12 Spinal Cord Injury Nursing Care Plans

ADVERTISEMENTS

A spinal cord injury (SCI) is damage to any part of the spinal cord or nerves at the end of the spinal canal. The condition often causes permanent changes in strength, sensation, and other body functions below the site of the injury.

Motor vehicle accidents, acts of violence, and sporting injuries are the common causes of spinal cord injury (SCI). 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, reduced 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 Plans

Nursing care planning and goals for patients with spinal cord injuries include: maximizing respiratory function, preventing injury to the spinal cord, promote mobility and/or independence, prevent or minimize complications, support psychological adjustment of patient and/or SO, and providing information about the injury, prognosis, and treatment.

Here are 12 nursing care plans (NCP) and nursing diagnosis for patients with spinal cord injury: 

  1. Risk for Ineffective Breathing Pattern
  2. Risk for Trauma
  3. Impaired Physical Mobility
  4. Disturbed Sensory Perception
  5. Acute Pain
  6. Anticipatory Grieving
  7. Situational Low Self-Esteem
  8. Constipation
  9. Impaired Urinary Elimination
  10. Risk for Autonomic Dysreflexia
  11. Risk for Impaired Skin Integrity
  12. Deficient Knowledge
  13. Other Possible Nursing Care Plans
ADVERTISEMENTS

Risk for Ineffective Breathing Pattern

Nursing Diagnosis

Risk factors may include

  • Impairment of innervation of diaphragm (lesions at or above C-5)
  • Complete or mixed loss of intercostal muscle function
  • Reflex abdominal spasms; gastric distension

Possibly evidenced by

  • [Not applicable; presence of signs and symptoms establishes an actual diagnosis.]

Desired Outcomes

  • Maintain adequate ventilation as evidenced by absence of respiratory distress and ABGs within acceptable limits
  • Demonstrate appropriate behaviors to support the respiratory effort.
Nursing InterventionsRationale
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.
Auscultate breath sounds. Note areas of absent or decreased breath sounds or development of adventitious sounds (rhonchi).Hypoventilation is common and leads to accumulation of secretions, atelectasis, and pneumonia (frequent complications). Note: Respiratory compromise is one of the leading causes of mortality, especially during the acute stage as well as later in life.
Note strength or effectiveness of cough.Level of injury determines the function of intercostal muscles and ability to cough spontaneously or move secretions.
Observe skin color for developing cyanosis, duskiness.May reveal impending respiratory failure, need for immediate medical evaluation and intervention.
Assess for abdominal distension and muscle spasm.Abdominal fullness may impede diaphragmatic excursion, reducing lung expansion and further compromising respiratory function.
Monitor and limit visitors as indicated.General debilitation and respiratory compromise place patient at increased risk for acquiring URIs.
Monitor diaphragmatic movement when phrenic pacemaker is implanted.Stimulation of phrenic nerve may enhance respiratory effort, decreasing dependency on mechanical ventilator.
Elicit concerns and questions regarding mechanical ventilation devices.Acknowledges reality of situation.
Provide honest answers.Future respiratory function needs will not be totally known until spinal shock resolves and acute rehabilitative phase is completed. Even though respiratory support may be required, alternative devices and techniques may be used to enhance mobility and promote independence.
Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated.Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient airway.
Assist patient in “taking control” of respirations as indicated. Instruct in and encourage deep breathing, focusing attention on steps of breathing.Breathing may no longer be a totally voluntary activity but require conscious effort, depending on level of injury and involvement of respiratory muscles.
Assist with coughing as indicated for level of injury (have patient take deep breath and hold for 2 sec before coughing, or inhale deeply, then cough at the end of a slow exhalation). Alternatively, assist by placing hands below diaphragm and pushing upward as patient exhales (quad cough).Adds volume to cough and facilitates expectoration of secretions or helps move them high enough to be suctioned out. Note: Quad cough procedure is generally reserved for patients with stable injuries once they are in the rehabilitation stage.
Suction as necessary. Document quality and quantity of secretions.If cough is ineffective, suctioning may be needed to remove secretions, enhance gas exchange, and reduce risk of respiratory infections. Note: “Routine” suctioning increases risk of hypoxia, bradycardia (vagal response), tissue trauma. Therefore, suctioning needs are based on inability to move secretions.
Reposition and turn periodically. Avoid and limit prone position when indicated.Enhances ventilation of all lung segments, mobilizes secretions, reducing risk of complications such as atelectasis and pneumonia. Note: Prone position significantly decreases vital capacity, increasing risk of respiratory compromise and failure.
Encourage fluids (at least 2000 mL per day).Aids in liquefying secretions, promoting mobilization and expectoration.
Measure or graph:
  • Vital capacity (VC), tidal volume (VT), inspiratory force;
Determines level of respiratory muscle function. Serial measurements may be done to predict impending respiratory failure (acute injury) or determine level of function after spinal shock phase and while weaning from ventilatory support.
  • Serial ABGs and pulse oximetry.
Documents status of ventilation and oxygenation, identifies respiratory problems such as hypoventilation (low Pao2 and elevated Paco2) and pulmonary complications.
Administer oxygen by appropriate method (nasal prongs, mask, intubation, ventilator).Method is determined by level of injury, degree of respiratory insufficiency, and amount of recovery of respiratory muscle function after spinal shock phase.
Assist with use of respiratory adjuncts (incentive spirometer, blow bottles) and aggressive chest physiotherapy (chest percussion).Preventing retained secretions is essential to maximize gas diffusion and to reduce risk of pneumonia.
Refer and consult with respiratory and physical therapists.Helpful in identifying exercises individually appropriate to stimulate and strengthen respiratory muscles and effort. For example, glossopharyngeal breathing uses muscles of mouth, pharynx, and larynx to swallow air into lungs, thereby enhancing VC and chest expansion.
ADVERTISEMENTS

ADVERTISEMENTS

Recommended Resources

Recommended nursing diagnosis and nursing care plan books and resources.

Disclosure: Included below are affiliate links from Amazon at no additional cost from you. We may earn a small commission from your purchase. For more information, check out our privacy policy.

See also

Other recommended site resources for this nursing care plan:

Other nursing care plans for musculoskeletal disorders and conditions:

Other nursing care plans related to neurological disorders:

References and Sources

Recommended references and sources for this fracture nursing care plans:

  1. Auer, R., & Riehl, J. (2017). The incidence of deep vein thrombosis and pulmonary embolism after fracture of the tibia: an analysis of the National Trauma DatabankJournal of clinical orthopaedics and trauma8(1), 38-44.
  2. Biz, C., Fantoni, I., Crepaldi, N., Zonta, F., Buffon, L., Corradin, M., … & Ruggieri, P. (2019). Clinical practice and nursing management of pre-operative skin or skeletal traction for hip fractures in elderly patients: a cross-sectional three-institution studyInternational journal of orthopaedic and trauma nursing32, 32-40.
  3. Brent, L., Hommel, A., Maher, A. B., Hertz, K., Meehan, A. J., & Santy-Tomlinson, J. (2018). Nursing care of fragility fracture patientsInjury49(8), 1409-1412.
  4. Buckley, J. (2002). Massage and aromatherapy massage: Nursing art and scienceInternational Journal of Palliative Nursing8(6), 276-280.
  5. Desnita, O., Noer, R. M., & Agusthia, M. (2021, July). Cold Compresses Effect of on Postoperative Orif Pain in Fracture Patients. In KaPIN Conference (pp. 133-140).
  6. DiFazio, R., & Atkinson, C. C. (2005). Extremity fractures in children: when is it an emergency?Journal of pediatric nursing20(4), 298-304.
  7. Griffioen, M. A., Ziegler, M. L., O’Toole, R. V., Dorsey, S. G., & Renn, C. L. (2019). Change in pain score after administration of analgesics for lower extremity fracture pain during hospitalizationPain Management Nursing20(2), 158-163.
  8. Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences. [Link]
  9. Hommel, A., Kock, M. L., Persson, J., & Werntoft, E. (2012). The Patient’s view of nursing care after hip fractureISRN nursing2012. [Link]
  10. Lin, Y. C., Lee, S. H., Chen, I. J., Chang, C. H., Chang, C. J., Wang, Y. C., … & Hsieh, P. H. (2018). Symptomatic pulmonary embolism following hip fracture: A nationwide study. Thrombosis research172, 120-127.
  11. Maher, A. B., Meehan, A. J., Hertz, K., Hommel, A., MacDonald, V., O’Sullivan, M. P., … & Taylor, A. (2012). Acute nursing care of the older adult with fragility hip fracture: an international perspective (Part 1)International Journal of Orthopaedic and Trauma Nursing16(4), 177-194.
  12. McDonald, E., Winters, B., Nicholson, K., Shakked, R., Raikin, S., Pedowitz, D. I., & Daniel, J. N. (2018). Effect of Postoperative Ketorolac Administration on Bone Healing in Ankle Fracture Surgery. Foot & Ankle International, 39(10), 1135–1140. https://doi.org/10.1177/1071100718782489
  13. McDonald, E., Winters, B., Shakked, R., Pedowitz, D., Raikin, S., & Daniel, J. (2017). Effect of Post-Operative Toradol Administration on Bone Healing After Ankle Fracture Fixation. Foot & Ankle Orthopaedics2(3), 2473011417S000288.
  14. Metsemakers, W. J., Kuehl, R., Moriarty, T. F., Richards, R. G., Verhofstad, M. H. J., Borens, O., … & Morgenstern, M. (2018). Infection after fracture fixation: current surgical and microbiological conceptsInjury49(3), 511-522.
  15. Neri, E., Maestro, A., Minen, F., Montico, M., Ronfani, L., Zanon, D., … & Barbi, E. (2013). Sublingual ketorolac versus sublingual tramadol for moderate to severe post-traumatic bone pain in children: a double-blind, randomised, controlled trial. Archives of disease in childhood98(9), 721-724.
  16. Pan, Y., Mei, J., Wang, L., Shao, M., Zhang, J., Wu, H., & Zhao, J. (2019). Investigation of the incidence of perioperative pulmonary embolism in patients with below-knee deep vein thrombosis after lower extremity fracture and evaluation of retrievable inferior vena cava filter deployment in these patientsAnnals of vascular surgery60, 45-51.
  17. Patterson, J. T., Tangtiphaiboontana, J., & Pandya, N. K. (2018). Management of pediatric femoral neck fractureJAAOS-Journal of the American Academy of Orthopaedic Surgeons26(12), 411-419.
  18. Patzakis, M. J., & Wilkins, J. (1989). Factors influencing infection rate in open fracture woundsClinical orthopaedics and related research, (243), 36-40.
  19. Resch, S., Bjärnetoft, B., & Thorngren, K. G. (2005). Preoperative skin traction or pillow nursing in hip fractures: a prospective, randomized study in 123 patientsDisability and rehabilitation27(18-19), 1191-1195.
  20. Rothberg, D. L., & Makarewich, C. A. (2019). Fat embolism and fat embolism syndromeJAAOS-Journal of the American Academy of Orthopaedic Surgeons27(8), e346-e355.
  21. Willis, L. (2019). Professional guide to diseases. Lippincott Williams & Wilkins. [Link]
  22. Wilson, D., & Hockenberry, M. J. (2014). Wong’s Clinical Manual of Pediatric Nursing-E-Book. Elsevier Health Sciences.
ADVERTISEMENTS

Matt Vera is a registered nurse with a bachelor of science in nursing since 2009 and is currently working as a full-time writer and editor for Nurseslabs. During his time as a student, he knows how frustrating it is to cram on difficult nursing topics. Finding help online is nearly impossible. His situation drove his passion for helping student nurses by creating content and lectures that are easy to digest. Knowing how valuable nurses are in delivering quality healthcare but limited in number, he wants to educate and inspire nursing students. As a nurse educator since 2010, his goal in Nurseslabs is to simplify the learning process, break down complicated topics, help motivate learners, and look for unique ways of assisting students in mastering core nursing concepts effectively.
>
28256