Gausch P A, Linder S H, Williams T, Ryan S
SCI Nurs. 1991 Apr;8(1):4-10.
Spinal cord injury (SCI) patients have unique care needs, particularly related to the respiratory system. Respiratory problems now comprise a major cause of death in the acute and chronic phases of SCI, especially among quadriplegics. Previous literature has analyzed respiratory muscle dysfunction in SCI according to neurologic levels of injury (Alvarez, Peterson & Lunsford, 1981; McMichan, Michel & Westbrook, 1980). In general, the higher the level of injury, the greater the respiratory compromise and need for ventilatory assistance. Although level of injury is significant, it cannot be used as the sole determinant of respiratory compromise. For example, a 25 year old C4 quadriplegic with an intact diaphragm might have less respiratory impairment than a 60 year old C6 quadriplegic with CHF and a history of COPD. A new classification of SCI patients according to amount of respiratory compromise was developed by our team at the Spinal Cord Injury Unit at the Palo Alto VA Medical Center. The patient is scored in three categories: 1) level of injury; 2) completeness of injury; and 3) associating factors, i.e. age, preinjury chronic lung disease. The purpose of this grouping is to better predict the amount of ventilatory impairment in SCI patients. Used during the initial assessment, patients at high risk for impairment could be determined and optimal respiratory care initiated. This classification can also be used as a clinical nursing tool. Using this scoring system, the nurse could anticipate the patient's respiratory needs, i.e. suctioning, chest physiotherapy, oxygen, hydration, nutritional support and teaching of patient and family in order to comprehensively plan and implement care.(ABSTRACT TRUNCATED AT 250 WORDS)
脊髓损伤(SCI)患者有独特的护理需求,尤其是与呼吸系统相关的需求。呼吸问题现已成为SCI急性和慢性阶段的主要死亡原因,在四肢瘫痪患者中尤为突出。以往文献根据损伤的神经平面分析了SCI患者的呼吸肌功能障碍(阿尔瓦雷斯、彼得森和伦斯福德,1981年;麦克米坎、米歇尔和韦斯特布鲁克,1980年)。一般来说,损伤平面越高,呼吸功能受损越严重,对通气辅助的需求也越大。虽然损伤平面很重要,但它不能作为呼吸功能受损的唯一决定因素。例如,一名25岁、膈肌完好的C4四肢瘫痪患者可能比一名60岁、患有充血性心力衰竭和慢性阻塞性肺疾病史的C6四肢瘫痪患者呼吸功能受损程度轻。我们在帕洛阿尔托退伍军人医疗中心脊髓损伤科的团队制定了一种根据呼吸功能受损程度对SCI患者进行的新分类方法。患者按三类进行评分:1)损伤平面;2)损伤的完整性;3)相关因素,即年龄、伤前慢性肺病。这种分组的目的是更好地预测SCI患者的通气功能受损程度。在初始评估时使用该方法,可以确定功能受损高危患者,并启动最佳呼吸护理。这种分类也可作为一种临床护理工具。使用这种评分系统,护士可以预测患者的呼吸需求,即吸痰、胸部物理治疗、吸氧、补液、营养支持以及对患者和家属的宣教,以便全面规划和实施护理。(摘要截选至250字)