Nursing Care Plan for Spinal Cord Injury

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Pathophysiology

The spinal cord is the bundle of nerves that comes off of the brain stem, runs down through the vertebral column, and branches out to innervate the entire body. A spinal cord injury means that nerve impulses below that point will no longer be sent.  This includes motor and sensory impulses. Injuries to the spinal cord could be complete, in which the spinal cord is completely severed or damaged all the way through the cord. They could also be incomplete in which only a portion of the cord is damaged, such as anterior cord syndrome, central cord syndrome, and brown-sequard syndrome.

Etiology

Spinal cord injuries are most commonly caused by trauma like a motor vehicle collision or fall, but can also be caused by penetrating trauma like stabbings or gunshot wounds that penetrate the spinal column.

Desired Outcome

Preserve and maintain optimal function, minimize complications.

Spinal Cord Injury Nursing Care Plan

Subjective Data:

  • Loss of sensory function below the level of the injury

Autonomic Dysreflexia

  • Blurry vision
  • Feeling hot
  • Restless/anxious

Objective Data:

  • Loss of motor function below the level of the injury
  • Respiratory distress if high-level injury (C3-C5)

Autonomic Dysreflexia

  • Severe hypertension
  • Bradycardia
  • Increased temp
  • Flushed skin
  • Seizures

Neurogenic Shock

  • Hypotension
  • Bradycardia
  • Increased temp
  • Flushed skin

Nursing Interventions and Rationales

  • Immobilize initially with C-collar and spinal precautions (log-roll)

 

Maintain full spinal precautions until cleared by a neurosurgeon. This involves a c-collar to immobilize the neck, keeping the HOB flat, and using a strict log-roll technique for turning. Any twist or bend of the spine could cause further damage to the spinal cord.

 

  • Manage and maintain Halo brace, including pin care twice daily

 

Halo brace is used to immobilize the cervical spine with unstable vertebral fractures. Four pins are inserted into the skull – pin care should be done twice daily to prevent infection at the pin sites. A wrench should be kept at bedside to remove the vest in the case that chest compressions are needed.

 

  • Administer medications
    • Analgesics
    • Muscle Relaxants

 

Patients may experience pain from the initial trauma as well as neuropathic pain due to the nerve injuries. Muscle relaxants like cyclobenzaprine and gabapentin can also help ease any muscle spasms or nerve pain.

 

  • Encourage PT/OT, passive and active ROM

 

PT and OT can help the patient to maintain whatever functional ability they have. ROM exercises help to prevent atrophy and contractures.

 

  • Monitor hemodynamics for signs of Autonomic Dysreflexia or Neurogenic Shock

 

Neurogenic shock is a risk within the first 24-72 hours, autonomic dysreflexia is a risk any time. Both show warm, flushed skin and an elevated temperature. Neurogenic shock shows hypotension and bradycardia, while autonomic dysreflexia shows hypertension and bradycardia. Find and treat  cause of A.D. as soon as possible.

 

  • Monitor for and provide interventions to prevent complications of immobility:
    • Chest expansion exercises
    • DVT prophylaxis
    • Pad bony prominences, turn q2h

 

Immobility can lead to pneumonia, DVT/thrombophlebitis, and pressure ulcers. Monitor for signs and intervene to prevent them. Assess skin with every turn, monitoring for developing pressure ulcers (they can develop in as little as 2 hours).  

 

  • Provide resources for community support, refer to social worker for home care resources

 

Spinal cord injury patients often require many resources in the community and in their home for care, including wheelchairs, assistive devices, shower chairs, hospital beds, etc. The social worker can help to set these things up for the patient.

 


References

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