Nursing Care Plans

Nursing care planning and goals for patients with spinal cord injuries include:
maximizing respiratory function, preventing injury to the spinal cord, promoting
mobility and/or independence, preventing or minimizing complications, supporting
the psychological adjustment of patient and/or SO, and providing information about
the injury, prognosis, and treatment.

Here are twelve (12) nursing care plans (NCP) and nursing diagnosis for
patients with spinal cord injury:

1. Risk for Ineffective Breathing Pattern

2. Risk for Trauma
3. Impaired Physical Mobility
4. Disturbed Sensory Perception
5. Acute Pain
6. Grieving
7. Situational Low Self-Esteem
8. Constipation
9. Impaired Urinary Elimination
10. Risk for Autonomic Dysreflexia
11. Risk for Impaired Skin Integrity
12. Deficient Knowledge

Risk for Ineffective Breathing Pattern

Spinal cord injury can disrupt the normal functioning of the respiratory system,
leading to ineffective breathing patterns. This can result in reduced oxygenation and
ventilation, as well as an increased risk of complications such as pneumonia. Careful
monitoring and intervention to optimize breathing patterns are essential to promote
better patient outcomes and prevent further complications.

Risk factors may include

 Impairment of innervation of the diaphragm

 Complete or mixed loss of intercostal muscle function
 Reflex abdominal spasms; gastric distension

Possibly evidenced by

 Not applicable for risk diagnosis. A risk diagnosis is not evidenced by

signs and symptoms, as the problem has not occurred and nursing
interventions are directed at prevention.
Desired Outcomes

 The patient will maintain adequate ventilation as evidenced by the

absence of respiratory distress and ABGs within acceptable limits.
  The patient will demonstrate appropriate behaviors to support the
respiratory effort.

Nursing Assessment and Rationales

1. Assess respiratory function by asking the patient to take a deep breath.

2. Auscultate breath sounds. Note areas of absent or decreased breath sounds

or development of adventitious sounds (rhonchi).
Hypoventilation is common and leads to accumulation of secretions, atelectasis,
and pneumonia (frequent complications).

3. Note the strength or effectiveness of the cough.

Level of injury determines the function of intercostal muscles and ability to cough
spontaneously or move secretions.

4. Observe skin color for developing cyanosis, and duskiness.

May reveal impending respiratory failure, need for immediate medical evaluation and
intervention.

5. Assess for abdominal distension and muscle spasm.

Abdominal fullness may impede diaphragmatic excursion, reducing lung expansion
and further compromising respiratory function.

6. Monitor and limit visitors as indicated.

General debilitation and respiratory compromise place patients at increased risk for
acquiring URIs.

7. Monitor diaphragmatic movement when the phrenic pacemaker is implanted.

Stimulation of the phrenic nerve may enhance respiratory effort, decreasing
dependency on the mechanical ventilator.

8. Measure or graph:

 8.1. Vital capacity (VC), tidal volume (VT), inspiratory force

Determines the level of respiratory muscle function. Serial
measurements may be done to predict impending respiratory failure
(acute injury) or determine the level of function after the spinal shock
phase and while weaning from ventilatory support.
 8.2. Serial ABGs and pulse oximetry.
Documents status of ventilation and oxygenation; identifies respiratory
problems such as hypoventilation (low Pao2 and elevated Paco2) and
pulmonary complications.
Nursing Interventions and Rationales
1. Elicit concerns and questions regarding mechanical ventilation devices.
Acknowledges the reality of the situation.

2.Provide honest answers.

Future respiratory function needs will not be totally known until spinal shock resolves
and acute rehabilitative phase is completed. Even though respiratory support may be
required, alternative devices and techniques may be used to enhance mobility and
promote independence.

3. Maintain patent airway: keep head in a neutral position, elevate the head of
the bed slightly if tolerated, and use airway adjuncts as indicated.
Patients with high cervical injury and impaired gag and cough reflexes require
assistance in preventing aspiration and maintaining the patient’s airway.

Risk for Trauma

Patients with spinal cord injury are at increased risk for trauma due to impaired motor
function and sensation. The inability to move or feel certain body parts can lead to
accidental injuries such as falls, pressure ulcers, and burns.

Risk factors may include

 Temporary weakness/instability of the spinal column

Possibly evidenced by

 Not applicable for risk diagnosis. A risk diagnosis is not evidenced by

signs and symptoms, as the problem has not occurred and nursing
interventions are directed at prevention.
Desired Outcomes

 The patient will maintain proper alignment of the spine without further
spinal cord damage.

Nursing Assessment and Rationales

1. Check weights for ordered traction pull (usually 10–20 lb).

Weight pull depends on the patient’s size and the amount of reduction needed to
maintain vertebral column alignment.

2. Check the external stabilization device (Gardner-Wells tongs or skeletal

traction apparatus).
These devices are used for decompression of spinal fractures and stabilization of
vertebral column during the early acute phase of injury to prevent further spinal cord
injury.
Nursing Interventions and Rationales

1. Elevate the head of the traction frame or bed as indicated. Ensure that
traction frames are secure, pulleys aligned, and weights hanging free.
Creates safe, effective counterbalance to maintain both patient’s position and
traction pull.

2. Maintain bedrest and immobilization device(s) such as sandbags, traction,

halo, hard or soft cervical collars, and brace.
Body rest prevents vertebral column instability and aids healing. Note: Traction is
used only for cervical spine stabilization.

3. Reposition at intervals, using adjuncts for turning and support (turn sheets,
foam wedges, blanket rolls, pillows). Get at least three staff members when
turning and logrolling patients. Follow special instructions for traction
equipment, kinetic bed, and frames once the halo is in place.
Maintains proper spinal column alignment, reducing the risk of further trauma. Note:
Grasping the brace and halo vest to turn or reposition the patient may cause
additional injury.

4. Assist with preparation and maintain skeletal traction via tongs, calipers,
halo, or vest, as indicated.
Reduces vertebral fracture and dislocation.

5. Prepare for internal stabilization surgery (spinal laminectomy or fusion) if

indicated.
Surgery may be indicated for spinal stabilization and cord decompression or removal
of bony fragments.

Impaired Physical Mobility

Spinal cord injury can lead to impaired physical mobility due to the disruption of
motor function and sensation. Depending on the level and severity of the injury,
patients may experience varying degrees of paralysis, muscle weakness, and loss of
sensation. This can significantly impact their ability to perform daily activities and
require careful monitoring, interventions, and assistive devices to promote optimal
physical mobility and prevent further complications.

May be related to

 Neuromuscular impairment
 Immobilization by traction
Possibly evidenced by

 Inability to purposefully move; paralysis

 Muscle atrophy; contractures
Desired Outcomes

 The patient will maintain a position of function as evidenced by the

absence of contractures and foot drop.
 The patient will increase the strength of unaffected/compensatory body
parts.
 The patient will demonstrate techniques/behaviors that enable the
resumption of activity.

Nursing Assessment and Rationales

1. Continually assess motor function (as spinal shock or edema resolves) by

requesting the patient to perform certain actions such as shrugging the
shoulders, spreading fingers, squeezing, release the examiner’s hands.
Evaluates the status of the individual situation (motor-sensory impairment may be
mixed or not clear) for a specific level of injury, affecting the type and choice of
interventions.

2. Measure and monitor BP before and after activity in acute phases or until
stable. Change position slowly. Use a cardiac bed or tilt table and CircOlectric
bed as the activity level is advanced.
Orthostatic hypotension may occur as a result of venous pooling (secondary to loss
of vascular tone). Side-to-side movement or elevation of the head can
aggravate hypotension and cause syncope.

3. Inspect skin daily. Observe pressure areas, and provide meticulous skin
care. Teach the patient to inspect skin surfaces and to use a mirror to look at
hard-to-see areas.
Altered circulation, loss of sensation, and paralysis potentiate pressure sore
formation. This is a lifelong consideration.

4. Investigate sudden onset of dyspnea, cyanosis, and other signs of

respiratory distress.
Development of pulmonary emboli may be “silent” because pain perception is altered
and DVT is not readily recognized.

5. Assess for redness, swelling, and muscle tension of calf tissues. Record
calf and thigh measurements if indicated.
In a high percentage of patients with cervical cord injury, thrombi develop because of
altered peripheral circulation, immobilization, and flaccid paralysis. Risk is greatest
during the 2 wk immediately following injury and on through the next 3 mo.

Nursing Interventions and Rationales

1. Provide means to summon help (special sensitive call light).

Enables patient to have a sense of control, and reduces fear of being left
alone. Note: Quadriplegic on ventilator requires continuous observation in early
management.
2. Perform and assist with full ROM exercises on all extremities and joints,
using slow, smooth movements. Hyperextend hips periodically.
Enhances circulation, restores and maintains muscle tone and joint mobility, and
prevents disuse contractures and muscle atrophy.

3. Position arms at a 90-degree angle at regular intervals.

Prevents frozen shoulder contractures.

4. Maintain ankles at 90 degrees with a footboard, high-top tennis shoes, and

so on. Place trochanter rolls along thighs when in bed.
Prevents footdrop and external rotation of hips.

5. Elevate lower extremities at intervals when in a chair, or raise the foot of the
bed when permitted in the individual situation. Assess for edema of feet and
ankles.
Loss of vascular tone and “muscle action” results in the pooling of blood and venous
stasis in the lower abdomen and lower extremities, with an increased risk of
hypotension and thrombus formation.

6. Plan activities to provide uninterrupted rest periods. Encourage involvement

within individual tolerance and ability.
Prevents fatigue, allowing the opportunity for maximal efforts and participation by the
patient.

7. Reposition periodically even when sitting in a chair. Teach the patient how
to use weight-shifting techniques.
Reduces pressure areas, and promotes peripheral circulation.

8. Prepare for weight-bearing activities like the use of a tilt table for an upright
position, and strengthening and conditioning exercises for unaffected body
parts.
Early weight bearing reduces osteoporotic changes in long bones and reduces the
incidence of urinary infections and kidney stones. Note: Fifty percent of patients
develop heterotopic ossification that can lead to pain and decreased joint flexibility

9. Encourage the use of relaxation techniques.

Reduces muscle tension and fatigue, and may help limit the pain of muscle spasms
and spasticity.

10. Assist and encourage pulmonary hygiene like deep breathing, coughing,
and suctioning.
Immobility and bedrest increase the risk of pulmonary infection.

11. Place the patient in a kinetic therapy bed when appropriate.

Effectively immobilizes unstable spinal columns and improves systemic circulation,
which is thought to decrease complications associated with immobility.
12. Apply an anti-embolic hose or leotard or sequential compression devices
(SCDs) to the legs as appropriate.
Limits pooling of blood in lower extremities or abdomen, thus improving vasomotor
tone and reducing the incidence of thrombus formation and pulmonary emboli.

13. Administer muscle relaxants and antispasticity agents as indicated:

 13.1. Diazepam (Valium), baclofen (Lioresal), dantrolene

(Dantrium)
May be useful in limiting or reducing pain associated with spasticity.
Note: Baclofen may be delivered via an implanted intrathecal pump on
a long-term basis as appropriate.
 13.2. Tizanidine (Zanaflex)
Centrally acting [alpha]2-adrenergic agonist reduces spasticity. A short
duration of action requires careful dosage monitoring to achieve
maximum effect. May have an additive effect with baclofen (Lioresal)
but needs to be used with caution because both drugs have similar
side effects.
14. Consult with physical and occupational therapists and the rehabilitation
team.
Helpful in planning and implementing individualized exercise programs and
identifying or developing assistive devices to maintain function, and enhance mobility
and independence.

Disturbed Sensory Perception

Spinal cord injury can cause disturbed sensory perception due to the disruption of
sensory pathways. This can result in a range of sensory deficits, including
numbness, tingling, and loss of sensation. Patients may also experience alterations
in proprioception and kinesthesia, which can affect their ability to perceive the
position and movement of their limbs.

May be related to

 Destruction of sensory tracts with altered sensory reception,

transmission, and integration
 Reduced environmental stimuli
 Psychological stress (narrowed perceptual fields caused by anxiety)
Possibly evidenced by

 The measured change in sensory acuity, including the position of body

parts/proprioception
 Change in usual response to stimuli
 Motor incoordination
 Anxiety, disorientation, bizarre thinking; exaggerated emotional
responses
Desired Outcomes

The patient will recognize sensory impairments.

The patient will identify behaviors to compensate for deficits.
The patient will verbalize awareness of sensory needs and the
potential for deprivation/overload.
Nursing Assessment and Rationales

1. Assess and document sensory function or deficit (by means of touch,

pinprick, hot or cold, etc.), progressing from area of deficit to neurologically
intact area.
Changes may not occur during the acute phase, but as spinal shock resolves,
changes should be documented by dermatome charts or anatomical landmarks (“2 in
above nipple line”).

2. Note the presence of exaggerated emotional responses, and altered thought

processes (disorientation, bizarre thinking).
Indicative of damage to sensory tracts and psychological stress, requiring further
assessment and intervention.

Nursing Interventions and Rationales

1. Protect from bodily harm (falls, burns, positioning of arm or objects).

The patient may not sense pain or be aware of body position.

2. Assist the patient to recognize and compensate for alterations in sensation.

May help reduce the anxiety of the unknown and prevent injury.

3. Explain procedures before and during care, identifying the body part
involved.
Enhances patient perception of the “whole” body.

4. Provide tactile stimulation, touching the patient in intact sensory areas

(shoulders, face, head).
Touching conveys caring and fulfills a normal physiological and psychological need.

5. Position the patient to see surroundings and activities. Provide prism

glasses when prone on the turning frame. Talk to patients frequently.
Provides sensory input, which may be severely limited, especially when the patient is
in a prone position.

6. Provide diversional activities (television, radio, music, liberal visitation). Use

clocks, calendars, pictures, bulletin boards, and so on. Encourage SO and
family to discuss general and personal news.
Aids in maintaining reality orientation and provides some sense of normality in the
daily passage of time.
7. Provide uninterrupted sleep and rest periods.
Reduces sensory overload, enhances orientation and coping abilities and aids in
reestablishing natural sleep patterns.

Acute Pain

Spinal cord injury can cause acute pain due to the trauma and tissue damage that
occurs during the injury. Patients may experience pain at the site of the injury, as
well as referred pain to other areas of the body.

May be related to

 Physical injury
 Traction apparatus
Possibly evidenced by

 Hyperesthesia immediately above the level of injury

 Burning pain below the level of injury (paraplegia)
 Muscle spasm/spasticity
 Phantom pain; headaches
Desired Outcomes

The patient will report relief or control of pain/discomfort.

The patient will identify ways to manage pain.
The patient will demonstrate the use of relaxation skills and diversional
activities as individually indicated.
Nursing Assessment and Rationales

1. Assess for the presence of pain. Help the patient identify and quantify
pain (location, type of pain, intensity on a scale of 0–10).
The patient usually reports pain above the level of injury such as the chest and back
or headache possibly from the stabilizer apparatus. After the spinal shock phase, the
patient may also report muscle spasms and radicular pain, described as a burning or
stabbing pain (associated with injury to peripheral nerves and radiating in a
dermatomal pattern). The onset of this pain is within days to weeks after SCI and
may become chronic.

2. Evaluate increased irritability, muscle tension, restlessness, and

unexplained vital sign (VS) changes.
Nonverbal cues are indicative of pain and discomfort requiring intervention.

3. Assist the patient in identifying precipitating factors.

Burning pain and muscle spasms can be precipitated and aggravated by multiple
factors (anxiety, tension, external temperature extremes, sitting for long periods,
bladder distension).
Nursing Interventions and Rationales

1. Provide comfort measures (position changes, massage, ROM exercises,

warm or cold packs, as indicated).
Alternative measures for pain control are desirable for emotional benefit, in addition
to reducing pain medication needs and undesirable effects on respiratory function.

2. Encourage the use of relaxation techniques (guided imagery, visualization,

deep-breathing exercises). Provide diversional activities (television, radio,
telephone, unlimited visitors) as appropriate.
Refocuses attention, promotes a sense of control, and may enhance coping abilities.

3. Administer medications as indicated: muscle relaxants: dantrolene

(Dantrium), baclofen (Lioresal); analgesics; antianxiety agents: diazepam
(Valium).
May be desired to relieve muscle spasms and pain associated with spasticity or to
alleviate anxiety and promote rest.

Grieving

Patients with spinal cord injury may experience grieving due to the significant
changes in their physical and emotional well-being. The injury can lead to loss of
function, independence, and quality of life, which can be challenging to accept and
adjust to.

Nursing Diagnosis

 Grieving
May be related to

 Perceived/actual loss of physiopsychosocial well-being

Possibly evidenced by

Altered communication patterns

Expression of distress, choked feelings, e.g., denial, guilt, fear,
sadness; altered affect
 Alterations in sleep patterns
Desired Outcomes

The patient will express feelings.


The patient will begin to progress through recognized stages of grief,

focusing on 1 day at a time.
Nursing Assessment and Rationales

1. Identify signs of grieving (shock, denial, anger, depression).

The patient experiences many emotional reactions to the injury and its actual
or potential impact on life. These stages are not static, and the rate at which the
patient progresses through them is variable.
2. Shock

 2.1. Note lack of communication or emotional response, absence

of questions.
Shock is the initial reaction associated with overwhelming injury.
Primary concern is to maintain life, and patient may be too ill to express
feelings.
 2.2. Provide simple, accurate information to the patient and SO
regarding diagnosis and care. Be honest; do not give false
reassurance while providing emotional support.
The patient’s awareness of surroundings and activity may be blocked
initially, and attention span may be limited. Little is actually known
about the final outcome of a patient’s injuries during the acute phase,
and lack of knowledge may add to the frustration and grief of the family.
Therefore, the early focus of emotional support may be directed toward
SO.
 2.3. Encourage expressions of sadness, grief, guilt, and fear
among patients, SO, and friends.
The knowledge that these are appropriate feelings that should be
expressed may be very supportive to the patient and SO.
 2.4. Incorporate SO into problem-solving and planning for patient
care.
Assists in establishing therapeutic relationships. Provides some sense
of control over situations of many losses and forced changes, and
promotes the well-being of patients.
3. Denial

 3.1. Assist patient and SO to verbalize feelings about the situation,

avoiding judgment about what is expressed.
The important beginning step to deal with what has happened. Helpful
in identifying the patient’s coping mechanisms.
 3.2. Note comments indicating that the patient expects to walk
shortly and is making a bargain with God. Do not confront these
comments in the early phases of rehabilitation.
The patient may not deny the entire disability but may deny its
permanency. The situation is compounded by actual uncertainty of
outcome, and denial may be useful for coping at this time.
 3.3. Focus on present needs (ROM exercises, skin care).
Attention to the “here and now” reduces frustration
and hopelessness of an uncertain future and may make dealing with
today’s problems more manageable.
4. Anger

 4.1. Identify the use of manipulative behavior and reactions to

caregivers.
The patient may express anger verbally or physically (spitting, biting).
Patient may say that nothing is done right by caregivers and SO or may
pit one caregiver against another.
  4.2. Encourage the patient to take control when possible
(establishing care routines, dietary choices, and diversional
activities).
Helps reduce anger associated with powerlessness, and provides
patients with some sense of control and expectation of responsibility for
own behavior.
 4.3. Accept expressions of anger and hopelessness. Avoid
arguing. Show concern for the patient.
The patient is acknowledged as a worthwhile individual, and
nonjudgmental care is provided.
 4.4. Set limits on acting out and unacceptable behavior when
necessary (abusive language, sexually aggressive, or suggestive
behavior).
Although it is important to express negative feelings, patients and staff
need to be protected from violence and embarrassment. This phase is
traumatic for all involved, and the support of family is essential.
5. Depression

 5.1. Note the loss of interest in living, sleep disturbance, suicidal

thoughts, and hopelessness. Listen to but do not confront these
expressions. Let the patient know the nurse is available for
support.
The phase may last weeks, months, or even years. Acceptance of
these feelings and consistent support during this phase are important
to a satisfactory resolution.
 5.2. Arrange visits by individuals similarly affected, as
appropriate.
Talking with another person who has shared similar feelings and fears
and survived may help the patient reach acceptance of the reality of
the condition and deal with perceived and actual losses.

6. Consult with and refer to a psychiatric nurse, social worker, psychiatrist, or

pastor.
The patient and SO need assistance to work through feelings of alienation, guilt, and
resentment concerning lifestyle and role changes. The family (required to make
adaptive changes to a member who may be permanently “different”) benefits from
supportive, long-term assistance and counseling in coping with these changes and
the future. Patient and SO may suffer great spiritual distress, including feelings of
guilt, deprivation of peace, and anger at God, which may interfere with the
progression through and resolution of the grief process.

Situational Low Self-Esteem

Patients with spinal cord injury may experience situational low self-esteem due to the
significant impact of the injury on their physical and emotional well-being. The
resulting changes in body image, self-perception, and self-efficacy can be
challenging to manage and may contribute to feelings of inadequacy and reduced
self-esteem. Nurses can help address these issues by providing emotional support,
counseling, and education to promote a positive self-image and improve overall well-
being.

May be related to

 Traumatic injury; situational crisis; forced crisis

Possibly evidenced by

 Verbalization of forced change in lifestyle

 Fear of rejection/reaction by others
 Focus on past strength, function, or appearance
 Negative feelings about the body
 Feelings of helplessness, hopelessness, or powerlessness
 An actual change in structure and/or function
 Lack of eye contact
 Change in physical capacity to resume the role
 Confusion about self, purpose, or direction of life
Desired Outcomes

 The patient will verbalize acceptance of self in the situation.

 The patient will recognize and incorporate changes into self-concept in
an accurate manner without negating self-esteem.
 The patient will develop realistic plans for adapting to new role/role
changes.

Nursing Assessment and Rationales

1. Acknowledge difficulty in determining the degree of functional incapacity

and the chance of functional improvement.
During the acute phase of injury, long-term effects are unknown, which delays the
patient’s ability to integrate the situation into self-concept.

2. Listen to the patient’s comments and responses to the situation.

Provides clues to the view of self, role changes, and needs and is useful for
providing information at the patient’s level of acceptance.

3. Assess dynamics of patient and SOs (patient’s role in family, cultural

factors).
The patient’s previous role in the family unit is disrupted or altered by injury, adding
to the difficulty in integrating self-concept. In addition, issues of independence and
dependence need to be addressed.

4. Be alert to sexually oriented jokes, flirting, or aggressive behavior. Elicit

concerns, fears, and feelings about the current situation and future
expectations.
Anxiety develops as a result of perceived loss, and changes in masculine or feminine
self-image and role. Forced dependency is often devastating, especially in light of
changes in function and appearance.
5. Be aware of own feelings and reaction to the patient’s sexual anxiety.
Behavior may be disruptive, creating conflict between patient and staff, further
reinforcing negative feelings, and possibly eliminating the patient’s desire to work
through the situation and participate in rehabilitation.

Nursing Interventions and Rationales

1. Encourage SO to treat the patient as normally as possible (discussing home

situations, and family news).
Involving patients in the family unit reduces feelings of social isolation, helplessness,
and uselessness and provides an opportunity for SO to contribute to the patient’s
welfare.

2. Provide accurate information. Discuss concerns about prognosis and

treatment honestly at the patient’s level of acceptance.
The focus of information should be on present and immediate needs initially and
incorporated into long-term rehabilitation goals. Information should be repeated until
the patient has assimilated or integrated information.

3. Discuss the meaning of loss or change with the patient and SO. Assess
interactions between patient and SO.
An actual change in body image may be different from that perceived by the patient.
Distortions may be unconsciously reinforced by SO.

4. Accept the patient, and show concern for the individual as a person.
Encourage the patient, identify and build on strengths, and give positive
reinforcement for progress noted.
Establishes a therapeutic atmosphere for patients to begin self-acceptance.

5. Include the patient and SO in care, allowing the patient to make decisions
and participate in self-care activities as possible.
Recognizes that the patient is still responsible for own life and provides some sense
of control over the situation. Sets the stage for future lifestyle, patterns, and
interactions required in daily care. Note: Patient may reject all help or may be
completely dependent during this phase.

6. Arrange visits by a similarly affected person if the patient desires or the

situation allows.
May be helpful to patients by providing hope for the future and a role model. Can be
a vital post-discharge resource during the difficult period of adjustment after injury.

7. Refer to counseling and psychotherapy as indicated (psychiatric clinical

nurse specialist, psychiatrist, social worker, sex therapist).
May need additional assistance to adjust to changes in body image and life.
Constipation

Patients with spinal cord injury are at increased risk of constipation due to the
disruption of neural pathways that control bowel function. The resulting decreased
motility and altered sensory perception in the lower bowel can lead to
decreased peristalsis, increased transit time, and fecal impaction. Nurses must
closely monitor bowel function and implement interventions such as bowel
management programs, adequate fluid and fiber intake, and proper positioning to
prevent constipation and related complications.

May be related to

 Disruption of innervation to bowel and rectum

 Perceptual impairment
 Altered dietary and fluid intake
 Change in activity level
Possibly evidenced by

 Loss of ability to evacuate bowel voluntarily

 Constipation
 Gastric dilation, ileus
Desired Outcomes

 The patient will verbalize behaviors/techniques for individual bowel

programs.
 The patient will reestablish a satisfactory bowel elimination pattern.
Nursing Assessment and Rationales

1. Auscultate bowel sounds, noting location and characteristics.

Bowel sounds may be absent during the spinal shock phase. High tinkling sounds
may indicate the presence of ileus.

2. Observe for abdominal distension if bowel sounds are decreased or absent.

Loss of peristalsis (related to impaired innervation) paralyzes the bowel, creating
ileus and bowel distension. Note: Overdistension of the bowel is a precipitator of
autonomic dysreflexia once spinal shock subsides.

3. Note reports of nausea and onset of vomiting. Check vomitus or gastric

secretions (if the tube is in place) and stools for occult blood.
GI bleeding may occur in response to injury (Curling’s ulcer) or as a side effect of
certain therapies (steroids or anticoagulants).

4. Record frequency, characteristics, and amount of stool.

Identifies degree of impairment and dysfunction and level of assistance required.

5. Check for the presence of impaction (no formed stool for several days,
semiliquid stool, restlessness, increased feelings of fullness or distension of
the abdomen).
Early intervention is necessary to effectively treat constipation and retained stool and
reduce the risk of complications.

Nursing Interventions and Rationales

1. Establish a regular daily bowel program (digital stimulation, prune juice,

warm beverage, and use of stool softeners and suppositories at set intervals.
Determine the usual time and routine of post-injury evacuations.
A lifelong program is necessary to routinely evacuate the bowel because the ability
to control bowel evacuation is important to the patient’s physical independence and
social acceptance. Note: Bowel movements in patients with upper motor neuron
damage are generally regulated with suppositories or digital stimulation. The lower
motor neurogenic bowel is more difficult to regulate and usually requires manual
disimpaction. Incorporating elements of the patient’s usual routine may enhance
cooperation and the success of the program. Note: Many patients prefer the morning
program rather than the evening schedule often practiced in acute and rehab
settings.

2. Encourage a well-balanced diet that includes bulk and roughage and

increased fluid intake (at least 2000 mL per day), including fruit juices.
Improves consistency of stool for transit through the bowel. Note: A mixture of prune
juice, applesauce, and bran often provides adequate fiber for effective bowel
management.

3. Assist and encourage exercise and activity within the individual ability and
up in a chair as tolerated.
Improves appetite and muscle tone, enhancing GI motility.

4. Observe for incontinence and help the patient relate incontinence to

changes in diet or routine.
Patients can eventually achieve fairly normal routine bowel habits, which enhance
independence, self-esteem, and socialization.

5. Restrict intake of grapefruit juice and caffeinated beverages (coffee, tea,

cola, chocolate).
The diuretic effect can reduce fluid available in the bowel, increasing the risk of dry
and hard-formed stool.

6. Provide meticulous skin care.

Loss of sphincter control and innervation in the area potentiates the risk of skin
irritation and breakdown.

8. Insert and maintain the nasogastric tube and attach it to suction if

appropriate.
May be used initially to reduce gastric distension and prevent vomiting (reduces the
risk of aspiration).
9. Insert rectal tube as needed.
Reduces bowel distension, which may precipitate autonomic responses.

10. Administer medications as indicated:

 10.1. Stool softeners, laxatives, suppositories, enemas (eg,

Therevac-SB)
Stimulates peristalsis and routine bowel evacuation when necessary.
Suppositories should be warmed to room temperature and lubricated
before insertion. Therevac-SB is a 4cc mini enema of docusate and
glycerin that may cut time for bowel care by as much as 1 hr.
 10.2. Antacids, cimetidine (Tagamet), ranitidine (Zantac)
Reduces or neutralizes gastric acid to lessen gastric irritation and risk
of bleeding.
11. Consult with a dietitian and nutritional support team.
Aids in creating a dietary plan to meet individual nutritional needs with consideration
of the state of digestion and bowel function.

Impaired Urinary Elimination

Spinal cord injury patients have a higher likelihood of experiencing impaired urinary
elimination owing to disrupted neural pathways that regulate bladder function. This
condition manifests as reduced or absent sensation, decreased compliance, and
detrusor muscle function decline, which predisposes individuals to urinary retention,
incontinence, and urinary tract infections.

May be related to

 Disruption in bladder innervation

 Bladder atony
Possibly evidenced by

 Bladder distension; incontinence/overflow, retention

 Urinary tract infections
 Bladder, kidney stone formation
 Renal dysfunction
Desired Outcomes

 The patient will verbalize understanding of the condition.

 The patient will maintain balanced I&O with clear, odor-free urine, free
of bladder distension/urinary leakage.
 The patient will verbalize/demonstrate behaviors and techniques to
prevent retention/urinary infection.

Nursing Assessment and Rationales

1. Assess the voiding pattern (frequency and amount). Compare urine output
with fluid intake. Note specific gravity.
Identifies characteristics of bladder function (effectiveness of bladder emptying, renal
function, and fluid balance). Note: Urinary complications are a major cause of
mortality.

2. Palpate for bladder distension and observe for overflow.

Bladder dysfunction is variable but may include loss of bladder contraction and
inability to relax the urinary sphincter, resulting in urine retention and reflux
incontinence. Note: Bladder distension can precipitate autonomic dysreflexia.

3. Observe for cloudy or bloody urine, and foul odor. Dipstick urine as
indicated.
Signs of the urinary tract or kidney infection that can potentiate sepsis. Multistrip
dipsticks can provide a quick determination of pH, nitrite, and leukocyte esterase
suggesting the presence of infection.

Nursing Interventions and Rationales

1. Encourage intake (2–4 L per day), including acid ash juices (cranberry).
Helps maintain renal function, and prevents infection and the formation of urinary
stones. Note: Fluid may be restricted for a period during the initiation of
intermittent catheterization.

2. Begin bladder retraining per protocol when appropriate (fluids between

certain hours, digital stimulation of trigger area, contraction of abdominal
muscles, Credé’s maneuver).
Timing and type of bladder program depend on the type of injury (upper or lower
neuron involvement). Note: Credé’s maneuver should be used with caution because
it may precipitate autonomic dysreflexia.

3. Cleanse the perineal area and keep it dry. Provide catheter care as
appropriate.
Decreases risk of skin irritation or breakdown and development of ascending
infection.

4. Urinary Catheterization:

 4.1. Monitor BUN, creatinine, and white blood cell (WBC) count.
Reflects renal function, and identifies complications.
 4.2. Administer medications as indicated such as vitamin C, or
urinary antiseptics like methenamine mandelate (Mandelamine).
Maintains an acidic environment and discourages bacterial growth.
 4.3. Refer for further evaluation for bladder and bowel stimulation.
Clinical research is being conducted on the technology of electronic
bladder control. The implantable device sends electrical signals to the
spinal nerves that control the bladder and bowel. Early results look
promising.
 4.4. Keep the bladder deflated by means of an indwelling catheter
initially. Begin intermittent catheterization program when
 appropriate.
An indwelling catheter is used during the acute phase for the
prevention of urinary retention and for monitoring output. Intermittent
catheterization may be implemented to reduce complications usually
associated with the long-term use of indwelling catheters. A suprapubic
catheter may also be inserted for long-term management.
5. Measure residual urine via postvoid catheterization or ultrasound.
Helpful in detecting the presence of urinary retention and the effectiveness of
bladder training programs. Note: The use of ultrasound is noninvasive, reducing the
risk of colonization of the bladder.

Risk for Autonomic Dysreflexia

Patients with spinal cord injury are at risk of developing autonomic dysreflexia, a
potentially life-threatening condition, due to the disruption of autonomic reflexes that
regulate blood pressure and other bodily functions below the level of injury. Triggers
for autonomic dysreflexia can include noxious stimuli such as bladder distention or
bowel impaction. Early recognition and intervention are critical to prevent
complications such as seizures, stroke, or cardiac arrest, and to promote better
patient outcomes. Nurses must closely monitor patients with spinal cord injury for
signs and symptoms of autonomic dysreflexia and implement appropriate
interventions promptly.

Risk factors may include

 Altered nerve function (spinal cord injury at T-8 and above)

 Bladder/bowel/skin stimulation (tactile, pain, thermal)
Possibly evidenced by

 Not applicable for risk diagnosis. A risk diagnosis is not evidenced by

signs and symptoms, as the problem has not occurred and nursing
interventions are directed at prevention.
Desired Outcomes

 The patient will recognize signs/symptoms of the syndrome.

 The patient will identify preventive/corrective measures.
 The patient will not experience episodes of dysreflexia.
Nursing Assessment and Rationales

1. Identify and monitor precipitating risk factors (bladder and bowel distension
or manipulation; bladder spasms, stones, infection; skin/tissue pressure
areas, prolonged sitting position; temperature extremes or drafts).
Visceral distention is the most common cause of autonomic dysreflexia, which is
considered an emergency. Treatment of acute episodes must be carried out
immediately (removing stimulus, treating unresolved symptoms), then interventions
must be geared toward prevention.
2. Observe for signs and symptoms of a syndrome such as changes in VS,
paroxysmal hypertension, tachycardia or bradycardia; autonomic responses:
sweating, flushing above the level of the lesion; pallor below the injury, chills,
(gooseflesh) piloerection, nasal stuffiness, severe pounding headache,
especially in occiput and frontal regions. Note associated symptoms like chest
pains, blurred vision, nausea, metallic taste, Horner’s syndrome (contraction
of the pupil, partial stasis of eyelid, enophthalmos [recession of eyeball into
the orbit], and sometimes loss of sweating over one side of the face).
Early detection and immediate intervention are essential to prevent serious
consequences and complications. Note: Average systolic BP in tetraplegic patients is
120mmHg, therefore readings of 140+ may be considered high.

3. Monitor BP frequently (every 3–5 min) during acute autonomic dysreflexia

and take action to eliminate stimulus. Continue to monitor BP at intervals after
symptoms subside.
Aggressive therapy and removal of stimulus may drop BP rapidly, resulting in a
hypotensive crisis, especially in those patients who routinely have low BP. In
addition, autonomic dysreflexia may recur, particularly if a stimulus is not eliminated.

4. Obtain urinary culture as indicated.

The presence of infection may trigger autonomic dysreflexia episodes.

Nursing Interventions and Rationales

1. Stay with the patient during an episode.

This is a potentially fatal complication. Continuous monitoring and intervention may
reduce the patient’s level of anxiety.

2. Elevate the head of the bed to a 45-degree angle or place the patient in a
sitting position.
Lowers BP to prevent intracranial hemorrhage, seizures, or even death. Note:
Placing a tetraplegic in a sitting position automatically lowers BP.

3. Eliminate causative stimulus as able such as bladder, bowel, and skin

pressure (including loosening tight leg bands or clothing, removing abdominal
binder or elastic stockings); temperature extremes.
Removing noxious stimulus usually terminates the episode and may prevent more
serious autonomic dysreflexia (in the presence of sunburn, topical anesthetic should
be applied). Removal of constrictive clothing and vascular support also promotes
venous pooling to help lower BP. Note: Removal of bowel impaction must be
delayed until the cardiovascular condition is stabilized.

4. Inform the patient and SO of warning signals and how to avoid the onset of
the syndrome (gooseflesh, sweating, piloerection may indicate full bowel;
sunburn may precipitate episode).
This lifelong problem can be largely controlled by avoiding pressure from
overdistension of visceral organs or pressure on the skin.
5. Administer medications as indicated (IV, parenteral, oral, or transdermal),
and monitor response:

 5.1. Diazoxide (Hyperstat), hydralazine (Apresoline)

Reduces BP if severe and sustained hypertension occurs.
 5.2. Nifedipine (Procardia), 2% nitroglycerin ointment (Nitrostat)
Sublingual administration is usually effective, in absence of IV access
for diazoxide (Hyperstat), but may require a repeat dose in 30 to 60
min. May be used in conjunction with topical nitroglycerin.
 5.3. Atropine sulfate
Increases heart rate if bradycardia occurs.
 5.4. Morphine sulfate
Relaxes smooth muscle to aid in lowering blood pressure and muscle
tension.
 5.5. Adrenergic blockers like methysergide maleate (Sansert)
May be used prophylactically if the problem persists and recurs
frequently.
 5.6. Antihypertensives like prazosin (Minipress),
phenoxybenzamine (Dibenzyline)
Long-term use may relax the bladder neck and enhance bladder
emptying, alleviating the most common cause of chronic autonomic
dysreflexia.
6. Apply local anesthetic ointment to the rectum; remove impaction if indicated
after symptoms subside.
Ointment blocks further autonomic stimulation and eases later removal of impaction
without aggravating symptoms.

7. Prepare the patient for a pelvic or pudendal nerve block or posterior

rhizotomy if indicated.
Procedures may be considered if autonomic dysreflexia does not respond to other
therapies.

Risk for Impaired Skin Integrity

Patients with spinal cord injury are at risk of impaired skin integrity due to prolonged
immobility, decreased sensation, and impaired circulation. This condition can lead to
the development of pressure ulcers, skin breakdown, and infections. Nurses must
closely monitor the patient’s skin for any signs of breakdown and implement
interventions such as regular repositioning, pressure-relieving devices, and
adequate nutrition to prevent further complications and promote optimal skin health.

Risk factors may include

 Altered/inadequate peripheral circulation; sensation

 Presence of edema; tissue pressure
 Altered metabolic state
 Immobility, traction apparatus
Possibly evidenced by

 Not applicable for risk diagnosis. A risk diagnosis is not evidenced by

signs and symptoms, as the problem has not occurred and nursing
interventions are directed at prevention.
Desired Outcomes

 The patient will identify individual risk factors.

 The patient will verbalize understanding of treatment needs.
 The patient will participate in the level of ability to prevent skin
breakdown.
Nursing Assessment and Rationales

1. Inspect all skin areas, noting capillary blanching and refill, redness, and
swelling. Pay particular attention to the back of the head, skin under the halo
frame or vest, and folds where skin continuously touches.
Skin is especially prone to breakdown because of changes in peripheral circulation,
inability to sense pressure, immobility, and altered temperature regulation.

2. Observe halo and tong insertion sites. Note swelling, redness, and drainage.
These sites are prone to inflammation and infection and provide a route for
pathological microorganisms to enter the cranial cavity. Note: New style of halo
frame does not require screws or pins.

Nursing Interventions and Rationales

1. Encourage continuation of regular exercise program.

Stimulates circulation, enhancing cellular nutrition and oxygenation to improve tissue
health.

2. Elevate lower extremities periodically, if tolerated.

Enhances venous return. Reduces edema formation.

3. Avoid and limit injection of medication below the level of injury.

Reduced circulation and sensation increase the risk of delayed absorption, local
reaction, and tissue necrosis.

4. Massage and lubricate the skin with bland lotion or oil. Protect pressure
points by use of heel or elbow pads, lamb’s wool, foam padding, and egg-crate
mattress. Use skin hardening agents (tincture of benzoin, Karaya, Sween
cream).
Enhances circulation and protects skin surfaces, reducing the risk of ulceration.
Tetraplegic and paraplegic patients require lifelong protection from decubitus
formation, which can cause extensive tissue necrosis and sepsis.

5. Reposition frequently, whether in bed or in a sitting position. Place in a

prone position periodically.
Improves skin circulation and reduces pressure time on bony prominences.
6. Wash and dry skin, especially in high-moisture areas such as the perineum.
Take care to avoid wetting the lining of the brace or halo vest.
Clean, dry skin is less prone to excoriation and breakdown.

7. Keep bedclothes dry and free of wrinkles, and crumbs.

Reduces or prevents skin irritation.

8. Cleanse halo or tong insertion sites routinely and apply antibiotic ointment
per protocol.
Helpful in preventing local infection and reducing the risk of cranial infection.

9. Provide kinetic therapy or an alternating-pressure mattress as indicated.

Improves systemic and peripheral circulation and decreases pressure on the skin,
reducing the risk of breakdown.

Deficient Knowledge

Patients with spinal cord injury may have deficient knowledge regarding their
condition, treatment, and self-care. The injury can be complex, and patients may
require extensive education on topics such as bowel and bladder management,
skincare, and mobility. Nurses play an important role in providing education and
resources to promote patient understanding and empowerment, leading to better
self-management and overall outcomes.

May be related to

 Lack of exposure/recall
 Information misinterpretation
 Unfamiliarity with information resources
Possibly evidenced by

 Questions; statement of misconception; request for information

 Inadequate follow-through of instruction
 Inappropriate or exaggerated behaviors, e.g., hostile, agitated,
apathetic
 Development of preventable complication(s)
Desired Outcomes

 The patient will verbalize understanding of the condition, prognosis,

and treatment.
 The patient will correctly perform necessary procedures and explain
the reasons for the actions.
 The patient will initiate necessary lifestyle changes and participate in
the treatment regimen.
Nursing Assessment and Rationales

1. Discuss the injury process, current prognosis, and future expectations.

Provide a common knowledge base necessary for making informed choices and
commitment to the therapeutic regimen. Note: Improvement in managing the effects
of SCI has increased the life expectancy of patients to only about 5 yr below the
norm for the specific age group.

2. Identify symptoms to report immediately to the healthcare provider such as

infection of any kind, especially urinary, respiratory; skin breakdown;
unresolved autonomic dysreflexia; suspected pregnancy.
Early identification allows for intervention to prevent or minimize complications.

Nursing Interventions and Rationales

1. Provide information and demonstrate:

 1.1. Positioning
Promotes circulation; reduces tissue pressure and risk of
complications.
 1.2. Use of pillow supports, and splints
Keeps the spine aligned and prevents or limits contractures, thus
improving function and independence.
2. Encourage continued participation in daily exercise and conditioning
programs and avoidance of fatigue and chills.
Reduces spasticity, and risk of thromboembolic (common complication). Increases
mobility, muscle strength, and tone for improving organ and body function such
as squeezing a rubber ball, arm exercises enhance upper body strength to increase
independence in transfers or wheelchair mobility; tightening or contracting rectum or
vaginal muscles improves bladder control; pushing abdomen up, bearing down,
contracting abdomen strengthens trunk and improves GI function (paraplegic).

3. Identify energy conservation techniques and stress the importance of

pacing activities and adequate rest. Review drug regimen note use of baclofen
(Lioresal), diazepam (Valium), tizanidine (Zanaflex).
Fatigue is common and limits patients’ ability to participate in and manage care,
decreasing quality of life and increasing feelings of helplessness or hopelessness.
Medications used to treat spasticity can exacerbate fatigue, necessitating a change
in drug choice/dosage. Note: Amantadine (Symmetrel) and fluoxetine (Prozac) may
decrease a sense of fatigue by potentiating the action of dopamine or selectively
inhibiting serotonin uptake in the CNS.

4. Have SO and caregivers participate in patient care and demonstrate proper

procedures such as applications of splints, braces, suctioning, positioning,
skin care, transfers, bowel and bladder program, and checking the
temperature of bath water and food.
Allows home caregivers to become adept and more comfortable with the care tasks
they are called on to provide, and reduces the risk of injury and complications.
5. Instruct caregiver in techniques to facilitate cough as appropriate.
“Quad coughing” is performed to facilitate the expectoration of secretions or to move
them high enough to be suctioned out.

6. Recommend applying abdominal binder before arising (tetraplegic) and

remind to change position slowly. Use a safety belt and an adequate number
of people during bed-to-wheelchair transfers.
Reduces pooling of blood in the abdomen and pelvis, minimizing postural
hypotension. Protects patient from falls and injury to caregivers.

7. Instruct in proper skin care, inspecting all skin areas daily, using adequate
padding (foam, silicone gel, water pads) in bed and chair, and keeping skin
dry. Stress the importance of regularly monitoring the condition and
positioning of support surfaces (cushions, mattresses, and overlays).
Reduces skin irritation, decreasing incidence of decubitus (patient must manage this
throughout life). Timely recognition of product fatigue, improper orientation, or other
misuses can reduce the risk of pressure ulcer formation.

8. Discuss the necessity of preventing excessive diaphoresis by using tepid

bath water, providing a comfortable environment (fans), and removing excess
clothes.
Reduces skin irritation and possible breakdown.

9. Review dietary needs, including adequate bulk and roughage. Problem-

solve solutions to alterations in muscular strength and tone and GI function.
Provides adequate nutrition to meet energy needs and promote healing, and prevent
complications (constipation, abdominal distension, and gas formation).

10. Review pain management techniques. Discuss the potential for future pain
management therapies if the pain becomes chronic. Recommend avoidance of
over-the-counter (OTC) drugs without the approval of the healthcare provider.
Enhances patient safety and may improve cooperation with specific regimens. Note:
Pain often becomes chronic in patients with spinal cord injury and may be
mechanical (overuse syndrome involving joints); radicular (from injury to peripheral
nerves); or cervical (burning, aching just below the level of injury). Dysesthetic pain
(distal to the site of injury) is extremely disabling (similar to phantom pain).
Treatment for these painful conditions may include a team pain management
approach, medications (Neurontin, Klonopin, Elavil), or electrical stimulation.

11. Discuss ways to identify and manage autonomic dysreflexia.

Patients may be able to recognize signs, but caregivers need to understand how to
prevent precipitating factors and know what to do if autonomic dysreflexia occurs.

12. Stress the importance of continuing with the rehabilitation team to achieve
specific functional goals and continue long-term monitoring of therapy needs.
No matter what the level of injury, the individual may ultimately be able to exercise
some independence like manipulating an electric wheelchair with a mouth stick (C-3,
C-4); being independent in dressing, transferring to bed, car, toilet (C-7); or
achieving total wheelchair independence (C-8 to T-4). Over time, new discoveries
continue to modify equipment or therapy needs and increase patients’ potential.

13. Evaluate the home layout and make points for necessary changes. Identify
equipment and medical supply needs and resources.
Physical changes may be required to accommodate patients and support equipment.
Prior arrangements facilitate the transfer to the home setting.

14. Discuss sexual activity and reproductive concerns. Review alternative

sexual activities and positions, and spasticity management as indicated
(opposing pressure on the area of spasm, using pillows for support, regular
stretching and ROM exercises, and appropriate medications).
Concerns about individual sexuality and resumption of activity are frequently
unspoken concern that needs to be addressed. Spinal cord injury affects all areas of
sexual functioning. In addition, the choice of contraception is impacted by the level of
spinal cord injury and side effects or adverse complications of a specific method.
Finally, some female patients may develop autonomic dysreflexia during intercourse
or labor/delivery.

15. Identify community resources such as health agencies, visiting nurses,

financial counselors; service organizations, and Spinal Cord Injury
Foundation.
Enhances independence, assisting with home management and providing respite for
caregivers.

16. Coordinate cooperation among community and rehabilitation resources.

Various agencies, therapists, and individuals in the community may be involved in
the long-term care and safety of patients, and coordination can ensure that needs
are not overlooked and an optimal level of rehabilitation is achieved. Note:
Individuals with SCI are living longer, and more injuries are occurring at advanced
ages, creating new challenges in care as SCI patients deal with the effects of aging.

17. Arrange for a transmitter and emergency call system.

Provides for safety and access to emergency assistance and equipment.

18. Plan for alternate caregivers as needed.

May be needed to provide respite if regular caregivers are ill or other unplanned
emergencies arise.