Autonomic Dysreflexia- a.k.a. autonomic hyperrefflexia, is a condition of an excessively high blood pressure in a person with a spinal cord injury (SCI).
Concussion- injury to soft tissue , especially the barin, due to a violent force or shock.
Contusion- a bruising caused by injury.
Laceration- an injury to the skin which causes tearing.
Paraplegia- paralysis of the lower extremities with bowel and dysfunction from a lesion in the thoracic, lumbar, or sacral regions of the spinal cord
Quadriplegia- paralysis of both arms and leg, with bowel and bladder dysfunction from a lesion of a cervical segments of the spinal cord.
Traction- The use of a system of weights and pulleys to gradually change the position of a bone. It may be used in cases of bone injury or congenital defect, to prevent scar tissue from building up in ways to limit movement, and to prevent contractures in disorders
Transection-severing of the spinal cord itself; it could either be complete or incomplete
Thrombophlebitis - is an inflammation of a vein with a blood clot at the site of inflammation. The term comes from a combination of thrombus , meaning blood clot, and phlebitis , meaning inflammation or infection of a vein.
Anatomy and Physiology
Spinal Cord: is enclosed in a bony structure called vetebral collumn.
Cervical (C1 – C7)
Thoracic (T1 – T12)
Lumbar (L1 – L5)
Sacral (S1- S5)
A total of 33 vertebral bone covers the spinal cord.
Pathology and Physiology
Spinal Cord Injury – is a traumatic experience of the cord induced to the vertebrae by any force done which affects the cord. Forces could be coming from any of the following:
Any traumatic vehicular accidents.
Hazing or Violet acts that caused human injuries.
Any history of fall.
Categorized as acute impact or compression .
Acute impact injury is a concussion of the spinal cord
This type of injury initiates a cascade of events focused in the gray matter, and results in hemorrhagic necrosis
The initiating event is a hypoperfusion of the gray matter
Increases in intracellular calcium and reperfusion injury play key roles in cellular injury, and occur early after injury.
Spinal cord compression occurs when a mass impinges on the spinal cord causing increased parenchymal pressure.
The tissue response is gliosis, demyelination, and axonal loss
This occurs in the white matter, whereas gray matter structures are preserved
Rapid or a critical degree of compression will result in collapse of the venous side of the microvasculature, resulting in vasogenic edema.
Vasogenic edema exacerbates parenchymal pressure, and may lead to rapid progression of disfunction.
Types SCI according to its Site of affectation:
Central Cord Syndrome – motor deficits in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities
Anterior Cord Syndrome – loss of pain and motor function is noted below the level of the lesion; and vibration sensation remain intact.
Brown–Sequard Syndrome (Lateral Cord Syndrome) – paresis or paralysis of the Ipsilateral, with pressure and contralateral loss of pain sensation and temperature.
To assess for spinal cord injury the following should be considered by the nurse to the client seek for medical attention:
Complete Health History of the patient.
Complete Physical Assessment.
Neurologic Function Examination of the patient.
Cranial Nerve Assessment.
Diagnostic imaging begins with the acquisition of standard radiographs of the affected region of the spine.
CT scanning is reserved for delineating bony abnormalities or fracture. Some studies have suggested that CT scanning with sagittal and coronal reformatting is more sensitive than plain radiography for the detection of spinal fractures.
* MRI is best for suspected spinal cord lesions, ligamentous injuries, or other soft tissue injuries or pathology.
* ECG ( bradycardia and asystole are common in acute spinal injuries)
The goals of management are to prevent the further injury to the spine.
Pharmacologic therapy –
> High Dose of Corticosteroids
( methylprednisolone )
Oxygen Therapy – to maintain High PO 2, to prevent hypoxemia that may worsen the disease.
Skeletal Fracture Reduction and Traction – management of the SCI requires immobilization to stabilized the vertebral column and to reduce the risk of dislocations to the vertebrae and to the spine.
Surgery – e.g. laminectomy
Indications for surgery:
Compression of the cord
The injury results in a fragmented or unstable vertebral body.
Infection from the wound ->spinal cord
Nursing Care Plan
Physical Assessment must be done. The way the patient breath’s is observed, the lungs is auscultated.
Test motor abilities through muscle testing and reflex response analysis.
Assess for spinal shock.
Assess for neurologic function. Orientation to time, place, date.
Palpate the bladder for urinary retention and distension.
Assess for gastric dilation and ileus due to aronic bowel.
Monitor Vital Signs
Assess for Drug And Food Allergies. Because contrast media are sometimes iodine based.
Ineffective breathing patterns related to weakness or paralysis of abdominal and intercostal muscles and inability to clear secretions
Ineffective airway clearance related to weakness of intercostals muscle
Constipation related to presence of atonic bowel as a result of autonomic disruption
Disturbed sensory perception related to immobility and sensory loss
Risk for impaired skin integrity related to immobilityor sensory loss
Impaired physical mobility related to motor and sensory impairment
Pain and discomfort related to treatment and prolonged immobility
Urinary retention related to inability to void spontaneously
Planning of Care
Goals for the care of the Client includes :
the improvement of breathing pattern
maintaining of the skin’s integrity
relief of urinary retention
improving the bowel function
improving sensory and perceptual awareness, and absence of complications.
Promoting Adequate Breathing Patterns :
Detect potential respiratory failure by observing patient, measuring vital capacity, and monitoring oxygen saturation through pulse oximetry and arterial blood gas values.
Prevent retention of secretions and resultant atelectasis with early and vigorous attention to clearing bronchial and pharyngeal secretions.
Suction with caution, because this procedure can stimulate the vagus nerve, producing bradycardia and cardiac arrest.
Initiate chest physical therapy and assisted coughing to mobilize secretions.
Supervise breathing exercises to increase strength and endurance of inspiratory muscles, particularly the diaphragm.
Ensure proper humidification and hydration to maintain thin secretions.
PROM (passive range of motion) Exercise. To promote muscle tone and prevent atrophy.
Maintaining Proper body alignment.
Turning patient q2°, to promote drainage and prevent bed sores.
Applying splints to prevent footdrop and trochanter rolls to prevent hip joint rotation reapply q2°.
Maintaining Skin Integrity:
Change the patient’s position q2°, and inspect skin, particularly under cervical collar.
Assess for redness or breaks in the skin over pressure points; check perineum for soilage.
Check the patency of the catheter
Assess general body alignment and comfort.
Wash skin every few hours with a mild soap, rinse well, and pat dry keep pressure-sensitive arrears of the body lubricated and soft ; gently massage the patient to promote good circulation of blood.
Teach patient about pressure ulcers and encourage participation in preventive measures.
Promoting Urinary Elimination:
Perform intermittent cathetherization to avoid overstretching the bladder and infection. If this is not feasible, insert an indwelling catheter.
Show family member how to catheterize
Encourage significant other participation in plan of care of the patient
Teach the patient to record fluid intake, voiding pattern, amounts of residual urine after catheterization, quality of urine and any unusual feelings.
Promoting Adaptation to Disturbed Sensory Perception:
Stimulate the area above the level of injury through touch, aromas, flavorful foods, conversation and music.
Provide prism glasses to enable patient to see from supine position.
Provide emotional support.
Teaching the patient diversionary measures and strategies to cope with sensory deficits.
Improving Bowel Function:
Monitor reactions to gastric intubation.
Provide a high-calorie , high- protein, and high- fiber diet.
Administer stool softeners to counteract effects of immobility.
Cleanse pin sites daily, and observed for redness, drainage, and pain; observe for loosen screws.
Assess for skull for signs of infection, including drainage around halo-vest tongs.
Check back of the head periodically for signs of pressure.
Inspect skin under halo vest for excessive perspiration, redness, and skin blistering, especially on bony promineces.
Health Teaching for Home Care:
Shift emphasis from ensuring that patient is stable and free of complications to specific assessment and planning for independence and the skills necessary for activities of daily living.
Coordinate management group and serve as liaison with rehabilitation centers and home care agencies.
Remind the patient to comply with the medications and post hospitalization visits or monthly check-ups.
After the patient’s hospital stay, the patient Demonstration of improvement in gas exchange and clearance of secretions.
After series of nursing interventions, the patient adopts to sensory and perceptual alterations.
After the shift the patient is demonstrating optimal skin integrity.
After 72 hours of stay in the hospital the patient regains his urinary bladder function.
After a few nursing intervention such as administration of stool softeners the patient regains its bowel elimination pattern.
After the shift the patient verbalizes the absence of discomfort and pain.
During the whole hospital stay, the patient achieves optimal care and made him free from any complications.
American Spinal Injury Association: Guidelines for Facility Categorization and Standards of Care: Spinal Cord Injury. 1981.
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Bracken MB, Shepard MJ, Hellenbrand KG, et al: Methylprednisolone and neurological function 1 year after spinal cord injury. Results of the National Acute Spinal Cord Injury Study. J Neurosurg 1985 Nov; 63(5): 704-13 [Medline] .
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