Nursing Care Plan for Spinal Cord Injury
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.
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.
Preserve and maintain optimal function, minimize complications.
Spinal Cord Injury Nursing Care Plan
- Loss of sensory function below the level of the injury
- Blurry vision
- Feeling hot
- Loss of motor function below the level of the injury
- Respiratory distress if high-level injury (C3-C5)
- Severe hypertension
- Increased temp
- Flushed skin
- 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
- 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.
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell