonstrate understanding of medical condition and hospital environment
Family performs ROM/ stretching program with assistance
Able to sit upright > 60 min with an appropriate hemodynamic response No complications of autonomic dysreflexia Functional ROM in all 4 extremities Family is independent with ROM/stretching program
High-dose methylprednisolone implemented according to protocol Spine stabilized Taking adequate calories orally or parenterally
Patient and family education
Family is knowledgeable of proper positioning and pressure relief techniques Patient and family demonstrate understanding of coping skills and the stages of grief and loss Patient and family understand pathophysiology of injury
Form of communication
Readiness for discharge
Patient and staff begin to develop a mode of communication, eg, communication board
Patient is able to manage the following environmental elements with assistance or adaptive device: call light, telephone, television, and bed position Communication mode established with patient, staff, and family Patient and family discuss and explore potential discharge options with physician(s) or staff Staff assist patient and family in preparing for discharge
Family is knowledgeable of proper positioning and pressure relief techniques Patient and family demonstrate understanding of coping skills and the stages of grief and loss Patient and family understand pathophysiology of injury Patient and family are knowledgeable of progression of activity Patient is able to manage the following environmental elements independently or with adaptive device: call light, telephone, television, and bed position
Patient and family complete plan for discharge
Patient and family are knowledgeable of rehabilitation levels of care and the variety of rehabilitation programs available VSS, Vital signs stable; BS, breath sounds; BP, blood pressure; U/O, urine output; ROM, range of motion.
APRIL-JUNE 2001
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Danis 65
Table 2. Interdisciplinary interventions Interventions
Initial admission and stabilization: 48 h
Interim hospitalization and treatment: 48 h to 1 wk
Assessments
VS Neuro check Evaluate need for halo/surgery Bowel and bladder assessment Skin assessment Nutritional status Patient and family comprehension and ability to cope Posttraumatic stress, anxiety, grieving Problem solving, self-directing behaviors, coping skills Identify best communication methods for patient (OT, SLP) Daily assessments by clinical team
VS Neuro check Evaluate need for tracheostomy Bowel and bladder assessment Skin assessment Nutritional status Patient and family comprehension and ability to cope Posttraumatic stress, anxiety, grieving Problem solving, self-directing behaviors, coping skills Identify best communication methods for patient (OT, SLP) Daily assessments by clinical team
Consults
Spine consult PT and CPT OT and splint evaluation Speech (SLP) consult Physiatry consult Rehabilitation nursing Nutrition RT (assess for special needs) Case management SW for psychosocial support APS as indicated Weekly case conference
Physiatry as indicated Referral to Learning Center
Medications
Methylprednisolone according to protocol Pain management Pain management Psychopharmacologic management IV fluids as indicated IV fluids as indicated Pressors to maintain perfusion pressure as ordered DVT prophylaxis DVT prophylaxis
Treatments
Activity and safety
Pulmonary hygiene and airway management as indicated NG/OG tube Urinary catheter OT/PT/CPT Halo traction/vest as indicated Rotating bed as indicated Implement collar care guidelines Develop methods of communication RT DVT prophylaxis ROM Nutrition Immobility precautions Turn q2h CPT q2h
Patient education
Instruct patient and family in: Coping with crisis Pathophysiology of injury Overview of hospital course
Discharge planning
Clarify and verify patient’s insurance benefits Initiate discussion about rehabilitation Apply for insurance, free care, or Medicaid as necessary Financial counseling as indicated
Weekly case conference
Predischarge and discharge: 1 to 2 wk VS Neuro check S&Sx of autonomic dysreflexia Bowel and bladder assessment Skin assessment Nutritional status Patient and family comprehension and ability to cope Posttraumatic stress, anxiety, grieving Problem solving, self-directing behaviors, coping skills Identify best communication methods for patient (OT, SLP) Daily assessments by clinical team
Weekly case conference Pain management IV fluids as indicated
DVT prophylaxis
Bowel program
Bowel program
Bladder program Skin care management
Bladder program Skin care management
Collar care Collar changed to allow OOB Provide pressure-reducing chairpad for patient OT/PT/CPT RT DVT prophylaxis ROM Nutrition Initiate activity/mobilization plan Turn q2h Provide adequate communication system When able to transfer to chair, use appropriate specialty equipment as indicated (ie, Hoyer lift, recliner, wheelchair, seat cushions, etc) Instruct patient and family in: Coping skills and the stages of grief and loss ROM/stretching S&Sx autonomic dysreflexia Proper positioning and pressure relief techniques Discuss what to expect at rehabilitation hospital Rehabilitation screening initiated Patient and family provided with discharge options
RT DVT prophylaxis ROM Nutrition Continue activity/mobilization plan Turn q2h Begin wheelchair mobility as able
Review with patient and family in: Coping skills and the stages of grief and loss ROM/stretching S&Sx autonomic dysreflexia Proper positioning and pressure relief techniques Prepare for discharge to rehabilitation
VS, Vital signs; S&Sx, signs and symptoms; OT, occupational therapy; SLP, speech language pathology; PT, physical therapy; CPT, chest physical therapy; RT, respiratory therapy; SW, social work; APS, acute psychiatry service; IV, intravenous; DVT, deep venous thrombosis; NG/OG, nasogastric/orogastric; OOB, out of bed; ROM, range of motion; q2h, every 2 hours.
66
INTERNATIONAL JOURNAL OF TRAUMA NURSING/Danis
VOLUME 7, NUMBER 2