eNursing Care Plan 60-1

Patient with a Spinal Cord Injury

Nursing Diagnosis*
Impaired Breathing
Etiology: Respiratory muscle fatigue, neuromuscular paralysis, retained secretions
Supporting data: Decreased vital capacity, alterations in depth of breathing, decreased
tidal volume, decreased minute ventilation, poor cough, diminished breath sounds

Patient Goals
1. Maintains adequate ventilation
2. Has no signs of respiratory distress

Outcomes (NOC) Interventions (NIC) and Rationales

Respiratory Status
 Respiratory rate _____
 Respiratory rhythm _____
 Depth of respiration _____
 Auscultated breath sounds
_____
 Tidal volume _____
 Achievement of expected
incentive spirometer _____
 Vital capacity_____
 O2 saturation _____
 Pulmonary function tests _____
Measurement Scale
1 = Severe deviation from normal
range
2 = Substantial deviation from
normal range
3 = Moderate deviation from normal
range
4 = Mild deviation from normal
range
5 = No deviation from normal range
Respiratory Monitoring
 Monitor rate, rhythm, depth, and effort of
respirations to note baseline and changes in status.
 Monitor for diaphragmatic muscle fatigue, as
indicated by paradoxical motion, to identify need
for ventilation assistance.
 Auscultate for crackles and rhonchi over major
airways to determine need for suctioning.
 Note changes in SaO2, SvO2, end-tidal CO2, and
ABG values.
 Monitor PFT values, particularly vital capacity,
maximal inspiratory force, and forced expiratory
volume, to identify hypoventilation requiring
mechanical ventilation.
 Monitor patient’s ability to cough effectively to
identify need for suctioning.
Airway Management
 Identify patient requiring actual/potential airway
insertion to ensure timely intervention.
 Perform endotracheal or nasotracheal suctioning to
stimulate coughing and to clear respiratory -
secretions.

*Nursing diagnoses listed in order of priority.

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eNursing Care Plan 60-2

Nursing Diagnosis
Impaired Skin Integrity
Etiology: Skull tong placement, immobility, and/or poor tissue perfusion
Supporting data: Open tong sites and reddened skin over bony prominences

Patient Goals
1. Has no signs of infection at skull tong sites
2. Maintains intact skin over bony prominences

Outcomes (NOC) Interventions (NIC) and Rationales

Tissue Integrity: Skin
and Mucous Membranes
 Skin lesions _____
 Erythema _____
 Necrosis _____
 Induration_____
 Blanching _____
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
Skin Surveillance
 Monitor for sources of pressure and friction to identify
areas at risk for breakdown.
 Monitor for infection at open tong sites to promote early
detection and treatment.
Infection Control
 Ensure appropriate wound care technique to prevent
bacterial colonization at tong sites.
Pressure Management
 Monitor skin for areas of redness and breakdown so that
interventions can be initiated promptly if a problem
develops.
 Place on an appropriate therapeutic mattress/bed to
relieve pressure.
 Use appropriate devices to keep heels and bony
prominences off the bed.
 Facilitate small shifts of body weight to relieve pressure
without disrupting traction.
 Monitor the patient’s nutritional status to maintain
healthy skin resistant to breakdown.

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eNursing Care Plan 60-3

Nursing Diagnosis
Constipation
Etiology: Neurogenic bowel, inadequate fluid intake, diet low in roughage, immobility
Supporting data: Lack of bowel movement for more than 2 days, decreased bowel
sounds, palpable impaction, hard stool, stool incontinence

Patient Goals
1. Establishes a bowel management program based on neurologic function and personal
preference
2. Maintains a bowel movement no less than every other day

Outcomes (NOC) Interventions (NIC) and Rationales

Bowel Elimination
 Elimination pattern _____
 Control of bowel movements
_____
 Stool soft and formed _____
 Ease of stool passage _____
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
Bowel Management
 Monitor bowel movements, including frequency,
consistency, shape, volume, and color, to establish
baseline function.
 Monitor bowel sounds to determine if peristalsis is
present.
 Teach patient foods high in fiber because bulk and
fiber are necessary to the success of a bowel
program.
 Initiate a bowel training program to establish a
bowel routine as quickly as possible.

Nursing Diagnosis
Impaired Urinary System Function
Etiology: Spinal injury, limited fluid intake
Supporting data: Urinary retention, bladder distention, involuntary emptying of bladder
(after spinal shock)

Patient Goal
Establishes a bladder management program based on neurologic function, caregiver
status, and lifestyle choices

Outcomes (NOC) Interventions (NIC) and Rationales

Urinary Elimination
 Urinary retention _____
 Urinary incontinence _____
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
Urinary Retention Care
 Monitor intake and output to evaluate fluid balance.
 Monitor degree of bladder distention by palpation and
percussion because loss of autonomic and reflex
control of bladder and sphincter can cause urinary
retention.
 Insert urinary catheter to relieve urinary retention in
spinal shock.

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eNursing Care Plan
4 = Mild
5 = None
Nursing Diagnosis
Risk for Injury
Risk factors: Autonomic dysreflexia
Patient Goals
1. Has no episodes of dysreflexia
2. Describes causes, prevention, symptoms, and management of dysreflexia
Outcomes (NOC)
Neurologic Status: Autonomic
 Apical heart rate _____
 Systolic blood pressure _____
 Diastolic blood pressure _____
 Bowel elimination pattern
_____
 Urinary elimination pattern
_____
Measurement Scale
1 = Severely compromised
2 = Substantially compromised
3 = Moderately compromised
4 = Mildly compromised
5 = Not compromised
 Headaches _____
 Dysreflexia _____
Measurement Scale
1 = Severe
2 = Substantial
3 = Moderate
4 = Mild
5 = None
Nursing Diagnosis
Difficulty Coping
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60-4
 Implement intermittent catheterization in postacute
phase of spinal cord injury to maintain bladder tone
and avoid infection associated with long-term use of
indwelling catheter.
 Refer to urinary continence specialist to establish long-
term bladder management program.
Interventions (NIC) and Rationales
Dysreflexia Management
 Identify and minimize stimuli that may precipitate
dysreflexia (e.g., bladder distention, renal calculi,
infection, fecal impaction, rectal examination,
suppository insertion, skin breakdown, and
constrictive clothing or bed linen) to prevent
occurrence.
 Monitor for signs and symptoms of autonomic
dysreflexia to recognize occurrence and initiate
treatment.
 Investigate and remove offending cause (e.g.,
distended bladder, fecal impaction, skin lesions, and
constricting bed clothes) to reverse occurrence.
 Place head of bed in upright position to reduce
blood pressure and promote cerebral venous
return.
 Stay with patient and monitor status every 3-5
minutes if hyperreflexia occurs.
 Administer antihypertensive agents intravenously,
as ordered, to reduce blood pressure.
 Instruct patient and caregiver(s) about causes,
symptoms, treatment, and prevention of dysreflexia
to reverse occurrence and prevent occurrence of
status epilepticus, stroke, and possible death.
eNursing Care Plan 60-5

Etiology: Loss of control over body functions and altered lifestyle secondary to paralysis
Supporting data: States inability to cope, expression of anger or other negative feelings,
refusal to discuss changes in function and/or participate in social contacts

Patient Goals
1. Reports ability to cope with effects of spinal cord injury
2. Expresses feelings of grief in adapting to losses related to chronic condition

Outcomes (NOC) Interventions (NIC) and Rationales

Coping
 Identifies effective coping
patterns _____
 Identifies ineffective coping
patterns _____
 Verbalizes sense of control
_____
 Verbalizes acceptance of
situation _____
 Modifies lifestyle to reduce
stress _____
 Uses personal support system
_____
 Uses effective coping strategies Support use of appropriate coping mechanisms.
_____
 Reports decrease in negative
feelings _____
Measurement Scale
1 = Never demonstrated
2 = Rarely demonstrated
3 = Sometimes demonstrated
4 = Often demonstrated
5 = Consistently demonstrated
ABG, Arterial blood gas; PFT, pulmonary function test; SaO2, arterial oxygen saturation;
SvO2, venous oxygen saturation.
Coping Enhancement
 Assess patient’s adjustment to changes in body
image.
 Assess the impact of patient’s life situation on roles
and relationships.
 Provide an atmosphere of acceptance.
 Encourage verbalization of feelings, perceptions,
and fears to aid patient in clarifying feelings.
 Provide factual information concerning diagnosis,
treatment, and prognosis because knowledge of
expectations can help patient cope with the future.
 Provide patient with realistic choices about certain
aspects of care.
 Assist patient to identify positive strategies to deal
with limitations and manage needed lifestyle or role
changes to prevent patient from practicing
ineffective behaviors such as smoking, drinking, or
angry outbursts.
 Encourage family involvement to enhance patient’s
sense of worth and value as a person.
 Assist patient to grieve and work through the losses
resulting from chronic illness and/or disability
because spinal cord injury results in a real loss,
which requires adjustment through grieving.

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