Jerash University

Faculty of Nursing
Critical nursing clinical
Case Study
Student Name: ‫ روان جدعان‬، ‫ تسنيم عبدالعال‬، ‫زهيه العجوري‬
Date: 25/3/2021

 Demographics:
Client’s Initials: A.M Age: 20 years
Gender: male
Admission Date: 20/6/ 2020 Ward: Trauma center
Medical Diagnosis: spinal cord injury

 Definition of the disease:

 A spinal cord injury occurs with a sudden, traumatic blow to the spine that fractures or
dislocates vertebrae, This affects the conduction of sensory and motor signals across the
site of the lesion.There are two types: incomplete and complete injury. 
Incomplete Lesion: not all the nerves are severed or the nerves are only slightly
damaged. Recovery is possible, but never to pre-injury level.
Complete lesion: the nerves are severed and there is no motor or sensory function
preserved of this point.
-Complete lesion can result in paraplegia (paralysis of the lower body) or quadriplegia
(Paralysis of all four extremities).
-Incomplete spinal cord lesions are classified according to the area of spinal cord
damage: central, lateral, anterior, or peripheral.

 Background and Etiology of the disease:

In your patient In text book
Traffic accident while crossing the street
Causes Spinal cord injuries have a variety
of causes, including:
•hard impacts and collisions in
•sports automobile accidents
•falls
•hitting the head when diving
•injuries from violent acts, such as
gunshot wounds
•certain types of cancer
•arthritis
•specific types of infections

pathophysiology:
The spinal cord is made up of nerve fibers
that allow communication between the
brain and the rest of the bedy. Damage to
the spinal curd ranges from transient
concumion to contu cion, laceration and
compression of the cord substance to
complete transaction of the cord and
results in interference with the
communication process Damage may be
caused by bruksing. cutting or bleeding
Into the cord, external forees or by
tragments of fractured bone. The most
frequently involved vertebrae are 1.
Cervical 5,6 and 7 2. Thoracic 12 SCIS can
be separated into two categories: primary
injuries and secondary injuries. Primary
injuries are the result of the initial insult
or trauma and are usually permanent.
Secondary injuries are usually the result of
a contusion or tear injury, in which the
nerve fibers begin to swell and
disintegrate. A secondary chain of events
produces ischemia, hypoxia, edema, and
hemorrhagic lesions, which in turn result
in destruction of myelin and axons. These
secondary reactions, believed to be the
principal causes of spinal cord
degeneration at the level of injury.
 Clinical manifestations include (sign ,symptom, P/E, V/S):
In your patient
Signs and symptoms:
 Sever pain in the neck
 Unable to move his arms and
legs
 Drowsy but, oriented
 Weak cough
 Shallow breathing
 Color pale
 Skin cold and clammy to the
touch
Vital Signs:
 Blood Pressure 94 / 55
 Heart Rate 64
 Respiratory Rate 32
 Oral Temperature 35.1 Degrees
Celsius
Reflexes:
Minimal biceps brachii stretch reflexes,
with no triceps or wrist extensor
reflexes.
All other muscle stretch reflexes in the
upper and lower extremities were
absent
Sensation:
Perception of sensory stimuli ended
bilaterally at an imaginary line drawn
across his chest 1/2 inch above the
nipples
Some sensation in his arms, but could
not localize touch or describe texture
with any consistency there
Strength:
Able to elevate his shoulders and
isometrically contract his biceps brachia
slightly in each arm, but could not raise
In text book
Spinal cord injuries of any kind may
result in one or more of the following
signs and symptoms:
1. Loss of movement
2. Loss or altered sensation, including
the ability to feel heat, cold and touch
3. Loss of bowel or bladder control
4. Exaggerated reflex activities or
spasms
5. Changes in sexual function, sexual
sensitivity and fertility
6. Pain or an intense stinging sensation
caused by damage to the nerve fibers in
your spinal cord
7. Difficulty breathing, coughing or
clearing secretions from your lungs.
Emergency signs and symptoms of a
spinal cord injury after an accident may
include:
1. Extreme back pain or pressure in your
neck, head or back
2. Weakness, incoordination or paralysis
in any part of your body
3. Numbness, tingling or loss of
sensation in your hands, fingers, feet or
toes
4. Loss of bladder or bowel control
5. Difficulty with balance and walking
6. Impaired breathing after injury
The breathing pattern is observed, the
strength of the cough is assessed, and
the lungs are auscultated, because
paralysis of abdominal and respiratory
muscles diminishes coughing and makes
it difficult to clear bronchial and
pharyngeal secretions. Reduced
either arm against gravity.
Lower extremities were flaccid, despite
attempts to move them.
excursion of the chest also results. The
patient is monitored closely for any
changes in motor or sensory function
and for symptoms of progressive
neurologic damage. It may be
impossible in the early stages of SCI to
determine whether the cord has been
severed, because signs and symptoms
of cord edema are indistinguishable
from those of cord transection. Edema
of the spinal cord may occur with any
severe cord injury and may further
compromise spinal cord function. Motor
and sensory functions are assessed
through careful neurologic examination.
These findings are recorded most often
on a flow sheet so that changes in the
baseline neurologic status can be
closely monitored accurately.
• Motor ability is tested by asking the
patient to spread the fingers, squeeze
the examiner's hand, and move the toes
or turn the feet.
• Sensation is evaluated by gently
pinching the skin or touching it lightly
with a small object such as a tongue
blade, starting at shoulder level and
working down both sides of the
extremities. The patient should have
both eyes closed so that the
examination reveals true findings, not
what the patient hopes to feel. The
patient is asked where the sensation is
felt.
Any decrease in neurologic function is
reported immediately.
The patient is also assessed for spinal
shock, a complete loss of reflex, motor,
sensory, and autonomic activity below
the level of the lesion that causes
bladder paralysis and distention. The
lower abdomen is palpated for signs of
urinary retention and overdistention of
 the bladder. Temperature is monitored
because the patient may have periods
of hyperthermia as a result of alteration
in temperature control due to
autonomic disruption.

Vital Signs - The patient is checked for

signs of spinal shock, such as
hypotension, bradycardia, and low body
temperature due to vasodilation. A
cardiac monitor is frequently used to
monitor the effects of bradycardia.
Blankets are used to control the
lowered body temperature.

 History:(Past and family):

Past history:
Past Medical History
Exercise- Induced Asthma

Past surgery:
None

Childhood history:
The patient took all the vaccinations.

Present illnesses:
According to the patient's said that while crossing the street, his personal wallet
inadvertently fell from him and reached for his hand to pick it up. Then a speeding car
came and hit himHe was positioned lying on his back, supported at the neck and
covered with a blanket to try to maintain his body temperature as they waited for
assistance to arrive.
Patient was lying in the supine position, he reported severe pain in his neck and was
unable to move his arms and legs.
He was drowsy but, oriented to his current location, and some details of the accident.
He complained that he could not feel his arms and legs. His pupils were equal and
reactive to light.
 He showed no other signs of injury but paramedics were concerned as he may have
inhaled some water during the accident. His vital signs revealed a blood pressure of
100/72, heart rate of 82 beats per minute, respirations of 22 per minute.
The paramedics applied a cervical collar, placed him on Ferno Scoop Stretcher,
immobilized his head, and provided 100% Oxygen. He arrived at the hospital and
underwent an initial assessment within 120 mins of the accident.

Family history:
Routine family history taken but not considered specifically relevant to a diagnosis of
spinal cord injury resulting from trauma.

 Diagnostic procedures and test:

Date Type Results and Nursing
interpretation consideration
 X-rays. Cervical Spine: Remove all metallic
Unstable C6 objects. ...
Compression
Fracture.
Chest: Decreased
Lung Expansion
upon Inhalation,
Mild Pulmonary
Edema.

CT Spine: -Informed Consent:

C6 Lesion with no Obtain an informed
 CT Vascular consent properly
Computerized Hemorrhages noted signed.
tomography but some blood -Look for allergies
evident at C5-6 with Check for NPO.
bone fragments in
the Spinal Canal

-Provide inform
about contrast
medium. ...
 CT Brain: Mild Frontal -Instruct the
Contusion patient to remain
 still.

-After procedure
encourage patient
to increase fluid
intake.

ABG:
-Identify patient by
name
 Blood Gas: Acute -explain procedure
Decompensated -Heparinize 2 ml
Respiratory Acidosis syringe
with Hypoxemia & -Wash hands -wear
Hypercapnia gloves.
pH 7.27 -Palpate the radial,
PaO2 60 mmHg brachial or femoral
PaCO2 70mmHg artery
HCO325.2mEq/L -Perform Allen test
SPO2 89%

 Medications:

Name of drug Action and Dose Route Frequency Main S/E & Ng
classification considerations
1. Opioids: Action: Preferred Common side
Morphine Treat severe route (P.O) effects of
. pain. Can be given: opioid use
In the spinal Intramuscular include
 cord, opioids and Epidural drowsiness,
act on nausea, and
specific mood
receptors changes,
located in constipation,
pre-and dry mouth. 
postsynaptic -monitor signs
synapses in of addiction in
the dorsal patients.
horn. - Provide
fluids and
Classification: fiber for
Opioids constipation.
analgesics.

Name of drug Action and Dose Route Frequency Main S/E & Ng
classification considerations
2. Benzodiazepines Action: IV S/E:
: relieve Benzodiazepines
Diazepam. muscle cause depression
spasms of the CNS and
- Diazepam related side effects
specifically such as dizziness,
increases the drowsiness, and
inhibitory lethargy.
effect of Orthostatic
GABA by hypotension is a
binding to frequent
pre- and complication in
postsynaptic patients with a
neurons SCI. Patients can
found in the experience
CNS orthostatic
promoting hypotension when
depression of beginning a
the central benzodiazepine
nervous regimen.
system -Confusion, ataxia.
Skeletal Ng considerations:
muscle -Assess baseline
relaxation is vital signs.
 subsequently
induced by - Assess blood
the inhibition pressure, pulse
of afferent and respiration if
pathways in IV administration.
the spinal
cord. - Evaluate
- therapeutic
Classification: response, mental
Skeletal state and physical
muscle dependency after
relaxant long-term use

Name of drug Action and Dose Route Frequency Main S/E & Ng
classification considerations
3. Gabapentin Classification: PO Side effects
Antiepileptic include
Action: drowsiness,
Treat neuropathic dizziness,
pain in SCI. confusion,
It is proposed to ataxia and
work as a GABA edema.
agonist and inhibit Ng
calcium channels. consideration:
Gabapentin has a Urinary function
high affinity for and drug
alpha-2 receptors elimination
of calcium should be
channels and monitored. Pain
decreases the levels should be
release of recorded using
excitatory an appropriate
neurotransmitters. scale to ensure
the drug’s
effectiveness.
Taking care to
schedule
around daytime
drowsiness may
improve safety
and productivity
 during rehab
sessions.

Name of drug Action and Dose Route Frequency Main S/E & Ng
classification considerations
4. Baclofen: Action: used PO S/E: nausea,
Kemstro in the Intrathecal dizziness,
or treatment of drowsiness, fatigue,
Lioresal. spasticity in weakness and
spinal cord constipation.
injuries. This Ng consideration:
drug acts as Monitoring for
an allosteric specific CNS
modulator to symptoms, such as
GABA b seizures and
receptors nausea, are
which leads important for
to the maintaining patient
inhibition of safety.
alpha motor Supervise
neurons ambulation. Initially,
within the the loss of spasticity
spinal cord. induced by baclofen
Pre- and may affect patient's
postsynaptic ability to stand or
inhibition walk.
leads to a Lab tests: baseline
reduction in and periodic BP,
skeletal weight, blood sugar,
muscle tone. hepatic function
The weak tests, and urine.
permeability
to the blood-
brain barrier
makes
baclofen
more
effective in
treating
spasticity at
the level of
the spinal
 cord.
Classification:
Skeletal
muscle
relaxants.

Name of drug Action and Dose Route Frequency Main S/E & Ng
classification considerations
5. Corticosteroids: Action: Spinal, S/E: Noted
Methylprednisolon reduction of inhaled, complications
e oxidative and local such as wound
stress and it injection. infections,
is a primary sepsis, and
degenerative pneumonia are
event post prevalent in
trauma. patients with
Classification: spinal cord
Anti- injuries.
inflammatory Gastrointestinal
and collagenous
tissue disruption
have been
exhibited with
long-term use of
MP. The
catabolic effects
of
glucocorticoids
on various tissue
such as bone,
ligament, and
tendon are well-
documented. In
addition, this
class of steroids
may lead to
muscle atrophy,
hypertension,
diabetes
exaggeration,
glaucoma, and
cataracts.
Ng
 consideration:
-Perform a
physical
examination to
establish
baseline data for
assessing the
effectiveness of
the drug and the
occurrence of
any adverse
effects
associated with
drug therapy.

-Assess
temperature to
monitor for
possible
infections.

-Monitor blood
pressure, pulse,
and auscultation
to evaluate
cardiovascular
response.

-Assess
respirations and
adventitious
sounds to
monitor drug
effectiveness.

 Nursing process:
Diagnosis(prioritize) Plan/ objectives Interventions and Evaluation
rational
A. Ineffective Plan: -Promoting Goal met As
airway To improved Adequate evidenced by
clearance breathing pattern Breathing and patient maintain a
related to and airway Airway Clearance clear airway,
weakness of clearance and -monitoring oxygen breathing
intercostal breathing within saturation through normally
muscles AMB the normal range. pulse oximetry, And improvement
Shallow and monitoring in gas exchange
breathing. Objectives: arterial blood gas and clearance of
-patient will be values secretions.
able to Breathes Rational :
easily without Documents status
shortness of of ventilation and
breath oxygenation,
-Patient will be identifies
able to Performs respiratory
hourly deep problems such as
breathing hypoventilation
exercises, coughs (low Pao2 and
effectively, and elevated Paco2)
clears pulmonary and pulmonary
secretions complications.
-patient will be
free of respiratory
infection (has _Early and vigorous
normal attention to
temperature, clearing bronchial
respiratory rate, and pharyngeal
and pulse, normal secretions can
breath sounds and prevent retention
absence of of secretions.
purulent sputum) _Suctioning may be
indicated,
but caution must
be used during
suctioning because
this procedure can
stimulate the vagus
nerve, producing
bradycardia, which
can result in
cardiac arrest.
_If the patient
cannot cough
effectively because
of decreased
 inspiratory volume
and inability to
generate sufficient
expiratory
pressure, chest
physical therapy
and assisted
coughing may be
indicated.
Rational :
Preventing
retained secretions
is essential to
maximize gas
diffusion and to
reduce risk of
pneumonia.

-Assisted coughing
promotes clearing
of secretions from
the upper
respiratory tract
_Encourage fluids
Rational :
Aids in liquefying
secretions.

B. Impaired
physical Plan: _Proper body Goal partially met
mobility To avoid the alignment is as evidence by pt
related to hazards of maintained at all show improve in
motor and immobility, times range of motion
sensory Prevent dependent _The patient is but not as pre-
impairment disabilities, and repositioned injury level.
AMB Inability assist the patient frequently and is
to move in restoring, assisted
purposefully preserving, or out of bed as soon
within the maintaining as as the
physical much mobility and spinal column is
environment, functional stabilized
including bed independence. _The feet are
mobility, prone to footdrop
transfers. Objective: therefore, various
-patient will be types of splints are
able to moves used to prevent
within limits of the footdrop. When
dysfunction. used, the splints
-Patient will be are removed and
able to reapplied every 2
demonstrate hours.
completion of _Trochanter rolls,
exercises within applied from the
functional crest of the ilium to
limitations. the midthigh of
-patient will be both legs, help
able to increase prevent external
strength and rotation of the hip
function of Joints.
affected body part Rational:
Move within range These movements
of motion. keep the patient as
functionally
working as
possible. Early
mobility increases
self-esteem about
reacquiring
independence and
reduces the chance
that debilitation
will transpire.
_Monitor
nutritional needs
as they relate to
immobility.
Rational :
Good nutrition also
gives required
 energy for
participating in an
exercise or
rehabilitative
activities.

C. Disturbed
sensory _Promoting
perception Plan: Adaptation To Goal partially met
related to To improved Sensory And as evidence by
motor and sensory and Perceptual patient was able
sensory perceptual Alterations : to improve
impairment awareness. The intact senses sensory
AMB patient above the level of impairments but
 could not Objective: the injury are not completely.
localize touch -patient will be stimulated through
or describe able to touch, aromas
texture with demonstrate flavorful food and
any adaptation to beverages,
consistency. sensory and conversation, and
perceptual music.
alterations. _Providing prism
-Patient will be glasses to enable
able to uses the patient to see
assistive devices from the supine
(prism glasses, position
hearing aids. _Encouraging use
computers) as of hearing aids, if
indicated. indicated, to
Patient will be able enable the patient
to describe sensory to hear
and perceptual conversations and
alterations as a environmental
consequence of sounds.
injury. _Providing
emotional support
to the patient.
_Teaching the
patient strategies
to compensate for
or cope with these
deficits.

 Medical management:

Management Rational
Emergency management: Emergency management:
The paramedics applied a cervical collar, The immediate management of the
placed him on Ferno Scoop Stretcher,
immobilized his head, provided 100%
Oxygen and transported him to the
trauma center by helicopter.
Management
Surgical management:
Intensive Care:
Stabilize Condition
Intubated to Manage Respiratory
Function
Monitored and Treated for Neurogenic
Shock.
Surgery:
Spinal Fixation at C4 - C8 with Spinal
Decompression on Day 2
patient at the scene of the injury is
critical, because improper handling can
cause further damage and loss of
neurologic function. Any patient involved
in a motor vehicle or diving injury, a
contact sports injury, a fall, or any direct
trauma to the head and neck must be
considered to have SCI until such an
injury is ruled out. Initial care must
include a rapid assessment,
immobilization, extrication, stabilization
or control of life-threatening injuries, and
transportation to the most appropriate
medical facil٠
Rational
Surgical management:
Surgery is indicated in any of the
following instances:
• Compression of the cord is evident.
• The injury results in a fragmented or
unstable vertebral body.
• The injury involves a wound that
penetrates the cord.
• There are bony fragments in the spinal
canal.
• The patient's neurologic status is
deteriorating.
Surgery is performed to reduce the spinal
fracture or dislocation or to decompress
the cord. A laminectomy (excision of the
posterior arches and spinous processes
of a vertebra) may be indicated in the
presence of progressive neurologic
deficit, suspected epidural hematoma,
bony fragments, or penetrating injuries
that require surgical debridement, or to
permit direct visualization and
exploration of the cord. Vertebral bodies
may also be surgically fused to create a
stable spinal column.
 Research studies( related to the case subject):
- Study: Neuropathic Pain Experiences of Spinal Cord Injury Patients.
Author information:
LI, Chin-Ching, PhD, RN, Assistant Professor, Department of Nursing, Mackay Medical
College.
LIN, Hung-Ru, PhD, RN, Professor, School of Nursing, National Taipei University of
Nursing and Health Sciences

Publication:
Journal of Nursing Research: August 2018 - Volume 26 - Issue 4 - p 280-287
doi: 10.1097/jnr.0000000000000227

Background:
Neuropathic pain (NP) is a common, severe problem that affects spinal cord injury (SCI)
patients. Only SCI patients truly understand the impact and extent of this type of pain.

Purpose: 
The aim of this study was to understand the NP experienced by SCI patients and the
influence of this type of pain on their daily life.

Setting: 
In a neurorehabilitation department at a medical center in northern Taiwan.

Methods:
 A qualitative design was used. An interview guide including a semistructured
questionnaire and in-depth interviews was conducted with SCI patients with NP. The
data were collected using a purposive sampling method. Content analysis was
performed on the interview data, which were obtained from 13 SCI patients with NP.

Participants:
A purposive sampling method with an in-depth interview process was adopted. Patients
who met the following were recruited as participants: (a) having experienced a
traumatic SCI and experienced NP; (b) aged ≥ 18 years, able to speak Mandarin, and
willing to be interviewed; and (c) having experienced various levels of motor and
sensory impairment and paralysis due to an acute traumatic SCI. The recruitment
process ended when new participants did not add new information, indicating data
saturation. The exclusion criteria included brain trauma, ventilator or oxygen
 dependence, psychiatric disorders, suicidal trauma, cognitive deficits, and major chronic
illness.

Results: 
Three themes and eight subthemes were identified that described the NP experience of
the participants and the influence of NP on their daily life. The three themes included
elusive pain (changing and individual pain sensations, erratically haunting threat, and
phantom limb sensations), complicated feelings about pain (converting depression into
an active attitude toward life, having feelings of anticipation and anxiety about future
pain relief, and facing and experiencing pain), and renewed hope (bravely fighting pain
and seeking pain relief methods).

-Nursing implications for practice, education and research:

It is important to know that neuropathic pain can effects daily living activities and SCI
patients should be evaluated in detail to determine the characteristic of pain and
medical treatment prescribed should be closely monitored. Nurses should tell patients
that stress and tension can increase pain so health education about relaxation
techniques is important. Also health professionals should obtain knowledge about the
clinical characteristics of pain, listen to the experience of their patients, and improve
pain management based on patient needs. Nurses should understand the nature of NP,
provide pain assessment, and design a proper plan for pain management to care for
patients.

References:
●Textbook of medical surgical Nursing,Suzanne c .smeltzer Brenda Bare,10ediction

●https://www.medicalnewstoday.com/articles/spinal-cord-injuries#causes

●https://www.google.com/url?
sa=t&source=web&rct=j&url=https://rnspeak.com/spinal-cord-injury-nursing-
care-
plan/&ved=2ahUKEwif16GB77zvAhWJmBQKHWG3C_cQFjANegQIGhAC&usg=AOv
Vaw2SmEV4aRC7CdPxQbJmejt2&cshid=1616174858991
●https://www.google.com/url?
sa=t&source=web&rct=j&url=https://nurseslabs.com/12-spinal-cord-injury-
nursing-care-
plans/&ved=2ahUKEwiDpIbDn8fvAhUFC2MBHc6ZARYQFjABegQIExAC&usg=AOvV
aw3-wWwnTYgWbpXYcB7GfFN4&cshid=1616531094240.