Topics to Review for Module 6 and Final Review NUR2243C
Spinal Cord Injury
Spinal cord injury (SCI) is an injury to the spinal cord that runs through the spinal column. Depending on the
degree of injury, SCI may result in temporary or permanent neurologic impairment and mobility.
Spinal cord injuries (SCIs) are classified as complete or incomplete. A complete SCI is one in which the spinal cord
has been damaged in a way that eliminates all innervation below the level of the injury. Injuries that allow some
function or movement below the level of the injury are described as an incomplete SCI. Incomplete injuries are
more common than complete SCIs. Loss of or impaired motor function (MOBILITY), SENSORY PERCEPTION, and
bowel and bladder control often result from an SCI.
Causes
o Trauma is the leading cause of spinal cord injuries (SCIs), with more than a third resulting from vehicle
crashes. Other leading causes are falls, acts of violence (usually gunshot wounds [GSWs]), and sport-
related accidents
o The causes of SCI can be divided into primary and secondary mechanisms of injury.
• Five primary mechanisms may result in an SCI:
Hyperflexion
Hyperextension
Axial loading or vertical compression
Excessive rotation
Penetrating trauma
• Secondary injury worsens the primary injury. Secondary injuries include:
Hemorrhage
Ischemia (lack of oxygen, typically from reduced/absent blood flow)
Hypovolemia (decreased circulating blood volume)
Impaired tissue perfusion from neurogenic shock (a medical emergency)
Local edema
Assessment
o Gather as much data as possible about how the accident occurred and the probable mechanism of injury
once the patient is stabilized
o The initial and priority assessment focuses on the patient's ABCs (airway, breathing, and circulation).
o Level of consciousness (Glasgow Coma Scale)
• OF NOTE: High GSC scores are good, low GSC are bad.
o Level of injury: tetraplegia (all four extremities) – AKA quadriplegia, quadriparesis (all four extremities),
paraplegia and paraparesis (involves lower extremities only)
• Plegia = Paralysis
• Paresis = Weakness
o Spinal shock, also called spinal shock syndrome, occurs immediately as the cord's response to the injury.
Spinal shock is NOT the same as neurogenic shock.
o Establish baseline data for future comparison
o Assess the patient's abdomen for symptoms of internal bleeding, such as abdominal distention, pain, or
paralytic ileus.
o Monitor for abdominal pain and changes in bowel sounds.
o Assess skin integrity (due to immobility)
o Monitor for signs of VTE
o Monitor intake, output, and weight to assess hydration and nutrition status.
Symptoms
o Complete transection of the cord: spinal cord is severed completely, with total loss of sensation,
movement, and reflex activity below the level of injury.
1
, o Partial transection of the cord: spinal cord is damaged or severed partially. The symptoms depend on the
extent and location of the damage.
o Neurologic system
• Hypoesthesia – decreased sensation
• Hyperesthesia – increased sensation
o Cardiovascular system
• Bradycardia
• Hypotension
• Hypothermia
o Respiratory system
• Breathing problems
o Gastrointestinal system
• Hemorrhage
• Paralytic ileus
• Distention
Treatment
o Prioritize
• Airway management is the priority for a patient with cervical spinal cord injury!
• Respiratory secretions are managed with manually assisted coughing, pulmonary hygiene, and
suctioning.
• Maintain adequate hydration through IV therapy and oral fluids as appropriate
• Observe for manifestations of neurogenic shock
• Monitor for autonomic dysreflexia (AD)
• Spinal cord stabilization
• OF NOTE: rehab for patients with spine injuries is to maintain functional ability and prevent
further disability
• OF NOTE: if you notice a patient with compromised, reddened skin because they are
immobile; reposition the patient off of the area, you can also get a consult for a specialty
mattress
Complications
o Respiratory failure
o Autonomic dysreflexia
o Spinal shock
o Further cord damage
o Death
Neurogenic shock
o May occur within 24 hours after injury
o Most commonly in patients with injuries above T6
o Massive vasodilation occurs leading to pooling of blood in blood vessels, tissue hypoperfusion and
impaired cellular metabolism
o OF NOTE: decreased O2 sat, symptomatic bradycardia, decreased LOC, decreased urinary output,
hypotension
o Monitor the patient with acute spinal cord injury at least hourly for:
• Pulse oximetry (SpO2) <95% or symptoms of aspiration (e.g., stridor, garbled speech, or inability
to clear airway)
• Symptomatic bradycardia, including reduced level of consciousness and deceased urine output
• Hypotension with systolic blood pressure (SBP) <90 or mean arterial pressure (MAP) <65 mm Hg
• Notify the PHCP immediately if these symptoms occur because this problem is an emergency!
o Respiratory compromise from aspiration may be treated with intubation or bronchial endoscopy. Similar
to interventions for any type of shock, neurogenic shock is treated symptomatically by providing fluids to
2
, the circulating blood volume, adding vasopressor IV therapy, and providing supportive care to stabilize
the patient.
Autonomic Dysreflexia
o Definition: A potentially life-threatening condition in which noxious visceral or cutaneous stimuli cause a
sudden, massive, uninhibited reflex sympathetic discharge in people with high-level SCI.
o Risk factors: bladder distention, urinary tract infection, epididymitis or scrotal compression, bowel
distention or impaction from constipation, irritation of hemorrhoids, pain; circumferential constriction of
the thorax, contact with hard or sharp objects; and temperature fluctuations, abdomen, or an extremity
o Prioritize nursing interventions
• Raise HOB immediately to help reduce the blood pressure
• Notify PHCP or Rapid Response Team immediately for drug therapy to quickly reduce BP
• Determine the cause and treat it promptly
• Loosen tight clothing
• Check for bladder distention and fecal impaction
• Monitor BP every 10-15 min
• Give meds to lower BP
• OF NOTE: if a patient presents with symptoms of AD, the 1 st thing you will do is palpate the
bladder for distention
o Adverse Outcome
• Hemorrhagic stroke
• AD is a neurologic emergency and must be promptly treated to prevent a hypertensive stroke!
o Signs and Symptoms
• Sudden, significant rise in systolic and diastolic BP, accompanied by bradycardia
• Profuse sweating above the level of injury
• Piloerection (goose bumps)
• Blurred vision
• Spots in the patient's visual field
• Nasal congestion
• Sudden onset of severe, throbbing headache
• Flushing about the level of injury; especially in the face
• Pale skin below the level of injury
• Nausea
• Feeling of apprehension/restlessness
• OF NOTE: one of the signs of AD is a sudden rise in BP; this can cause a hypertensive stroke
Psychosocial Issues
o Patients experiencing an SCI may have significant behavior and emotional reactions as a result of
changes in functional ability, body image, role performance, and self-concept.
o Assess patients for their reaction to the injury and provide opportunities to listen to their concerns.
o Be realistic about their abilities and projected function but offer hope and encouragement.
o Aggressive rehabilitation can help most patients live productive and independent lives.
o Assist in verbalizing feelings and fears about body image, self-concept, role performance, self-esteem,
and sexuality.
Therapeutic Communication
o Pretty sure we know this by now! �
Complication Preventions
Thermoregulation-Across the Lifespan
Thermoregulation is defined as the process of maintaining core body temperature at a near constant value.
o Assessment
History: presence of recent injury, illnesses, or environmental exposure
3
Spinal Cord Injury
Spinal cord injury (SCI) is an injury to the spinal cord that runs through the spinal column. Depending on the
degree of injury, SCI may result in temporary or permanent neurologic impairment and mobility.
Spinal cord injuries (SCIs) are classified as complete or incomplete. A complete SCI is one in which the spinal cord
has been damaged in a way that eliminates all innervation below the level of the injury. Injuries that allow some
function or movement below the level of the injury are described as an incomplete SCI. Incomplete injuries are
more common than complete SCIs. Loss of or impaired motor function (MOBILITY), SENSORY PERCEPTION, and
bowel and bladder control often result from an SCI.
Causes
o Trauma is the leading cause of spinal cord injuries (SCIs), with more than a third resulting from vehicle
crashes. Other leading causes are falls, acts of violence (usually gunshot wounds [GSWs]), and sport-
related accidents
o The causes of SCI can be divided into primary and secondary mechanisms of injury.
• Five primary mechanisms may result in an SCI:
Hyperflexion
Hyperextension
Axial loading or vertical compression
Excessive rotation
Penetrating trauma
• Secondary injury worsens the primary injury. Secondary injuries include:
Hemorrhage
Ischemia (lack of oxygen, typically from reduced/absent blood flow)
Hypovolemia (decreased circulating blood volume)
Impaired tissue perfusion from neurogenic shock (a medical emergency)
Local edema
Assessment
o Gather as much data as possible about how the accident occurred and the probable mechanism of injury
once the patient is stabilized
o The initial and priority assessment focuses on the patient's ABCs (airway, breathing, and circulation).
o Level of consciousness (Glasgow Coma Scale)
• OF NOTE: High GSC scores are good, low GSC are bad.
o Level of injury: tetraplegia (all four extremities) – AKA quadriplegia, quadriparesis (all four extremities),
paraplegia and paraparesis (involves lower extremities only)
• Plegia = Paralysis
• Paresis = Weakness
o Spinal shock, also called spinal shock syndrome, occurs immediately as the cord's response to the injury.
Spinal shock is NOT the same as neurogenic shock.
o Establish baseline data for future comparison
o Assess the patient's abdomen for symptoms of internal bleeding, such as abdominal distention, pain, or
paralytic ileus.
o Monitor for abdominal pain and changes in bowel sounds.
o Assess skin integrity (due to immobility)
o Monitor for signs of VTE
o Monitor intake, output, and weight to assess hydration and nutrition status.
Symptoms
o Complete transection of the cord: spinal cord is severed completely, with total loss of sensation,
movement, and reflex activity below the level of injury.
1
, o Partial transection of the cord: spinal cord is damaged or severed partially. The symptoms depend on the
extent and location of the damage.
o Neurologic system
• Hypoesthesia – decreased sensation
• Hyperesthesia – increased sensation
o Cardiovascular system
• Bradycardia
• Hypotension
• Hypothermia
o Respiratory system
• Breathing problems
o Gastrointestinal system
• Hemorrhage
• Paralytic ileus
• Distention
Treatment
o Prioritize
• Airway management is the priority for a patient with cervical spinal cord injury!
• Respiratory secretions are managed with manually assisted coughing, pulmonary hygiene, and
suctioning.
• Maintain adequate hydration through IV therapy and oral fluids as appropriate
• Observe for manifestations of neurogenic shock
• Monitor for autonomic dysreflexia (AD)
• Spinal cord stabilization
• OF NOTE: rehab for patients with spine injuries is to maintain functional ability and prevent
further disability
• OF NOTE: if you notice a patient with compromised, reddened skin because they are
immobile; reposition the patient off of the area, you can also get a consult for a specialty
mattress
Complications
o Respiratory failure
o Autonomic dysreflexia
o Spinal shock
o Further cord damage
o Death
Neurogenic shock
o May occur within 24 hours after injury
o Most commonly in patients with injuries above T6
o Massive vasodilation occurs leading to pooling of blood in blood vessels, tissue hypoperfusion and
impaired cellular metabolism
o OF NOTE: decreased O2 sat, symptomatic bradycardia, decreased LOC, decreased urinary output,
hypotension
o Monitor the patient with acute spinal cord injury at least hourly for:
• Pulse oximetry (SpO2) <95% or symptoms of aspiration (e.g., stridor, garbled speech, or inability
to clear airway)
• Symptomatic bradycardia, including reduced level of consciousness and deceased urine output
• Hypotension with systolic blood pressure (SBP) <90 or mean arterial pressure (MAP) <65 mm Hg
• Notify the PHCP immediately if these symptoms occur because this problem is an emergency!
o Respiratory compromise from aspiration may be treated with intubation or bronchial endoscopy. Similar
to interventions for any type of shock, neurogenic shock is treated symptomatically by providing fluids to
2
, the circulating blood volume, adding vasopressor IV therapy, and providing supportive care to stabilize
the patient.
Autonomic Dysreflexia
o Definition: A potentially life-threatening condition in which noxious visceral or cutaneous stimuli cause a
sudden, massive, uninhibited reflex sympathetic discharge in people with high-level SCI.
o Risk factors: bladder distention, urinary tract infection, epididymitis or scrotal compression, bowel
distention or impaction from constipation, irritation of hemorrhoids, pain; circumferential constriction of
the thorax, contact with hard or sharp objects; and temperature fluctuations, abdomen, or an extremity
o Prioritize nursing interventions
• Raise HOB immediately to help reduce the blood pressure
• Notify PHCP or Rapid Response Team immediately for drug therapy to quickly reduce BP
• Determine the cause and treat it promptly
• Loosen tight clothing
• Check for bladder distention and fecal impaction
• Monitor BP every 10-15 min
• Give meds to lower BP
• OF NOTE: if a patient presents with symptoms of AD, the 1 st thing you will do is palpate the
bladder for distention
o Adverse Outcome
• Hemorrhagic stroke
• AD is a neurologic emergency and must be promptly treated to prevent a hypertensive stroke!
o Signs and Symptoms
• Sudden, significant rise in systolic and diastolic BP, accompanied by bradycardia
• Profuse sweating above the level of injury
• Piloerection (goose bumps)
• Blurred vision
• Spots in the patient's visual field
• Nasal congestion
• Sudden onset of severe, throbbing headache
• Flushing about the level of injury; especially in the face
• Pale skin below the level of injury
• Nausea
• Feeling of apprehension/restlessness
• OF NOTE: one of the signs of AD is a sudden rise in BP; this can cause a hypertensive stroke
Psychosocial Issues
o Patients experiencing an SCI may have significant behavior and emotional reactions as a result of
changes in functional ability, body image, role performance, and self-concept.
o Assess patients for their reaction to the injury and provide opportunities to listen to their concerns.
o Be realistic about their abilities and projected function but offer hope and encouragement.
o Aggressive rehabilitation can help most patients live productive and independent lives.
o Assist in verbalizing feelings and fears about body image, self-concept, role performance, self-esteem,
and sexuality.
Therapeutic Communication
o Pretty sure we know this by now! �
Complication Preventions
Thermoregulation-Across the Lifespan
Thermoregulation is defined as the process of maintaining core body temperature at a near constant value.
o Assessment
History: presence of recent injury, illnesses, or environmental exposure
3
