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Nursing Care Plan for Spinal Cord Injury: Overview

Nursing Care Plan for Spinal Cord Injury

Spinal Cord Injury

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The leading causes of spinal cord injury (SCI) include motor vehicle crashes, falls, acts of violence, and sporting injuries. The mechanism of injury influences the type of SCI and the degree of neurological deficit. Spinal cord lesions are classified as a complete (total loss of sensation and voluntary motor function) or incomplete (mixed loss of sensation and voluntary motor function).

Physical findings vary, depending on the level of injury, degree of spinal shock, and phase and degree of recovery, but in general, are classified as follows:

  • C-1 to C-3: Tetraplegia with total loss of muscular/respiratory function.
  • C-4 to C-5: Tetraplegia with impairment, poor pulmonary capacity, complete dependency for ADLs.
  • C-6 to C-7: Tetraplegia with some arm/hand movement allowing some independence in ADLs.
  • C-7 to T-1: Tetraplegia with limited use of thumb/fingers, increasing independence.
  • T-2 to L-1: Paraplegia with intact arm function and varying function of intercostal and abdominal muscles.
  • L-1 to L-2 or below: Mixed motor-sensory loss; bowel and bladder dysfunction.

Nursing Care Plan for Spinal Cord Injury

Nursing Care Plan for Spinal Cord Injury (Acute Rehabilitative Phase)

Nursing Care Plan for Spinal Cord Injury: Nursing Priorities & Discharge Goals

Nursing Priorities | Nursing Care Plan for Spinal Cord Injury

  1. Maximize respiratory function.
  2. Prevent further injury to spinal cord.
  3. Promote mobility/independence.
  4. Prevent or minimize complications.
  5. Support psychological adjustment of patient/SO.
  6. Provide information about injury, prognosis and expectations, treatment needs, possible and preventable complications.

Discharge Goals | Nursing Care Plan for Spinal Cord Injury

  1. Ventilatory effort adequate for individual needs.
  2. Spinal injury stabilized.
  3. Complications prevented/controlled.
  4. Self-care needs met by self/with assistance, depending on specific situation.
  5. Beginning to cope with current situation and planning for future.
  6. Condition/prognosis, therapeutic regimen, and possible complications understood.
  7. Plan in place to meet needs after discharge.

Nursing Care Plan for Spinal Cord Injury: Nursing Diagnosis

Nursing Care Plan for Spinal Cord Injury | Nursing Diagnosis of Spinal Cord Injury

  • Breathing Pattern, risk for ineffective related to Impairment of innervation of diaphragm (lesions at or above C-5); Complete or mixed loss of intercostal muscle function; Reflex abdominal spasms; gastric distension.

Nursing Care Plan for Spinal Cord Injury: Nursing Intervention & Rationale

Nursing Interventions of Spinal Cord Injury with Rationale

Respiratory Monitoring (NIC)

Nursing Interventions of Spinal Cord Injury with Rationale: Independent

  1. Assess respiratory function by asking patient to take a deep breath. Note presence or absence of spontaneous effort and quality of respirations, e.g., labored, using accessory muscles. Rationale: C-1 to C-3 injuries result in complete loss of respiratory function. Injuries at C-4 or C-5 can result in 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/impairment of intercostal muscles may impair effectiveness of cough and the ability to sigh, deep breathe.
  2. Auscultate breath sounds. Note areas of absent or decreased breath sounds or development of adventitious sounds (e.g., rhonchi). Rationale: Hypoventilation is common and leads to accumulation of secretions, atelectasis, and Spinal Cord Injury (frequent complications). Note: Respiratory compromise is one of the leading causes of mortality, especially during the acute stage as well as later in life.
  3. Note strength/effectiveness of cough.
  4. Observe skin color for developing cyanosis, duskiness.
  5. Assess for abdominal distension and muscle spasm.
  6. Monitor/limit visitors as indicated. Rationale: risk for acquiring URIs.
  7. Monitor diaphragmatic movement when phrenic pacemaker is implanted. Rationale: Stimulation of phrenic nerve may enhance respiratory effort, decreasing dependency on mechanical ventilator
  8. Elicit concerns/questions regarding mechanical ventilation devices. Rationale: Acknowledges reality of situation.

Nursing Care Plan for Spinal Cord Injury

Nursing Intervention with Rationale: Independent | Continuation:

  1. Provide honest answers. Rationale: Future respiratory function/support needs will not be totally known until spinal shock resolves and acute rehabilitative phase is completed.
  2. Maintain patient airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Rationale: prevents aspiration/maintaining patient airway.
  3. Assist patient in “taking control” of respirations as indicated. Instruct in and encourage deep breathing, focusing attention on steps of breathing. Rationale: Breathing may no longer be a totally voluntary activity but require conscious effort, depending on level of injury/involvement of respiratory muscles.
  4. Assist with coughing as indicated for level of injury.
  5. Suction as necessary. Note: “Routine” suctioning increases risk of hypoxia, bradycardia (vagal response), tissue trauma.
  6. Reposition/turn periodically. Avoid/limit prone position when indicated. Note: Prone position significantly decreases vital capacity, increasing risk of respiratory compromise/failure.
  7. Encourage fluids (at least 2000 mL/day). Rationale: Aids in liquefying secretions, promoting mobilization/expectoration.
  8. Measure/graph:
  • Vital capacity (VC), tidal volume (VT), inspiratory force; Rationale: Determines level of respiratory muscle function.

Nursing Care Plan for Spinal Cord Injury

Nursing Interventions of Spinal Cord Injury with Rationale: Collaborative

Airway Management (NIC)

  1. Serial ABGs and/or pulse oximetry. Rationale: Documents status of ventilation and oxygenation, identifies respiratory problems, e.g., hypoventilation (low PaO2/elevated PaCO2) and pulmonary complications.
  2. Administer oxygen by appropriate method, e.g., nasal prongs, mask, intubation/ventilator. Rationale: Method is determined by level of injury, degree of respiratory insufficiency, and amount of recovery of respiratory muscle function after spinal shock phase.
  3. Assist with use of respiratory adjuncts (e.g., incentive spirometer, blow bottles) and aggressive chest physiotherapy (e.g., chest percussion). Rationale: Preventing retained secretions is essential to maximize gas diffusion and to reduce risk of Spinal Cord Injury.
  4. Refer to/consult with respiratory and physical therapists.

Nursing Care Plan for Spinal Cord Injury: Overview; Nursing Care Plan for Spinal Cord Injury: Nursing Priorities & Discharge Goals; Nursing Care Plan for Spinal Cord Injury: Nursing Diagnosis; Nursing Care Plan for Spinal Cord Injury: Nursing Intervention with Rationale. Nursing Care Plan for Spinal Cord Injury.

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