Our care plan guide to spinal cord injury and nursing diagnosis provides an in-depth understanding of the typical complications associated with this condition. It details the latest assessment and nursing intervention strategies, such as the risk for autonomic dysreflexia, impaired skin integrity, and deficient knowledge, enabling nurses to provide the most effective care and support to patients with spinal cord injury. The guide aims to promote better outcomes and a higher quality of life for patients with spinal cord injury through evidence-based strategies.
What is Spinal Cord Injury?
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, promoting mobility and/or independence, preventing or minimizing complications, supporting the psychological adjustment of patient and/or SO, and providing information about the injury, prognosis, and treatment.
Here are twelve (12) nursing care plans (NCP) and nursing diagnosis for patients with spinal cord injury:
- Risk for Ineffective Breathing Pattern
- Risk for Trauma
- Impaired Physical Mobility
- Disturbed Sensory Perception
- Acute Pain
- Situational Low Self-Esteem
- Impaired Urinary Elimination
- Risk for Autonomic Dysreflexia
- Risk for Impaired Skin Integrity
- Deficient Knowledge
Risk for Ineffective Breathing Pattern
Spinal cord injury can disrupt the normal functioning of the respiratory system, leading to ineffective breathing patterns. This can result in reduced oxygenation and ventilation, as well as an increased risk of complications such as pneumonia. Careful monitoring and intervention to optimize breathing patterns are essential to promote better patient outcomes and prevent further complications.
- Risk for Ineffective Breathing Pattern
Risk factors may include
- Impairment of innervation of the 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 for risk diagnosis. A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
- The patient will maintain adequate ventilation as evidenced by the absence of respiratory distress and ABGs within acceptable limits.
- The patient will demonstrate appropriate behaviors to support the respiratory effort.
Nursing Assessment and Rationales
1. Assess respiratory function by asking the patient to take a deep breath. Note the 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.
2. 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.
3. Note the strength or effectiveness of the cough.
Level of injury determines the function of intercostal muscles and ability to cough spontaneously or move secretions.
4. Observe skin color for developing cyanosis, and duskiness.
May reveal impending respiratory failure, need for immediate medical evaluation and intervention.
5. Assess for abdominal distension and muscle spasm.
Abdominal fullness may impede diaphragmatic excursion, reducing lung expansion and further compromising respiratory function.
6. Monitor and limit visitors as indicated.
General debilitation and respiratory compromise place patients at increased risk for acquiring URIs.
7. Monitor diaphragmatic movement when the phrenic pacemaker is implanted.
Stimulation of the phrenic nerve may enhance respiratory effort, decreasing dependency on the mechanical ventilator.
8. Measure or graph:
- 8.1. Vital capacity (VC), tidal volume (VT), inspiratory force
Determines the level of respiratory muscle function. Serial measurements may be done to predict impending respiratory failure (acute injury) or determine the level of function after the spinal shock phase and while weaning from ventilatory support.
- 8.2. 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.
Nursing Interventions and Rationales
1. Elicit concerns and questions regarding mechanical ventilation devices.
Acknowledges the reality of the situation.
2. 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.
3. Maintain patent airway: keep head in a neutral position, elevate the head of the bed slightly if tolerated, and use airway adjuncts as indicated.
Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining the patient’s airway.
4. Assist the 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 the level of injury and involvement of respiratory muscles.
5. Assist with coughing as indicated for the level of injury (have the patient take a 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.
6. Suction as necessary. Document the quality and quantity of secretions.
If the cough is ineffective, suctioning may be needed to remove secretions, enhance gas exchange, and reduce the risk of respiratory infections. Note: “Routine” suctioning increases the risk of hypoxia, bradycardia (vagal response), and tissue trauma. Therefore, suctioning needs are based on the inability to move secretions.
7. Reposition and turn periodically. Avoid and limit prone position when indicated.
Enhances ventilation of all lung segments, and mobilizes secretions, reducing the risk of complications such as atelectasis and pneumonia. Note: Prone position significantly decreases vital capacity, increasing the risk of respiratory compromise and failure.
8. Encourage fluids (at least 2000 mL per day).
Aids in liquefying secretions, promoting mobilization and expectoration.
9. Administer oxygen by an appropriate method (nasal prongs, mask, intubation, ventilator).
The method is determined by the level of injury, degree of respiratory insufficiency, and amount of recovery of respiratory muscle function after the spinal shock phase.
10. Assist with the use of respiratory adjuncts (incentive spirometer, blow bottles) and aggressive chest physiotherapy (chest percussion).
Preventing retained secretions is essential to maximize gas diffusion and reduce the risk of pneumonia.
11. 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 the mouth, pharynx, and larynx to swallow air into the lungs, thereby enhancing VC and chest expansion.
Other Possible Nursing Care Plans
Nursing diagnosis you can use to develop your care plan for spinal cord injury:
- Risk for Disuse Syndrome—paralysis/mechanical immobilization.
- Autonomic Dysreflexia—bladder/bowel distension, skin irritation, lack of caregiver knowledge.
- Self-Care deficit—neuromuscular impairment, decreased strength/endurance, pain, depression.
- Nutrition: imbalanced risk for (specify)—dysfunctional eating pattern, excessive/inadequate intake in relation to metabolic need.
- Role Performance, ineffective/Sexual dysfunction—situational crisis and transition, altered body function.
- Interrupted Family Process—situational crisis and transition.
- Caregiver Role Strain—discharge of family member with significant home care needs, situational stressors, such as significant loss, economic vulnerability; duration of caregiving required, lack of respite for caregiver, inexperience with caregiving, caregiver’s competing role commitments.
Recommended nursing diagnosis and nursing care plan books and resources.
Ackley and Ladwig’s Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care
We love this book because of its evidence-based approach to nursing interventions. This care plan handbook uses an easy, three-step system to guide you through client assessment, nursing diagnosis, and care planning. Includes step-by-step instructions showing how to implement care and evaluate outcomes, and help you build skills in diagnostic reasoning and critical thinking.
Nursing Care Plans – Nursing Diagnosis & Intervention (10th Edition)
Includes over two hundred care plans that reflect the most recent evidence-based guidelines. New to this edition are ICNP diagnoses, care plans on LGBTQ health issues and on electrolytes and acid-base balance.
NANDA International Nursing Diagnoses: Definitions & Classification, 2021-2023
The definitive guide to nursing diagnoses is reviewed and approved by the NANDA International. In this new version of a pioneering text, all introductory chapters have been rewritten to provide nurses with the essential information they need to comprehend assessment, its relationship to diagnosis and clinical reasoning, and the purpose and application of taxonomic organization at the bedside. A total of 46 new nursing diagnoses and 67 amended nursing diagnostics are presented.
Nurse’s Pocket Guide: Diagnoses, Prioritized Interventions, and Rationales
Quick-reference tool includes all you need to identify the correct diagnoses for efficient patient care planning. The sixteenth edition includes the most recent nursing diagnoses and interventions from NANDA-I 2021-2023 and an alphabetized listing of nursing diagnoses covering more than 400 disorders.
Nursing Diagnosis Manual: Planning, Individualizing, and Documenting Client Care
Identify interventions to plan, individualize, and document care for more than 800 diseases and disorders. Only in the Nursing Diagnosis Manual will you find for each diagnosis…. subjectively and objectively – sample clinical applications, prioritized action/interventions with rationales – a documentation section, and much more!
All-in-One Nursing Care Planning Resource – E-Book: Medical-Surgical, Pediatric, Maternity, and Psychiatric-Mental Health
Includes over 100 care plans for medical-surgical, maternity/OB, pediatrics, and psychiatric and mental health. Interprofessional “patient problems” focus familiarizes you with how to speak to patients.
Other recommended site resources for this nursing care plan:
- Nursing Care Plans (NCP): Ultimate Guide and Database MUST READ!
Over 150+ nursing care plans for different diseases and conditions. Includes our easy-to-follow guide on how to create nursing care plans from scratch.
- Nursing Diagnosis Guide and List: All You Need to Know to Master Diagnosing
Our comprehensive guide on how to create and write diagnostic labels. Includes detailed nursing care plan guides for common nursing diagnostic labels.
Other nursing care plans for musculoskeletal disorders and conditions:
- Amputation | 4 Care Plans
- Congenital Hip Dysplasia | 4 Care Plans
- Fracture | 11 Care Plans
- Juvenile Rheumatoid Arthritis | 4 Care Plans
- Laminectomy (Disc Surgery) | 8 Care Plans
- Osteoarthritis | 4 Care Plans
- Osteoporosis | 4 Care Plans
- Rheumatoid Arthritis | 6 Care Plans
- Scoliosis | 4 Care Plans
- Spinal Cord Injury | 12 Care Plans
- Total Joint (Knee, Hip) Replacement | 5 Care Plans
Other nursing care plans related to neurological disorders:
- Alzheimer’s Disease | 15 Care Plans
- Brain Tumor | 3 Care Plans
- Cerebral Palsy | 7 Care Plans
- Cerebrovascular Accident | 12 Care Plans
- Guillain-Barre Syndrome | 6 Care Plans
- Meningitis | 7 Care Plans
- Multiple Sclerosis | 9 Care Plans
- Parkinson’s Disease | 9 Care Plans
- Seizure Disorder | 4 Care Plans
- Spinal Cord Injury | 12 Care Plans
References and Sources
Recommended references and sources for this fracture nursing care plans:
- 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 Databank. Journal of clinical orthopaedics and trauma, 8(1), 38-44.
- 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 study. International journal of orthopaedic and trauma nursing, 32, 32-40.
- Brent, L., Hommel, A., Maher, A. B., Hertz, K., Meehan, A. J., & Santy-Tomlinson, J. (2018). Nursing care of fragility fracture patients. Injury, 49(8), 1409-1412.
- Buckley, J. (2002). Massage and aromatherapy massage: Nursing art and science. International Journal of Palliative Nursing, 8(6), 276-280.
- 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).
- DiFazio, R., & Atkinson, C. C. (2005). Extremity fractures in children: when is it an emergency?. Journal of pediatric nursing, 20(4), 298-304.
- 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 hospitalization. Pain Management Nursing, 20(2), 158-163.
- Gulanick, M., & Myers, J. L. (2016). Nursing Care Plans: Diagnoses, Interventions, and Outcomes. Elsevier Health Sciences. [Link]
- Hommel, A., Kock, M. L., Persson, J., & Werntoft, E. (2012). The Patient’s view of nursing care after hip fracture. ISRN nursing, 2012. [Link]
- 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 research, 172, 120-127.
- 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 Nursing, 16(4), 177-194.
- 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
- 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 Orthopaedics, 2(3), 2473011417S000288.
- 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 concepts. Injury, 49(3), 511-522.
- 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 childhood, 98(9), 721-724.
- 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 patients. Annals of vascular surgery, 60, 45-51.
- Patterson, J. T., Tangtiphaiboontana, J., & Pandya, N. K. (2018). Management of pediatric femoral neck fracture. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 26(12), 411-419.
- Patzakis, M. J., & Wilkins, J. (1989). Factors influencing infection rate in open fracture wounds. Clinical orthopaedics and related research, (243), 36-40.
- Resch, S., Bjärnetoft, B., & Thorngren, K. G. (2005). Preoperative skin traction or pillow nursing in hip fractures: a prospective, randomized study in 123 patients. Disability and rehabilitation, 27(18-19), 1191-1195.
- Rothberg, D. L., & Makarewich, C. A. (2019). Fat embolism and fat embolism syndrome. JAAOS-Journal of the American Academy of Orthopaedic Surgeons, 27(8), e346-e355.
- Willis, L. (2019). Professional guide to diseases. Lippincott Williams & Wilkins. [Link]
- Wilson, D., & Hockenberry, M. J. (2014). Wong’s Clinical Manual of Pediatric Nursing-E-Book. Elsevier Health Sciences.