Student Nurses’ Community

NURSING CARE PLAN – Spinal Cord Injury

ASSESSMENT DIAGNOSIS INFERENCE PLANNING INTERVENTION RATIONALE EVALUATION
Independent:
SUBJECTIVE: Impaired Spinal cord After 8 hours of • Continually asses • Evaluates status of After 8 hours of
physical injury may result nursing motor function (as individual situation nursing
“Hindi ako mobility related from trauma, interventions, the spinal shock or edema (motor-sensory interventions, the
makagalaw” (I to vascular patient will resolves) by impairment may be patient was able
can’t move) as neuromascular disruption, demonstrate requesting patient to mixed and/ or not to demonstrate
verbalized by the impairment. infection, tumor, techniques or perform certain clear) for a specific techniques or
patient. and other insults. behaviors that actions. level of injury, behaviors that
The injury may be enable affecting type and enable
OBJECTIVE: partial or resumption of choice of intervention. resumption of
complete and activity. activity.
 Paralysis vary from a mild • Provide means to • Enables patient to
 Muscle cord concussion summon help. have sense of control,
atrophy with transient and reduces fear of
 Irritability numbness to being left alone.
 V/S taken as complete cord
follows: transaction • Assist in range of • Enhances circulation,
causing motion exercises on all restores or maintains
T: 37.3 immediate and extremities and joints, muscle tone and joint
P: 92 permanent using slow, smooth mobility, and prevent
R: 19 tetraplegia. The movements. disuse contractures
BP: 120/80 most common and muscle atrophy.
sites of injury are
the cervical areas • Plan activities to • Prevents fatigue,
C5, C6, and C7,
provide uninterrupted allowing opportunity
and the junction
rest periods. for maximal efforts or
of the thoracic
Encourage participations by
and lumbar
involvement within patient.
vertebrae, T12
individual tolerance or
and L1. Clinical
ability.
manifestations
• Reposition periodically • Reduces pressure
vary with the
location and even when sitting in areas, promotes
severity of cord chair. Teach patient peripheral circulation.
damage. In how to use weight-
general, complete shifting techniques.
transaction
Student Nurses’ Community

causes loss of all • Inspect the skin daily. • Altered circulation,

function below Observe for pressure loss of sensation, and
the level of lesion, areas, and provide paralysis potentiate
and incomplete meticulous skin care. pressure sore
cord damage formation.
results in a
variety of regional Collaborative:
deficits. • Consult with physical • Helpful in planning
Complications or occupational and implementing
include shock, therapist. individualized
respiratory or exercise program and
cardiac arrest, identifying or
thromboembolism developing assistive
, infections, and devices to maintain
autonomic function, enhance
dysreflexia. mobility and
independence.

• Administer muscle • May be useful in

relaxants or limiting or reducing
antispasticity as pain associated with
prescribed. spasticity