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Nursing Care Plan for Spinal Cord Injury

This nursing care plan addresses a patient with a spinal cord injury resulting in impaired physical mobility. The plan assesses paralysis, muscle atrophy, and irritability in the patient who reported "I can't move." Spinal cord injuries can be caused by trauma, vascular issues, infection, tumors or other insults, and may result in partial or complete paralysis depending on the location and severity of damage. The plan aims to have the patient demonstrate resumption of activity techniques within 8 hours through interventions like range of motion exercises, skin inspection, consulting therapists, and muscle relaxants to address complications and improve mobility.

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Dan Leo Unico
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345 views3 pages

Nursing Care Plan for Spinal Cord Injury

This nursing care plan addresses a patient with a spinal cord injury resulting in impaired physical mobility. The plan assesses paralysis, muscle atrophy, and irritability in the patient who reported "I can't move." Spinal cord injuries can be caused by trauma, vascular issues, infection, tumors or other insults, and may result in partial or complete paralysis depending on the location and severity of damage. The plan aims to have the patient demonstrate resumption of activity techniques within 8 hours through interventions like range of motion exercises, skin inspection, consulting therapists, and muscle relaxants to address complications and improve mobility.

Uploaded by

Dan Leo Unico
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Student Nurses Community

NURSING CARE PLAN Spinal Cord Injury


ASSESSMENT

SUBJECTIVE:
Hindi ako
makagalaw (I
cant move) as
verbalized by the
patient.
OBJECTIVE:

Paralysis
Muscle
atrophy
Irritability
V/S taken as
follows:
T: 37.3
P: 92
R: 19
BP: 120/80

DIAGNOSIS

SCIENTIFIC
RATIONALE

PLANNING

Impaired
physical
mobility related
to
neuromascular
impairment.

Spinal cord
injury may result
from trauma,
vascular
disruption,
infection, tumor,
and other insults.
The injury may be
partial or
complete and
vary from a mild
cord concussion
with transient
numbness to
complete cord
transaction
causing
immediate and
permanent
tetraplegia. The
most common
sites of injury are
the cervical areas
C5, C6, and C7,
and the junction
of the thoracic
and lumbar
vertebrae, T12
and L1. Clinical
manifestations
vary with the
location and
severity of cord
damage. In

After 8 hours of
nursing
interventions, the
patient will
demonstrate
techniques or
behaviors that
enable
resumption of
activity.

INTERVENTION
Independent:
Continually asses
motor function (as
spinal shock or edema
resolves) by
requesting patient to
perform certain
actions.

RATIONALE

Evaluates status of
individual situation
(motor-sensory
impairment may be
mixed and/ or not
clear) for a specific
level of injury,
affecting type and
choice of intervention.

Provide means to
summon help.

Enables patient to
have sense of control,
and reduces fear of
being left alone.

Assist in range of
motion exercises on all
extremities and joints,
using slow, smooth
movements.

Enhances circulation,
restores or maintains
muscle tone and joint
mobility, and prevent
disuse contractures
and muscle atrophy.

Plan activities to
provide uninterrupted
rest periods.
Encourage
involvement within
individual tolerance or
ability.
Reposition periodically
even when sitting in
chair. Teach patient
how to use weightshifting techniques.

Prevents fatigue,
allowing opportunity
for maximal efforts or
participations by
patient.

Reduces pressure
areas, promotes
peripheral circulation.

EVALUATION

After 8 hours of
nursing
interventions,
the patient was
able to
demonstrate
techniques or
behaviors that
enable
resumption of
activity.

Student Nurses Community


general, complete
transaction
causes loss of all
function below
the level of lesion,
and incomplete
cord damage
results in a
variety of regional
deficits.
Complications
include shock,
respiratory or
cardiac arrest,
thromboembolism
, infections, and
autonomic
dysreflexia.

Inspect the skin daily.


Observe for pressure
areas, and provide
meticulous skin care.

Collaborative:
Consult with physical
or occupational
therapist.

Administer muscle
relaxants or
antispasticity as
prescribed.

Altered circulation,
loss of sensation, and
paralysis potentiate
pressure sore
formation.

Helpful in planning
and implementing
individualized
exercise program and
identifying or
developing assistive
devices to maintain
function, enhance
mobility and
independence.

May be useful in
limiting or reducing
pain associated with
spasticity

Student Nurses Community

Factors :
Trauma , Vascular disruption , infection, tumor and other insults.
mild cord concussion
transient numbness to complete cord transaction
limited movement of the hands, fingers and arms, or absolutely no movement at all.
complete transaction causes loss of all function below the level of lesion, and incomplete cord damage
variety of regional deficits

Complications include shock, respiratory or cardiac arrest, thromboembolism, infections, and autonomic dysreflexia.

most common sites of injury are the cervical areas C5, C6, and C7, and the junction of the thoracic and lumbar vertebrae

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