Nursing Care Plan (NCP) for Spinal Cord Injury

Join NURSING.com to watch the full lesson now.

Included In This Lesson

Study Tools

Outline

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.

Writing a Nursing Care Plan (NCP) for Spinal Cord Injury

A Nursing Care Plan (NCP) for Spinal Cord Injury starts when at patient admission and documents all activities and changes in the patient’s condition. The goal of an NCP is to create a treatment plan that is specific to the patient. They should be anchored in evidence-based practices and accurately record existing data and identify potential needs or risks.


References

Join NURSING.com to watch the full lesson now.

Transcript

Hey guys, today, we’re going to take a look at the care plan for a spinal cord injury. In this lesson, we’ll briefly take a look at the pathophysiology and etiology of a spinal cord injury. We’ll also take a look at additional things like subjective and objective data that your patient with this issue may present with, and also any nursing interventions and the rationale for those interventions. 

 

Let’s jump in. The spinal cord is a bundle of nerves that come off of the brainstem. They run down through the vertebral column and innervate the entire body. Basically when there is an injury to the spinal cord, nerve impulses below the point of injury will no longer be scent. This includes motor and sensory impulses. Spinal cord injuries are most commonly caused by trauma, like a motor vehicle accident or a fall, but they also can be caused by a penetrating trauma, like a stabbing or even a gunshot wound, so anything that penetrates the spinal column. The goal or desired outcome is to preserve and maintain optimal function and minimize any complications of the injury. 

 

Let’s take a look at some of the subjective data that your patient with a spinal cord injury may present with. Remember, subjective data are going to be things that are based on your patient’s opinions or feelings. These things might include loss of sensory function below the level of the injury. Also, autonomic dysreflexia symptoms, which are common with spinal cord injuries include blurry vision, feeling hot, or being restless or anxious. 

 

Objective or measurable data, which you may see in this patient includes loss of motor function below the level of the injury. Also respiratory distress, especially if the injury is high between C3 and C5, and autonomic dysreflexia. Other objective data includes severe hypertension, bradycardia, increased temp, flush skin, and even seizures. Neurogenic shock could also occur and with this, we would see hypotension, bradycardia, increased temp, and flushed skin. 

 

Let’s take a look at some of the nursing interventions necessary when caring for a patient with a spinal cord injury. Immobilizing the patient and maintaining full spinal precautions until the patient is cleared by a neurosurgeon is critical. This includes placing a C-collar to immobilize the neck, keeping the head of the bed flat and using a strict log roll technique for any turning, because any twist or bend of the spine could create further damage. A halo brace is used to immobilize the cervical spine with unstable or tibial fractures. With this, four pins are inserted into the skull and Pin care must be completed twice daily to prevent or protect from infections at the pin site. Also guys, a wrench should be kept at the bedside in case the halo vest needs to be removed for chest compressions. 

 

So as far as medication administration is concerned, analgesics and muscle relaxants are common to be used because of the pain that the patient experiences from the initial trauma, as well as from any neuropathic pain due to nerve injuries. Muscle relaxants like cyclobenzaprine and also Gabapentin can also help to ease any muscle spasms or nerve pain. PT and OT can help to maintain whatever functionality remains, and also passive and active range of motion can help prevent atrophy and even contractures. Monitoring hemodynamics is important to recognize signs of autonomic dysreflexia or neurogenic shock. Neurogenic shock is a risk that we see within the first 24 to 72 hours, but autonomic dysreflexia can actually occur at any time. Both of these complications show warm/ flush skin and an elevated temperature. However, neurogenic shock shows hypotension and bradycardia, while autonomic dysreflexia shows hypertension and bradycardia. We must monitor and provide for any interventions to prevent complications of immobility, which can lead to pneumonia, DVT, or thrombophlebitis and pressure ulcers. You’re going to want to assess the skin with every turn, monitoring for developing pressure ulcers, which can develop in as little as two hours. That’s super important. Spinal cord injury patients often require resources within the community and also in their home. For care, these things could include wheelchairs, assisted devices, shower chairs, hospital beds, anything like that. We want to include the social worker to set these things up for the patient.

 

Okay guys, here is a look at the completed care plans for spinal cord injuries. Alright, let’s do a quick review. The spinal cord contains a bundle of nerves, which come off of the brainstem and innervate the body. When an injury occurs to the spinal cord, impulses will not be sent below the level of injury, including sensory and motor impulses. Subjective data includes loss of sensory function, autonomic dysreflexia, there’ll be blurry vision, they’ll be hot and restless. Objective data includes loss of motor function with autonomic dysreflexia, severe hypertension and bradycardia, but with neurogenic shock hypotension and bradycardia.  Analgesics and muscle relaxants will be administered, and PT and OT should be encouraged. Monitor hemodynamics closely for signs of autonomic dysreflexia or neurogenic shock. Prevent complications of immobility like contractures and pressure ulcers. Prevent further damage with the use of a C-collar, keeping the head of the bed flat and log rolling the patients, and also providing necessary community resources and services. 

 

That’s it for this lesson on the care plan for spinal cord injuries. We love you guys. Now, go out and be your best self today and as always, happy nursing!

 

Join NURSING.com to watch the full lesson now.