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Ch. 60: Spinal cord injury summary

Terms in this set (125)

What is a spinal cord injury (SCI)?
Caused by trauma or damage to the SC that can result in temporary or permanent alteration in the function of the SC
Where does paralysis occur in a SC injury?
Below the level of injury. The higher the injury, the greater the loss of function.
What do injuries higher than C-4 result in?
Paralysis of respiratory muscles and all 4 extremities (tetraplegia).
Who has the greatest risk of having a SCI?
Young adult males ages 16-30 years old. However, the number of older adults w/ SCIs has also increased.
Has the mortality increased or decreased with SCI's as of late?
Decreased
Long term issues w/ SCI's
Disruption in growth and development, altered family dynamics, economic loss, and round the clock care
Causes of SCIs
38%=MVC
30%=falls
14%=violence
9%=sports injuries
9%=other
SCI can result from cord compression caused by what?
Bone displacement, interruption of blood supply to the cord, or traction from pulling on the cord
Penetrating trauma can result in an SCI by what?
Tearing and transecting the SC
What is the primary injury in a SCI?
The initial mechanical disruption of axons as a result of stretch or laceration
What is the secondary injury in a SCI?
Refers to the ongoing, progressive damage that occurs after the primary injury. Several theories exist on what causes this ongoing damage.
What may occur w/ in 24 hours of a SCI?
Permanent damage may occur because of edema. Edema secondary to the inflammatory response is harmful b/c of limited space for tissue expansion. Edema extends above and below injury increasing ischemic damage.
When is the extent of damage and prognosis for recovery with an SCI most accurately determined and why?
72 hours or more after the injury because secondary injury progresses over time.
When does the greatest improvement with an SCI often occur?
The first 3-6 months following the injury
What is spinal shock?
Condition that may occur following an acute SCI characterized by decreased reflexes, loss of sensation, absent thermoregulation, flaccid paralysis below the level of injury. Lasts days to weeks and may mask postinjury neurologic function.
A patient with SCI has spinal shock. The nurse plans care for the patient based on what knowledge?
a. Rehabilitation measures cannot be initiated until spinal shock has resolved.
b. The patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia.
c. Resolution of spinal shock is manifested by spasticity, reflex return, and neurogenic bladder.
d. Patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected.
c. Spinal shock occurs in many people with acute SCI.
In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflex activity, although spastic, signals the end of spinal shock. Rehabilitation activities are not contraindicated during spinal shock and should be instituted if the patient's cardiopulmonary status is stable. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased cardiac output (CO). Sympathetic function is impaired below the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas and cranial parasympathetic nerves predominate in control over respirations, heart, and all vessels and organs below the injury, which includes autonomic functions.
The resolution of spinal shock vs. the resolution of neurogenic shock
Occurs over a period of days to months, and spinal shock slowly transitions to spasticity. S/S: Return of reflex activity, although spastic, signals the end of spinal shock.
the resolution of neurogenic shock: hyperreflexia
Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. What is the best response by the nurse?
a. "You will have more normal function when spinal shock resolves and the reflex arc returns."
b. "The extent of your injury cannot be determined until the secondary injury to the cord is resolved."
c. "When your condition is more stable, MRI will be done to reveal the extent of your cord damage.
"d. "Because long-term rehabilitation can affect the return of function, it will be years before we can tell what the complete effect will be."
b. "The extent of your injury cannot be determined until the secondary injury to the cord is resolved."

Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, or how much the cord was damaged by edema that extended above the level of the original injury. The return of reflexes may be inappropriate and excessive, causing spasms that complicate rehabilitation.
What is neurogenic shock seen with SCI?
Results from a loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of SNS innervation causes peripheral vasodilation, venous pooling, and decreased CO. Usually associated w/ an injury at T6 or higher.
A patient is admitted to the emergency department (ED) with SCI at the level of T2. Which finding is of most concern to the nurse?
a. SpO2 of 92%
b. Heart rate of 42 bpm
c. Blood pressure of 88/60 mm Hg
d. Loss of motor and sensory function in arms and legs
b. Neurogenic shock associated with SCI above the level of T6 greatly decreases the effect of the sympathetic nervous system and bradycardia and hypotension occur. A heart rate of 42 bpm is not adequate to meet the oxygen needs of the body. While low, the blood pressure is not at a critical point. The oxygen saturation is satisfactory and the motor and sensory losses are expected.
What 3 things classify an SCI?
1. Mechanism of injury
2. Level of injury
3. Degree of injury
What are the 5 types of mechanism of SCI?
1. Flexion (ruptures the posterior ligaments)
2. Hyperextension (ruptures anterior ligaments)
3. Flexion-rotation (tearing of ligamentous structures that normally stabilize the spine)
4. Compression (crush the vertebrae and force bony fragments into the spinal canal)
5. Extension-rotation
A patient with spinal cord injury is experiencing severe neurologic deficits. What is the most likely mechanism of injury for this patient?
a. Compression
b. Hyperextension
c. Flexion-rotation
d. Extension-rotation
c. Flexion-rotation
(The major mechanisms of SCI are flexion, hyperextension, flexion-rotation, extension-rotation, and compression. The flexion-rotation injury is the most unstable because spinal ligaments are torn. This injury most often contributes to severe neurologic deficits.)
Skeletal v neurological level of SCI
Skeletal level of injury is the vertebral level with the most damage to vertebral bones and ligaments. Neurologic level is the lowest segment of the SC w/ normal sensory and motor function on both sides of the body.
What are the 4 locations for the level of injury with an SCI?
Cervical, thoracic, lumbar, and sacral. Cervical and lumbar injuries are the most common.
If the cervical cord is involved in the SCI, what does this result in?
Paralysis of all 4 extremities occurs, resulting in tetraplegia. The degree of impairment in the arms following a cervical injury depends on the level of injury. The lower the level, the more function is retained in the arms.
If the thoracic, lumbar, or sacral SC is damaged, what does this result in?
Paraplegia (loss of sensation in the legs).
Complete spinal cord injury
Results in a total loss of sensory and motor function below the level of injury
Incomplete (partial) spinal cord injury
Mixed loss of voluntary motor activity and sensation and leaves some tracts intact. Degree of sensory and motor loss depends on the level of injury and reflects specific damaged nerve tracts.
What are the CM's of a SCI r/t?
Related to the level and degree of injury and are a direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection.
What does a C4 SCI result in?
Tetraplegia, complete paralysis below the neck
What does a C6 SCI result in?
Partial paralysis of hands and arms as well as the lower body
A patient who had a C7 spinal cord injury 1 week ago has a weak cough effort and crackles. The initial intervention by the nurse should be to
a.suction the patient's nasopharynx.
b.notify the patient's health care provider.
c.push upward on the epigastric area as the patient coughs.
d.encourage incentive spirometry every 2 hours during the day.
ANS: C
Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the patient's ability to mobilize secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action. The health care provider should be notified if airway clearance interventions are not effective or additional collaborative interventions are needed.
What does a T6 SCI result in?
Paraplegia, paralysis below the chest
What does an L1 SCI result in?
Paraplegia, paralysis below the waist
What is the American Spinal Injury Association (ASIA) Impairment Scale?
Recommended for classifying the severity of impairment from SCI. Combines assessments of motor and sensory function to determine neurologic level and completeness of injury.
CMs of the respiratory system with SCIs
Closely correspond to the level of injury. SCI above C4 result in a total loss of respiratory muscle function. SCI below the level of C4 results in diaphragmatic breathing leading to respiratory insufficiency. Cervical/thoracic injuries results in the paralysis of abdominal and intercostal muscles (ineffective cough->risk for aspiration, atelectasis, pneumonia). Risk for neurogenic pulmonary edema.
CM's of the cardiovascular system with an SCI
Injury above T6 leads to dysfunction of SNS that can result in neurogenic shock (bradycardia, peripheral vasodilation, hypotension). Peripheral vasodilation causes a relative hypovolemia b/c of the increase in the capacity of the dilated veins and also a reduced venous return leading to decreased CO
CM's of the urinary system w/ a SCI
May have a neurogenic bladder which is bladder dysfunction r/t abnormal or absent bladder innervation that may have no reflex detrusor contractions (flaccid, hypotonic), hyperactive reflex detrusor contractions (spastic), or a lack of coordination b/w detrusor contraction and urethral relaxation (dyssynergia).
CM's of the urinary system in the acute phase w/ a SCI
Urinary retention. Bladder is atonic, overdistended, and fails to empty so may need an indwelling catheter
CM's of the urinary system in the postacute phase of a SCI
Bladder may become hyperirritable. A loss of inhibition from the brain leads to reflex emptying and failure to store urine (urinary incontinence).
CMs of the GI system with a SCI
Decreased GI motor activity results in gastric distention, development of paralytic ileus, delayed gastric emptying, excessive release of HCl may cause stress ulcers, and dysphagia may be present. Intraabdominal bleeding may be hard to dx
CM's of the integumentary system with a SCI
Risk for skin breakdown over bony prominences in areas of decreased or absent sensation. Pressure ulcers can occur quickly and lead to infection/sepsis.
What is poikilothermism?
CM of an SCI. Adjustment of body temp to room temp. Occurs b/c interruption of the SNS prevents peripheral temperature sensations from reaching the hypothalamus. Decreased ability to sweat or shiver below the level of injury. More common w/ high cervical injury.
Metabolic needs with a SCI
Nasogastric suctioning can lead to metabolic alkalosis. Monitor electrolytes esp. Na+ and K+. Increased nutritional needs due to increased metabolism and more protein breakdown. Nutritional support should focus on caloric and nitrogen needs. Prevent skin breakdown, reduce infection, and decrease muscle atrophy.
CM's of peripheral vascular problems of a SCI
Venous thromboembolism (VTE). DVT may be difficult to detect b/c pain/tenderness may not be present. Pulmonary embolism is the leading cause of death in pts with a SCI
Nociceptive pain with a SCI
Musculoskeletal pain that is dull/aching and worsens w/ movement. Visceral pain in thorax, abdomen, and pelvis that is dull, tender, or cramping.
Neuropathic pain with a SCI
Located at or below level of injury. Hot, burning, tingling, pins and needles, cold, shooting. May be extremely sensitive to stimuli.
Diagnostic studies for a SCI
CT scan, cervical x-rays, MRI, comprehensive neuro exam, CT angiogram
Immediate prehospital/postinjury goals for a SCI
Patent airway, adequate ventilation/breathing, adequate circulating blood volume, and prevent extension of SC damage. Maintain systolic BP>90 mmHg
Immobilization with a SCI prehospital
Combo of rigid cervical collar and supportive blocks on a backboard with straps. Spinal immobilization w/ penetrating trauma is not recommended.
Initial acute care for a SCI in the hospital
Cervical injury requires more intense support. Obtain hx emphasizing incident. Assess extent of injury. Initial assessment (manage ABCs and VS). Complete neuro assessment using ASIA tool. Appropriate medical interventions and diagnostics to ensure pt is hemodynamically stable
What should the additional assessments of a SCI include?
Brain injury and/or vertebral artery injury (hx of unconsciousness, signs of concussion, increased ICP). Musculoskeletal injuries and trauma to internal organs.
How should you move a pt with a SCI?
Logroll during transfers and when repositioning to prevent further injury.
What should you monitor in the acute care of a pt with a SCI?
Monitor respiratory, cardiac, urinary, and GI functions
Nonoperative stabilization for a SCI
Nonoperative txs involve stabilization of the injured spinal segment and decompression thru traction or realignment. Stabilization eliminates damaging motion at injury site. Early realignment by closed reduction through craniocervical traction has been found to be effective and safe.
Surgical therapy for a SCI
For PT who is continuously spinal cord compression: Used following an acute SCI to fix instability and decompress the spinal cord. Surgery w/in the first 24 hours is associated w/ improved neuro outcomes. Surgery to stabilize the spine can be done from the back of the spine (posterior approach) or the front (anterior approach). Fusion involves attaching metal screws/plates to the bones of the spine to keep them aligned.
Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what should the nurse anticipate that the patient will need?
a. IV fluids
b. Tube feedings
c. Parenteral nutrition
d. Nasogastric suctioning
d. Nasogastric suctioning
During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur and nasogastric suction must be used to remove secretions and gas from the GI tract until peristalsis resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic ileus. Tube feedings would be used only for patients who have difficulty swallowing and not until peristalsis returns. Parenteral nutrition would be used only if the paralytic ileus was unusually prolonged.
Drug therapy for a SCI
Low molecular weight heparin (Lovenox) used to prevent VTE. Vasopressor agents used to maintain MAP >85-90 mmHg but have significant risk of complications. Pts with a SCI have altered drug metabolism which can result in an increased risk for drug interactions.
Overall goals for a pt with a SCI
Optimal level of neuro functioning, minimal to no complications of immobility, learn skills/gain new knowledge, and acquire new behaviors to care for self. Return to home at optimum level of functioning
Health promotion for SCIs
Identify high risk populations, counseling, and teaching. Support legislation to prohibit texting while driving, mandate use of seat belts in cars, mandate helmets for motorcyclists/bicyclists, mandate child safety seats, and recommend tougher penalties for drunk driving. Refer pt to programs, perform routine physical exams, facilitate wheelchair-accessible health care screening and exam rooms
Skeletal traction used for immobilization in SCIs
For cervical injuries, closed reduction w/ skeletal traction is used for early realignment (reduction) of the injury. Crutchfield, Gardner-Wells, or halo ring can provide this kind of traction. May use rope, pulley, and weights. Traction maintained at all times. If displacement occurs, hold head in neutral position and get help.
Pin site care for skeletal traction in SCIs
Potential for infection at sites of tongs or halo pin insertion. Preventative care based on hospital protocol. Common protocol involves cleansing w/ 1/2 strength peroxide and normal saline 2x a day and apply an antibiotic ointment.
The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan?
a. Keep a wrench close or attached to the vest.
b. Use the frame and vest to assist in positioning.
c. Clean around the pins using betadine swab sticks.
d. Loosen both sides of the vest to provide skin care.
a. Keep a wrench close or attached to the vest.
(A halo vest is used to provide cervical spine immobilization while vertebrae heal.
A wrench should accompany the halo vest at all times in case emergency removal of the vest is needed (e.g., performance of CPR). Cleaning around the pins is typically performed with half strength hydrogen peroxide, normal saline, or chlorhexidine, based on provider instructions. Only one side of the vest can be loosened for skin care and changing clothes. After that side has been reattached, the other side of the vest can be loosened.)
What is kinetic therapy used in SCIs?
Continual side to side rotation of a pt to 40 degrees or more to prevent pulmonary complications and prevent pressure ulcers
What are the 2 ways a pt with a stable thoracic or lumbar spine injury can be immobilized?
Custom thoracolumbar orthosis (TLSO or body jacket) or a Jewett brace
Respiratory dysfunction in a pt with a SCI
Spinal cord edema may increase during the first 48 hrs. May need intubation and mechanical ventilation. Increased risk for pneumonia and atelectasis.
How can you intervene to maintain ventilation in a pt with a SCI?
-Administer O2,
-Breath sounds
-Breathing pattern esp.using of accessory muscle
-amount of sputum and color
-PaCO2<45 and PaO2>60 for uncomplicated tetraplegia
-ABGs and tidal volume
-provide ventilator support,
-chest physiotherapy,
-assisted (augmented) coughing,
-tracheal suctioning,
-incentive spirometry, and
- appropriate pain management.
Frequent assessment.
-** Immediately action: if pat is unable to count 10 around without taking a breath
-Older adult: watching for hypocia and hyerpcarpnea
Cardiovascular instability seen in a pt with an SCI
Risk for bradycardia and cardiac arrest. Loss of SNS tone in peripheral vessels results in chronic low BP w/ postural hypotension. Lack of muscle tone to aid venous return can cause sluggish blood flow and increase risk for DVT. Dysrhythmias may occur.
How can you help prevent a DVT in those w/ a SCI?
Prophylactic low-molecular weight heparin or low dose heparin. SCDs and/or gradient stockings. Assess thighs and calves every shift. ROM exercises and stretching.
How to care for a pt with cardiovascular instability with a SCI
Frequently assess VS. If bradycardia is symptomatic, give anticholinergic drug or insert pacemaker. If blood loss occurred, monitor Hgb/Hct and possibly give blood. Assess orthostatic BP->for symptomatic pts, use ana bdominal binder and compression stockings. may need drug therapy to increase intravascular volume.
Fluid and nutritional maintenance in those with SCIs
-Paralytic ileus may ---requiring an NG tube.
-Monitor fluid and electrolytes.
-Nutrition should be started w/in 72 hours-->individualized solutions/additives, high protein, high calorie, possible parenteral nutrition
If a pt with a SCI has inadequate nutritional intake, what should you do?
Assess for the cause. Make a contract w/ the pt w/ mutual goal setting for the diet. Create a pleasant eating environment and give adequate time. Count calories. May need to give a dietary supplement and increase dietary fiber
How do you initially treat a neurogenic bladder in a pt with a SCI?
Indwelling urinary catheter w/ strict aseptic technique. Increase fluid intake. to prevent UTI
What is the intermittent catheterization program with SCIs?
Should be done 4-6x per day to prevent bacterial overgrowth from urinary stasis. Monitor for UTI.
-keep urine residual under 500ml to prevent bladder distension
Bowel management in pts with SCIs
Neurogenic bowel initially. Bowel programs are started during acute care->daily rectal stimulant (suppository or small-volume enema). digital stimulation or manual evacuation. adequate fluid/fiber intake. Increased activity and exercise.
A patient with paraplegia has developed an irritable bladder with reflex emptying. Along with possible use of medications, what will be most helpful for the nurse to teach the patient?

a. Hygiene care for an indwelling urinary catheter
b. How to perform intermittent self-catheterization
c. To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns
d. That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination
b. Patients with a complete lower motor neuron lesion are able to have reflex erections and use drugs to maintain erection for sexual satisfaction if S2-S4 nerve pathways are intact. Patients with complete upper motor neuron lesions usually have only reflex sexual function with rare ejaculation. Patients with incomplete lower motor neuron lesions have the highest possibility of successful psychogenic erections with ejaculation, whereas patients with incomplete upper motor neuron lesions may experience reflex erections with ejaculation.
Temperature control in pts with SCIs
No vasoconstriction, piloerection, or heat loss thru perspiration below the level of injury. Temp control is external. Monitor environment and body temp. Do not use excessive covers or unduly expose pt.
Stress ulcers in pts with SCIs
Increased risk secondary to severe trauma and physiologic stress. Monitor stool, gastric contents, and Hct. May need prophylactic meds.
Sensory deprivation in pts with SCIs
Secondary to absent sensations. Stimulate pt above level of injury. Conversation, music, & interesting foods can be part of nursing care plan. Prism glasses to read and watch TV if head needs to remain flat. Help pt avoid withdrawing from environment.
Pain management for musculoskeletal nociceptive pain in SCIs
Antiinflammatory drugs and opioids
Pain management for visceral nociceptive pain in SCIs
Diagnostic imaging to evaluate cause.
Pain management for neuropathic pain in SCIs
Gabapentin (Neurotin) or pregabalin (Lyrica) may be used to reduce pain. Teach about pain triggers and relaxation therapy.
Skin care for pt with a SCI
Comprehensive visual and tactile exam. Careful positioning every 2 hours. Specialty mattresses, pressure relieving cushions. Assess nutritional status.
Reflexes in a pt with a SCI
Return of reflexes may complicate rehab due to hyperactive reflexes, exaggerated responses, penile erections can occur when unwanted, and spasms. Spasms may be controlled w/ antispasmodic drug
-balcorofen, botulism inject,dentrolene,tizanidine
A patient has a T7-level complete spinal cord injury (SCI). He wishes to discuss the related sexual problems with the nurse. What information and advice regarding sexual dysfunction should the nurse give the patient? Select all that apply.

1 Male fertility will not be affected by the injury.
2 A reflex erection could be easily elicited in the patient.
3The patient may have erectile dysfunction that can be treated.
4The patient's ability to have psychogenic erections is not affected.
5Vacuum suction devices help in improving blood flow to the penis.
2,3,4,5
Men with complete injuries are less likely to experience psychogenic erections. However, most men with SCI are able to have a reflex erection with physical stimulation, regardless of the extent of the injury if the S2-S4 nerve pathways are not damaged. Treatment for erectile dysfunction includes drugs, vacuum devices, and surgical procedures. If sildenafil (Viagra) fails to improve erectile dysfunction, vacuum suction devices use negative pressure to encourage blood flow into the penis. Male fertility is affected by SCI, causing poor sperm quality and ejaculatory dysfunction.
Before administering botulinum antitoxin to a patient in the emergency department, it is most important for the nurse to

a.obtain the patient's temperature.
b.administer an intradermal test dose.
c.document the neurologic symptoms.
d.ask the patient about an allergy to eggs.
ANS: B
To assess for possible allergic reactions, an intradermal test dose of the antitoxin should be administered. Although temperature, allergy history, and symptom assessment and documentation are appropriate, these assessments will not affect the decision to administer the antitoxin.
A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse that he is recovering some function. What is the nurse's best response to the patient?
a. "It really is too soon to know if you will have a return of function."
b. "That could really be a positive finding. Can you show me the movement?"
c. "That's wonderful. We will start exercising your legs more frequently now."
d. "I'm sorry but the movement is only a reflex and does not indicate normal function."
b. "That could really be a positive finding. Can you show me the movement?"
When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function; however, with the resolution of edema, some normal function may also occur. It is important when movement occurs to determine whether the movement is voluntary and can be consciously controlled, which would indicate some return of function.
What is autonomic dysreflexia seen in pts w/ SCIs?
Massive uncompensated cardiovascular rxn mediated by the SNS. SNS responds to stimulation of sensory receptors and the PNS is unable to counteract these responses. Leads to HTN and bradycardia. Triggered by sustained stimuli at T6 or below from restrictive clothing, full bladder/UTI, pressure areas, or fecal impaction.
A patient with a spinal cord injury suddenly experiences a throbbing headache, flushed skin, and diaphoresis above the level of injury. After checking the patient's vital signs and finding a systolic blood pressure of 210 and a heart rate of 48 bpm, number the following nursing actions in priority from highest to lowest.___
a. Administer ordered prn nifedipine (Procardia).___
b. Check for bladder distention.___
c. Document the occurrence, treatment, and response.___
d. Place call to physician.___
e. Raise the head of bed (HOB) to 45 degrees and above.___
f. Loosen tight clothing on the patient.
1 - e. Raise the head of bed (HOB) to 45 degrees and above.
2 - b. Check for bladder distention.
3 - d. Place call to physician.
4 - f. Loosen tight clothing on the patient.
5 - a. Administer ordered prn nifedipine (Procardia).
6 - c. Document the occurrence, treatment, and response.

The patient is experiencing autonomic dysreflexia. The initial response by the nurse should be to elevate the head of bed (HOB) to decrease blood pressure (BP) and then to remove noxious stimulation. Frequently the trigger is bladder distention, which can be dealt with quickly. The physician needs to be notified as soon as possible and, depending on the communication system available to the nurse, he or she should have the call placed. Meanwhile, the nurse should stay with the patient and loosen any restrictive clothing. The physician may order an antihypertensive and documentation should be an accurate and thorough description of the entire episode.
What is the most common precipitating factor for autonomic dysreflexia seen in pts with SCIs?
Distended bladder or rectum
The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which patient statement indicates teaching about autonomic dysreflexia is successful?
a. "I will perform self-catheterization at least six times per day.
"b. "A reflex erection may cause an unsafe drop in blood pressure.
"c. "If I develop a severe headache, I will lie down for 15 to 20 minutes."
d. "I can avoid this problem by taking medications to prevent leg spasms."
a. "I will perform self-catheterization at least six times per day."
(Autonomic dysreflexia usually is caused by a distended bladder. Performing self-catheterization five or six times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache, hypertension, bradycardia, flushing, piloerection (goosebumps), and nasal congestion. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.)
Manifestations of autonomic dysreflexia
Hypertension (up to 300 mmHg systolic), throbbing headache, marked diaphoresis above level of injury, bradycardia (30-40 bpm), piloerection, flushing of skin above level of injury, blurred vision or spots in visual field, nasal congestion, anxiety, nausea
Autonomic Hyperdysflexia: priority of intervention
o The nurse must monitor BP frequently during the episode
o If symptoms have been relieved, administers rapid onset and short duration agent
(e.g nitroglycerin, nitroprusside, or hydralazine)
-An α-adrenergic blocker or an arteriolar vasodilator
Nursing interventions for autonomic dysreflexia
Elevate head 45 degrees, sit upright, notify HCP, assess for and remove cause (immediate catheterization, remove stool impaction if cause, remove constrictive clothing/tight shoes). Monitor and treat BP. Teach pt and caregiver teaching regarding signs and symptoms.
Rehab and home care for pt's with a SCI
Complex. Goal is to function at highest level of wellness. Retraining focus. Interprofessional team effort. Organized around a pt's goals/needs. Pt expected to be involved in therapies and to learn self care. Can be very stressful. Pt needs frequent encouragement.
Respiratory rehab for a pt with a SCI above C3
Needs mechanical ventilation b/c the phrenic nerve is not stimulated and thus the diaphragm is not functional. Need round the clock caregiver, respiratory hygiene, and trach care. Some pts w/ high cervical SCI may have increased mobility w/ phrenic nerve stimulator or diaphragmatic pacemakers. Some ventilators are portable.
3 types of neurogenic bladder
1. Areflexic (flaccid)
2. Hyperreflexic (spastic)
3. Dyssynergia
Common problems w/ a neurogenic bladder seen in SCIs
Urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux of urine into kidneys
Drug therapy for neurogenic bladder
1.Anticholinergic drugs- oxybutynin,tolterodine to supress bladder contraction
alpha adrenergic blockers---zosine
and antispasmodic drugs-balcrofen
Drainage methods for neurogenic bladder
Bladder reflex training
Indwelling, intermittent, external catheterization
Urinary diversion surgery
Management of neurogenic bladder
Voluntary control may be lost. High fiber diet, adequate fluid intake, suppositories, small-volume enemas, digital stimulation (mandatory for upper motor neuron injury), stool softener, oral stimulant laxatives, valsalva maneuver w/ manual stimulation, use of gastrocolic reflex, and timing to not interrupt therapy
A patient with paraplegia has developed an irritable bladder with reflex emptying. What will be most helpful for the nurse to teach the patient?
a. Hygiene care for an indwelling urinary catheter
b. How to perform intermittent self-catheterization
c. To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns
d. That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination
b. How to perform intermittent self-catheterization

Intermittent self-catheterization five to six times a day is the recommended method of bladder management for the patient with a spinal cord injury and reflexic neurogenic bladder because it more closely mimics normal emptying and has less potential for infection. The patient and family should be taught the procedure using clean technique and if the patient has use of the arms, self-catheterization should be performed. Indwelling catheterization is used during the acute phase to prevent overdistention of the bladder and surgical urinary diversions are used if urinary complications occur.
How is urinary function maintained during the acute phase of spinal cord injury?
a. An indwelling catheter
b. Intermittent catherization
c. Insertion of a suprapubic catheter
d. Use of incontinent pads to protect the skin
a. An indwelling catheter
During the acute phase of spinal cord injury, the bladder is hypotonic, causing urinary retention with the risk for reflux into the kidney or rupture of the bladder. An indwelling catheter is used to keep the bladder empty and to monitor urinary output.
Intermittent catheterization or other urinary drainage methods may be used in long-term bladder management.
Use of incontinent pads is inappropriate because they do not help the bladder to empty.
Spasticity in SCIs
Pt may start to have involuntary spasms of the muscles below the level of injury. Can be both beneficial and undesirable. Can aid w/ mobility and improves circulation by promoting venous return. But pt may also have difficulty w/ positioning and mobility secondary to the spasms. Ashworth and modified Ashworth scales used to evaluate spasticity
Tx for spasticity
ROM exercises, antispasmodic drugs, Botulinum toxin injections.
Management of neurogenic skin for SCIs
Prevention is essential. Comprehensive daily exam. Teach to reposition at least every hour while in bed and every 15-20 min when in a chair. Pressure relieving mattress or cushion. Adequate nutrition. Protect from thermal injury.
Pain management for acute pain with SCIs
Assess, evaluate, and treat routinely. Analgesics. Massage and reposition
Pain management for chronic pain with SCIs
May be result of overuse of muscles. Sleep may be disrupted. may refer to pain management specialist
Psychogenic erections with SCIs
Begin in the brain w/ sexual thoughts. Men w/ low level incomplete injuries are more likely to have these than with higher level incomplete injuries or men w/ complete injuries in general.
Reflex erections with SCIs
Occurs w/ direct physical contact to the penis or other erotic areas. Involuntary and can occur w/o sexually stimulating thoughts. Often short lived and uncontrolled. Most men with SCI are able to have a reflex erection w/ physical stimulation regardless of extent of injury if the S2-4 nerve pathways are not damaged.
In counseling patients with spinal cord lesions regarding sexual function, how should the nurse advise a male patient with a complete lower motor neuron lesion?
a. He is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs.
b. He may have uncontrolled reflex erections but orgasm and ejaculation are usually not possible.
c. He has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm.
d. He will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm.
d. He will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm.
Most patients with a complete lower motor neuron lesion unable to have either psychogenic or reflexogenic erections and alternative methods of obtaining sexual satisfaction may be suggested. Patients with incomplete lower motor neuron lesions have the highest possibility of successful psychogenic erections with ejaculation whereas patients with incomplete upper motor neuron lesions are more likely to experience reflexogenic erections with ejaculation. Patients with complete upper motor neuron lesions usually have only reflex sexual function with rare ejaculation.
Tx's for erectile dysfunction seen in SCIs
Drugs, vacuum devices, surgical procedures
Fertility in SCIs
Fertility is usually not affected and pregnancy can be uncomplicated. Risk for precipitous delivery if uterine contractions are not always felt.
Female sexual activity with a SCI
Do not dislodge Urinary catheter during sexual activity. Plan for bowel evacuation prior. Incontinence is always possible so inform partner. May need water soluble lubricant
Grief and depression with a SCI
Depression is common. Overwhelming sense of loss and loss of control. Adjustment more than acceptance. Wide fluctuation in emotion. Allow mourning while encouraging hope. Sympathy isn't helpful. Encourage pt participation. Consistency of care. Psychiatric consult. Caregiver and family counseling. Support groups.
Gerontologic considerations for SCIs
Increased incidence. Increased complications->hospitalized longer and increased mortality rates. Health promotion and screening. Rehab longer.
How many of each type of vertebrae are there?
7 cervical, 12 thoracic, 5 lumbar, 5 sacral
Indicate the level of acute spinal cord injury at which the following effects occur.
1. Loss of all respiratory muscle function
2. Diaphragmatic breathing
3. Decreased response of the sympathetic nervous system
4. Paralytic ileus
5. Incontinence
6. Tetraplegia (Quadriplegia)
7. Paraplegia
Loss of all respiratory muscle function -- Above C4
Diaphragmatic breathing -- Below C4
Decreased response of the sympathetic nervous system -- Above T6
Paralytic ileus -- Above T5
Incontinence -- Below T12
Tetraplegia (Quadriplegia) -- C8 and above
Paraplegia -- T1 and below
Priority Decision: During assessment of a patient with SCI, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action?
a. Institute frequent turning and repositioning.
b. Use tracheal suctioning to remove secretions.
c. Assess lung sounds and respiratory rate and depth.
d. Prepare the patient for endotracheal intubation and mechanical ventilation
c. Because pneumonia and atelectasis are potential problems related to ineffective coughing and the loss of intercostal and abdominal muscle function, the nurse should assess the patient's breath sounds and respiratory function to determine whether secretions are being retained or whether there is progression of respiratory impairment. If the patient cannot count to 10 aloud without taking a breath, immediate attention is needed. Suctioning is not indicated unless lung sounds indicate retained secretions. Position changes will help to mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if arterial blood gases (ABGs) deteriorate.
The most common early symptom of a spinal cord tumor is
a. urinary incontinence.
b. back pain that worsens with activity.
c. paralysis below the level of involvement.
d. impaired sensation of pain, temperature, and light touch.
b. back pain that worsens with activity.
(The most common early symptom of a spinal cord tumor is pain in the back, with radicular pain following the nerve(s) affected. The location of the pain depends on the level of compression. The pain worsens with activity, coughing, straining, and lying down.)
The patient is diagnosed with Brown-Séquard syndrome after a knife wound to the spine. Which description accurately describes this syndrome?
a. damage to the most distal cord and nerve roots, resulting in flaccid paralysis of the lower limbs and areflexic bowel and bladder
b. spinal cord damage resulting in ipsalateral motor paralysis and contralateral loss of pain and sensation below the level of the injury
c. rare cord damage resulting in loss of proprioception below the lesion level with retention of motor control and temperature and pain sensation
b. spinal cord damage resulting in ipsalateral motor paralysis and contralateral loss of pain and sensation below the level of the injury
Which finding in a patient with a spinal cord tumor requires an immediate report to the health care provider?
a.Depression about the diagnosis
b.Anxiety about scheduled surgery
c.Decreased ability to move the legs
d.Back pain that worsens with coughing
ANS: C
Decreasing sensation and leg movement indicates spinal cord compression, an emergency that will require rapid action (such as surgery) to prevent paralysis. The other findings will also require nursing action but are not emergencies.
1. When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)?
a.Urinary catheter care
b.Nasogastric (NG) tube feeding
c.Continuous cardiac monitoring
d.Administration of H2 receptor blockers
e.Maintenance of a warm room temperature
ANS: A, C, D, E
The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication, but can be avoided through the use of the H2 receptor blockers such as famotidine. Gastrointestinal motility is decreased initially, and NG suctioning is indicated.
1. In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].)
a. Infuse normal saline at 150 mL/hr.
b. Monitor cardiac rhythm and blood pressure.
c. Administer O2 using a nonrebreather mask.
d. Immobilize the patient's head, neck, and spine.
e. Transfer the patient to radiology for spinal computed tomography (CT).

ANS:
D, C, B, A, E
The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.
THIS SET IS OFTEN IN FOLDERS WITH...