Nursing Care Plan Spinal Cord Injury (Acute Rehabilitative Phase)

CARE SETTING

Inpatient medical/surgical and subacute/rehabilitation units.

RELATED CONCERNS

1. Disc surgery
2. Fractures
3. Pneumonia: microbial
4. Psychosocial aspects of care
5. Thrombophlebitis: deep vein thrombosis
6. Total nutritional support: parenteral/enteral feeding
7. Upper gastrointestinal/esophageal bleeding
8. Ventilatory assistance (mechanical)
9. Patient Assessment Database

ACTIVITY/REST

May exhibit: 
Paralysis of muscles (flaccid during spinal shock) at/below level of lesion
Muscle/generalized weakness (cord contusion and compression)

CIRCULATION

May report: 

1. Palpitations
2. Dizziness with position changes

May exhibit:

1. Low BP, postural BP changes, bradycardia
2. Cool, pale extremities
3. Absence of perspiration in affected area

ELIMINATION

May exhibit: 

1. Incontinence of bladder and bowel
2. Urinary retention
3. Abdominal distension; loss of bowel sounds
4. Melena, coffee-ground emesis/hematemesis

EGO INTEGRITY

May report: 
Denial, disbelief, sadness, anger

May exhibit: 
Fear, anxiety, irritability, withdrawal

FOOD/FLUID

May exhibit: 
Abdominal distension; loss of bowel sounds (paralytic ileus)

HYGIENE

May exhibit:
Variable level of dependence in ADLs

NEUROSENSORY

May report: 

1. Absence of sensation below area of injury, or opposite side sensation
2. Numbness, tingling, burning, twitching of arms/legs
3. May exhibit: Flaccid paralysis (spasticity may develop as spinal shock resolves, depending on area of cord involvement)
4. Loss of sensation (varying degrees may return after spinal shock resolves)
5. Loss of muscle/vasomotor tone
6. Loss of/asymmetrical reflexes, including deep tendon reflexes
7. Changes in pupil reaction, ptosis of upper eyelid
8. Loss of sweating in affected area

PAIN/DISCOMFORT

May report: 
Pain/tenderness in muscles
Hyperesthesia immediately above level of injury

May exhibit: 
Vertebral tenderness, deformity

RESPIRATION

May report: 
Shortness of breath, “air hunger,” inability to breathe

May exhibit: 

1. Shallow/labored respirations; periods of apnea
2. Diminished breath sounds, rhonchi
3. Pallor, cyanosis

SAFETY

May exhibit: 
Temperature fluctuations (taking on temperature of environment)

SEXUALITY

May report: 
Expressions of concern about return to normal functioning

May exhibit: 
Uncontrolled erection (priapism)
Menstrual irregularities

TEACHING/LEARNING

1. Discharge plan
2. DRG projected mean length of inpatient stay: 17.1–90 days (inclusive of inpatient rehabilitation)
3. Will require varying degrees of assistance with transportation, shopping, food preparation, self-care, finances, medications/treatment, and homemaker/maintenance tasks
4. May require changes in physical layout of home and/or placement in a rehabilitative center
5. Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES

1. Spinal x-rays: Locates level and type of bony injury (fracture, dislocation); determines alignment and reduction after traction or surgery.
2. CT scan: Locates injury, evaluates structural alterations. Useful for rapid screening and providing additional information if x-rays questionable for fracture/cord status.
3. MRI: Identifies spinal cord lesions, edema, and compression.
4. Myelogram: May be done to visualize spinal column if pathology is unclear or if occlusion of spinal subarachnoid space is suspected (not usually done after penetrating injuries).
5. Somatosensory evoked potentials (SEP): Elicited by presenting a peripheral stimulus and measuring degree of latency in cortical response to evaluate spinal cord functioning/potential for recovery.
6. Chest x-ray: Demonstrates pulmonary status (e.g., changes in level of diaphragm, atelectasis).
7. Pulmonary function studies (vital capacity, tidal volume): Measures maximum volume of inspiration and expiration; especially important in patients with low cervical lesions or thoracic lesions with possible phrenic nerve and intercostal muscle involvement.
8. ABGs: Indicates effectiveness of gas exchange and ventilatory effort.

NURSING PRIORITIES

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

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.