Post-discharge nursing problems of spinal cord injured patients: on which ” elds can nurses contribute to rehabilitation?

Objective: To identify nursing problems of spinal cord injured (SCI) patients after discharge from clinical rehabilitation and to identify gaps in the nursing care regarding the prevention of these problems.

Design: The study had an exploratory character and was divided into three phases. Phase 1 had a qualitative nature. Eight patients were interviewed to obtain insight into experienced problems after discharge. In phase 2, a panel of experts regarding nursing care for SCI patients selected nursing problems out of all problems mentioned. Phase 3 consisted of a mailed questionnaire including the nursing problem areas identified in phase 2, which was sent to all patients that were discharged during the last 18 months before the study.

Setting: Specialist rehabilitation centre, the Netherlands.

Subjects: Eight patients participated in phase 1 (100% response rate), 35 nurses participated in phase 2 (87.5% response rate) and 35 patients participated in phase 3 (62.5% response rate).

Results: The most important nursing problems in the response group appeared to be: limitations to activities of daily living, having difficulties in asking for help (assertiveness), pain, coping with the disability, dependency on personal help and problems with changed bladder regulation. The respondents made several suggestions for improving nursing care, involving both clinical care and care after discharge.

Conclusions: SCI patients experience serious problems after discharge from clinical rehabilitation. Nurses can give input on a wide variety of these problems.

Squamous cell carcinoma arising from a recurrent ischial pressure ulcer: a case report

Marjolin's ulcer is the malignant transformation of long-standing chronic pressure ulcers and requires prompt diagnosis and treatment. A 46-year-old man with an 8-year history of traumatic spinal injury with paraplegia presented with a recurrent ischial pressure ulcer. The initial ulcer, which developed 6 years earlier, was a Stage IV sacral ulcer. The wound was debrided and pathology showed epithelial hyperplasia, acanthosis, hyperkatosis accompanied by mild inflammation, and fibrosis without any malignant transformation. The lesion was covered with a fasciocutaneous bipedicled flap. Four years later, the patient presented with a similar ulcer in the same location. Histology showed the presence of a well-differentiated squamous cell carcinoma (SCC). Following a wide excision, the lesion was covered with a gluteal maximal V-Y musculocutaneous advancement flap. At last follow-up 14 months postoperatively, there was no evidence of recurrence or metastatic disease. Clinicians must be aware of known risk factors for the development of SCC.

Health-related quality of life of primary caregivers of persons with paraplegia

STUDY DESIGN

A cross-sectional descriptive study was performed with structured questionnaires and interviews conducted with 60 primary caregivers of persons with paraplegia (T1 to S2) owing to traumatic spinal cord injury (SCI).

OBJECTIVES

The purpose of this study was the assessment of the health-related quality of life (HRQoL) of primary caregivers of persons with paraplegia owing to traumatic SCI.

SETTING

São Paulo, SP, Brazil.

METHODS

The HRQoL was assessed by the Short Form-36 (SF-36) health survey questionnaire and caregiver burden was evaluated by the Caregiver Burden Scale (CBS).

RESULTS

Among 60 caregivers evaluated, 49 (81.7%) were female, with mean age of 35.8 (SD=12.91) years, 16 (26.6%) being wives and 14 (23.4%) sisters of persons with paraplegia. It was found that the caregivers spend an average of 11.3 h/day caring for individuals with paraplegia. Twenty-three caregivers (38.3%) had a chronic disease and 32 (53.3%) were sole caregivers taking upon themselves the full responsibility of caring for the persons with paraplegia. The subjects reported lower scores on bodily pain and vitality than the other dimensions of the SF-36. The mean global CBS score was 1.71 (SD=0.50) and mean scores for each dimension ranged from 1.39 (SD=0.64) for emotional involvement to 2.44 (SD=0.79) for environment dimension.

CONCLUSION

The primary caregivers of spinal cord-injured persons reported low scores on all of the SF-36 and CBS dimensions, bodily pain and vitality being the SF-36 dimensions that received the lowest scores.

Design and evaluation of a stand-up motorized prone cart

BACKGROUND/OBJECTIVE

Prone carts are used for mobility by individuals with spinal cord injury in whom seated mobility (wheelchair) is contraindicated due to ischial or sacral pressure ulcers. Currently available prone carts are uncomfortable, subjecting the user to neck and shoulder strain, and make social interaction and performing activities of daily living difficult. A better design of prone carts is needed. In addition, standing devices have shown some medical benefits. The objective was to design and evaluate an improved prone cart that facilitates standing.

DESIGN

Engineering development project with user feedback through questionnaire. Users selected by convenience sampling.

METHODS

A marketing survey was performed of nurse managers of spinal cord injury units. Then 2 prototype carts were designed and built. These carts are able to tilt up to 45 degrees and have a joystick-controlled motor for propulsion and other design features, including a workspace storage shelf and rearview mirrors. The carts were evaluated by both patients and caregivers at 2 Veteran's Administration hospitals.

OUTCOME MEASURES

Questionnaire of subjects, both patients and caregivers, who used the cart.

FINDINGS

Both patients and caregivers liked the carts and the ability to assume a nonhorizontal body angle. The major complaint about the cart was that it seemed too long when it came to making turns.

CONCLUSION

This prone cart design is an improvement over the standard, flat variety. However, further design changes will be necessary. This study provided valuable information that will be useful in the next-generation prone cart design project.

[Abdominal massage as intervention for patients with paraplegia caused by spinal cord injury--a pilot study]

Patients with paraplegia caused by spinal cord injuries have to deal with the loss of the central nervous regulation of the bowel functions. The management of defaecation can take a lot of their daily time. To support the colon motility, different methods of abdominal massage are used in nursing practice. But a review of current international literature reveals, that there is still a lack of evidence for the effect of abdominal massage on defaecation. In order to prove this effect, a pilot study was conducted using a quasi-experimental design with time series and including seven patients with paraplegia caused by spinal cord injury. Data were collected over three weeks: one week before intervention, during the intervention week and one week after intervention. In the intervention week, the patients received a specific abdominal massage each morning before breakfast. Following outcome-criteria have been considered: frequency and duration of defaecation, amount and consistency of faeces as well as subjective perception of the massage and its effects.

RESULTS

Some distinctive changes in the frequency and duration of defaecation could be registered over time. Most patients regarded the massage as a comfortable intervention that may have positive effects of the defaecation. Due to the pilot character of the study further research is necessary in order to validate these effects.

Stress responses, pressure ulcer development and adaptation

This case study explores the possible psychosocial concepts underpinning a spinal cord-injured patients' pressure ulcer development, his response to the treatment offered and subsequent self-discharge. By examining both the physiological and psychological reactions of stress through conceptual models, it was possible to depict that there is a close relationship between autonomic responses and an individual's emotional and appraisal attributes. The effect of stress on the immune system was reviewed, with particular focus placed on the wound-healing process and the inflammatory phase. This identified a probable correlation between emotional stress and pressure ulcer development. An individual's reaction to emotional stressors is frequently associated with his/her unique coping strategies and their interplay with social support mechanisms. This case study will depict both positive and negative coping strategies and how the lack of social support influenced the final outcome. Through the provision of an anonymous patient history, investigation will be made into the effects of stress experienced by a patient. Models of stress and the patient's related physiological and psychological reactions will be discussed. Examination will be made into how the use of social support could have influenced the patient's coping mechanisms.

A case study in evidence-based wound management

On the first of July 1998, Frank Dobson, the then Secretary of State for Health, revealed the consultation document 'A First Class Service' (Department of Health (DoH), 1998). This article describes a wound management case study which showed how a first class service was provided for a patient with very severe pressure ulcers and complex medical problems. A multiprofessional approach to her complex and challenging problems was maintained. Evidence-based guidelines for the prevention and management of pressure damage were followed, supported by modern researched-based wound management and pressure relief. In addition, risk management strategies were observed, and provided the basis for planning and evaluating her individualized care.

Stigma of visible and invisible chronic conditions

Nurses deliver care to people with various forms of chronic illnesses and conditions. Some chronic conditions, such as paraplegia, are visible while others, such as diabetes, are invisible. Still others, such as multiple sclerosis, are both visible and invisible. Having a chronic illness or condition and being different from the general population subjects a person to possible stigmatization by those who do not have the illness. Coping with stigma involves a variety of strategies including the decision about whether to disclose the condition and suffer further stigma, or attempt to conceal the condition or aspects of the condition and pass for normal. We present a beginning framework that describes the relationship between the elements of stigma and the decision to disclose or hide a chronic condition based on its visibility or invisibility. The specific aims were to combine the results from a meta-study on qualitative research with a review of the quantitative literature, then develop a theoretical framework. Although an understanding of how patients cope with stigmatizing conditions is essential for nurses who aim to deliver comprehensive individualized patient care, there is little current literature on this subject. The relationship between visibility and invisibility and disclosure and non-disclosure remains poorly understood. A framework to facilitate a deeper understanding of the dynamics of chronic illnesses and conditions may prove useful for practice.

Paraplegia

Nurses caring for people who have sustained an injury resulting in paraplegia must have an understanding of both the psychological and physical effects. This Update examines the nurse's role in preparing the patient for the future.

Restraining an aggressive suicidal, paraplegic patient: a look at the ethical and legal issues

This paper focuses on a case of an intently suicidal, paraplegic patient in a critical care unit and the need for collaboration among nursing leaders to provide a safe environment through the use of wrist restraints. Ethical questions regarding patient rights, liberties, and privileges are reviewed. Legal points of negligence and intentional torts are also included in the analysis of the case.

Nursing care of the patient with spinal cord compression

Spinal cord compression (SCC) is a common oncologic emergency that can profoundly affect the remainder of the patient's life. SCC develops when pressure is exerted on the spinal cord by a tumor or by a collapsed vertebral body that has been replaced by cancer. When the condition is diagnosed and treated early, the patient may maintain ambulatory status; however, when the diagnosis is made late and neurologic compromise has occurred already, there is minimal expectation that impaired functions will return. SCC is treated with dexamethasone and radiation therapy, and surgery occasionally is performed. Nursing care, an integral component in the management of this challenging condition, may be as simple as educating the at-risk patient about the signs and symptoms of SCC or as complex as meeting the many needs of the paraplegic patient. This article reviews the etiology and clinical presentation of SCC as well as assessment, treatment, and nursing care related to the condition.

Understanding and combating helplessness

Helplessness is the perceived inability to influence or control an outcome, which results in the suppression of overt behavior to affect an outcome. This article examines the concept of helplessness to help nurses differentiate between the dependent, passive behaviors that are motivated by a need for attention and are within the patient's control and the dependent behaviors of learned helplessness. Interventions are discussed that are intended to assist nurses in working effectively with patients to prevent or to reverse helplessness.

[Management of the spinal cord injured patient--hospital routine or principles of comprehensive rehabilitation?]

Based on her own experience in the rehabilitation of spinal cord injured patients, the author describes the nursing service's self-concept and its development over the past 25 years, as well as changes in its working conditions inter alia entailed by technical advances. Requirements are posited, which are considered indispensable for comprehensive rehabilitation, specifically with regard to the aftercare necessary for the person with SCI in the domiciliary situation.

Follow-up study of owner attitudes toward home care of paraplegic dogs

A questionnaire was mailed to 30 owners of paraplegic dogs who had been caring for their dogs at home for 3 to 72 months. It was designed to collect information on demographic variables, duration of ownership and paralysis, age of the pet, pet/owner relationship, owner expectations and perceptions of the pet's quality of life, problems the pet experienced, effect that maintaining a paralyzed pet had on the owners' quality of life, and whether use of a cart was beneficial. Significant correlation was found between prior expectations that the pet would lead a high-quality life and perception that the pet, in fact, had a high quality of life during paralysis (r2 = 0.61, P = 0.01). Owners who had anticipated that extra work would be necessary to care for their paraplegic dog had a more positive attitude toward home care (r2 = 0.55, P = 0.03). Overall, owners involved in the study were satisfied with all aspects of maintaining paraplegic dogs at home. Our findings support the feasibility of dedicated owners successfully maintaining small (average body weight, 9 kg) paraplegic dogs at home for extended periods.