Conditions › Neurological
Spinal Cord Injury Nursing Care Plan and Interventions
Spinal cord injury nursing care starts with the airway (jaw thrust, not head tilt), keeping the spine aligned and log rolling. Injuries at C3 to C5 threaten breathing, neurogenic shock causes low BP with a slow pulse, and autonomic dysreflexia is a medical emergency to treat by sitting the client up and finding the trigger.
Spinal cord injury nursing care plan
| Nursing problem | Goal | Key interventions |
|---|---|---|
| Ineffective breathing pattern | Airway kept open; SpO2 and cough strength monitored and stable. | |
| Risk for further injury to the cord | Spine stays aligned during every move. | |
| Risk for decreased cardiac output (neurogenic shock, autonomic dysreflexia) | BP and HR in range; dysreflexia recognized and treated at once. | |
| Impaired urinary and bowel elimination; risk for skin breakdown | Bladder and bowel program in place; skin intact. |
Problem wording is plain-language nursing diagnosis style. Your program may require NANDA-I labels and your own assessment data.
What it is
Spinal cord injury (SCI)
Damage to the cord blocks signals below the injury. Complete: all movement and feeling lost below it. Incomplete: some are kept. 1,2
Function above the injury level stays. Below it, function is lost or weak.
The level decides function
The higher the injury, the more is lost. Cervical: tetraplegia (arms, trunk, legs). Thoracic or lower: paraplegia, arms spared. 3,2
Bladder and bowel control are often lost at any level.
C3, 4, 5 keeps the diaphragm alive
The phrenic nerve to the diaphragm leaves the cord at C3 to C5. At or above C5, breathing can fail; at or above C3, often a ventilator. 4,2
In any cervical injury, assess breathing first and keep reassessing.
Assessment: what you will see
Weak cough, shallow breaths
Lower injuries weaken chest and belly muscles too: low lung volume, a weak cough and dyspnea. Secretions pool, so pneumonia follows. 5,2
Report breathing that turns fast and shallow, or a cough too weak to clear secretions.
Spinal shock
Right after injury: flaccid paralysis, no reflexes, no feeling, and no bladder or bowel control below the injury. It is temporary. 5,2
Returning reflexes and spasticity mean spinal shock is ending, not that the cord has healed.
Complications and red flags
Neurogenic shock
A cervical or upper thoracic injury cuts sympathetic tone. Vessels dilate and nothing speeds the heart: low BP, slow HR, warm, dry skin. 5
Other shocks speed the heart up. Low BP with bradycardia after SCI points here.
Autonomic dysreflexia (AD)
Injury at T6 or above: a trigger below the injury, such as a full bladder, sends BP dangerously high with a pounding headache. 2,6
Sit the client up, find and remove the trigger, and check BP at least every 5 minutes.
Priority: what the nurse does first
Airway with a neck injury
Open the airway with a jaw thrust, not a head tilt. Keep the head and neck in line, even during intubation. 2
Bending or extending an unstable neck can bruise or cut the cord.
Protect the cord
Rigid cervical collar and a firm, flat surface until the spine is cleared. Prevent low BP and low oxygen, which harm the injured cord. 2
Keep the SpO2 at 90% or higher to protect the cord.
Log roll
Turn the client as one unit, keeping the head, neck and spine in line. No bending, lifting or twisting of the spine. 7
Use the log roll every time you examine, turn or move the client.
Nursing interventions and treatment
Treating neurogenic shock
IV fluids first, then vasopressors, to a MAP of 85 to 90 mm Hg. Atropine for bradycardia. Listen to the lungs for fluid overload. 5
Suctioning can slow the heart even more: keep atropine at hand.
Prevent immobility complications
Pressure injuries, DVT, pneumonia and UTI. Turn at least every 2 hours, give DVT prophylaxis, and inspect the skin often. 2,5
The client can't feel pressure below the injury, so you check the skin.
Neurogenic bladder and bowel
The bladder often retains urine: intermittent catheterization drains it. A timed bowel program with laxatives prevents constipation. 2,5
Long term, teach clean self-catheterization. A full bladder can trigger autonomic dysreflexia.
Halo vest care
Keep the wrench taped to the front of the vest so it can come off fast in an emergency. Never lift or move the client by the halo or vest. 8,6,9
Clean pin sites as ordered. Report redness, drainage or a loose pin; the provider retightens pins.
Meds after SCI
Baclofen or tizanidine ease spasticity. High-dose steroids are no longer routine for an acute SCI. 2
Older texts teach steroids for every SCI; current guidance does not.
Client teaching
Coping and rehab
Depression after losing control of the body is common. Involve family and a rehab team; teach skin, bladder, bowel and AD care. 2
Rehab teaches the client how to control spasticity and autonomic dysreflexia.
NCLEX traps
Spinal vs neurogenic shock
Spinal shock is a nerve problem: flaccid, no reflexes. Neurogenic shock is a circulation problem: low BP and a slow heart rate. 5
Spinal shock can follow injury at any level. Neurogenic shock needs a high injury.
Try a spinal cord injury question
NCLEX-style, approved by a licensed RN. Pick an answer, check it, then read the rationale.
Question 1 · Physiological Adaptation
A client with a T4 spinal cord injury has a blood pressure of 78/50 mmHg and a heart rate of 52/min. The skin is warm and dry. Which type of shock does the nurse suspect?
Show answer and rationale
Answer: C. Neurogenic shock occurs after spinal cord injury due to loss of sympathetic tone, producing the hallmark combination of hypotension with bradycardia and warm, dry skin from vasodilation. Cardiogenic shock typically presents with tachycardia, cool clammy skin, and signs of pump failure, not bradycardia with warm skin. Hypovolemic shock causes tachycardia and cool, pale skin as the body compensates for volume loss. Septic shock in its early stage also causes tachycardia and warm skin, but bradycardia is not a feature.
Checked against: OpenStax Medical-Surgical Nursing, 23.4
Keep studying spinal cord injury in NurseLingo Pro
Pro has 30 spinal cord injury questions like these, with a rationale for every answer. Everything for spinal cord injury in one place. A free account gets 5 free opens of any condition; Pro opens all 277.
Test yourself: free med-surg practice questions with answers and rationales.
Frequently asked questions
What are the priority nursing diagnoses for spinal cord injury?
Common nursing problems for spinal cord injury include ineffective breathing pattern; risk for further injury to the cord; risk for decreased cardiac output (neurogenic shock, autonomic dysreflexia); impaired urinary and bowel elimination; risk for skin breakdown. Choose the ones your assessment supports and rank airway, breathing and circulation problems first.
What does the nurse do first for spinal cord injury?
Open the airway with a jaw thrust, not a head tilt. Keep the head and neck in line, even during intubation. Rigid cervical collar and a firm, flat surface until the spine is cleared. Prevent low BP and low oxygen, which harm the injured cord. Turn the client as one unit, keeping the head, neck and spine in line. No bending, lifting or twisting of the spine.
Which complication results from a spinal cord injury at the level of C4?
Breathing is the big risk. The nerves that run the diaphragm leave the spinal cord at C3 to C5 ("C3, 4, 5 keeps the diaphragm alive"), so an injury at C4 can weaken or stop breathing. Expect close monitoring of respiratory effort, SpO2 and cough strength, and possible ventilator support.
More neurological
Related cheat sheets
Sources
- OpenStax Medical-Surgical Nursing, 17.9
- merckmanuals.com
- OpenStax Fundamentals of Nursing, 23.2
- OpenStax Clinical Nursing Skills, 26.1
- OpenStax Medical-Surgical Nursing, 23.4
- pmc.ncbi.nlm.nih.gov
- OpenStax Medical-Surgical Nursing, 17.8
- ncbi.nlm.nih.gov
- OpenStax Clinical Nursing Skills, 9.5
For study only, not medical advice. Follow your program, your facility's policies and the provider's orders.