Nursing Care Plan (NCP) for Spinal Cord Injury
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Study Tools For Nursing Care Plan (NCP) for Spinal Cord Injury
Outline
Lesson Objectives for Spinal Cord Injury (SCI)
- Understanding Spinal Cord Injury (SCI):
- Define and comprehend the anatomy and function of the spinal cord.
- Understand the different types and levels of spinal cord injuries, including complete and incomplete injuries.
- Recognizing Etiology and Risk Factors:
- Explore the common causes of spinal cord injuries, such as trauma (falls, accidents, sports injuries) and non-traumatic factors (tumors, infections).
- Identify risk factors that may contribute to the occurrence and severity of spinal cord injuries.
- Classifying Spinal Cord Injuries:
- Classify spinal cord injuries based on the American Spinal Injury Association (ASIA) impairment scale.
- Understand the significance of neurological assessment in determining the level and severity of injury.
- Complications and Impact on Function:
- Examine potential complications associated with spinal cord injuries, including neurogenic shock, respiratory compromise, and autonomic dysreflexia.
- Understand the impact of spinal cord injuries on motor, sensory, and autonomic functions.
- Multidisciplinary Care Approach:
- Emphasize the importance of a multidisciplinary approach to care, involving healthcare professionals such as neurologists, orthopedic surgeons, physical therapists, and occupational therapists.
- Recognize the role of rehabilitation and ongoing support in maximizing functional outcomes and enhancing quality of life for individuals with spinal cord injuries.
Pathophysiology of Spinal Cord Injury (SCI)
- Primary Injury:
- SCI results from a primary injury caused by mechanical trauma, often involving fractures, dislocations, or compression of the vertebral column.
- The initial injury disrupts the normal structure and function of the spinal cord.
- Secondary Injury:
- Secondary injury processes follow the primary injury and involve a cascade of events that exacerbate tissue damage.
- These processes include inflammation, edema, ischemia, and the release of neurotoxic substances, contributing to ongoing cellular damage.
- Axonal Damage:
- Axonal damage occurs due to the disruption of nerve fibers within the spinal cord.
- Axons may be directly injured by the primary trauma or undergo Wallerian degeneration in the aftermath of the injury.
- Loss of Blood Flow:
- The primary and secondary injuries can lead to a decrease in blood flow to the spinal cord, resulting in ischemia and further damage to neural tissue.
- Impaired blood flow contributes to the development of cysts and scar tissue within the injured area.
- Formation of Glial Scar:
- A glial scar forms at the site of injury, composed of astrocytes and fibrous tissue.
- While the scar acts as a barrier to prevent further damage, it also creates an inhibitory environment for axonal regeneration, limiting functional recovery.
Etiology of Spinal Cord Injury (SCI)
- Traumatic Causes:
- Motor vehicle accidents, falls, sports injuries, and acts of violence are common traumatic causes of SCI.
- High-impact forces can lead to fractures, dislocations, or compression of the spinal cord.
- Non-Traumatic Causes:
- Non-traumatic causes include tumors, infections (such as abscesses or meningitis), and vascular disorders affecting the spinal cord.
- These conditions can exert pressure on the spinal cord, leading to injury.
- Degenerative Conditions:
- Degenerative conditions like spinal stenosis or intervertebral disc herniation can contribute to the development of SCI.
- Chronic compression of the spinal cord over time may result in injury.
- Inflammatory Diseases:
- Conditions such as transverse myelitis or multiple sclerosis, characterized by inflammation of the spinal cord, can cause SCI.
- Inflammatory processes may damage neural tissue and disrupt normal spinal cord function.
- Congenital Abnormalities:
- Congenital anomalies, such as spina bifida or tethered spinal cord, can predispose individuals to spinal cord injuries.
- Anomalies in the development of the spinal column and cord may increase the risk of injury throughout life.
Desired Outcome in the Management of Spinal Cord Injury (SCI)
- Optimal Neurological Function:
- Preserve and improve neurological function to the highest extent possible.
- Enhance motor and sensory capabilities based on the level and severity of the spinal cord injury.
- Prevention of Complications:
- Minimize the risk of complications, including respiratory infections, pressure ulcers, and contractures.
- Implement preventive measures to address potential issues associated with immobility and neurogenic dysfunction.
- Pain Management:
- Provide effective pain management to enhance patient comfort and improve overall quality of life.
- Tailor pain interventions to address neuropathic pain and musculoskeletal discomfort associated with the injury.
- Achievement of Independence:
- Facilitate the patient’s ability to perform activities of daily living (ADLs) independently, considering assistive devices and adaptive techniques.
- Promote self-care and independence to enhance the patient’s overall well-being.
- Psychosocial Adjustment and Support:
- Support the patient in adjusting to the emotional and psychosocial challenges associated with SCI.
- Promote mental well-being, coping mechanisms, and a positive outlook on life post-injury.
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 Assessment for Spinal Cord Injury (SCI)
- Neurological Assessment:
- Conduct a thorough neurological assessment, including the level and completeness of the spinal cord injury based on the ASIA impairment scale.
- Monitor for changes in motor and sensory function, reflexes, and signs of neurogenic shock.
- Respiratory Assessment:
- Assess respiratory status, including respiratory rate, depth, and signs of respiratory distress.
- Monitor for any respiratory complications, such as pneumonia or atelectasis, and intervene promptly.
- Skin Integrity Assessment:
- Perform regular skin assessments to identify areas at risk for pressure ulcers.
- Implement preventive measures, such as turning schedules, pressure-relieving devices, and meticulous skin care.
- Musculoskeletal Assessment:
- Evaluate muscle strength, tone, and joint range of motion.
- Monitor for signs of contractures and implement measures to prevent joint immobility.
- Bowel and Bladder Function Assessment:
- Assess bowel and bladder function, implementing a bowel and bladder management program as appropriate.
- Monitor for complications such as urinary tract infections or bowel impaction.
- Pain Assessment:
- Assess and reassess pain levels, including both neuropathic and musculoskeletal pain.
- Collaborate with the healthcare team to develop a comprehensive pain management plan.
- Psychosocial Assessment:
- Conduct a psychosocial assessment to identify emotional responses, coping mechanisms, and support systems.
- Address mental health concerns and provide emotional support as needed.
- Functional Independence Assessment:
- Evaluate the patient’s ability to perform ADLs independently.
- Identify areas of impairment and collaborate with occupational therapists to develop strategies for enhancing independence.
Implementation for Spinal Cord Injury (SCI)
- Neurological Monitoring:
- Implement routine neurological monitoring to assess changes in motor and sensory function.
- Utilize standardized assessments, such as the ASIA impairment scale, to track neurological status over time.
- Respiratory Management:
- Provide respiratory care, including chest physiotherapy, deep breathing exercises, and assisted coughing techniques.
- Ensure proper positioning and use of respiratory aids to prevent complications like pneumonia.
- Pressure Ulcer Prevention:
- Implement a structured pressure ulcer prevention program, including regular turning schedules, the use of pressure-relieving devices, and skin inspections.
- Educate the patient and caregivers on the importance of skin care and early detection of potential issues.
- Pain Management:
- Administer pain medications as prescribed, considering both neuropathic and musculoskeletal pain.
- Collaborate with the healthcare team to explore non-pharmacological pain management strategies, such as physical therapy or relaxation techniques.
- Mobility and Independence Promotion:
- Collaborate with physical and occupational therapists to develop a personalized rehabilitation plan.
- Facilitate the use of assistive devices and adaptive techniques to promote independence in activities of daily living.
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.
Evaluation for Spinal Cord Injury (SCI)
- Neurological Status:
- Regularly assess and document changes in neurological status, including improvements or deterioration in motor and sensory function.
- Use standardized assessments to quantify progress and inform adjustments to the care plan.
- Respiratory Function:
- Evaluate respiratory function through ongoing monitoring and assessment of respiratory status.
- Assess the effectiveness of respiratory interventions and adjust strategies as needed.
- Skin Integrity:
- Monitor skin integrity regularly, assessing for the development of pressure ulcers.
- Evaluate the success of pressure ulcer prevention measures and intervene promptly if any issues arise.
- Pain Control:
- Assess the effectiveness of pain management interventions, considering both pharmacological and non-pharmacological approaches.
- Adjust the pain management plan based on the patient’s reported pain levels and overall well-being.
- Functional Independence:
- Evaluate the patient’s progress in achieving functional independence and performing ADLs.
- Collaborate with the rehabilitation team to assess improvements in mobility, strength, and overall functional outcomes.
Regular evaluation is essential to ensure the effectiveness of interventions, monitor patient progress, and make necessary adjustments to optimize outcomes for individuals with spinal cord injuries. The collaborative effort of the healthcare team is crucial in achieving positive results and enhancing the overall quality of life for the patient.
References
- https://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/symptoms-causes/syc-20377890
- http://www.aans.org/Patients/Neurosurgical-Conditions-and-Treatments/Spinal-Cord-Injury
- https://medlineplus.gov/spinalcordinjuries.html
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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!
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Nursing Care Plans
Concepts Covered:
- Basics of NCLEX
- Test Taking Strategies
- Central Nervous System Disorders – Brain
- Lower GI Disorders
- Pregnancy Risks
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- Disorders of the Adrenal Gland
- Substance Abuse Disorders
- Cognitive Disorders
- Shock
- Hematologic Disorders
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- Anxiety Disorders
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- Noninfectious Respiratory Disorder
- Emergency Care of the Cardiac Patient
- Neurologic and Cognitive Disorders
- Peripheral Nervous System Disorders
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- Microbiology
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- Postpartum Care
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- Neurological
- Bipolar Disorders
- Central Nervous System Disorders – Spinal Cord
- Newborn Care
- Female Reproductive Disorders
- Trauma-Stress Disorders
- Postpartum Complications
- Labor and Delivery
- Musculoskeletal Disorders
- Sexually Transmitted Infections
- Psychotic Disorders
- Emergency Care of the Neurological Patient
- Musculoskeletal Trauma
- Somatoform Disorders
- Neurological Trauma
- Neurological Emergencies
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