A patient with a new spinal cord injury has no sensation below the injury. What is the initial nursing focus?

• A. Maintain ROM and mobility only
• B. Begin aggressive rehabilitation
• C. Immediate surgery
• D. Maintain airway and monitor respiratory status; assess for autonomic dysreflexia risk; protect skin and plan for ROM

Answer: (D)

In an acute spinal cord injury with no sensation below the level of injury, the top priority is protecting the airway and ensuring adequate breathing. Injury to the spinal cord can compromise respiratory mechanics, especially if the cervical or high thoracic segments are involved, so the nurse must assess respirations, monitor oxygenation, and be ready to support ventilation as needed.

Another critical consideration is the risk of autonomic dysreflexia, particularly with injuries above T6. Even if the patient cannot feel below the injury, stimuli such as bladder distention, stool impaction, or skin irritation can trigger a dangerous autonomic response. Early assessment for risk factors, vigilance for signs (like sudden hypertension, headaches, flushing), and prevention of triggers are essential components of the initial plan.

Protecting the skin and planning for range of motion are also important in the early phase to prevent skin breakdown and contractures from immobility. Implement turning schedules, use pressure-relieving devices, and begin ROM as soon as medically feasible to maintain joint mobility and circulation.

Immediate surgery or aggressive rehabilitation is not the immediate focus in the acute phase; surgery depends on medical evaluation, and rehab is started after stabilization.