Spinal Cord Injury Nursing Diagnosis and Care Plans

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Spinal Cord Injury Nursing Care Plans Diagnosis and Interventions

Spinal Cord Injury NCLEX Review and Nursing Care Plans

Damage to the spinal cord or the nerves at the spinal canal’s base (the cauda equina) can have long-term and often irreversible effects on a person’s sense of touch, strength, and other bodily processes. In definition, a spinal cord injury (SCI) is a rupture or breakdown of the complex network of nerves and cells that connects the brain to the rest of the body.  

Anatomy and Physiology of the Spinal Cord

Regions of the spine:

  • Cervical spinal cord – this is the part of the spine where the spinal cord attaches to the brain. It attaches the neck with the back. It has eight vertebrae, C1-C8.
  • The spine’s thoracic region – thoracic vertebrae (T1-T12) comprise the mid-spinal cord.
  • The lumbar region of the spine – the spinal cord begins to curve here. L1-L5 are the vertebrae in this area.
  • Sacral region of the spine – the sacral area is a triangle-shaped part of the spine just under the lumbar region. This area lacks a spinal cord. But it has nerve roots that exit the spine at various vertebral locations.

The spinal cord provides communication pathways that allow the brain and body to work together as a unit. The motor tracts are the conduits through which the brain communicates with the muscles. Meanwhile, sensory pathways transmit information to the brain about the body’s temperature, tension, discomfort, and limb posture or position.

When there is damage to the nerve fibers, whether due to trauma or not, the transfer of sensory information from the body to the brain is significantly hindered. Depending on the location of the nerve damage, this may result in pain or movement issues for the patient.

Types of Spinal Cord Injury

  • Complete Injury – occurs when the spinal cord is injured, preventing the brain from sending impulses below the injured area. Total or complete cervical spine injuries frequently result in a loss of motor function in both the lower and upper extremities (quadriplegia). 
  • Incomplete Injury – occurs when compression or damage to the spinal cord impairs the brain’s capacity to transmit messages below the injury site. Because the spinal cord is partially affected, incomplete injuries vary greatly between individuals. Some sensory and motor functions may be slightly reduced or nearly lost entirely. Generally, remaining functions can be found on either side of the body, while certain routes between the brain and the body remain open for communication.

Causes of Spinal Cord Injury

Spinal cord injuries can be caused by injury or trauma to the spinal column. However, it can also be caused by trauma to the ligaments and discs of the vertebral column and the spinal cord itself.

Injury to one or more vertebrae as a result of an unexpected and violent hit to the spine usually results in serious spinal cord damage. Traumatic spine injuries can also occur when one or more vertebrae fracture, are injured, are dislocated, or are deformed. A gunshot or knife trauma that penetrates and slices the spinal cord might also result in the injury.

Additional damage may be due to: 

  • Edema or swelling in the area surrounding the spinal cord.
  • Inflammation of the spinal cord
  • Hemorrhage or bleeding 
  • Fluid accumulation
  • A buildup of fluid surrounding the spinal cord.

Whereas these induce a nontraumatic spinal cord injury:

  • Arthritis
  • Infection in the CNS
  • Degenerative disc disease
  • Cancer or malignancies

In the U.S., these are the most prevalent causes of spinal cord injury:

  • Acts of aggression or violence. About 12 percent of all spinal cord injuries are caused by violent confrontations, with gunshot wounds accounting for the majority. Knife wounds are also prevalent.
  • Symptoms of illness. The following conditions can also result in spinal cord injuries: cancer or malignancies, osteoporosis, arthritis, and spinal cord inflammation.
  • Falls. An accident involving a fall is the most common cause of spinal cord injury in people over the age of 65.
  • Accidents involving vehicles. Accidents involving automobiles and motorcycles account for about half of all new spinal cord injuries that occur each year.
  • Accidental injury in sports and recreation: athletic activity, such as high-impact sports and shallow water diving, is responsible for around 10% of all spinal cord injuries in the United States.

Risk Factors of Spinal Cord Injury

Typically, a spinal cord injury results from an accident, although it can happen to anyone at any moment. However, numerous factors can increase one’s chances of sustaining a spinal cord injury, including those listed below.

  • Suffering from specific illnesses
  • The age range of 16 to 30 years
  • Being over the age of 65. At the age of 65
  • Engaging in risky activities
  • Drinking alcohol
  • Being a man or male

Signs and Symptoms of Spinal Cord Injury

  • Tetraplegia with complete loss of muscle and respiratory function, from C1 to C3
  • Tetraplegia with impaired respiratory capacity; total dependent on ADLs, from C-4 to C-5.
  • Tetraplegia from C-6 to C-7 allows the ability to move one’s arms and hands; it enables some degree of autonomy in daily activities.
  • Tetraplegia from C-7 to T-1, with restricted thumb/finger use and growing autonomy
  • Paraplegia from T2 to L1, with varied intercostal and abdominal muscular function and unaffected arm movement
  • L-1 to L-2 and lower: Urinary incontinence and bowel impairment due to mixed motor-sensory loss

Diagnosis of Spinal Cord Injury

  • Use of magnetic resonance imaging (MRI) to visualize the spinal cord or soft tissues.
  • Use of computed tomography (CT) imaging to detect or reveal broken bones, fractures, blood clots, or damage to blood vessels.
  • Use of X-rays to detect or reveal fractures, displacements, and other bone injuries.
  • Evaluation. The purpose of an evaluation is to determine an individual’s neurologic abilities.

Treatment for Spinal Cord Injury

According to many studies, corticosteroids may speed up the recovery of spinal cord injury. Affected individuals should be given their medication within eight hours of occurrence. The following may occur as a result of this treatment:

  • Increase blood flow.
  • Preserve the function of the nerves.
  • Lessen the body’s inflammatory responses.

Prevention of Spinal Cord Injury

  • Don’t get behind the wheel while intoxicated. Avoid driving under the influence of alcohol or drugs. Don’t get in the car with a drunk driver.
  • Preventing falls is essential. Get high-up items by using the step stool with a grab bar. Tile floors and tubs should be covered with non-slip mats. Install window guards and utilize safety gates to obstruct stairways for young children. Make stairways safer by installing handrails.
  • Drive carefully and slowly. Keep the seat belt on at all times when driving. Seat belts or kid safety seats should be used by all children, regardless of their age or weight.
  • When participating in sports, remember to use safety precautions.

Complications of Spinal Cord Injury

  • Dysfunction in bladder control
  • Dysfunction in bowel control
  • Circulatory alterations
  • Overuse of specific muscle groups causes discomfort in some people, including muscle and joint pain.
  • Problematic breathing
  • Dysfunction of the pulmonary system
  • Below-injury osteoporosis and fracture risk.
  • In men, erection and ejaculation may be affected, whereas, in women, the lubrication may be altered.

Nursing Diagnosis for Spinal Cord Injury

Spinal Cord Injury Nursing Care Plan 1

Nursing Diagnosis: Impaired Physical Mobility related to symptoms of neuromuscular damage, secondary to spinal cord injury as evidenced by contractures, muscle atrophy, the inability to move as one would intend, immobility and paralysis.

Desired Outcome: The patient will demonstrate operative approaches and habits that allow him/her to resume normal activities.

Spinal Cord Injury Nursing InterventionsRationale
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.
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.
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.  
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.
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.
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. 

Spinal Cord Injury Nursing Care Plan 2

Nursing Diagnosis: Acute Pain related to physical trauma or injury, secondary to spinal cord injury, as evidenced by onset of hyperesthesia directly above the point of injury, paraplegia, burning sensation beneath the site of the injury, phantom pain, spasticity of the muscles, and headaches.

Desired Outcome: The patient indicates whether or not he/she experienced any improvement in his/her level of discomfort or pain.

Spinal Cord Injury Nursing InterventionsRationale
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.
Incorporate steps to ensure patient safety and well-being such as methods to ease his/her discomfort such as:Range of motion exercisesCold and warm packsRepositioningMassageBecause 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.
Assist the patient in determining what triggered his/her symptomsStress, 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. 
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. 

Spinal Cord Injury Nursing Care Plan 3

Nursing Diagnosis: Impaired Urinary Elimination related to dysfunction of bladder innervation, secondary to spinal cord injury, as evidenced by urinary incontinence, retention dysfunction, overflow, urinary tract infections, formation of bladder and kidney stones, and renal insufficiency. 

Desired Outcomes: 

  • The patient will demonstrate a thorough knowledge of the condition.
  • The patient will take preventative measures to avoid urinary retention and infection.
Spinal Cord Injury Nursing InterventionsRationale
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.
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.
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.
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. 

Spinal Cord Injury Nursing Care Plan 4

Nursing Diagnosis: Disturbed Sensory Perception related to the inability to receive, transmit, and integrate information due to the destruction of sensory pathways, secondary to spinal cord injury, as evidenced by alteration of regular reaction to stimuli, irregularities in movement, alterations in sensory acuity, anxiousness, confusion, and irrational thinking.

Desired Outcomes: 

  • The patient will effectively recognize the presence of sensory deficiencies.
  • The patient demonstrates an understanding of sensory requirements and the dangers of sensory deprivation or overload.
Spinal Cord Injury Nursing InterventionsRationale
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.
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.
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.
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.
Support the patient in identifying and adapting to changes in sensations.To prevent injuries and reduce anxiety.
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.
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.  

Spinal Cord Injury Nursing Care Plan 5

Nursing Diagnosis: Ineffective Breathing Pattern related to spinal cord injuries above or at C-5 affecting diaphragm innervation, secondary to spinal cord injury, as evidenced by respiratory dysfunction, demonstrated respiratory distress, signs of inspiratory efforts, and laboratory results outside of the allowed range.

Desired Outcome: The patient will demonstrate and maintain satisfactory ABGs with no signs of respiratory discomfort or inadequate ventilation.

Spinal Cord Injury Nursing InterventionsRationale
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.
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 soundsAs 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
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.
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.

Nursing References

Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier.  Buy on Amazon

Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon

Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier.  Buy on Amazon

Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier.  Buy on Amazon

Disclaimer:

Please follow your facilities guidelines, policies, and procedures.

The medical information on this site is provided as an information resource only and is not to be used or relied on for any 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.

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