Risk for Spinal Trauma | Nursing Care Plan for Spinal Cord Injury

Risk factors may include
Temporary weakness and instability of spinal column

Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)

Desired Outcomes/Evaluation Criteria—Client Will
Bone Healing
Maintain proper alignment of spine without further spinal cord damage.

Nursing intervention with rationale
1. Maintain bedrest and immobilization device(s)—sandbags, traction, halo, hard or soft cervical collars, or brace.
Rationale: Immobilization prevents vertebral column instability and aids healing. Note: Traction is used only for cervical spine stabilization.

2. Check external stabilization devices, such as Gardner-Wells tongs or skeletal traction apparatus.
Rationale: These devices are used for decompression of spinal fractures and stabilization of vertebral column during the early acute phase of injury to prevent further spinal cord damage.

3. Elevate head of traction frame or bed as indicated. Ensure that traction frames are secured, pulleys are aligned, and weights are hanging free.
Rationale: Creates safe, effective counterbalance to maintain both client’s alignment and proper traction pull.

4. Check weights for ordered traction pull (usually 10 to 20 lb).
Rationale: Weight pull depends on client’s size and amount of reduction needed to maintain vertebral column alignment.

5. Reposition at intervals, using adjuncts for turning and support— turn sheets, foam wedges, blanket rolls, and pillows. Use several staff members when turning or logrolling client. Follow special instructions for traction equipment, kinetic bed, and frames once halo is in place.
Rationale: The use of adjuncts for turning and support maintains proper spinal column alignment and thus reduces the risk of further trauma. Note: Grasping the brace or halo vest to turn or reposition client may cause additional injury.

6. Assist with preparation and maintain skeletal traction via tongs, calipers, and halo or vest, as indicated.
Rationale: Reduces vertebral fracture and dislocation.

7. Prepare for internal stabilization surgery, such as spinal laminectomy or fusion, if indicated.
Rationale: Surgery may be indicated for spinal stabilization, cord decompression, or removal of bony fragments.

8. Administer medications as indicated, such as methylprednisolone (Depo-Medrol).
Rationale: Although many experts recommend the use of high-dose cortisone within 8 hours of a nonpenetrating SCI as the standard of care, many national organizations are now changing their recommendations to include this therapy for the improvement of neurological outcome, but are not requiring it, suggesting that its benefits be weighed against the client’s potential for developing sepsis.