Spinal Cord Injury Nursing Diagnosis & Care Plan

Spinal cord injury (SCI) is a devastating event that can cause significant physical, emotional, and financial burden on the affected individual and their families.

The injury can result from trauma or non-traumatic causes such as motor vehicle accidents, infections, tumors, or degenerative diseases. SCI can cause a wide range of complications such as paralysis, loss of sensation, respiratory failure, ileus and bowel distension, autonomic dysreflexia, altered temperature regulation, altered peripheral circulation, pressure sore formation, among others.

Nursing diagnosis is a critical component of the nursing process for patients with SCI. It involves the identification of actual or potential health problems that the patient is experiencing or at risk of developing.

The nursing diagnosis is based on a thorough assessment of the patient’s physical, psychological, and social needs.

The nursing diagnosis guides the development of a comprehensive care plan that addresses the patient’s unique needs and goals. The care plan includes interventions to prevent further spinal cord injury, manage complications, promote recovery, and support rehabilitation.

Diagnosis

Spinal cord injury (SCI) can cause a range of symptoms and complications, depending on the location and severity of the injury. Nurses play a crucial role in diagnosing and managing SCI patients. A thorough assessment of the patient’s condition is necessary to diagnose the type and level of injury and develop an appropriate nursing care plan.

Complete Injury

A complete SCI results in total loss of motor and sensory function below the level of injury. The patient may experience paralysis, loss of sensation, bowel and bladder dysfunction, and impaired respiratory function. The diagnosis of complete SCI is made based on the absence of any motor or sensory function below the level of injury.

Incomplete Injury

An incomplete SCI results in partial loss of motor and sensory function below the level of injury. The patient may experience weakness, spasticity, loss of sensation, and impaired mobility. The diagnosis of incomplete SCI is made based on the presence of some motor or sensory function below the level of injury.

Cervical Spinal Cord Injury

Cervical SCI affects the neck region of the spinal cord and can cause paralysis of the arms, legs, and diaphragm. The patient may require ventilator support and may be at risk of autonomic dysreflexia. The diagnosis of cervical SCI is made based on the level of injury, which is determined by assessing the patient’s motor and sensory function.

Thoracic Spinal Cord Injury

Thoracic SCI affects the chest region of the spinal cord and can cause paralysis of the legs and trunk. The patient may experience impaired bowel and bladder function and may be at risk of pressure ulcers. The diagnosis of thoracic SCI is made based on the level of injury and the patient’s motor and sensory function.

Lumbar Spinal Cord Injury

Lumbar SCI affects the lower back region of the spinal cord and can cause paralysis of the legs and hips. The patient may experience impaired bowel and bladder function and may be at risk of falls. The diagnosis of lumbar SCI is made based on the level of injury and the patient’s motor and sensory function.

Nurses must conduct a thorough assessment of the patient’s condition to diagnose the type and level of SCI. The assessment involves evaluating the patient’s motor and sensory function, reflexes, and autonomic function. Imaging tests such as MRI may be used to confirm the diagnosis and determine the extent of the injury.

Once the diagnosis is made, nurses develop a nursing care plan that addresses the patient’s specific needs, such as pain management, bowel and bladder management, and pressure ulcer prevention.

Medications such as muscle relaxants and analgesics may be used to manage spasticity and pain. Nurses also educate the patient and family on coping strategies, self-esteem, and quality of life issues.

Complications

Patients with spinal cord injuries are at risk for developing various complications due to the damage to the spinal cord. Some of the most common complications include pneumonia, urinary tract infections, deep vein thrombosis, respiratory infections, and skin breakdown.

Pneumonia

Pneumonia can occur due to ineffective cough reflex, decreased vital capacity or respiratory function, and phrenic nerve involvement. Patients with spinal cord injury may have difficulty clearing secretions from their lungs, decreased breath sounds, which can lead to the development of pneumonia. Nursing care plans should include measures to promote respiratory function, such as deep breathing exercises and coughing techniques.

Urinary Tract Infections

Patients with spinal cord injury are at increased risk for urinary tract infections due to the disruption of normal bladder function.

The use of catheters and other devices can also increase the risk of infection. Nursing care plans should include measures to promote bladder health, such as frequent catheterization and the use of sterile technique.

Deep Vein Thrombosis

Deep vein thrombosis (DVT) is a common complication in patients with spinal cord injury. Immobility and decreased muscle strength can lead to blood flow stasis, which increases the risk of developing blood clots.

Nursing care plans should include measures to promote blood flow, such as frequent position changes and the use of compression stockings.

Respiratory Infections

Respiratory infections can occur due to ineffective breathing pattern, respiratory muscle weakness, and poor oxygen saturation. Patients with spinal cord injury may also be at increased risk for aspiration due to ineffective cough reflex.

Nursing care plans should include measures to promote respiratory function, such as frequent suctioning and monitoring of oxygen saturation levels.

Bladder and Bowel Distension

Patients with spinal cord injury are at risk for decreased bowel function and decreased bowel sounds. The goal for the healthcare team would be to acheive or maintain a satisfactory bowel elimination pattern.

Skin Breakdown

Patients with spinal cord injury are at increased risk for skin breakdown due to decreased sensation and mobility.

Pressure ulcers can develop quickly and can be difficult to treat. Nursing care plans should include measures to promote skin integrity, such as frequent turning and repositioning, the use of pressure-relieving devices, and the monitoring of skin condition.

In summary, patients with spinal cord injury are at risk for developing various complications due to the damage to the spinal cord. Nursing care plans should address these complications and include measures to promote respiratory function, bladder health, blood flow, skin integrity, and mobility.

Rehabilitation

Rehabilitation is a crucial component of healing for patients with spinal cord injuries. It aims to restore function, prevent complications, and improve the patient’s quality of life. Rehabilitation therapy may be necessary for some patients, and it can be intensive.

Physical Therapy

Physical therapy is a vital component of rehabilitation for spinal cord injury patients. It helps to improve mobility, strengthen muscles, and prevent muscle atrophy.

Physical therapists work with patients to develop an exercise program tailored to their specific needs and abilities. They also teach patients how to use assistive devices such as wheelchairs, walkers, and canes.

Nursing Interventions

Nurses play a critical role in the rehabilitation of spinal cord injury patients. They work with physical therapists and other healthcare providers to develop a care plan that addresses the patient’s specific needs.

Nursing interventions may include wound care, bowel and bladder management, and medication management.

Communication

Communication is essential during rehabilitation. Patients need to understand their condition, treatment options, and progress. Healthcare providers need to communicate effectively with patients, their families, and caregivers. Communication can take many forms, including verbal, written, and visual aids.

Safety

Safety is a top priority during rehabilitation. Patients with spinal cord injuries are at risk of falls, pressure ulcers, and other complications.

Healthcare providers must take steps to ensure the patient’s safety. This may include modifying the patient’s environment, providing education on safe practices, and using assistive devices.

Coping

Spinal cord injuries can be life-changing and psychologically distressing for the patient and their family. Coping strategies can help patients and their families adjust to the changes in their lives. Healthcare providers can provide emotional support, counseling, and education on coping strategies.

Self-Esteem

Spinal cord injuries can have a significant impact on a patient’s self-esteem. Patients may struggle with feelings of loss, grief, and depression.

Healthcare providers can help patients rebuild their self-esteem by providing emotional support, education, and counseling. They can also encourage patients to participate in activities that promote self-confidence and self-worth.

Spinal Cord Injury Nursing Diagnosis

Impaired Physical Mobility

Impaired Physical Mobility is often a primary consequence of a spinal cord injury. The damage to the spinal cord can interrupt the transmission of signals between the brain and the body, resulting in paralysis or weakness of the limbs, trunk, and/or other parts of the body.

Nursing Diagnosis: Impaired Physical Mobility

Related To:

• Loss of sensation and motor function due to SCI.
• Effects of prolonged immobility on the musculoskeletal system.
• Patient’s emotional response to the loss of mobility and independence.

As Evidenced By:

• limited mobility,
• difficulty in changing positions,
• impaired balance,
• inability to perform activities of daily living (ADLs), and
• decreased muscle strength.

Expected Outcomes:

• The patient will achieve optimal physical mobility within their limitations.
• The patient will be able to perform ADLs independently or with minimal assistance.
• The patient will have an increased sense of control and independence over their environment.
• The patient will maintain skin integrity and prevent pressure ulcers.
• The patient will have an improved quality of life.

Nursing Assessment with Rationales:

• Assess the patient’s level of mobility and ability to perform ADLs to determine their baseline functioning. This assessment helps to identify the patient’s limitations, needs, and abilities.
• Assess the patient’s skin integrity and risk for pressure ulcers. Patients with limited mobility are at a higher risk for pressure ulcers, and early identification and intervention are critical.
• Assess the patient’s psychological status, including their emotional response to the injury, coping strategies, and level of depression or anxiety. Spinal cord injuries can cause significant psychological distress, and addressing these issues is critical to the patient’s recovery.
• Assess the patient’s pain level and the effectiveness of current pain management. Pain management is essential to facilitate physical therapy and promote mobility.
• Assess the patient’s nutrition status and bowel and bladder function. Spinal cord injuries can impact these functions, and proper nutrition and bowel and bladder management are necessary to promote healing and prevent complications.

Nursing Interventions and Rationales:

1. As the effects of spinal shock or edema subside, monitor the patient’s motor function by asking the patient to shrug shoulders, spread, extend or stretch fingers, squeeze, and hold the examiner’s hand and then release them. Because motor-sensory impairment may be blended or not apparent for a specific threshold of injury, it is necessary to evaluate the state or status of the patient. This will influence the type and choice of therapies.
2. Ensure that all joints and extremities of the patient are being exercised to their full range of motion (ROM). Assist the patient in regularly flexing or extending the hips. Improves blood flow, restores and preserves mobility and muscular tone, and protects against muscle atrophy and contractures caused by disuse or lack of use.
3. Ensure undisturbed intervals of relaxation for the patient while creating his/her daily routines. Encourage participation within the limits of the patient’s tolerance, endurance, and abilities. Maintaining energy levels allows patients to put out their maximum effort and take an active part in all activities.
4. Offer the patient lumbar support while they are sitting, elevate their lower extremities or raise the foot of their bed. Check the ankles and feet for swelling. When vascular tone and muscle activity are compromised, blood accumulates in the lower abdominal region and the legs (which is a normal physiological response to a penetrating spinal injury), increasing the risk of hypotension and thrombus or clot formation.
5. When necessary, place the patient on a kinetic therapy bed. To reduce the risks associated with prolonged immobility, patients who receive this treatment will have their unstable spinal column stabilized and their circulation improved. Meanwhile, the beds were designed to maximize pulmonary secretion clearance while significantly reducing skin breakdown.
6. Discuss other options with the patient’s health care provider (e.g., occupation therapists) and the rehabilitation team. Preserving function as well as developing and maintaining functional independence require exercise programs that are adapted to the demands of each patient. 

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Acute Pain

Acute pain can cause damage to nerve fibers, resulting in pain signals being sent to the brain.

Nursing Diagnosis: Acute Pain

Related To:

• Nerve damage
• Muscle spasms,
• Surgical interventions
• Pressure ulcers

As Evidenced By:

• Patient reports of pain
• Facial expressions indicating discomfort
• Changes in vital signs
• Guarding or protecting the affected area

Expected Outcomes:

• The patient will have pain relief within acceptable limits.
• The patient will have a decreased need for pain medication.
• The patient will participate in pain management interventions and report pain relief.
• The patient will have a decreased risk of complications related to pain.
• The patient will have an improved quality of life.

Nursing Assessment with Rationales:

1. Assess the patient’s pain level and location, including any radiation or referred pain. This assessment helps to identify the source and intensity of the pain and determine the appropriate interventions.
2. Assess the patient’s vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation. These assessments help to identify any physiological changes related to pain.
3. Assess the patient’s response to current pain management interventions, including medication effectiveness, side effects, and adverse reactions. This assessment helps to determine if changes are needed to the current pain management plan.
4. Assess the patient’s psychological response to pain, including coping mechanisms, anxiety, and depression. Addressing these issues is critical to the patient’s overall well-being and pain management.

Nursing Interventions and Rationales:

1. Evaluate the patient’s verbalized or observed pain. Use a 0–10 scale to help the patient describe the location and intensity of their discomfort/pain. Patients who have undergone stabilization device treatment may experience chest, back, or even headache pain. Radicular pain may sometimes be described by the patient as a searing or stabbing feeling after the spinal shock phase of the illness (relate to damage in peripheral nerves, spreading dermatomal). Chronic pain can set up just days or weeks of an SCI, depending on the severity of the injury.
2. Incorporate steps to ensure patient safety and well-being such as methods to ease his/her discomfort such as: Range of motion exercises, Cold and warm packs, Repositioning, and Massage. Because of their ability to lessen the need for pain medications while also reducing the detrimental effects on respiratory function, alternative techniques of coping with pain are appealing for both emotional and practical reasons.
3. Assist the patient in determining what triggered his/her symptoms. Stress, tension, high or low temperatures, prolonged sitting, and bladder distension can all cause or exacerbate burning discomfort and spasms. Having a better understanding of the traumatic events that led to a spinal injury can help lessen the pain and risk. 
4. Employ guided imagery, visualization, and deep-breathing exercises to help the patient relax and cope with symptoms. Provide a range of entertainment alternatives, such as television, radio, telephone, and a limitless number of visitors, as and when they are required. The sensation is compromised after a spinal cord injury. Because of this, the use of relaxation exercises and approaches may help to alleviate this problem by providing a better sense of control and the ability to cope. 

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Impaired Urinary Elimination

Spinal cord injury can affect the nerves that control the bladder and bowel function, resulting in urinary retention, urinary incontinence, and other urinary dysfunctions.

Nursing Diagnosis: Impaired Urinary Elimination

Related To:

• Loss of sensation & control of bladder function due to spinal cord injury.
• Nerve Damage

As Evidenced By:

• Urinary retention
• Urinary incontinence
• Incomplete bladder emptying
• Overflow urinary incontinence

Expected Outcomes:

• The patient will demonstrate a thorough knowledge of the condition.
• The patient will take preventative measures to avoid urinary retention and infection.
• The patient will have improved bladder function.
• The patient will have a decreased risk of urinary tract infections and other complications related to impaired urinary elimination.
• The patient will have an increased sense of control and independence over their urinary function.
• The patient will be able to perform bladder care independently or with minimal assistance.
• The patient will have an improved quality of life.

Nursing Assessment with Rationales:

1. Assess the patient’s bladder function, including frequency, urgency, and voiding patterns. This assessment helps to identify any urinary dysfunctions and determine the appropriate interventions.
2. Assess the patient’s urinary output and signs of urinary retention, such as distention, discomfort, and leakage. This assessment helps to identify any complications related to impaired urinary elimination.
3. Assess the patient’s ability to perform bladder care independently or with minimal assistance, including the use of catheters or other medical interventions. This assessment helps to identify any education or training needs for the patient and their caregivers.
4. Assess the patient’s psychological response to impaired urinary elimination, including anxiety, depression, and coping strategies. Addressing these issues is critical to the patient’s recovery and quality of life.

Nursing Interventions and Rationales:

1. Evaluate the patient’s frequency and amount of voiding. Compare the amount of urine produced to the amount of fluid consumed. Check the urine-specific gravity. SCI patients are at risk of developing neurogenic bladder dysfunction, which can severely impact their health. As a result, the patient’s ability to empty their bladder, kidney function, and fluid balance is assessed during this examination to decide when intervention is most necessary.
2. Whenever necessary, perform bladder retraining methods in accordance with the protocol (e.g., drinking water at specific times of the day, digital stimulation of the trigger area, and performing the Credé technique). Based on the type of damage, a patient’s bladder program and timing should be customized. Due to the risk of causing autonomic dysreflexia (AD), Credé’s procedure should only be employed with extreme caution.
3. Pay attention to the odor and cloudiness of the patient’s urine. Use a urine dipstick, as instructed. The physical appearance of urine and a number of test data can indicate whether or not a patient is in danger of acquiring kidney infection or urinary tract infection, most notably sepsis. (Note: Individuals who have had a spinal cord injury are more likely to get sepsis than the general public). Dipsticks can reveal information on the urine’s nitrite, pH, and leukocyte esterase, which are hallmarks that may indicate the presence of an infection.
4. Promote the patient’s fluid consumption, including acid ash juices and water of about 2–4 Liters per day. Reduce the risk of kidney infection and urinary stone development. 

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Disturbed Sensory Perception

Spinal cord injury can effect the sensory pathways, resulting in altered or decreased sensation, hypersensitivity, or phantom sensations.

Nursing Diagnosis: Disturbed Sensory Perception

Related To:

• Damage to the spinal cord resulting in altered or decreased sensation
• Hypersensitivity
• Phantom sensations

As Evidenced By:

• Patient reports of altered sensation
• Hypersensitivity
• Phantom sensations
• Loss of sensation

Expected Outcomes:

• The patient will have improved sensory perception within their limitations.
• The patient will be able to perform activities of daily living (ADLs) with minimal assistance.
• The patient will have an increased sense of control and independence over their environment.
• The patient will have an improved quality of life.

Nursing Assessment with Rationales:

1. Assess the patient’s level of sensory perception and the type of sensory disturbance, including altered sensation, hypersensitivity, phantom sensations, or loss of sensation. This assessment helps to identify the patient’s limitations, needs, and abilities.
2. Assess the patient’s psychological response to sensory disturbances, including anxiety, depression, and coping strategies. Addressing these issues is critical to the patient’s recovery and quality of life.
3. Assess the patient’s ability to perform ADLs independently or with minimal assistance. This assessment helps to identify any limitations or modifications needed to promote independence and improve self-esteem.

Nursing Interventions and Rationales:

1. Using a variety of techniques such as hot or cold application, touch, pinprick, and so on, evaluate and record the patient’s motor and sensory function and deficit, gradually going from the area of deficit to the area of normal function. The presence of abnormalities or changes during the early stages of spinal shock is possible; however, when the shock subsides, changes should be documented using dermatome diagrams or anatomical body landmarks.
2. Ensure that the patient can get adequate rest and sleep by designating a dedicated rest schedule. To help with re-establishing normal sleep patterns reduces the effects of sensory overload. It is essential to note that an injured spinal cord means that the body has to work harder and consume more energy to move around; thus, energy conservation is needed in the SCI population.
3. Ensure that the patient does not suffer any physical harm from situations like falls, poor positioning of arms or objects, and burns. Pain and awareness of one’s bodily position are not always experienced by the patient.
4. Preparation and care procedures should be explained to the patient, with the body portion to be treated identified. It helps the patient see his/her body as a whole and helps with the confrontation of the various injury-related alterations in the mind and body.
5. Support the patient in identifying and adapting to changes in sensations. To prevent injuries and reduce anxiety.
6. Assist the patient’s positioning in a way that they can view their environment and activities. Prism glasses should be provided. Talk to the patient regularly. Allows patients to get sensory input that may be highly restricted, particularly when they are in the prone or supine position.
7. Take note of the presence of excessive emotional reactions, changes in responses and behaviors in patients, as well as changed mental processes such as a demonstrated condition of confusion or unusual thinking. This suggests damage to the sensory tracts as well as psychological stress, both of which necessitate further evaluation and care.  

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Ineffective Breathing Pattern

Spinal cord injury can affect the nerves that control the respiratory muscles, resulting in impaired lung function, respiratory failure, and the need for mechanical ventilation.

Nursing Diagnosis: Ineffective Breathing Pattern

Related To:

• Impaired lung function
• Respiratory failure
• The need for mechanical ventilation

As Evidenced By:

• Dyspnea
• Decreased oxygen saturation
• Abnormal respiratory rate and rhythm
• Use of accessory muscles
• Need for mechanical ventilation

Expected Outcomes:

• The patient will have improved respiratory function.
• The patient will have a decreased need for mechanical ventilation.
• The patient will participate in respiratory therapy and report improved breathing.
• The patient will have a decreased risk of complications related to ineffective breathing pattern.
• The patient will have an improved quality of life.

Nursing Assessment with Rationales:

1. Assess the patient’s respiratory rate, depth, and pattern, as well as any use of accessory muscles, cyanosis, or decreased oxygen saturation. This assessment helps to identify the patient’s respiratory status and determine the appropriate interventions.
2. Assess the patient’s need for mechanical ventilation, including settings, oxygenation, and weaning protocols. This assessment helps to determine if changes are needed to the current respiratory therapy plan.
3. Assess the patient’s response to current respiratory therapy interventions, including medication effectiveness, side effects, and adverse reactions. This assessment helps to determine if changes are needed to the current respiratory therapy plan.
4. Assess the patient’s psychological response to ineffective breathing pattern, including anxiety, depression, and coping strategies. Addressing these issues is critical to the patient’s recovery and quality of life.

Nursing Interventions and Rationales:

1. Ask the patient to take a deep breath to determine their level of respiratory function. Check for involuntary effort and respiratory quality (labored with accessory muscles for respiration), and note whether or not they are present.  Injury to the C-1 through C-3 vertebrae results in the full cessation of respiratory function. A reduction in vital capacity and an increase in the inspiratory effort are the most common outcomes of the phrenic nerve and diaphragmatic function injuries at C-4 or C-5 levels. The degree of respiratory function loss depends on the degree of the phrenic nerve and diaphragmatic function complicity. If the injury occurs below the level of the C-6 or C-7, the respiratory muscle function is unchanged; however, intercostal muscular weakness or dysfunction may restrict the efficiency of coughing, as well as the ability to sigh and take a deep breath in such situations.
2. Observe and auscultate the patient’s breath sounds. Monitor specific locations where there are no or fewer breath sounds or where there is an increase in the number of ad hoc sounds. As a result of inadequate ventilation, secretions build up, atelectasis occurs, and pneumonia develops. It is also believed that hypoventilation is a contributing factor to the development of sleep-disordered breathing in the SCI population.
3. Take note of if the patient has a distended abdomen, as well as whether he/she is experiencing any muscle spasms. The diaphragmatic excursion may be impeded by abdominal fullness, resulting in reduced pulmonary function and expansion, as well as worsening of respiratory performance. Additionally, discomfort and issues in the abdomen are thought to accompany the development of spinal cord damage.
4. Answer the patient truthfully. Prospective respiratory function requirements will not be ascertained until the acute rehabilitative period is through and spinal shock has subsided. Even if respiratory assistance is required, it is possible to increase mobility and improve autonomy using different technologies and approaches.

Disclaimer:

Please follow your facility’s guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and should not be used or relied on for diagnostic or treatment purposes.

This information is intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.