The spinal cord is enclosed and safeguarded by layers of tissue known as the meninges and a column of vertebrae (spinal bones). It is responsible for transmitting nerve signals from the brain to the rest of the body. Damage that occurs to the spinal cord is called a spinal cord injury (SCI).
An SCI may be temporary or permanent and life-threatening. Depending on the level of injury, motor, sensory, and autonomic functions may be lost. An SCI may occur from traumatic causes like motor vehicle accidents or nontraumatic causes, such as tumors or infections.
In this article:
- Anatomy
- Types of Spinal Cord Injuries
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Ineffective Breathing Pattern
- Ineffective Thermoregulation
- Self-Care Deficit
- Situational Low Self-Esteem
Anatomy
The spinal cord is divided into regions by their corresponding vertebrae and spinal nerves. Each segment is responsible for specific bodily functions:
- Cervical spine (nerves C1-C7): Control the head, neck, upper body, and diaphragm. Injuries at this level may affect breathing.
- Thoracic spine (nerves T1-T12): Control the chest muscles, some back muscles, the abdomen, and muscles used for breathing.
- Lumbar spine (nerves L1-L5): Control the lower abdomen, buttocks, genitals, and upper legs.
- Sacral spine (nerves S1-S5): Control the thighs, lower legs, feet, and muscles needed for bowel and bladder control.
Types of Spinal Cord Injuries
The severity of an SCI depends on whether the injury is complete or incomplete.
A complete SCI results in complete loss of function and sensation below the level of injury.
This includes paraplegia (paralysis of the lower body) or quadriplegia (paralysis of all four limbs).
An incomplete SCI means some function below the level of injury is still present. There is a greater potential for recovery with this type of SCI.
Nursing Process
At the scene of an SCI, immobilization by witnesses or emergency personnel is vital to prevent further injury. Nurses play a key role in monitoring and providing supportive care to prevent secondary injuries and complications. Physical rehabilitation is a crucial component of healing, and for some patients, intensive rehabilitation therapy may be necessary.
An SCI can be life-changing and emotionally distressing for the patient and their family. The nurse can coordinate or refer the patient to mental health services to learn to cope with feelings of anxiety, depression, isolation, and body image issues.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to a spinal cord injury.
Review of Health History
1. Assess the patient’s general symptoms.
Symptoms of an SCI may be permanent or temporary and correspond to the level of injury. After stabilization of the airway and circulation, the patient may report sensory or motor function abnormalities, such as:
- Difficulty coughing or breathing
- Loss of movement
- Pain and numbness
- Muscle spasms
- Difficulty performing ADLs
- Loss of bladder or bowel control
- Sexual dysfunction
2. Identify the cause.
Most SCIs result from a traumatic cause, such as:
- Motor vehicle accidents (most common cause)
- Falls
- Violence (gunshot or stab wounds)
- Sports-related injuries
- Workplace injuries
Nontraumatic causes directly compress the spinal cord or narrow the spinal column and include:
- Tumors
- Infections
- Degenerative spinal changes like degenerative cervical myelopathy
- Chronic conditions like osteoporosis
- Autoimmune disorders like multiple sclerosis
- Congenital spinal conditions like spina bifida
3. Determine the patient’s risk factors.
Certain risk factors increase the incidence of an SCI:
- Age (between the ages of 16 and 30 or after age 65)
- Male gender (80% of SCIs occur in males)
- Alcohol use
- Risky behaviors (diving into shallow water, not wearing a seatbelt)
Physical Assessment
1. Assess the ABCs of life.
Immediately assess the airway, breathing, and circulation to determine the urgency of the patient’s condition. Place the patient in a cervical collar and use a logrolling technique to maintain a neutral spine to examine the head, neck, and spine.
2. Perform a respiratory evaluation.
The nurse should promptly assess the patient’s respiratory rate, depth, and rhythm. Examine the chest wall for injuries. Assess the patient’s ability to cough, as an absent or ineffective cough is associated with a higher level of injury. Obtain ABGs and pulse oximetry to determine hypoxia.
3. Assess the neurological status.
The nurse can assist with assessing sensations, motor function, and reflexes. Sensory testing uses light touch and a pinprick at specific areas to determine if the patient can feel and differentiate between the sensations. Motor strength is assessed with the patient supine and is graded from 0 to 5. The rectal area must also be examined to determine if the sacral region is affected.
4. Monitor the vital signs.
In an SCI, autonomic pathways are disrupted. Tachycardia that results from hemorrhage may be absent. If hypotension occurs, assess for sources of internal bleeding. If hemorrhage is ruled out, neurogenic shock is the most likely cause.
5. Remain aware of symptoms in chronic conditions.
Causes such as cancer, infection, or degenerative changes may present with gradual symptoms like persistent back or neck pain, stiffness, limited mobility, and paresthesias. In later stages, symptoms become more severe and include loss of grasp, ambulation, and bowel and bladder control.
Diagnostic Procedures
1. Prepare the patient for imaging scans.
CT scans are the most reliable imaging modality to identify spinal cord injuries. MRIs are most useful for detecting lesions, abscesses, tumors, or contusions to the spinal cord.
2. Obtain blood samples for testing.
Laboratory tests, such as ABGs, lactate levels, and hemoglobin/hematocrit, may be useful for assessing respiratory abnormalities, shock, and blood loss.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient suffering from a spinal cord injury.
Acute Stabilization After Spinal Cord Injury
1. Manage the airway.
Keep the cervical spine in a neutral position and immobilize the patient to prevent further neurologic injury. Avoid turning or bending the neck. Maintain the patient’s airway through jaw thrust maneuver and oral airway insertion. Prepare for possible intubation if respiratory distress occurs. A tracheostomy may be necessary if long-term ventilation is expected.
2. Treat signs of shock or hemorrhage.
Fractures or trauma can result in hemorrhage that requires stabilization through fluid and blood transfusions. If hemorrhage is ruled out, hypotension from neurogenic shock is managed through IV fluid replacement and vasopressors.
3. Prepare the patient for surgery.
Surgery decompresses the spinal cord and may improve neurological outcomes. Following surgery, the patient may continue to require a cervical collar, traction, or other devices to maintain spinal alignment. Ensure the patient adheres to activity restrictions.
Reduce and Manage Complications
1. Perform frequent neurological evaluations.
The nurse should monitor for any deterioration in the hours and days following an SCI. Sensory deterioration that progresses toward the upper body/head is the first sign of this.
2. Reduce the risk of aspiration.
Respiratory complications are common with an SCI and a significant cause of death. Monitor for weak or absent coughing, increased work of breathing, and adventitious lung sounds. An NG tube or frequent suctioning may be necessary to prevent aspiration.
3. Prepare for bowel and bladder complications.
Patients with an SCI may experience neurogenic bowel or bladder dysfunction, causing ileus or retention. Insert a urinary catheter to monitor urine output and administer laxatives or stool softeners as needed.
4. Prevent deep vein thrombosis.
Nerve damage may affect blood flow, increasing the risk of blood clots. The patient’s immobility is another major contributor. Anticoagulants like enoxaparin and compression stockings should be implemented as soon as it is safe to do so.
5. Monitor for autonomic dysreflexia.
SCIs can result in a potentially life-threatening condition called autonomic dysreflexia (AD). This complication may occur within several months after SCI in patients with an injury at the level of T6 or higher. AD is triggered by painful or irritating stimuli, like bladder distension or tight clothing. Teach the patient and caregivers about AD signs and symptoms to watch for, such as:
- Flushing
- Sweating
- A pounding headache
- Anxiety
- An abrupt spike in blood pressure
- Changes in vision
- Piloerection (goosebumps)
The immediate action with AD is to sit the patient upright to reduce the blood pressure and locate the underlying cause.
6. Prevent skin breakdown.
Patients with decreased or absent sensations or who are paralyzed are at an increased risk for pressure injuries. Turn the patient frequently, utilize alternating pressure mattresses, and ensure that medical equipment, clothing, and bedding do not place excess pressure on the skin.
7. Manage pain.
Neuropathic pain (severe burning or tingling) and muscle spasticity are common for patients after an SCI. Offer interventions to manage pain, such as:
- Medication
- NSAIDs
- Muscle relaxants
- Anticonvulsants
- Antidepressants
- Opioids
- Acupuncture
- Massage
- Transcutaneous electrical nerve stimulation (TENS)
Recovery and Coping Strategies
1. Collaborate with rehabilitation services.
Long-term rehabilitation is essential for many patients after an SCI to optimize recovery and quality of life. Physical and occupational therapists help enhance mobility through exercise programs and the use of adaptive equipment.
2. Assist the patient and family with a life-changing diagnosis.
An SCI can result in permanent damage to the patient’s mobility, affecting their ability to work, live independently, or care for themselves. It’s common for the patient to experience depression, anxiety, and grief in relation to these changes. Refer the patient and family members to local support groups and community resources that can assist them with coping.
3. Coordinate resources.
The nurse case manager can connect the patient with resources to help them navigate medical, social, financial, and vocational challenges. The patient may require home health services, medical or assistive equipment, transportation, and more.
Nursing Care Plans
Once the nurse identifies nursing diagnoses for spinal cord injuries, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for spinal cord injuries.
Autonomic Dysreflexia
Autonomic dysreflexia occurs when the body reacts to an unpleasant stimulus, such as pain or pressure, below the level of the spinal cord injury, resulting in a sympathetic nervous system reflex.
Nursing Diagnosis: Autonomic Dysreflexia
Related to:
- Constipation/Fecal impaction
- Urinary retention
- Urinary tract infection
- Skin irritation
- Pressure ulcers/Wounds
- Muscle spasms
- Tight clothing
- Improper positioning
- Sexual intercourse
As evidenced by:
- Headache
- Blurred vision
- Nasal congestion
- Flushing
- Chills
- Tachycardia
- Bradycardia
- Hypertension
- Diaphoresis above the injury
Expected outcomes:
- Patient will maintain vital signs within normal range.
- Patient or caregiver will verbalize the triggers of autonomic dysreflexia.
Assessment:
1. Assess for signs and symptoms of autonomic dysreflexia.
About 85% of patients with an SCI at the level of T6 and above will experience AD. If the patient exhibits an abrupt increase in blood pressure and other symptoms, such as headache, flushing, and tachycardia, suspect AD.
2. Assess and monitor blood pressure every 3-5 minutes.
Frequent monitoring of the patient’s blood pressure is essential as the nurse attempts to locate and resolve the irritating stimuli. The nurse will then need to monitor for rebound hypotension after implementing interventions.
3. Monitor for cardiac arrhythmias.
Patients experiencing a hypertensive crisis are at risk for dysrhythmias, myocardial infarction, seizures, and death.
Interventions:
1. Immediately place the patient in a high Fowler’s position.
This will help lower blood pressure by promoting venous pooling in the lower extremities.
2. Check for urinary or bowel issues.
Urinary issues are the most common cause of AD. Assess for urinary distension and catheterize if needed. If the patient has a catheter, ensure it is not kinked. Next, assess when the patient last had a bowel movement or check for fecal impaction.
3. Administer antihypertensives.
If the systolic BP remains at 150 mmHg, antihypertensives should be administered. Nitrates and nifedipine are commonly ordered.
4. Encourage the patient to carry a medical alert card.
A medical alert card can alert medical providers to the patient’s risk for AD and aid in the prompt recognition and treatment of symptoms.
5. Instruct on the prevention of AD.
Educate caregivers to prevent episodes of AD by ensuring the patient receives routine bladder and bowel care, nail and skin care, and is turned and repositioned frequently to prevent skin breakdown.
Ineffective Breathing Pattern
Ineffective breathing patterns associated with spinal cord injury can be related to weakness or paralysis of respiratory muscles and impaired coughing reflexes.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Cervical spinal cord injury
- Thoracic spinal cord injury
- Decreased lung volumes
- Weak cough reflex
- Diaphragm muscle weakness
- Impaired diaphragm function
- Respiratory muscle paralysis
As evidenced by:
- Paradoxical or unequal chest wall movement
- Irregular breathing pattern
- Breathlessness
- Alterations in oxygen saturation
- Alterations in respiratory rate
- Alterations in respiratory rhythm
- Alterations in respiratory depth
- Changes in arterial blood gas
- Use of accessory muscles
Expected outcomes:
- Patient will demonstrate a respiratory rate and rhythm within expected limits.
- Patient will maintain an oxygen saturation of 95-100%.
- Patient will demonstrate clear breath sounds.
- Patient will demonstrate effective coughing.
Assessment:
1. Assess for respiratory symptoms.
The priority of an SCI is to maintain the airway and breathing. Symptoms of an inefficient breathing pattern include irregular breathing, dyspnea, shallow or rapid breaths, and diminished breath sounds upon auscultation, which signifies a need for emergency actions.
2. Assess spirometry.
Spirometry can be performed routinely at the bedside and offers actual results on the vital capacity and any airflow blockage to determine the patient’s lung function.
3. Check the patient’s muscle strength.
Take muscle strength measurements at the bedside. Maximal inspiratory pressure (MIP) and nasal inspiratory pressure are the most accurate noninvasive indicator of functional respiratory muscle strength.
4. Assess the patient’s coughing abilities.
Peak cough flow can be regularly measured using a peak flow meter to evaluate the ability to cough.
5. Consider the patient’s level of injury.
Depending on the involvement of the phrenic nerve and the diaphragmatic function, injuries at the chest level can cause varying degrees of loss of respiratory function. However, they often result in decreased vital capacity and inspiratory effort.
Interventions:
1. Manage physiological distress.
Breathlessness can evoke anxiety and fear, worsening hypoxia. Administer sedatives or antianxiety medications to relax the patient.
2. Maintain a patent airway.
Keep the head in a neutral position, raise the head of the bed if it is safe to do so, and assist with the placement of an artificial airway if needed.
3. Prevent pneumonia.
Pneumonia and related complications are common causes of death in an SCI. Preventing the development of respiratory conditions through suctioning, instructing on deep breathing, and respiratory muscle training can reduce the risk.
4. Consider cough assist and chest physiotherapy.
A weak cough is a common finding and can lead to a build-up of secretions. A mechanical cough assist device can apply pressure to stimulate a cough. Chest PT can also assist in clearing the airways.
5. Prepare for mechanical ventilation.
An SCI at the cervical level may affect the patient’s respiratory pattern and ventilatory efforts. Mechanical ventilation may be required to ensure oxygenation.
Ineffective Thermoregulation
Spinal cord injuries may disrupt the sympathetic nervous system and the patient’s ability to regulate their body temperature, resulting in hypothermia or hyperthermia.
Nursing Diagnosis: Ineffective Thermoregulation
Related to:
- Spinal cord injury, especially at higher levels
- Disrupted sensations/Nerve damage
- Decreased sweat response
As evidenced by:
- Mild shivering
- Moderate pallor
- Flushed skin
- Headache
- Dizziness
- Skin cool to touch
- Skin warm to touch
- Hypertension
- Tachycardia
- Reduction in body temperature below the normal range
- Increased body temperature above the normal range
Expected outcomes:
- Patient will maintain a body temperature within normal range.
- Patient will demonstrate interventions to maintain a body temperature within normal limits.
Assessment:
1. Assess and monitor the patient’s temperature frequently.
After an SCI, the hypothalamus in the brain may be unable to sense changes in temperature below the level of injury or send signals to stimulate sweating to cool the patient down or shivering to warm them up. Taking the patient’s temperature may be the only accurate method to detect hypothermia or hyperthermia.
2. Assess the extent and severity of the patient’s spinal cord injury.
Patients with injuries above the level of T6 and complete SCIs are more likely to experience ineffective thermoregulation.
3. Monitor the other vital signs.
As the patient experiences problems with thermoregulation, alterations in other vital signs can also occur. Hypothermia will initially cause tachycardia, hypertension, and tachypnea as the body attempts to compensate, but these vitals will drop if hypothermia becomes severe. In hyperthermia, the patient will experience tachycardia, tachypnea, and hypotension.
Interventions:
1. Be mindful of the environmental temperature.
Keep the external environment comfortable. If the patient is outside, ensure they are dressed appropriately for the weather. If temperatures are extreme (very hot or cold), limit time outdoors. Avoid direct sunlight and utilize a fan and air conditioning as needed.
2. Adjust the patient’s clothing to facilitate passive warming or cooling as appropriate.
Since the patient may not be able to sense overheating or feeling too cold, offer layers. Light and loose clothing is recommended. Limit blankets or use light bed linens.
3. Encourage adequate fluid intake.
Adequate fluid intake is important to prevent dehydration and becoming overheated, especially when the patient is exercising or in a warm environment.
4. Educate on signs of ineffective thermoregulation.
Educate the patient and caregivers on the signs that indicate the patient is too hot or too cold. Depending on the level of injury, the patient may or may not shiver. Other signs of hypothermia may include goosebumps, decreased capillary refill, blue nailbeds, and altered mental status. Hyperthermia may cause flushing, headache, tachypnea, nausea, and fatigue.
Self-Care Deficit
Muscle weakness or paralysis can impact the patient’s ability to perform ADLs.
Nursing Diagnosis: Self-Care Deficit
Related to:
- Muscle weakness
- Paralysis
- Impaired peripheral nerve transmission
- Impaired mobility
As evidenced by:
- Inability to perform self-care tasks
- Unable to bathe independently
- Unable to dress independently
- Unable to eat independently
- Unable to use the toilet independently
Expected outcomes:
- Patient will be able to identify the activities in which they need assistance.
- Patient will be able to verbalize independence in doing an activity.
- Patient will be able to perform self-care activities within their capability.
Assessment:
1. Determine the patient’s capabilities and limits.
Self-care deficits are common among those with an SCI, but rehabilitation and equipment can help them overcome barriers.
2. Assess the patient’s health perception.
Perceptions of health are highly influenced by other self-care elements such as health habits, agency, and health literacy. Patients unable to perform self-care tasks are considerably more likely to have poor perceptions of their health.
3. Assess barriers to participation in activities.
Barriers to participation include lack of information, psychological or personal issues, family/ carer problems, fear of appearing dependent, social or economic limitations, depression, and work or home environment problems.
Interventions:
1. Instruct on ways to preserve self-care despite limitations.
Dependence on others for basic care can feel dehumanizing. At the very least, implement ways for the patient to communicate their needs. Recommend devices and equipment that allow the patient to participate.
2. Assist the patient in meeting their needs.
While encouraging and integrating self-care independence, assisting with personal care is a necessary component of nursing care.
3. Encourage decision-making.
Allow the patient to make any decisions they can, such as choosing what to eat or wear, to encourage independence and participation.
4. Consider home health services.
The patient and family may need additional help in the home with ADLs. Refer to case management for assistance with referrals.
5. Refer to rehabilitative services.
Rehabilitation will help the patient optimize their ability to perform at their highest capacity. Adaptive services such as wheelchair fitting or creating handicap-accessible transportation can improve the patient’s access to the environment.
Situational Low Self-Esteem
Situational low self-esteem associated with spinal cord injury can be caused by loss of body functions, change in physical abilities, and perceived loss of self/identity.
Nursing Diagnosis: Situational Low Self-Esteem
Related to:
- Alteration in body image
- Functional impairment
- Role change
- Helplessness
- Decreased control over the environment
As evidenced by:
- Poor perception about own body or self
- Feelings of helplessness/uselessness
- Loss of interest in care or outcomes
- Change in social involvement
Expected outcomes:
- Patient will openly discuss their feelings about their situation.
- Patient will be able to demonstrate self-confidence through goal planning and active participation in care.
- Patient will be able to express positive self-appraisal.
Assessment:
1. Assess the patient’s self-esteem.
Identify the patient’s sense of self-worth and self-image, as this affects how the patient can handle the current scenario or crisis and overcome barriers.
2. Determine the patient’s sense of control.
It is crucial to assess if the patient feels they have control over their circumstances or if they are at the hands of luck or fate.
3. Assess the support system.
Navigating an SCI will require support from family and friends, possibly for a lifetime. Assess how strong and willing the patient’s support system is, as this can influence how they feel about themselves and their future.
4. Assess cultural and religious beliefs.
Throughout a person’s life, cultural and religious influences impact their self-perception, sense of value, and crisis management skills.
5. Note if there are any suicidal thoughts.
The high stress and devastation of an SCI can result in suicidal thoughts and may indicate the need for additional assessment and recommendations for mental health services.
Interventions:
1. Identify the patient’s coping mechanisms.
Coping mechanisms boost resilience because they teach how to deal effectively with unpleasant emotions and other adverse circumstances.
2. Listen to the patient’s self-talk.
Unconsciously, someone who feels unimportant, incompetent, or out of control frequently speaks negatively about themselves, contributing to a loss of self-esteem.
3. Refer to mental health services.
Spinal cord injuries alter the patient’s physical abilities but also the potential for life achievements and future plans. Realization of this can cause immense depression that requires expert mental health support.
4. Encourage support groups.
Meeting and developing relationships with others who have experienced an SCI can improve the patient’s self-esteem and remind them that they are not alone.
5. Encourage verbalization of feelings.
Expression of one’s own feelings aids in the process of loss and grief.
6. Promote patient involvement.
Patients involved in their care are more likely to adhere to treatment regimens, are more knowledgeable about their conditions, and report higher levels of satisfaction with their care.
7. Appreciate the patient’s efforts.
Recognize improvement by acknowledging it. Encouragement from others promotes perseverance and continued growth.
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
- Spinal cord injuries treatment & management: Approach considerations, prehospital management, emergency department management. (2024, March 4). Diseases & Conditions – Medscape Reference. Retrieved March 2024, from https://emedicine.medscape.com/article/793582-treatment#showall
- Spinal cord injury – Diagnosis and treatment – Mayo Clinic. (2021, October 2). Top-ranked Hospital in the Nation – Mayo Clinic. Retrieved March 2024, from https://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/diagnosis-treatment/drc-20377895
- Spinal cord injury. (2023, November 28). National Institute of Neurological Disorders and Stroke. Retrieved March 2024, from https://www.ninds.nih.gov/health-information/disorders/spinal-cord-injury
- Spinal cord injury: Types, symptoms, causes & treatment. (2023, December 18). Cleveland Clinic. Retrieved March 2024, from https://my.clevelandclinic.org/health/diseases/12098-spinal-cord-injury
