Spinal Cord Injury Nursing Diagnosis & Care Plan

The spinal cord transmits nerve signals from the brain to the rest of the body. It is enclosed and safeguarded by layers of tissue known as the meninges and a column of vertebrae (spinal bones). Damage to the spinal cord is called spinal cord injury (SCI).

SCI may be permanent and life-threatening. Depending on the level of injury, motor and sensory functions may be lost. The most common cause of spinal cord injury is an abrupt, severe impact on the spinal cord caused by trauma or from compression of the vertebra, masses, or abscesses. Less commonly, the spinal cord can suffer damage from impaired blood flow, inflammatory reactions, abnormal metabolic processes, or toxins.

The nerve fibers and neurons in the spinal cord can be partially or completely destroyed by trauma. The most frequently involved parts of the vertebrae are the following:

  • Cervical—C5, C6, and C7
  • Thoracic—T12
  • Lumbar—L1

The severity is divided into the following categories:

Complete:

  • A spinal cord contusion, bruising, or disruption of blood flow to the affected spinal cord area results in complete loss of function
  • The body is affected bilaterally
  • It may cause paralysis of the lower body (paraplegia) or all four limbs (quadriplegia)

Incomplete:

  • Some function below the primary level of the injury is still present
  • There is still some transmission between the body and the brain
  • The individual might be able to move one arm or leg more than the other or function better on one side of the body than the other

A clinical examination that includes a comprehensive and precise evaluation of the motor and sensory nerves is necessary for classification. The American Spinal Injury Association (ASIA) Impairment Scale is used to grade SCI.

To correctly diagnose the injuries, imaging is essential. CT scan can identify fractures, and MRI can accurately assess the level of injury.

Nursing Process

A thorough physical examination and clinical assessment of the spinal cord injury are required immediately. Recognizing the signs and symptoms determines the exact location and kind of injury that was sustained. 

Immobilization by witnesses or emergency personnel is vital to prevent further injury. Nurses play an essential role in stabilizing and preserving the airway and circulation. Patients will often be monitored in the neurological ICU setting.

Rehabilitation is a crucial component of healing, and for some patients, intensive rehabilitation therapy may be necessary. Once the patient is prepared to leave the inpatient rehabilitation hospital, rehabilitation must continue outpatient.

Spinal cord injury can be life-changing and psychologically distressing for the patient and their family. Counsel the patient regarding prognosis, complications, and outcomes as necessary. Management of problems like anxiety, frustration, loneliness, and depression can be aided by referring to mental health services and support groups. 

Nursing Care Plans

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

  • 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 
  • Shallow rapid breaths
  • 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. Determine the causative factors.
Spinal cord injury can develop due to non-traumatic conditions like vascular abnormalities, tumors, or infections.

2. 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, unequal chest wall movement, shallow rapid breaths, diminished breath sounds upon auscultation, and breathlessness which can signify a need for emergency actions.

3. 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.

4. 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. 

5. Assess the patient’s coughing abilities.
Peak cough flow can be regularly measured using a peak flow meter to evaluate the ability to cough.

6. Consider the patient’s spinal cord injury level.
Depending on the involvement of the phrenic nerve and the diaphragmatic function, injuries at cervical 5 (C5) can cause varying degrees of loss of respiratory function. However, they often result in decreased vital capacity and inspiratory effort.

Interventions:

1. Relax the respiratory muscles.
Help the patient deal with the physiological side effects of hypoxia, which might include anxiety and terror.

2. Maintain patent airway.
Keep the head in a neutral posture, raise the head of the bed a little if it is safe to do so, and use an airway device if needed.

3. Prevent pneumonia.
Pneumonia and related complications are common causes of death in SCI. Preventing the development of respiratory conditions by 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 tracheostomy or mechanical ventilation.
SCI that affects the phrenic nerve at the cervical level causes an impairment in respiration. Long-term tracheostomy and mechanical ventilation may be required.


Self-Care Deficit

Self-care deficit associated with spinal cord injury can be caused by impaired muscles of the extremity, paralysis, and muscle weakness.

Nursing Diagnosis: Self-Care Deficit

  • 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.

4. 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.

5. 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.

6. 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

  • 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 cause loss not only of physical abilities but the potential loss of 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 in a positive way encourages perseverance and continued growth.


References

  1. 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
  2. Cleveland Clinic. (2022). Spinal cord injury: Types, symptoms, causes & treatment. https://my.clevelandclinic.org/health/diseases/12098-spinal-cord-injury
  3. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2019). Nurse’s pocket guide: Diagnoses, interventions, and rationales (15th ed.). F A Davis Company.
  4. 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/
  5. 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
  6. Mayo Clinic. (2021). Spinal cord injury – Symptoms and causes. https://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/symptoms-causes/syc-20377890
  7. Silvestri, L. A., & Silvestri, A. E. (2022). Saunders comprehensive review for the NCLEX-RN examination (9th ed.). Elsevier Inc.
  8. World Health Organization (WHO). (2013). Spinal cord injury. https://www.who.int/news-room/fact-sheets/detail/spinal-cord-injury
Published on
Photo of author

Kathleen Salvador, MSN, RN

Kathleen Salvador is a registered nurse and a nurse educator holding a Master’s degree. She has more than 10 years of clinical and teaching experience and worked as a licensed Nursing Specialist in JCI-accredited hospitals in the Middle East. Her nursing career has brought her through a variety of specializations, including medical-surgical, emergency, outpatient, oncology, and long-term care.