Nursing Care Plan for SCI

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: The patient Deficient fluid After 8 hours of nursing Assessed airway and breathing status such After 8 hours of nursing intervention:
manifests confusion and volume related to intervention, the patient will as respiratory rate, and breath sounds.
weakness; and also states active fluid loss from be able to: Rationale: to anticipate intubation and Goal met. Pt’s HGB was 14
that he has no capability to provision of positive airway pressure or high
gunshot wounds.
move. - Pt’s HGB will be flow oxygen. Goal not met. The patient was not able to
greater or equal to void in sufficient quantity without
Objective: 14 Assessed for circulation through experiencing palpable bladder distention.
- BP: BP 90/62 mmHg - Pt’s input will be assessment of the following pulse pressure,
- PR: 121 bpm equal to output pulse rate, blood pressure, and color and Goal not met. Pt manifests adequate fluid
- RR: 35 bpm - Pt will maintain fluid texture of the skin. volume as evidenced by stable vital
- Temperature: 35 °C volume at a Rationale: is to determine for any signs, good skin turgor, capillary refill
- Pt looks pale, functional level as circulatory collapse or signs and symptoms less than 2, moist mucous membranes
diaphoretic, mucous evidenced by stable of shock. and adequate urinary output with normal
membranes are dry vital signs, good specific gravity.
- Pt urine output is 20 skin turgor, good Monitored ECG for any changes
mL/hour capillary refill, moist Rationale: An ECG will reveal sinus
- Pt has pooling of mucous tachycardia during massive bleeding as a
sanguineous membranes and compensatory mechanism.
drainage over the adequate urinary
wound stressing output with normal Assessed for neurologic status such as
specific gravity. GCS and PERRLA every 15 mins
Laboratory Exams Rationale: to anticipate provision of et tube
- Hgb 7.4 placement, if the client is not capable of
- Hct: 35% breathing on their own due to the injury
caused within the spine.

Monitored CVP and observed for

temperature elevation and orthostatic
hypotension.
Rationale: CVP measurements are helpful
in determining the degree of fluid deficit and
response to fluid replacement therapy.
Fever also indicates increase in cellular
metabolism and can exacerbates fluid loss
 Monitored for a sudden or marked elevation
of blood pressure, dyspnea, basilar
crackles, frothy sputum, moist cough, and
restlessness.
Rationale: To determine for any
cardiopulmonary problem related to rapid
infusion of fluid, especially if colloids are
used in general fluid replacement.

Administered 2 units of Packed Red Blood

Cells as per MD order and HGB will be
rechecked 1 hour after transfusion has
completed.
Rationale: to improve persian and correct
blood loss

Started administration of Normal Saline IV

at 150 cc/hr for 24 hours per MD order and
mucous membranes will be reassessed
within 24 hours.

Maintain a high-flow oxygen

Rationale: to maximize oxygenation

Provided safety precautions, as indicated,

such as the use of side rails when
appropriate, bed in low position, frequent
observation, and soft restraints if required.
Rationale: Decreased cerebral perfusion
frequently results in changes in mentation or
altered thought process, requiring protective
measures to prevent client injury.

Nursing Care Plan for SCI client

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
Subjective: The patient Risk for Autonomic After 8 hours of nursing Identify and monitor precipitating risk factors (bladder After 8 hours of nursing
verbalizes difficulty to void Dysreflexia intervention, the patient and bowel distension or manipulation). intervention:
for almost an hour will be able to: Rationale: Visceral distention is the most common
accompanied with pounding cause of autonomic dysreflexia, which is considered Goal met. Prevented
headache and blurry vision - Prevent an emergency. complications such as seizure
associated and fall
Objective: complication Observe signs and symptoms of syndrome such as
- Flushed face such as seizure changes in VS, paroxysmal hypertension, sweating, Goal met. Patient and SO
- BP: 120/80 mmHg by means of flushing above level of lesion; pallor below injury, verbalizes numerous signs and
- PR: 80 bpm maintaining his severe pounding headache, especially in occipital and symptoms associated with
- RR: 20 bpm treatment frontal regions. autonomic dysreflexia
- Temperature: 35 °C regimen Rationale: Early detection and immediate intervention
- Pt urine output is 8 - recognize is essential to prevent serious consequences and Goal met: Able to identify the
mL/hour signs/symptoms complications. cause of the predisposing risk
of syndrome.. factor (urinary retention) and aid
- Experience no Stay with the patient during the episode. the patient to void it.
episodes of Rationale: This is a potentially fatal complication.
dysreflexia. Continuous monitoring and intervention may reduce a
- Identify the patient's level of anxiety.
noxious stimuli
and prevent Monitor BP frequently (every 3–5 min) during acute
autonomic autonomic dysreflexia and take action to eliminate
dysreflexia. stimulus.
Rationale: Aggressive therapy and removal of
stimulus may drop BP rapidly, resulting in a
hypotensive crisis, especially in those patients who
routinely have low BP.

Elevate the head of the bed to 45-degree angle or

place the patient in a sitting position.
Rationale: Lowers BP to prevent intracranial
hemorrhage, seizures, or even death.

Eliminate causative stimulus as much as possible

such as bladder, bowel, skin pressure (including
loosening tight leg bands or clothing, removing
 abdominal binder or elastic stockings); temperature
extremes.
Rationale: Removing noxious stimulus usually
terminates episode and may prevent more serious
autonomic dysreflexia (in the presence of sunburn

Insert foley catheter to aid voiding as per MD order:

Rationale: to eliminate the noxious stimuli that
predisposes autonomic dysreflexia.

Inform patient and SO of warning signals and how to

avoid onset of syndrome
Rationale: This lifelong problem can be largely
controlled by avoiding pressure from overdistension of
visceral organs or pressure on the skin.

Anticipate the administer of medications as per MD

order (IV, parenteral, oral, or transdermal), and
monitor response
Rationale: Reduces BP if severe and sustained
hypertension occurs.

REFERENCE:

Martin, P. (2017, April 26). 10 Fluid And Electrolyte Imbalances Nursing Care Plans. Nurseslabs; Nurseslabs. https://nurseslabs.com/fluid-electrolyte-imbalances-

nursing-care-plans/

Nurse Sarah. (2012, August 7). Nursing Care Plan for Dehydration, Fluid Volume Deficit, GI Bleed, Hemorrhage, Hypotension, Abdominal Pain. Registered Nurse RN.

https://www.registerednursern.com/nursing-care-plan-for-fluid-volume-deficit-gi-bleed-dehydration-hemmorrhage-hypotension-abdominal-pain/
 RENOLLA, Clouise Junice B.
RLE-4 Week 11
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

Subjective: “Hindi ko Impaired Physical After 7 days of nursing Independent Nursing Interventions: After 7 days of nursing intervention:
magalaw ang aking mga Mobility related to intervention, the patient will be
paa. Wala rin akong neuromuscular able to: Assess the patient’s level of physical activity and Goal met. Patient exhibits tolerance
maramdaman sa may mobility. Continually assess motor function (as during activity with a perceived
paralysis in the
bandang ibaba ko.” as - Exhibit tolerance during spinal shock or edema resolves) by requesting the exertion of 2 during ADLs and
verbalized by the patient lower limbs physical activity as patient to perform certain actions such as to passive ROM exercises. HR: 78 (at
evidenced by a rating of 3 dorsiflex or plantar flex, move toes, and raise leg. rest) and 98 (during activity), BP:
Objective: or less for perceived Rationale: This information will serve as a basis for 100/80 (at rest), 120/80 (during
- Restlessness/irrita exertion (on a scale of 0- formulating short term and long term goals. Motor activity), RR: 16 (at rest), 23 (during
bility 10), heart rate within 60- function evaluates status of the patient (motor- activity). Patient reports no chest
- Generalized 100 bpm, systolic BP sensory impairment may be mixed or not clear) for pain and dyspnea.
weakness within 20 mm Hg increase a specific level of injury, affecting type and choice
- Inability to over resting systolic blood of interventions. Goal met. Patient actively involves
reposition self in pressure, respiratory rate in scheduling his activities, complies
bed and turn from within 12-20 breaths/min, Assess nutritional status. to physical therapy and medication.
side to side absence of chest pain or Rationale: Adequate energy reserves are required
- CT scan: fracture dyspnea; for activity. Goal met. Contractures and foot
of the first lumbar - Actively participates in drop are absent.
vertebra and injury planning and adheres to Monitor the patient’’s sleep pattern and amount of
at the right physical therapy and sleep achieved over the past few days. Goal met. Unaffected body parts
paraspinal muscles medication regimen; Rationale: Difficulties sleeping need to be have increased in strength.
and L1-2 - Maintain position of addressed before successful activity progression
intervertebral disc function as evidenced by can be achieved. Goal met. Patient demonstrates
absence of contractures, adherence to rest periods, eating
foot drop; Assess the patient’s perception of effort required to adequate meals, and hydration
- Increase strength of perform desired activity. before activity.
unaffected/compensatory Rationale: The Borg Scale uses rating from 0-10 to
body parts; determine rating of perceived exertion. A rating of 2 Goal partially met. Patient reports
- Demonstrate (light) to 3 (moderate) is an acceptable level for ability to perform in some ADLs like
techniques/behaviors that most people performing ADLs. eating, upper body
enable resumption of grooming/dressing. Patient still
 activity; Inspect skin daily. Observe pressure areas, and needs assistance in mobility that
- Reports ability to perform provide meticulous skin care. requires turning and using his lower
required activities of daily Rationale: Altered circulation, loss of sensation, body strength.
living; and paralysis potentiate pressure sore/ulcer
- Verbalizes and uses formation. Goal met. Patient’s skin has no
energy conservation erythema, edema, and break.
techniques; Provide means for patient independence.
- Skin is nonerythremic, Rationale: Enables the patient to have a sense of Goal met. Patient verbalizes
unswollen and unbroken; control, and reduces fear of being left alone. reduced feelings of fear and
- Express improvement in anxiety. He demonstrates positive
mood and coping. Assess emotional response to limitations in coping mechanisms by reading the
physical abilities. Encourage verbalization of Bible and praying with his rosary.
feelings regarding limitations.
Rationale: Depression over inability to perform
desired/required activities can be a source of stress
and aggravation. Acknowledgment that living with
immobility is both physically and emotionally
difficult aids of coping.

Use portable pulse oximetry to assess for oxygen

desaturation during activity.
Rationale: Supplemental oxygen may help
compensate for the increased oxygen demands
during physical activity.

Establish guidelines and goals of activity with the

patient.
Rationale: Motivation is enhanced if the patient
participates in goal setting.

Encourage adequate rest periods.

Rationale: Rest between activities provides time
for energy conservation and recovery. Heart rate
recovery following activity is greatest at the
beginning of a rest period.
Assist the patient with changing body position every
2 hours.
Rationale: Changing positions promotes circulation
and prevents skin and tissue breakdown by
alternating sites of pressure relief.

Assist and encourage pulmonary hygiene like deep

breathing, coughing, suctioning.
Rationale: Immobility and bedrest increase risk of
pulmonary infection.

Assist with ADLs as indicated. Avoid patient

dependency as much as possible.
Rationale: Assisting the patient with ADLs allows
for conservation of energy.

Assist patients with planning activities for times

when they have the most energy.
Rationale: Activities should be planned to coincide
with the patient’s peak energy level. Not all self-
care and hygiene activities need to be completed in
the morning.

Encourage physical activity consistent with the

patient’s energy resources.
Rationale: Promotes a sense of autonomy while
being realistic about capabilities.

Perform and assist with full ROM exercises on all

extremities and joints, using slow, smooth
movements. Hyperextend hips periodically.
Rationale: Enhances circulation, restores and
maintains muscle tone and joint mobility, and
prevents disuse contractures and muscle atrophy.

Observe and document response to activity. Signs

of abnormal responses to be reported include the
following:
● Increased HR of more than 20 to 30
beats/min over resting rate, or 120
beats/min
● Palpitations/noticeable change in heart
rhythm
● Significant increase in systolic BP (greater
than 20 mm Hg)
● Significant decrease in systolic BP (greater
than 10 mm Hg)
● Dyspnea, labored breathing, wheezing
● Excessive weakness, fatigue
● Lightheadedness, dizziness, pallor,
diaphoresis
● Chest discomfort
Rationale: Close monitoring serves as a guide for
optimal progression of activity.

Maintain ankles at 90 degrees with footboard, high-

top tennis shoes, and so on. Place the trochanter
rolls along thighs when in bed.
Rationale: Prevents foot drop and external rotation
of hips.

Elevate lower extremities at intervals when in chair,

or raise foot of bed when permitted in patient’s
situation. Assess for edema of feet and ankles.
Rationale: Loss of vascular tone and “muscle
action” results in pooling of blood and venous stasis
in the lower abdomen and lower extremities, with
increased risk of hypotension and thrombus
formation.

Teach the patient that some factors that trigger

spasms are cold temperatures, anxiety, fatigue,
emotional distress, infections (especially UTI),
bowel or bladder distention, ulcers, pain, tight
clothing, lying too long in one position, and
touching. Teach caregivers that touch may need to
be limited.
Rationale: Controlling these factors may reduce
the number of spasms experienced.Touching, if
necessary, should be done in a firm, gentle, steady
manner. Tactile stimulation may trigger spasms.

Dependent Nursing Interventions

Administer clonazepam as prescribed.

Rationale: Benzodiazepines may be appropriate
for concurrent anxiety states such as clonazepam.
Clonazepam is a benzodiazepine that operates via
GABA-mediated mechanisms through the
internuncial neurons of the spinal cord to provide
muscle relaxation.

References:

Gulanick, M., & Myers, J. L. (2013). Nursing care

plans: diagnoses interventions, & outcomes. 8th
edition. St. Louis, Missouri: Mosby, an imprint of
Elsevier Inc.

Swearingen, P. L., & Wright, J. (2018). All-in-one

nursing care planning resource (5th ed.). Mosby.

Matt Vera (2019, April 11). Spinal Cord Injury.

Nurseslabs.https://nurseslabs.com/12-spinal-cord-
injury-nursing-care-plans/3/.