Pathophysiology

Normal Spinal Cord

Spinal cord begins at

the foramen
magnum in the
cranium
Cord ends at the L1L2 vertebra level
Spinal nerves
continue to the last
sacral vertebra
The Human Spine

Spinal
Cord
Gray matter-

cell bodies of
voluntary and
autonomic
motor neurons

White matter

axons of
ascending and
descending
motor fibers

Normal Spinal Cord

White tracts send

messages to and
from the brain
Ascending Tractscarry into higher

levels of CNS
touch, deep
pressure,vibration,
position,
temperature

Descending Tracts
impulses for
voluntary muscle
movement

PyramidalVoluntary
movements
Posterior column
(Dorsal)- touch,
proprioception,
and vibration
sense
Lateral
spinothalamic
tract- pain and
temperature
sensation (only
tract that
crosses within
the cord)
voluntary
movement

Upper Motor Neurons

UMN
Originate in cerebral cortex
Project downward
Result in skeletal muscle
movement
Injury = SPASTIC paralysis
Lower Motor Neurons
LMN
Originate at each vertebral
level
Project to specific parts of
the body
Result in movement
/sensation
Injury = FLACCID paralysis

Normal Spinal Cord

Reflex Arc
Involuntary response to a

stimulus

Where sensory and motor

nerves arise from cord

Sensory fibers enter posterior
Synapse in the grey matter
Motor fibers leave anterior
Once outside cord join form
spinal nerve
reflex movement

Normal Spinal Cord

Dermatones
Skin innervated by

sensory spinal nerves

Myotome- muscle group
innervated by motor
neurons

ANS
Nervous
can be affected
System

by SCI
Spinal
Cord
Sympathetic chains
on both sides of the
spinal column (T1L2)
Parasympathetic
nervous system is
the cranial-sacral
branch (brainstem,
S2-4)

and the

Spinal
Cord
Bones- vertebral
column
Protectio
7 Cervical
n
12 Thoracic
5- Lumbar
5- Sacral
Discsbetween
vertebra

Spinal Cord Protection

Internal and

external ligaments
Dura
Meninges
CSF in subarachnoid
space allow for
movement within
spinal canal

Etiology of Traumatic SCI

MVA- most common cause
Other: falls, violence, sport injuries
SCI typically occurs from indirect injury from

vertebral bones compressing cord

SCI frequently occur with head injuries
Cord injury may be caused by direct trauma
from knives, bullets, etc

Etiology of Traumatic SCI

78% people with SCI are male
Typically young men 16-30
Number of older adults rising (>61 yr)
Greater complications
Life Expectancy 5 years less than same age

without injury
90% go home

Spinal Cord Injury- SCI

Compression
Interruption of blood supply
Traction
Penetrating Trauma

Spinal Cord Injury

Primary
Initial mechanism of injury

Secondary
Ongoing progressive damage
Ischemia
Hypoxia
Microhemorrhage
Edema

Spinal Cord Injury

Hemorrhage and edema occur in the cord

post injury, causing more damage to cord

Extension of the cord injury from cord edema

can occur over the first few days

watch the phrenic nerve!

Initially SCI experience spinal shock

depression of all cord & ANS function below
injury. Lasts from few min to wks

Spinal and Neurogenic

Shock
Spinal Shock
Decreased reflexes and loss of sensation

below the level of injury

Motor loss- flaccid paralysis below level
injury
Sensory loss- loss touch, pressure,
temperature pain and proprioception
perception below injury
Lasts days to months

Spinal and Neurogenic

Shock
Neurogenic shock
Due to loss of vasomotor tone
SNS

loss results in parasympathetic

dominance with vasomotor failure
Loss of SNS innervation causes peripheral
pooling and decreased cardiac output
Hypotension and Bradycardia
Orthostatic hypotension and poor
temperature control (poikilothermic)

How do you know spinal shock is

over?
Clonus is one of the first

signs
Hyperreflexia of foot
Test by flexing leg at
knee & quickly dorsiflex
the foot
Rhythmic oscillations of
foot against hand
clonus

Classifications of SCI
Mechanism of Injury
Skeletal and Neurologic Level
Completeness (degree) of Injury

Mechanism of Injury
Flexion
Hyperextension
Compression
Flexion /Rotation

Classifications of SCI
Mechanism of Injury
Flexion (hyperflexion)
Most common because of

natural protection
position.
Generally cause neck to
be unstable because
stretching of ligaments

Classifications of SCI
Mechanism of Injury
Hyperextention
Caused by chin hitting a

surface area, such as

dashboard or bathtub
Usually causes central
cord syndrome
symptoms

Classifications of SCI
Mechanism of Injury
Compression
Caused by force from

above, as hit on head

Or from below as landing
on butt
Usually affects the
lumbar region

Classifications of SCI
Mechanism of Injury
Flexion/Roatation
Most unstable
Results in tearing of

ligamentous structures
that normally stabilize
the spine
Usually results in serious
neurologic deficits

Skeletal level
Vertebral level where
the most damage to
the bones
Neurologic level
The lowest segment

of the spinal cord

with normal sensory
and motor function
on both sides of the
body

Levels of Function in

Spinal Cord Injury

Classification of SCILevel of Injury

Spinal cord level
When referring to spinal

cord injury, it is the reflex

arc level (neurologic)not
the vertebral or bone
level.

the thoracic, lumbar &

sacral reflex arcs are

higher than where the
spinal nerves actually
leave through the
opening of vertebral
bone

Classifications of SCI
Completeness (Degree) of
Injury
Complete
Incomplete
Central cord syndrome
Anterior Cord syndrome
Brown-Sequard Syndrome
Posterior Cord Syndrome
Cauda Equina and Conus Medullaris

Classification of SCI
Completeness (degree) of
Complete (transection)
Injury
After spinal shock:
Motor deficitsspastic paralysis

below level of injury

Sensoryloss of all sensation
perception
Autonomic deficitsvasomotor failure and
spastic bladder

Classification of SCI
Completeness (degree) of
Incomplete
Injury
Central Cord Syndrome
Injury to the center of

the cord by edema

and hemorrhage
Motor weakness and

sensory loss in all

extremities
Upper extremities
affected more

Classification of SCI
Completeness (degree) of
Incomplete
Injury
Brown-Squard Syndrome
Hemisection of cord
Ipsilateral paralysis
Ipsilateral superficial

sensation, vibration and

proprioception loss
Contralateral loss of
pain and temperature
perception

Classification of SCI
Completeness (degree) of
incomplete
Injury
Anterior Cord Syndrome
Injury to anterior cord
Loss of voluntary motor,

pain and temperature

perception below injury
Retains posterior
column function
(sensations of touch,
position, vibration,
motion)

Classification of SCI
Completeness (degree) of
incomplete
Injury
Posterior Cord Syndrome
Least frequent syndrome
Injury to the posterior

(dorsal) columns
Loss of proprioception
Pain, temperature,
sensation and motor
function below the level
of the lesion remain intact

Classification of SCI
Completeness (degree) of
incomplete
Injury
Conus Medullaris
Injury to the sacral

cord (conus) and

lumbar nerve roots
Cauda Equina
Injury to the
lumbosacral nerve
roots
Result- areflexic
(flaccid)bladder and
bowel, flaccid lower limbs

Clinical Manifestations of
SCI
Skin:
Cardio:
pressure ulcers

dysrhythmias
spinal shock

Neuro:
pain
sensory loss
upper/lower motor
deficits
autonomic
dysreflexia

loss of SNS control

over blood vessels

orthostatic
hypotension,
poikilothermic

Respiratorydecrease chest

expansion, cough
reflex & vital
capacity
diaphragm functionphrenic nerve

GI

GU
upper/lower motor

bladder
Impotence
sexual dysfunction

Musculoskeletal
joint contractures
bone demineralization

stress ulcers

osteoporosis

paralytic ileus

muscle spasms

bowel- impaction &

muscle atrophy

incontinence

pathologic fractures
para/tetraplegia

Common
Manifestation/Complications
Upper and Lower Motor
Deficits

Upper motor deficits

result in spastic paralysis

Lower motor deficits

result in flaccid paralysis

and muscle atrophy

Common
Manifestations/Complications
Spinal cord injuries are described by the level of the injury the

cord segment or dermatome level

Such as C6; L4 spinal cord injury
Terms used to describe motor deficits
Prefix:

para- meaning two extremities

tetra- or quadra- all four extremities
Suffix :
-paresis meaning weakness
-plegia meaning paralysis

Quadraparesis means what?

Common
Manifestations/Complicati
C1-3 usually fatalons

Loss of phrenic
innervation ventilator
dependent
No B/B control
Spastic paralysis
Electric w/c with
chin/mouth control

Common
Manifestations/Complicati
C6- weak grasp
ons

Has shoulder/biceps to
transfer & push w/c
No bowel/bladder
control.
Considered level of

independence

Common
Manifestations/Complicati
T1-6- full use of upper
ons
extremity
Transfer
Drive car with hand

controls and do ADLs

No bowel/bladder control

Immediate Care
Emergency Care at
Scene, ER & ICU
Transport with cervical

collar
Assess ABCs; O2;
tracheotomy/vent
IV for life line
NG to suction
Foley

Diagnostic Studies for

SCI
X-ray of spinal column
CT/MRI
Blood gases

Therapeutic Interventions
Medications

IV methylprednisolone (Solu-Medrol) within

8 hrs to decrease cord edema

Therapeutic
Interventions
Medications
To control or to prevent complications of

SCI and immobility:

Vasopressors to maintain perfusion
Histamine H2 blockers to prevent stress ulcers
Anticoagulants
Stool softeners
Antispasmodics

Therapeutic
Interventions
Stabilization/
Immobilization
TractionGardner-wells tongs
Halo
Casts
Splints
Collars
Braces

Therapeutic Interventions
Surgery for SCI

Manipulation to

correct dislocation or
to unlock vertebrae
Decompression
laminectomy
Spinal fusion
Wiring or rods to hold
vertebrae together

Nursing Management
Assessment

HEALTH HISTOY
Description of how and when injury

occurred
Other illnesses or disease processes
Ability to move, breathe, and associated
injury such as a head injury, fractures

Nursing Management
Assessment
PHYSICAL EXAM

LOC and pupils- may have indirect SCI from

head injury
Respiratory status- phrenic nerve
(diaphragm) and intercostals; lung sounds
Vital signs
Motor
Sensory
Bowel and bladder function

Nursing Management
Assessment
Motor Assessment
Upper Extremity

Movement, strength

and symmetry

Hand grips
Flex and extend arm

at elbow- with and

without resistance

Nursing Management
Assessment
Motor Assessment
Lower Extremity

Flex and extend leg

at knee with and

without resistance
Planter and dorsi
flexion of foot
Assess for Clonus

Nursing Management
Assessment
Sensory assessment

With the sharp and dull

ends of a paperclip have

the individual, with their
eyes closed identify

Use the dermatome as

reference to identify level

C6 thumb; T4 nipple; T10

naval

Nursing
Problems/Interventions
1.Impaired mobility
2.Impaired gas exchange
3. Impaired skin integrity
4. Constipation
5. Impaired urinary elimination
6. Risk for autonomic dysreflexia
7. Ineffective coping

1. Impaired Physical
needed to keep alignment; teach patient
Mobility
Care traction, collars, splints, braces,

Log roll as a single unit; provide assistance as

assistive devices for ADLs

Flaccid paralysis- use high top tennis shoes or
splints to prevent contractures. Remove at
least every 2 hrs for ROM (active ROM best)

1.
Impaired
Physical
Spastic Paralysis
Mobility
Prevent spasms by avoiding; sudden movements
or jarring of the bed; internal stimulus (full
bladder/skin breakdown; use of footboard;
staying in one position too long; fatigue
Treat spasms by decreasing causes; hot or cold
packs; passive stretching; antispasmodic
medications

Assess skin break down thrombophlebitis;

remove TED hose at least every shift

1.
Impaired
Physical
Prevent/treat orthostatic hypotension
Mobility
Abdominal binder, calf compressors, TED hose
when individual gets up
Assess BP, especially when rising

Teach use of transfer board

Assist Physical Therapy with tilt table as individual

gradually gets use to being in an upright position

2.
Impaired
Gas
Exchange

Phrenic nerve (C3-5) controls the diaphragm

bilaterally. If nerve is nonfunctioning then
individual is ventilator dependent.
Thoracic nerves control the intercostals
muscles for breathing and abdominal muscles
aide in breathing and coughing

2. Impaired Gas
Exchange
Respiratory rate, rhythm,

depth, breath sounds,

respiratory effort, ABGs, O2
saturation

Signs of impending extension

of SCI up cord to phrenic

nerve level (C3-5)
Need for ventilatory
assistance tracheotomy,
ventilator
Quad cough (assistive cough)

as needed

3. Impaired Skin Integrity

Change position frequently

Protection from extremes in temperature
Inspect skin at least 2x/day especially over boney

prominences
Avoid shearing and friction to soft tissue with
transfers
Removal of TED hose every 8 hours
Nutritional status

4. Constipation
Bowels rely more on bulk than on nerves
Stimulate bowels at the same time each day.

Best after a meal when normal peristalsis

occurs
Individual may progress from Dulcolax
suppository to glycerin then to gloved finger
for digital stimulation
Assess bowel sounds prior to giving food for
the first time paralytic ileus!

5. Impaired Urinary
Elimination
Flaccid bladder (lower motor neuron lesion)

No reflex from S2,3,4

Automatic empting of bladder
Urine fills the bladder and dribbles out
Need Foley or freq intermittent self catheterization
Spastic bladder (upper motor neuron lesion)
Reflex arc but no connection to or from brain
Reflex fires at will
Bladder training- trigger points to stimulate empting;
self catheterization

5. Impaired Urinary
Elimination

Use bladder scan to see amount of urine in

bladder
Goal- residual <100ml/20% bladder
capacity
Some individuals may need suprapubic
catheter
Assess effectiveness of medication
Urecholine to stimulate bladder contraction
Urinary antiseptic

6. Risk for Autonomic

Dysreflexia

SCI above T6
Results in loss of normal compensatory

mechanisms when sympathetic nervous system

is stimulated
Life threatening- if goes unchecked BP can result
in cerebral hemorrhage
Vasodilatation symptoms above SCI
Vasoconstriction symptoms below SCI
The cause of SNS stimulation

6. Risk for Autonomic

Dysreflexia
Elevate head of bed- causes orthostatic

hypotension
Identify cause/alleviate- if full bladder- cath; if
skin- remove pressure, if full bowel- empty, etc
Remove support hose/abdominal binder
Monitor blood pressure- can get > 300 S
Give PRN medication to lower BP
If above not effective call physician

7. Ineffective Coping/
Grief and Depression
Assess thoughts on quality of life; body

image; role changes

Physical and psychological support
Most common SCI is 15-30 yeas old and
generally a risk taker this greatly affects their
perception of life and rehabilitation

7. Ineffective
Coping/sexuality
Male
Female
UMN lesion
reflexogenic (S2,3,4)
erections
LMN lesion
psychogenic erections

(psychological
stimulation)

Ejaculation/fertility may

be affected

hormones more than

nerves regarding fertility.

C-section because of

chance for autonomic

dysreflexia during labor.
Lack of
sensation/movement
affects sexual
performance

7. Ineffective
Coping/sexuality
Assess readiness/knowledge/your ability
Use proper terminology
Suggestions:
empty bladder before sex
withhold fluids and antispasmodics
certain positions may increase spasms
explore new erogenous zones
penile implants

Refer to specially trained counselor

Home Care
Assess psychological, physiological resources
need for rehabilitation (in-house or out

patient)
need for community resources
Home assessment

Whats new in SCI

treatment?
Superman breather
YouTube - Superman breather USA

Kevin Everett
hypothermia treatment for SCI
Standing Tall
Travis Roy- 11 Seconds
Stem Cell treatment for SCI
Lipitor for SCI

Case study- Jim Valdez

1. Why does Jim have flaccid paralysis on

admission to ICU?
2. What symptoms indicate that he is in spinal
shock? What was done about these symptoms?
3. How will we know when he is out of spinal
shock?
4. How does progressive mobilization assist with
orthostatic hypotension? What else can be
done?
5. What are realistic functional goals for Jim?

Spinal Cord Anatomy

Function of disc is to

allow for mobility of

the spine and act as
shock absorber
spinal cord anatomy

Pathophysiology/Etiology
Located between

vertebral bodies
Composed of
nucleus pulposus a
gelatinous material
surrounded by
annulus fibrosis- a
fibrous coil
Spinal nerves come
out between
vertebra

Herniated Disc
Herniated nucleus pulposus, (HNP) slipped

disc, ruptured disc

HNP- annulus becomes weakened/torn and
the nucleus pulposus herniates through it.
Risk FactorsStanding erect
Aging changes
Poor body mechanics
Overweight
Trauma

Common
Manifestations/Complications
HNP compresses
Spinal nerve

(sensory or motor
component) as it
leaves the spinal
cord
Or the cord itselfthe white tracts
within the cord- rare

Common
Manifestations/Complications
Sensory root or nerve usually affected

pain, parenthesis, or loss of sensation

Motor root or nerve may be affected

paresis or paralysis

Manifestations
depend on what nerve root, spinal nerve is

being compressed which dermatomes

Radiculopathy pathology of the nerve root

Common Manifestations/Complications
Lumbar HNP
Most common site for HNP
L4-5 disc- the 5th lumbar nerve root

posterior sensory nerve or root compressed

Classic symptoms low back sciatica pain

pain increases with increase in intrathoracic

pressure

herniated disc L4-L5

Other Symptoms Lumbar HNP:

Postural changes
Urinary/male sexual function changes
Paresis or paralysis
Foot drop
Paresthesias
Numbness
Muscle spasms
Absent cord reflexes

Common
Manifestations/Complications
Cervical
HNP
C5-C6 disc- affects the 6th cervical nerve
root
Pain- neck, shoulder, anterior upper arm to

thumb
Absent/diminished reflexes to the arm
Motor changes- paresis or paralysis
Sensory- paresthesias or pain
Muscle spasms

Therapeutic Interventions- Diagnostic

Tests
X-ray
identify deformities

and narrowing of disk

space
CT/MRI
Mylogram p1336
Nerve conduction
studies (EMG)
detect electrical
activity of skeletal
muscles

Treatment- Conservative
Bed rest with firm mattress
log roll
side lying position with knees bent and pillow

between legs to support legs

Avoid flexion of the spine
brace/corset, cervical collar to provide support
Medications
non-narcotic analgesics, anti-inflammatory,
muscle relaxants, antispasmodics and
tranquilizers

Treatment- Conservative
Heat/cold therapy to decrease muscle

spasms
Break the pain-spasm-pain cycle
Ultrasound, massage, relaxation techniques
Progressive mobilization with approved
exercise program includes abdominal/thigh
strengthening
Teaching good body mechanics
Weight loss
TENS unit

Treatment- Surgery
Laminectomyremoval of a portion of the lamina to

relieve pressure and to get to the

herniated nucleus pulposus that is
protruding out
herniated disc repair
Foraminotomy
Enlargement of the bony overgrowth at the

opening which is compressing the nerve

Treatment- Surgery
Microdiskectomy
Use of electron microscope through a small

incision to remove a portion of the HNP that is

displaced

If cervical HNP, usually use the anterior

approach in the neck

anterior cervical fusion

Treatment- Surgery
Spinal fusion
removes most of the disc and replaces it with

bone usually from the patient iliac crest

Fusion also with rods, pins, synthetic protein
Flexibility is lost at the site- requires longer
hospital stay

spinal fusion
Artificial Disc
Combination of metal and plastic
Attached to vertebrae above and below

Prevention of HNP
Back school approachCauses of HNP
Learn how to prevent
Good body mechanics
Exercises to strengthen leg and abdominal

muscles

Change in life-style or occupation

Nursing Assessment Specific to HNP

Health History
Assess for risk factorsThe cumulative effect of standing erect

and daily stress

Aging changes in disc/ligaments
Poor body mechanics
Overweight
Trauma
Employment
History of pain and other neuro changes

Nursing Assessment Specific to

HNP
Physical Exam

Use similar methods to assess as utilized

SCI
Muscle strength and coordination
Sensation
sharp/dull of paperclip using dermatome as

reference

Pain evaluation- pain scale

Pre/Post-op assessment

Post-Op Assessment for HNP

Sensory/motor assessment- care not to

injure op site
Assess for CSF drainage or bleeding from
op site
Encourage turn (log roll, cough, deep
breath)
Assess for postural hypotension
especially if client was on bed rest for several

days/weeks prior to surgery

Post-op Assessment for HNP

If Anterior CervicalAssess injury to the carotid, esophagus, trachea,

laryngeal nerve (speech- hoarseness)

Assess respiration, neck size, swallowing and
speech

If Post-Op LumbarAssess bowels sounds, voiding.

Minimize stress of post-op site- flat with pillow

between knees, log roll, etc

Nursing Problems/Interventions
1. Acute Pain
Post surgery the individual may have similar

pain as pre-op due to lack of resiliency of

the spinal nerves to bounce back quickly

Donor site (illiac crest) may cause more

pain than laminectomy

Individual may be in a pain-spasm-pain

cycle, therefore may need both

antispasmodic as well as analgesic

2. Chronic Pain
Surgery may not relieve pain
Nonpharmalogical methods

to control pain
Pain clinic

3. Constipation
As a result of bed rest and decreased

mobility and fear of pain with straining of

stool
Constipation prevention methods fluids,

diet, etc

4. Home Care
When riding in a car, take frequent stops

to move and stretch

Prevention Back school approach
May have to deal with pain as a chronic
condition
May need to make life/job changes

Spinal Cord Tumors

CNS is made up of

neural tissue and

support tissue
These tissues undergo

changes and result in

spinal cord tumors
Blood vessels and

bone also can be part

of the tumor

Intramedullary- arise
from neural tissues of
the spinal cord
Extramedullary- arise
from tissues outside the
spinal cord may be
benign or malignant
Intradural-from
the nerve roots or
meninges in
subarachnoid space
Extradural- from
the epidural tissue
or vertebra

Classification by origin
Primary- originating in the

spinal cord or meninges

Secondary- metastases

from other parts of the

body
Most spinal cord tumors are
found in the thoracic region
Spinal cord tumors can

compress (benign), invade

the neural tissue, or cause
ischemia to the area
because of vascular
obstruction

Common
Manifestations/Complications
Symptoms depend on the anatomical level of

the spinal column, the anatomical location, the

type of tumor and the spinal nerves affected
Pain that is not relieved by bed rest is the

most common presenting symptom

Other symptoms are similar to those found with

HNP or spinal cord injury- sensory or motor

Common
Manifestations/Complications
Manifestations of thoracic cord tumor
Paresis & spasticity of one leg then the

other
Pain back & chest, not relieved by
bedrest
Sensory changes
Babinski reflex
Bowel (ileus); bladder dysfunction (UMN
in type)

Therapeutic Interventions
Diagnostic tests include:
X-ray of the spinal column
Myelogram
Lumbar puncture with CSF analysis

Therapeutic Interventions
Medications spinal tumors
Control pain- narcotic analgesics,

epidural catheter, PCA, NSAIDs

Reduce cord edema and tumor size Steroids-

high dose Dexamethasone

Therapeutic Interventions
Surgery for spinal cord tumors
Laminectomy to remove or to decrease

the size (decompression laminectomy) of

the spinal cord tumor
Spinal fusion or the insertion of rods if
several vertebra involved and the
column is unstable
Radiation to reduce size and control pain

Nursing Assessment
Health history
Pain, motor and sensory changes, bowel
and bladder changes, Babinski reflex.
Physical exam
Similar to physical assessment for HNP

Nursing
Problems/Interventions
1. Anxiety

Metatastic tumor vs benign spinal cord tumor

Education and support system

2. Risk for constipation

From spinal cord compression, narcotics, bed

rest
Adjust fluid and diet

Nursing
Problems/Interventions
3. Impaired physical mobility
From bed rest and motor involvement
Basic nursing- ROM, etc

4. Acute pain
From compression or invasion of tumor
Assess and treat

5. Sexual dysfunction
Male sacral reflex arc (S 2,3,4) interference
Similar care as discussed with SCI

Nursing
Problems/Interventions
6. Urinary retention
Reflex arc (S2,3,4) interference can cause

neurogenic bladder as discussed with SCI

7. Home care
Rehabilitation
Home evaluation
Support groups
case study

A 30-year-old was admitted to the progressive

care unit with a C5 fracture from a motorcycle

accident. Which of the following assessments
would take priority?
Bladder distension
Neurological deficit
Pulse ox readings
The clients feelings about the injury

While in the ER, a client with C8 tetraplegia

develops a blood pressure of 80/40, pulse 48,

and RR of 18. The nurse suspects which of the
following conditions?
Autonomic dysreflexia
Hemorrhagic shock
Neurogenic shock
Pulmonary embolism

A 22-year-old client with quadriplegia is

apprehensive and flushed, with a blood pressure

of 210/100 and a heart rate of 50 bpm. Which of
the following nursing interventions should be
done first?
Place the client flat in bed
Assess patency of the indwelling urinary catheter
Give one SL nitroglycerin tablet
Raise the head of the bed immediately to 90

degrees

The nurse is caring for an elderly client diagnosed

with a herniated nucleus pulposus of L4-L5. Which

scientific rationale explains the incidence of a
ruptured disc in the elderly?
The client did not use good body mechanics when

lifting an object.
There is an increased blood supply to the back as the
body ages.
Older clients develop atherosclerotic joint disease as a
result of fat deposits.
Clients develop intervertebral disc degeneration as
they age.

A client is admitted with a spinal cord injury at

the level of T12. He has limited movement of

his upper extremities. Which of the following
medications would be used to control edema
of the spinal cord?
Acetazolamide (Diamox)
Furosemide (Lasix)
Methylprednisolone (Solu-Medrol)
Sodium bicarbonate

A client with a cervical spine injury has

Gardner-Wells tongs inserted for which of the

following reasons?
To hasten wound healing
To immobilize the surgical spine
To prevent autonomic dysreflexia
To hold bony fragments of the skull together

Which of the following interventions describes

an appropriate bladder program for a client in

rehabilitation for spinal cord injury?
Insert an indwelling urinary catheter to straight

drainage
Schedule intermittent catherization every 2 to 4
hours
Perform a straight catherization every 8 hours
while awake
Perform Credes maneuver to the lower abdomen
before the client voids.

A client has a cervical spine injury at the level

of C5. Which of the following conditions would

the nurse anticipate during the acute phase?
Absent corneal reflex
Decerebate posturing
Movement of only the right or left half of the

body
The need for mechanical ventilation

The nurse is evaluating neurological signs of

the male client in spinal shock following spinal

cord injury. Which of the following
observations by the nurse indicates that
spinal shock persists?
Positive reflexes
Hyperreflexia
Inability to elicit a Babinskis reflex
Reflex emptying of the bladder

Your T1 spinal cord injured patient complains

of a headache. You should

Give him prn Tylenol
Disimpact his bowels
Call the doctor
Take his blood pressure

What can the nurse do to best speed the

patients recovery from a laminectomy of L5?

Keep patient flat in bed
Teach the back school approach
Medicate for pain q2 hours
Ambulate as soon as orders permit

Your patient has a malignant metastatic lesion

at T8 and is in for palliative radiation. What is

your main goal with this patient?
Teach patient self catheterization
Ensure patient receives pain medication as

needed
Encourage patient to discuss fears
Ambulate twice a shift