NCP Spinal Cord Injury (Acute Rehabilitative Phase)

The leading causes of spinal cord injury (SCI) include motor vehicle crashes, falls, acts of violence, and sporting injuries. The mechanism of injury influences the type of SCI and the degree of neurological deficit. Spinal cord lesions are classified as a complete (total loss of sensation and voluntary motor function) or incomplete (mixed loss of sensation and voluntary motor function).

Physical findings vary, depending on the level of injury, degree of spinal shock, and phase and degree of recovery, but in general, are classified as follows:

C-1 to C-3: Tetraplegia with total loss of muscular/respiratory function.
C-4 to C-5: Tetraplegia with impairment, poor pulmonary capacity, complete dependency for ADLs.
C-6 to C-7: Tetraplegia with some arm/hand movement allowing some independence in ADLs.
C-7 to T-1: Tetraplegia with limited use of thumb/fingers, increasing independence.
T-2 to L-1: Paraplegia with intact arm function and varying function of intercostal and abdominal muscles.
L-1 to L-2 or below: Mixed motor-sensory loss; bowel and bladder dysfunction.

CARE SETTING

Inpatient medical/surgical and subacute/rehabilitation units.

RELATED CONCERNS

Disc surgery
Fractures
Pneumonia: microbial
Psychosocial aspects of care
Thrombophlebitis: deep vein thrombosis
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding
Ventilatory assistance (mechanical)

Patient Assessment Database

ACTIVITY/REST
May exhibit: Paralysis of muscles (flaccid during spinal shock) at/below level of lesion
Muscle/generalized weakness (cord contusion and compression)

CIRCULATION
May report: Palpitations
Dizziness with position changes
May exhibit: Low BP, postural BP changes, bradycardia
Cool, pale extremities
Absence of perspiration in affected area

ELIMINATION
May exhibit: Incontinence of bladder and bowel
Urinary retention
Abdominal distension; loss of bowel sounds
Melena, coffee-ground emesis/hematemesis

EGO INTEGRITY
May report: Denial, disbelief, sadness, anger
May exhibit: Fear, anxiety, irritability, withdrawal

FOOD/FLUID
May exhibit: Abdominal distension; loss of bowel sounds (paralytic ileus)

HYGIENE
May exhibit: Variable level of dependence in ADLs

NEUROSENSORY
May report: Absence of sensation below area of injury, or opposite side sensation
Numbness, tingling, burning, twitching of arms/legs
May exhibit: Flaccid paralysis (spasticity may develop as spinal shock resolves, depending on area of cord involvement)
Loss of sensation (varying degrees may return after spinal shock resolves)
Loss of muscle/vasomotor tone
Loss of/asymmetrical reflexes, including deep tendon reflexes
Changes in pupil reaction, ptosis of upper eyelid
Loss of sweating in affected area

PAIN/DISCOMFORT
May report: Pain/tenderness in muscles
Hyperesthesia immediately above level of injury
May exhibit: Vertebral tenderness, deformity

RESPIRATION
May report: Shortness of breath, “air hunger,” inability to breathe
May exhibit: Shallow/labored respirations; periods of apnea
Diminished breath sounds, rhonchi
Pallor, cyanosis

SAFETY
May exhibit: Temperature fluctuations (taking on temperature of environment)
SEXUALITY
May report: Expressions of concern about return to normal functioning
May exhibit: Uncontrolled erection (priapism)
Menstrual irregularities

TEACHING/LEARNING
Discharge plan
DRG projected mean length of inpatient stay: 17.1–90 days (inclusive of inpatient rehabilitation)

Will require varying degrees of assistance with transportation, shopping, food preparation,
self-care, finances, medications/treatment, and homemaker/maintenance tasks

May require changes in physical layout of home and/or placement in a rehabilitative center
Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES
Spinal x-rays: Locates level and type of bony injury (fracture, dislocation); determines alignment and reduction after traction or surgery.
CT scan: Locates injury, evaluates structural alterations. Useful for rapid screening and providing additional information if x-rays questionable for fracture/cord status.
MRI: Identifies spinal cord lesions, edema, and compression.
Myelogram: May be done to visualize spinal column if pathology is unclear or if occlusion of spinal subarachnoid space is suspected (not usually done after penetrating injuries).
Somatosensory evoked potentials (SEP): Elicited by presenting a peripheral stimulus and measuring degree of latency in cortical response to evaluate spinal cord functioning/potential for recovery.
Chest x-ray: Demonstrates pulmonary status (e.g., changes in level of diaphragm, atelectasis).
Pulmonary function studies (vital capacity, tidal volume): Measures maximum volume of inspiration and expiration; especially important in patients with low cervical lesions or thoracic lesions with possible phrenic nerve and intercostal muscle involvement.
ABGs: Indicates effectiveness of gas exchange and ventilatory effort.

NURSING PRIORITIES

1. Maximize respiratory function.
2. Prevent further injury to spinal cord.
3. Promote mobility/independence.
4. Prevent or minimize complications.
5. Support psychological adjustment of patient/SO.
6. Provide information about injury, prognosis and expectations, treatment needs, possible and preventable complications.

DISCHARGE GOALS

1. Ventilatory effort adequate for individual needs.
2. Spinal injury stabilized.
3. Complications prevented/controlled.
4. Self-care needs met by self/with assistance, depending on specific situation.
5. Beginning to cope with current situation and planning for future.
6. Condition/prognosis, therapeutic regimen, and possible complications understood.
7. Plan in place to meet needs after discharge.