Spinal cord injury (SCI) is a devastating condition that disrupts the spinal cord’s ability to transmit nerve signals between the brain and the body. Protected by the meninges and vertebral column, the spinal cord is vulnerable to damage from trauma, compression, and various other insults. SCI can lead to permanent neurological deficits, significantly impacting motor, sensory, and autonomic functions depending on the injury’s level and severity. Understanding the complexities of SCI and implementing effective nursing care plans are crucial for optimizing patient outcomes and quality of life.
Understanding Spinal Cord Injury
Spinal cord injury occurs when there is damage to the spinal cord, often resulting from a sudden, forceful impact. Traumatic injuries, such as those from motor vehicle accidents, falls, sports injuries, and violence, are the most common causes. Non-traumatic causes include tumors, infections, vascular malformations, and degenerative conditions that can compress or damage the spinal cord.
The areas of the vertebral column most frequently affected by SCI are:
- Cervical (C5, C6, C7): Injuries in the neck region.
- Thoracic (T12): Injuries in the upper back.
- Lumbar (L1): Injuries in the lower back.
The severity of SCI is classified into two main categories:
Complete SCI:
- Complete SCI involves a total loss of motor and sensory function below the level of injury. This is typically due to significant spinal cord contusion, bruising, or disruption of blood supply.
- Function is lost bilaterally, affecting both sides of the body equally.
- Complete injuries can result in paraplegia (paralysis of the lower body and legs) or quadriplegia (tetraplegia, paralysis affecting all four limbs).
Incomplete SCI:
- Incomplete SCI means that some motor or sensory function is preserved below the level of injury.
- There is still some degree of communication between the brain and body below the injury level.
- Individuals with incomplete SCI may present with varying patterns of function, such as greater weakness in one limb compared to another, or better function on one side of the body.
Accurate diagnosis and classification are essential for guiding treatment and rehabilitation. A thorough neurological examination, using tools like the American Spinal Injury Association (ASIA) Impairment Scale, is crucial for assessing motor and sensory function. Imaging studies, including CT scans to detect fractures and MRI to evaluate soft tissue and spinal cord damage, are vital for determining the extent and nature of the injury.
The Nursing Process in Spinal Cord Injury Care
The nursing process is a systematic approach to patient care and is particularly critical in managing spinal cord injuries. It involves assessment, diagnosis, planning, implementation, and evaluation. For patients with SCI, immediate and ongoing nursing care is vital for stabilization, preventing complications, and promoting rehabilitation.
Assessment:
The initial assessment of a patient with a suspected SCI is paramount. This includes:
- Rapid Neurological Assessment: Evaluating motor and sensory function to determine the level and extent of injury. This involves testing muscle strength, sensation to light touch, pinprick, proprioception, and vibration in all extremities and dermatomes.
- Respiratory Assessment: Assessing airway, breathing, and oxygenation. Cervical and high thoracic injuries can impair respiratory muscle function, leading to ineffective breathing patterns. Monitor respiratory rate, depth, rhythm, oxygen saturation, and breath sounds.
- Cardiovascular Assessment: SCI can disrupt autonomic nervous system function, leading to neurogenic shock, characterized by hypotension and bradycardia. Monitor blood pressure, heart rate, and peripheral perfusion.
- Skin Assessment: Patients with SCI are at high risk for pressure injuries due to immobility and sensory loss. Regularly assess skin integrity, especially over bony prominences.
- Bowel and Bladder Assessment: SCI often results in bowel and bladder dysfunction. Assess for urinary retention, incontinence, constipation, and bowel impaction.
- Pain Assessment: SCI can cause various types of pain, including nociceptive pain (musculoskeletal) and neuropathic pain (nerve damage). Assess pain characteristics, location, intensity, and aggravating/relieving factors.
- Psychosocial Assessment: SCI has profound psychological and emotional impacts. Assess the patient’s emotional state, coping mechanisms, support system, and risk for depression, anxiety, and low self-esteem.
Nursing Diagnosis:
Based on the assessment findings, nurses formulate nursing diagnoses to identify patient problems and guide care planning. Common nursing diagnoses for patients with SCI include:
- Ineffective Breathing Pattern
- Self-Care Deficit
- Situational Low Self-Esteem
- Risk for Impaired Skin Integrity
- Impaired Urinary Elimination
- Constipation
- Acute Pain/Chronic Pain
- Risk for Autonomic Dysreflexia (for injuries at or above T6)
- Risk for Infection
- Impaired Physical Mobility
Planning:
Care planning involves setting patient-centered goals and outcomes and developing nursing interventions to achieve them. Plans are individualized based on the patient’s specific needs, level of injury, and overall condition.
Implementation:
Implementation involves carrying out the planned nursing interventions. This includes providing direct care, educating the patient and family, coordinating with other healthcare professionals, and advocating for the patient’s needs.
Evaluation:
Evaluation is an ongoing process to assess the effectiveness of nursing interventions and the patient’s progress toward achieving the set goals. The care plan is revised as needed based on the evaluation findings.
Nursing Care Plans for Spinal Cord Injury
The following are examples of nursing care plans for common nursing diagnoses associated with spinal cord injuries.
Ineffective Breathing Pattern
Ineffective breathing patterns are a significant concern in SCI, particularly with cervical and high thoracic injuries. Weakness or paralysis of respiratory muscles, impaired cough reflex, and decreased lung volumes contribute to this problem.
Nursing Diagnosis: Ineffective Breathing Pattern
Related Factors:
- Cervical spinal cord injury
- Thoracic spinal cord injury
- Respiratory muscle paralysis/weakness
- Impaired diaphragm function
- Decreased lung volumes and capacities
- Weak cough reflex
- Pain
Evidenced By:
- Dyspnea, shortness of breath
- Changes in respiratory rate, rhythm, and depth (tachypnea, bradypnea, shallow breathing)
- Use of accessory muscles of respiration
- Paradoxical chest wall movement
- Decreased oxygen saturation (SpO2 < 95%)
- Adventitious breath sounds (wheezes, crackles)
- Changes in arterial blood gases (ABGs)
- Ineffective cough or inability to cough
Desired Outcomes:
- Patient will maintain a respiratory rate and rhythm within the expected range (12-20 breaths per minute) and appropriate for their condition.
- Patient will maintain oxygen saturation levels of 95% or greater, or within their baseline.
- Patient will demonstrate clear breath sounds bilaterally.
- Patient will effectively clear secretions as evidenced by a strong cough and clear airway.
- Patient will demonstrate understanding of techniques to optimize breathing and prevent respiratory complications.
Nursing Assessments and Rationales:
- Determine causative and contributing factors: SCI level and completeness dictate the degree of respiratory compromise. Non-traumatic causes like tumors or infections may also contribute to respiratory dysfunction.
- Monitor respiratory rate, rhythm, depth, and effort every 1-2 hours and PRN: Early detection of changes in respiratory status is critical for timely intervention.
- Auscultate breath sounds before and after interventions: Assesses air movement in all lung fields and identifies adventitious sounds indicating respiratory problems.
- Continuously monitor oxygen saturation using pulse oximetry: Provides non-invasive monitoring of oxygenation status.
- Assess cough effectiveness and ability to clear secretions: A weak or ineffective cough increases the risk of secretion retention and respiratory infections.
- Monitor arterial blood gases (ABGs) as ordered: Provides objective data on oxygenation, ventilation, and acid-base balance.
- Assess spirometry, maximal inspiratory pressure (MIP), and peak cough flow as indicated: Provides objective measurements of lung function and respiratory muscle strength.
- Evaluate patient’s level of anxiety and fear related to breathing difficulties: Hypoxia can cause anxiety, and psychological factors can exacerbate respiratory distress.
Nursing Interventions and Rationales:
- Maintain a patent airway: Position the patient to optimize airway patency (e.g., semi-Fowler’s position if tolerated and not contraindicated). Use airway adjuncts as needed. Suction secretions PRN.
- Administer supplemental oxygen as ordered: To maintain adequate oxygenation and treat hypoxemia.
- Encourage deep breathing and coughing exercises every 1-2 hours while awake: Promotes lung expansion, mobilization of secretions, and prevents atelectasis and pneumonia.
- Assist with or provide chest physiotherapy (CPT) as ordered: CPT, including percussion, vibration, and postural drainage, helps mobilize and remove secretions from the airways.
- Utilize mechanical cough assist device as indicated: For patients with a weak cough, mechanical cough assist can augment expiratory flow and help clear secretions.
Mechanical cough assist device to stimulate cough.
- Administer bronchodilators and mucolytics as prescribed: Bronchodilators open airways, and mucolytics thin secretions, facilitating easier breathing and secretion clearance.
- Prepare for and assist with intubation and mechanical ventilation if respiratory distress worsens or ABGs deteriorate: Mechanical ventilation may be necessary to support breathing in patients with severe respiratory muscle weakness or failure.
- Provide emotional support and reassurance to reduce anxiety associated with dyspnea: Anxiety can worsen breathing difficulties. Calm reassurance and relaxation techniques can be helpful.
- Educate the patient and family on breathing exercises, secretion management techniques, and signs and symptoms of respiratory complications: Empowers patients and families to participate in care and recognize early warning signs.
- Implement infection prevention measures: Prevent pneumonia by encouraging frequent position changes, promoting adequate hydration, and meticulous oral care.
Self-Care Deficit
SCI often leads to significant physical limitations, resulting in self-care deficits. Paralysis, muscle weakness, and impaired mobility affect the ability to perform activities of daily living (ADLs).
Nursing Diagnosis: Self-Care Deficit (Specify area: Bathing/Hygiene, Dressing/Grooming, Feeding, Toileting)
Related Factors:
- Muscle weakness and paralysis
- Impaired mobility
- Decreased strength and endurance
- Pain
- Sensory deficits
- Cognitive or perceptual impairments
Evidenced By:
- Stated inability to perform self-care tasks
- Requires assistance with bathing, dressing, feeding, toileting
- Unable to wash body parts
- Unable to manage clothing
- Unable to feed self
- Unable to get to and use the toilet
Desired Outcomes:
- Patient will participate in self-care activities to the maximum extent possible given their abilities.
- Patient will identify personal strengths and resources to assist with self-care.
- Patient will utilize adaptive equipment and assistive devices to enhance independence in self-care.
- Patient will express satisfaction with their level of participation in self-care.
- Patient/caregiver will demonstrate safe and effective techniques for providing or assisting with self-care.
Nursing Assessments and Rationales:
- Assess the patient’s current functional abilities and limitations in each area of self-care (bathing, dressing, feeding, toileting): Identifies specific areas where the patient requires assistance and the extent of the deficit.
- Determine the level of assistance required for each self-care activity (total assistance, partial assistance, supervision, independent with assistive devices): Guides the planning of appropriate interventions and resource allocation.
- Assess muscle strength, range of motion, coordination, and sensation: These physical factors directly impact the patient’s ability to perform self-care tasks.
- Evaluate the patient’s perception of their self-care abilities and needs: Patient perception influences motivation and participation in rehabilitation and self-care activities.
- Identify barriers to participation in self-care activities (physical, psychological, environmental, financial): Addressing barriers is crucial for promoting patient independence and maximizing self-care abilities.
- Assess the availability of support systems and resources (family, caregivers, home health services, assistive devices): Support systems and resources are essential for successful self-care management, especially after discharge.
Nursing Interventions and Rationales:
- Provide assistance with self-care activities as needed, while encouraging maximum patient participation: Balances patient safety and hygiene with promoting independence and self-esteem.
- Adapt the environment and use assistive devices to promote independence (e.g., long-handled bath sponge, reacher, plate guard, wheelchair, raised toilet seat): Adaptive equipment compensates for physical limitations and enhances the patient’s ability to perform self-care tasks.
- Break down self-care tasks into smaller, manageable steps: Simplifying tasks makes them less overwhelming and increases the patient’s sense of accomplishment.
- Allow sufficient time for the patient to perform self-care activities: Patients with SCI may require more time to complete tasks due to physical limitations. Avoid rushing to foster independence and reduce frustration.
- Teach the patient and caregivers techniques for safe and effective self-care, including proper body mechanics and use of assistive devices: Education empowers patients and caregivers to manage self-care safely and effectively at home.
- Collaborate with occupational therapy (OT) and physical therapy (PT) to develop a comprehensive rehabilitation plan focused on self-care skills: OT and PT specialists are essential for assessing, training, and recommending adaptive equipment to improve self-care abilities.
- Provide positive reinforcement and encouragement for patient efforts and progress in self-care: Positive feedback enhances self-esteem and motivates continued effort in rehabilitation.
- Promote patient decision-making and control over self-care routines: Giving patients choices and control fosters a sense of autonomy and dignity.
- Refer to home health services and community resources as needed: Ensures continuity of care and access to necessary support after discharge.
Adaptive equipment aids in self-care for SCI patients.
Situational Low Self-Esteem
The physical changes and functional limitations resulting from SCI can significantly impact a patient’s self-esteem and body image. Loss of body functions, changes in physical abilities, and perceived loss of identity contribute to feelings of low self-worth.
Nursing Diagnosis: Situational Low Self-Esteem
Related Factors:
- Changes in body image and physical appearance
- Functional impairments and dependence on others
- Role changes and loss of previous roles
- Feelings of helplessness and loss of control
- Social isolation and decreased social involvement
- Pain and discomfort
- Prolonged hospitalization or rehabilitation
Evidenced By:
- Negative self-talk and self-deprecating statements
- Feelings of worthlessness, hopelessness, and helplessness
- Expressions of shame, guilt, or embarrassment related to their condition
- Withdrawal from social interactions
- Decreased participation in care or rehabilitation activities
- Poor eye contact, slumped posture
- Difficulty making decisions or setting goals
- Loss of interest in usual activities
Desired Outcomes:
- Patient will verbalize positive self-statements and express feelings of self-worth.
- Patient will actively participate in care planning and decision-making.
- Patient will engage in social interactions and support systems.
- Patient will demonstrate improved body image and acceptance of their physical changes.
- Patient will set realistic goals and demonstrate progress toward achieving them.
- Patient will utilize healthy coping mechanisms to manage feelings of low self-esteem.
Nursing Assessments and Rationales:
- Assess the patient’s self-concept, self-esteem, and body image: Identifies the patient’s perception of self-worth and how SCI has impacted their self-view.
- Observe verbal and nonverbal cues indicating low self-esteem (e.g., negative self-talk, withdrawal, poor posture): Provides insight into the patient’s emotional state and self-perception.
- Explore the patient’s feelings about their physical changes, functional limitations, and dependence on others: Understanding the patient’s specific concerns is crucial for developing targeted interventions.
- Assess the patient’s coping mechanisms and support systems: Identifies strengths and resources that can be utilized to enhance self-esteem and resilience.
- Evaluate the patient’s cultural and religious beliefs and their influence on self-perception: Cultural and spiritual beliefs can significantly impact how individuals perceive and cope with illness and disability.
- Screen for suicidal ideation and assess risk for depression and anxiety: Low self-esteem is a risk factor for depression and suicide. Early identification and intervention are critical.
Nursing Interventions and Rationales:
- Establish a therapeutic nurse-patient relationship based on trust, empathy, and respect: A supportive relationship is foundational for fostering positive self-esteem and open communication.
- Encourage the patient to verbalize feelings and concerns without judgment: Provides a safe space for emotional expression and validation of feelings.
- Actively listen and validate the patient’s feelings of loss, grief, and frustration: Acknowledging and validating emotions helps the patient feel understood and supported.
- Help the patient identify personal strengths, accomplishments, and positive attributes: Focusing on strengths counteracts negative self-perception and promotes self-worth.
- Provide positive feedback and reinforcement for patient efforts and progress in rehabilitation and self-care: Positive reinforcement boosts self-esteem and motivates continued effort.
- Encourage patient involvement in care planning and decision-making: Promotes a sense of control and autonomy, enhancing self-esteem.
- Facilitate peer support and connection with others who have experienced SCI: Peer support groups provide validation, encouragement, and practical advice from those with shared experiences.
- Promote activities that enhance self-esteem and sense of accomplishment (e.g., adaptive sports, hobbies, vocational rehabilitation): Engagement in meaningful activities fosters a sense of purpose and self-worth.
- Refer to mental health professionals (psychologist, counselor, psychiatrist) as needed: Professional counseling can provide specialized support for managing low self-esteem, depression, and anxiety.
- Educate the patient and family about the psychological impact of SCI and strategies for coping and building self-esteem: Education empowers patients and families to understand and address the emotional challenges of SCI.
Conclusion
Nursing care plans are essential tools for guiding and individualizing care for patients with spinal cord injuries. By addressing key nursing diagnoses such as ineffective breathing pattern, self-care deficit, and situational low self-esteem, nurses play a critical role in optimizing patient outcomes, preventing complications, and promoting rehabilitation. A comprehensive, patient-centered approach that integrates physical, psychological, and social aspects of care is vital to helping individuals with SCI achieve their highest possible level of function and quality of life. Continuous assessment, evidence-based interventions, and ongoing evaluation are fundamental to the nursing process in SCI management, ensuring that care remains responsive to the evolving needs of these complex patients.
References
- American Association of Neurological Surgeons. (2022). Spinal cord injury – Types of injury, diagnosis and treatment. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Spinal-Cord-Injury
- Cleveland Clinic. (2022). Spinal cord injury: Types, symptoms, causes & treatment. https://my.clevelandclinic.org/health/diseases/12098-spinal-cord-injury
- Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
- Joe Bennett, J., Das, J. M., & Emmady., P. D. (2022). Spinal cord injuries – StatPearls – NCBI bookshelf. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK560721/
- Johns Hopkins Medicine. (2021). Acute spinal cord injury. Johns Hopkins Medicine Baltimore, Maryland. https://www.hopkinsmedicine.org/health/conditions-and-diseases/acute-spinal-cord-injury
- Mayo Clinic. (2021). Spinal cord injury – Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/symptoms-causes/syc-20377890
- Silvestri, L. A., & Silvestri, A. E. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
- World Health Organization (WHO). (2013). Spinal cord injury. https://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury
