Spinal Cord Injury Nursing Diagnosis & Care Plan

A spinal cord injury (SCI) represents one of the most challenging conditions nurses encounter in clinical practice. This comprehensive guide explores the essential nursing diagnoses and interventions for optimal patient care. Understanding these elements is crucial for developing effective care strategies and improving patient outcomes.

Understanding Spinal Cord Injury

Spinal cord injury occurs when trauma or disease damages the spinal cord, disrupting communication between the brain and body. Depending on the injury’s location and severity, this disruption can lead to varying degrees of sensory and motor function loss.

Types of Spinal Cord Injury

Complete Injury:

• Total loss of sensory and motor function below the level of injury
• Bilateral involvement
• May result in paraplegia or quadriplegia

Incomplete Injury:

• Partial preservation of sensory or motor function below the injury level
• Variable presentation
• Potential for some functional recovery

Nursing Assessment for Spinal Cord Injury

A thorough nursing assessment includes:

1. Neurological status evaluation
2. Respiratory function assessment
3. Cardiovascular monitoring
4. Skin integrity examination
5. Bowel and bladder function assessment
6. Psychological status evaluation

Primary Nursing Care Plans for Spinal Cord Injury

Nursing Care Plan 1: Risk for Ineffective Breathing Pattern

Nursing Diagnosis: Risk for Ineffective Breathing Pattern related to neuromuscular impairment secondary to spinal cord injury.

Related Factors:

• Cervical or high thoracic cord injury
• Respiratory muscle weakness
• Impaired chest wall expansion
• Decreased vital capacity

Nursing Interventions and Rationales:

1. Monitor respiratory rate, depth, and pattern hourly
   Rationale: Early detection of respiratory compromise
2. Position patient with head elevated 30-45 degrees
   Rationale: Optimizes diaphragmatic excursion
3. Implement breathing exercises every 2 hours while awake
   Rationale: Maintains lung expansion and prevents atelectasis
4. Assess oxygen saturation continuously
   Rationale: Ensures adequate oxygenation

Desired Outcomes:

• Maintains respiratory rate of 12-20 breaths/minute
• Demonstrates clear breath sounds
• Maintains oxygen saturation >95% on room air

Nursing Care Plan 2: Impaired Physical Mobility

Nursing Diagnosis: Impaired Physical Mobility related to neuromuscular impairment secondary to spinal cord injury.

Related Factors:

• Muscle paralysis
• Decreased muscle strength
• Loss of sensory function
• Spinal cord compression

Nursing Interventions and Rationales:

1. Implement a range of motion exercises every shift
   Rationale: Prevents contractures and maintains joint mobility
2. Position patient using proper body alignment every 2 hours
   Rationale: Prevents pressure injuries and maintains proper posture
3. Initiate early mobilization as approved by a physician
   Rationale: Prevents complications of immobility

Desired Outcomes:

• Maintains joint mobility
• Participates in positioning activities
• Demonstrates understanding of mobility limitations

Nursing Care Plan 3: Risk for Autonomic Dysreflexia

Nursing Diagnosis: Risk for Autonomic Dysreflexia related to spinal cord injury above T6.

Related Factors:

• Injury level above T6
• Presence of noxious stimuli
• Bladder distention
• Bowel impaction

Nursing Interventions and Rationales:

1. Monitor blood pressure every 4 hours
   Rationale: Early detection of autonomic dysreflexia
2. Assess for triggering factors regularly
   Rationale: Prevents episodes of autonomic dysreflexia
3. Maintain bowel and bladder program
   Rationale: Prevents common triggers

Desired Outcomes:

• Remains free from autonomic dysreflexia episodes
• Demonstrates stable vital signs
• Shows no signs of bladder or bowel distention

Nursing Care Plan 4: Risk for Impaired Skin Integrity

Nursing Diagnosis: Risk for Impaired Skin Integrity related to immobility and decreased sensation.

Related Factors:

• Immobility
• Decreased sensation
• Moisture
• Nutritional deficits

Nursing Interventions and Rationales:

1. Perform comprehensive skin assessment every shift
   Rationale: Early detection of skin breakdown
2. Turn patient every 2 hours
   Rationale: Reduces pressure on bony prominences
3. Maintain clean, dry skin
   Rationale: Prevents moisture-associated skin damage

Desired Outcomes:

• Maintains intact skin
• Shows no signs of pressure injury
• Demonstrates proper skin care techniques

Nursing Care Plan 5: Acute Pain

Nursing Diagnosis: Acute Pain related to tissue trauma and nerve compression.

Related Factors:

• Tissue trauma
• Nerve compression
• Muscle spasms
• Inflammatory response

Nursing Interventions and Rationales:

1. Assess pain regularly using the appropriate scale
   Rationale: Ensures adequate pain management
2. Administer prescribed medications as scheduled
   Rationale: Maintains therapeutic pain control
3. Implement non-pharmacological pain management techniques
   Rationale: Provides comprehensive pain management approach

Desired Outcomes:

• Reports pain level as tolerable
• Demonstrates use of pain management techniques
• Shows improved comfort level

Patient Education and Support

Effective patient education includes:

• Understanding the injury and prognosis
• Learning self-care techniques
• Recognizing complications
• Managing medications
• Accessing community resources

References

1. Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2023). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. 
2. Biering-Sørensen F, Bickenbach JE, El Masry WS, Officer A, von Groote PM. ISCoS-WHO collaboration. International Perspectives of Spinal Cord Injury (IPSCI) report. Spinal Cord. 2011 Jun;49(6):679-83. doi: 10.1038/sc.2011.12. Epub 2011 Mar 22. PMID: 21423254.
3. Consortium for Spinal Cord Medicine. Early acute management in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med. 2008;31(4):403-79. doi: 10.1043/1079-0268-31.4.408. PMID: 18959359; PMCID: PMC2582434.
4. Harding, M. M., Kwong, J., & Hagler, D. (2022). Lewis’s Medical-Surgical Nursing: Assessment and Management of Clinical Problems, Single Volume. Elsevier.
5. Herdman, T. H., Kamitsuru, S., & Lopes, C. (2024). NANDA International Nursing Diagnoses – Definitions and Classification, 2024-2026.
6. Ignatavicius, D. D., Rebar, C., & Heimgartner, N. M. (2023). Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care. Elsevier.
7. Silvestri, L. A. (2023). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. 
8. Snider BA, Eren F, Reeves RK, Rupp R, Kirshblum SC. The International Standards for Neurological Classification of Spinal Cord Injury: Classification Accuracy and Challenges. Top Spinal Cord Inj Rehabil. 2023 Winter;29(1):1-15. doi: 10.46292/sci22-00036. Epub 2023 Feb 15. PMID: 36819931; PMCID: PMC9936898.