Nursing Interventions and Rationale
Assess respiratory function by asking patient to take a deep breath. Note presence or absence of spontaneous effort and quality of respirations (labored, using accessory muscles).
C-1 to C-3 injuries result in complete loss of respiratory function. Injuries at C-4 or C-5 can lead to variable loss of respiratory function, depending on phrenic nerve involvement and diaphragmatic function, but generally cause decreased vital capacity and inspiratory effort. For injuries below C-6 or C-7, respiratory muscle function is preserved; however, weakness or impairment of intercostal muscles may impair effectiveness of cough and the ability to sigh, deep breathe.