NUR 111 (Nursing Care of Clients with Life –

Threatening Conditions, Acutely Ill/Multi-organ

Problems, High Acuity and Emergency
STUDENT ACTIVITY SHEET Situation)
BS NURSING / FOURTH YEAR
Session # 17

Materials: MS notebook, paper, pen, index card,

LESSON TITLE: Spinal Cord Injury (SCI) and bond paper (short & long size)
References:
LEARNING TARGETS:
Smeltzer S.C., & Bare B.G. (2010) Brunner and
At the end of the lesson, the student nurses can: Suddarth’s Textbook of Medical- Surgical Nursing.
1. Identify common causes of spinal cord injuries; Lippincott William & Wilkins
2. Describe the types of SCI;
3. Discuss the emergency management of SCI; and, Sommer S., Johnson J. (2013) RN Adult Medical
4. Explain nursing management CSI. Surgical Nursing. Assessment Technology
Institute, LLC.
https://www.nurseslab.com

LESSON PREVIEW/REVIEW (10 minutes)

Instruction: List down the modifiable and non-modifiable risk factors of ischemic stroke.
Modifiable Factors Non - modifiable Factors

MAIN LESSON (60 minutes)

Spinal cord injuries (SCIs) are a major health problem.

Most SCIs result from motor vehicle crashes. Other causes include falls, violence (primarily from gunshot wounds), and
recreational sporting activities. Half of the victims are between 16 and 30 years of age; most are males.
Another risk factor is substance abuse (alcohol and drugs). There is a high frequency of associated injuries and medical
complications. The vertebrae most frequently involved in SCIs are the fifth, sixth, and seventh cervical vertebrae (C5–C7),
the 12th thoracic vertebra (T12), and the first lumbar vertebra (L1). These vertebrae are the most susceptible because
there is a greater range of mobility in the vertebral column in these areas.
Damage to the spinal cord ranges from transient concussion (patient recovers fully), to contusion, laceration, and
compression of the cord substance (either alone or in combination), to complete transection of the cord (paralysis below
the level of injury).
Injury can be categorized as primary (usually permanent) or secondary (nerve fibers swell and disintegrate as a result of
ischemia, hypoxia, edema, and hemorrhagic lesions). Whereas a primary injury is permanent, a secondary injury may be
reversible if treated within 4 to 6 hours of the initial injury.
The type of injury refers to the extent of injury to the spinal cord itself.

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  Incomplete spinal cord lesions are classified according to the area of spinal cord damage: central, lateral, anterior,
or peripheral.
 A complete SCI can result in paraplegia (paralysis of the lower body) or tetraplegia (formerly quadriplegia—
paralysis of all four extremities).

Clinical Manifestations
The consequences of SCI depend on the type and level of injury of the cord.

Neurologic Level
The neurologic level refers to the lowest level at which sensory and motor functions are normal.
Signs and symptoms include the following:
 Total sensory and motor paralysis below the neurologic level.
 Loss of bladder and bowel control (usually with urinary retention and bladder distention).
 Loss of sweating and vasomotor tone.
 Marked reduction of BP from loss of peripheral vascular resistance.
 If conscious, patient reports acute pain in back or neck; patient may speak of fear that the neck or back is broken.

Respiratory Problems
 Related to compromised respiratory function; severity depends on level of injury.
 Acute respiratory failure is the leading cause of death in high cervical cord injury.

Assessment and Diagnostic Methods

Detailed neurologic examination, x-ray examinations (lateral cervical spine x-rays), computed tomography (CT), magnetic
resonance imaging (MRI), and ECG (bradycardia and asystole are common in acute spinal injuries) are common
assessment and diagnostic methods.

Complications
 Spinal shock, a serious complication of SCI, is a sudden depression of reflex activity in the spinal cord (areflexia)
below the level of injury.
 The muscles innervated by the part of the cord segment situated below the level of the lesion become completely
paralyzed and flaccid, and the reflexes are absent. BP and heart rate fall as vital organs are affected.
 Parts of the body below the level of the cord lesion are paralyzed and without sensation.

Emergency Management
 Immediate patient management at the accident scene is crucial. Improper handling can cause further damage
and loss of neurologic function.
 Consider any victim of a motor vehicle crash, a diving or contact sports injury, a fall, or any direct trauma to the
head and neck as having an SCI until ruled out.
 Initial care includes rapid assessment, immobilization, extrication, stabilization or control of life-threatening
injuries, and transportation to an appropriate medical facility.
 Maintain patient in an extended position (not sitting); no body part should be twisted or turned.
 The standard of care is referral to a regional spinal injury center or trauma center for treatment in first 24 hours.

Medical Management
Acute Phase
 Goals of management are to prevent further SCI and to observe for symptoms of progressive neurologic deficits.
 The patient is resuscitated as necessary, and oxygenation and cardiovascular stability are maintained. High-dose
corticosteroids (methylprednisolone) may be administered to counteract spinal cord edema.
 Oxygen is administered to maintain a high arterial PaO2.
 Extreme care is taken to avoid flexing or extending the neck if endotracheal intubation is necessary.
 Diaphragm pacing (electrical stimulation of the phrenic nerve) may be considered for patients with high cervical
spine injuries.
 SCI requires immobilization, reduction of dislocations, and stabilization of the vertebral column.
 The cervical fracture is reduced and the cervical spine aligned with a form of skeletal traction (using skeletal
tongs or calipers or the halo-vest technique).
 Weights are hung freely so as not to interfere with the traction. Early surgery reduces the need for traction.

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  The goals of surgical treatment are to preserve neurologic function by removing pressure from the spinal cord
and to provide stability.

Management of Complications
Spinal and Neurogenic Shock
 Intestinal decompression is used to treat bowel distention and paralytic ileus caused by depression of reflexes.
 This loss of sympathetic innervation causes a variety of other clinical manifestations, including neurogenic shock
signaled by decreased cardiac output, venous pooling in the extremities, and peripheral vasodilation.
 Patient who does not perspire on paralyzed portion of body requires close observation for early detection of an
abrupt onset of fever.
 Body defenses are maintained and supported until the spinal shock abates and the system has recovered from
the traumatic insult (up to 4 months).
 Special attention is paid to the respiratory system (may not be enough intrathoracic pressure to cough effectively).
 Special problems include decreased vital capacity, decreased oxygen levels, and pulmonary edema.
 Chest physiotherapy and suctioning are implemented to help clear pulmonary secretions. Patient is monitored for
respiratory complications (respiratory failure, pneumonia).

Deep Vein Thrombosis and Other Complications

 Patient is observed for deep vein thrombosis (DVT), a complication of immobility (eg, pulmonary embolism).
 Symptoms include pleuritic chest pain, anxiety, shortness of breath, and abnormal blood gas values.
 Low-dose anticoagulation therapy is initiated to prevent DVT and pulmonary embolism, along with the use of
antiembolism stockings or pneumatic compression devices. A permanent indwelling filter may be placed in the
vena cava to prevent dislodged clots (emboli) from migrating to the lungs and causing pulmonary emboli.
 Patient is monitored for autonomic hyperreflexia (characterized by pounding headache, profuse sweating, nasal
congestion, piloerection [gooseflesh], bradycardia, and hypertension).
 Constant surveillance is maintained for signs and symptoms of pressure ulcers and infection (urinary, respiratory,
local infection at pin sites).

THE PATIENT WITH ACUTE SCI

Assessment
 Observe breathing pattern; assess strength of cough; auscultate lungs.
 Monitor patient closely for any changes in motor or sensory function and for symptoms of progressive neurologic
damage.
 Test motor ability by asking patient to spread fingers, squeeze examiner’s hand, and move toes or turn the feet.
 Evaluate sensation by pinching the skin or touching it lightly with a tongue blade, starting at shoulder and working
down both sides; patient’s eyes should be closed. Ask patient where sensation is felt.
 Assess for spinal shock.
 Palpate lower abdomen for signs of urinary retention and overdistention of the bladder.
 Assess for gastric dilation and paralytic ileus due to atonic bowel.
 Monitor temperature (hyperthermia may result due to autonomic disruption).

Nursing Interventions
Promoting Adequate Breathing and Airway Clearance
 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 if the patient cannot cough effectively.
 Supervise breathing exercises to increase strength and endurance of inspiratory muscles, particularly the
diaphragm.
 Ensure proper humidification and hydration to maintain thin secretions.
 Assess for signs of respiratory infection: cough, fever, and dyspnea.

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  Monitor respiratory status frequently.
Improving Mobility
 Maintain proper body alignment at all times.
 Reposition the patient frequently and assist patient out of bed as soon as the spinal column is stabilized.
 Apply splints (various types) to prevent foot drop and trochanter rolls to prevent external rotation of the hip joints;
reapply every 2 hours.
 Patients with lesions above the midthoracic level may tolerate changes in position poorly; monitor BP when
positions are changed.
 Do not turn patient who is not on a rotating specialty bed unless physician indicates that it is safe to do so.
 Perform passive range-of-motion exercises as soon as possible after injury to avoid complications such as
contractures and atrophy.
 Provide a full range of motion at least four or five times daily to toes, metatarsals, ankles, knees, and hips.
 For patients who have a cervical fracture without neurologic deficit, reduction in traction followed by rigid
immobilization for 6 to 8 weeks restores skeletal integrity. These patients are allowed to move gradually to an
erect position.
 Apply a neck brace or molded collar when the patient is mobilized after traction is removed.
Promoting Adaptation to Disturbed Sensory Perception
 Stimulate the area above the level of the injury through touch, aromas, flavorful food and beverages,
conversation, and music.
 Provide prism glasses to enable patient to see from supine position.
 Encourage use of hearing aids, if applicable.
 Provide emotional support; teach patient strategies to compensate for or cope with sensory deficits.
Maintaining Skin Integrity
 Change patient’s position every 2 hours, and inspect the skin, particularly under cervical collar.
 Assess for redness or breaks in skin over pressure points; check perineum for soilage; observe catheter for
adequate drainage; assess general body alignment and comfort.
 Wash skin every few hours with a mild soap, rinse well, and blot dry. Keep pressure-sensitive areas well
lubricated and soft with bland cream or lotion.
 Teach patient about pressure ulcers and encourage participation in preventive measures
Maintaining Urinary Elimination
 Perform intermittent catheterization to avoid overstretching the bladder and infection. If this is not feasible, insert
an indwelling catheter.
 Show family members how to catheterize, and encourage them to participate in this facet of care.
 Teach patient to record fluid intake, voiding pattern, amounts of residual urine after catheterization, characteristics
of urine, and any unusual feelings.
Improving Bowel Function
 Monitor reactions to gastric intubation.
 Provide a high-calorie, high-protein, and high-fiber diet. Food amount may be gradually increased after bowel
sounds resume.
 Administer prescribed stool softener to counteract effects of immobility and analgesic agents, and institute a
bowel program as early as possible.
Providing Comfort Measures
 Reassure patient in halo traction that he or she will adapt to steel frame (ie, feeling caged in and hearing noises).
 Cleanse pin sites daily, and observe for redness, drainage, and pain; observe for loosening. If one of the pins
becomes detached, stabilize the patient’s head in a neutral position and have someone notify the neurosurgeon;
keep a torque screwdriver readily available.
 Inspect the skin under the halo vest for excessive perspiration, redness, and skin blistering, especially on the
bony prominences. Open vest at the sides to allow torso to be washed. Do not allow vest to become wet; do not
use powder inside vest.

Monitoring and Managing Potential Complications

THROMBOPHLEBITIS Refer to ―Medical Management‖ in text on ―Vein Disorders‖ in Chapter V. ORTHOSTATIC
HYPOTENSION Reduce frequency of hypotensive episodes by administering prescribed vasopressor medications.
Provide antiembolism stockings and abdominal binders; allow time for slow position changes, and use tilt tables as
appropriate. Close monitoring of vital signs before and during position changes is essential.

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AUTONOMIC HYPERREFLEXIA
 Perform a rapid assessment to identify and alleviate the cause of autonomic hyperreflexia and remove the trigger.
 Place patient immediately in sitting position to lower BP.
 Catheterize the patient to empty bladder immediately.
 Examine rectum for fecal mass. Apply topical anesthetic for 10 to 15 minutes before removing fecal mass.
 Examine skin for areas of pressure, irritation, or broken skin.
 As prescribed, administer a ganglionic blocking agent such as hydralazine hydrochloride (Apresoline) if the above
measures do not relieve hypertension and excruciating headache.
 Label chart clearly and visibly, noting the risk for autonomic hyperreflexia.
 Instruct patient in prevention and management measures. Inform patient with lesion above T6 that hyperlexic
episode can occur years after initial injury.

Promoting Home- and Community-Based Care

TEACHING PATIENTS SELF-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.
 Initially, focus patient teaching on the injury and its effects on mobility, dressing, and bowel, bladder, and sexual
function. As the patient and family acknowledge the consequences of the injury and the resulting disability,
broaden the focus of teaching to address issues necessary for carrying out the tasks of daily living and taking
charge of their lives.
CONTINUING CARE
 Support and assist patient and family in assuming responsibility for increasing care and provide assistance in
dealing with psychological impact of SCI and its consequences.
 Coordinate management team, and serve as liaison with rehabilitation centers and home care agencies.
 Reassure female patients with SCI that pregnancy is not contraindicated and fertility is relatively unaffected, but
that pregnant women with acute or chronic SCI pose unique management challenges.
 Refer for home care nursing support as indicated or desired.
 Refer patient to mental health care professional as indicated.

CHECK FOR UNDERSTANDING (25 minutes)

You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
You are given 25 minutes for this activity:

Multiple Choice

1. A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short
time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute),
diaphoresis, and flushing of the face and neck. What action should you take first?
A. Administer the ordered acetaminophen (Tylenol).
B. Check the Foley tubing for kinks or obstruction.
C. Adjust the temperature in the patient’s room.
D. Notify the physician about the change in status.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

2. A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment?
A. Determine the level at which the patient has intact sensation.
B. Assess the level at which the patient has retained mobility.
C. Check blood pressure and pulse for signs of spinal shock.
D. Monitor respiratory effort and oxygen saturation level.
ANSWER: ________

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RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

3. You are pulled from the ED to the neurologic floor. Which action should you delegate to the nursing assistant when
providing nursing care for a patient with SCI?
A. Assess patient’s respiratory status every 4 hours.
B. Take patient’s vital signs and record every 4 hours.
C. Monitor nutritional status including calorie counts.
D. Have patient turn, cough, and deep breathe every 3 hours.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

4. You are helping the patient with an SCI to establish a bladder-retraining program. What strategies may stimulate the
patient to void? (Choose all that apply).
A. Stroke the patient’s inner thigh.
B. Pull on the patient’s pubic hair.
C. Initiate intermittent straight catheterization.
D. Pour warm water over the perineum.
E. Tap the bladder to stimulate detrusor muscle.
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

5. You are preparing a nursing care plan for the patient with SCI including the nursing diagnosis Impaired Physical
Mobility and Self-Care Deficit. The patient tells you, ―I don’t know why we’re doing all this. My life’s over.‖ What additional
nursing diagnosis takes priority based on this statement?
A. Risk for Injury related to altered mobility
B. Imbalanced Nutrition, Less Than Body Requirements
C. Impaired Adjustment to Spinal Cord Injury
D. Poor Body Image related to immobilization
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

6. A client with a C6 spinal injury would most likely have which of the following symptoms?
A. Aphasia
B. Hemiparesis
C. Paraplegia
D. Tetraplegia
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

7. A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine injury is suspected.
How should the first-responder open the client’s airway for rescue breathing?
A. By performing a jaw-thrust maneuver
B. By inserting a nasopharyngeal airway
C. By inserting a oropharyngeal airway
D. By performing the head-tilt, chin-lift maneuver
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

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8. The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in
minimizing the effects of
A. Using vasopressor medications as prescribed
B. Applying Teds or compression stockings.
C. Moving the client quickly as one unit
D. Monitoring vital signs before and during position changes
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

9. The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury
most effectively by:
A. Logrolling the client on a soft mattress
B. Keeping the client on a stretcher
C. Logrolling the client on a firm mattress
D. Placing the client on a Stryker frame
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

10. After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the
nurse expect?
A. Quadriplegia and loss of respiratory function
B. Loss of bowel and bladder control
C. Paraplegia with intercostal muscle loss
D. Quadriplegia with gross arm movement and diaphragmic breathing
ANSWER: ________
RATIO:___________________________________________________________________________________________
________________________________________________________________________________________________
______________________________________________________________

RATIONALIZATION ACTIVITY (THIS WILL BE DONE DURING THE FACE TO FACE INTERACTION)
The instructor will now rationalize the answers to the students. You can now ask questions and debate among yourselves.
Write the correct answer and correct/additional ratio in the space provided.

1. ANSWER: ________
RATIO:_______________________________________________________________________________________
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2. ANSWER: ________
RATIO:_______________________________________________________________________________________
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3. ANSWER: ________
RATIO:_______________________________________________________________________________________
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4. ANSWER: ________
RATIO:_______________________________________________________________________________________
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5. ANSWER: ________

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 RATIO:_______________________________________________________________________________________
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6. ANSWER: ________
RATIO:_______________________________________________________________________________________
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7. ANSWER: ________
RATIO:_______________________________________________________________________________________
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8. ANSWER: ________
RATIO:_______________________________________________________________________________________
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9. ANSWER: ________
RATIO:_______________________________________________________________________________________
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10. ANSWER: ________

RATIO:_______________________________________________________________________________________
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LESSON WRAP-UP (25 minutes)

You will now mark (encircle) the session you have finished today in the tracker below. This is simply a visual to help you
track how much work you have accomplished and how much work there is left to do.

You are done with the session! Let’s track your progress.

AL Strategy: Small Group Discussion/ Sharing

Instruction: You need to form groups of four as you will be asked to discussed answers to the question given by the
Instructor. You we’re given prior instruction on the materials needed (manila paper/ pentel pen) so that you can write your
answer to it. All groups will be given 4-5 minutes to discuss and answer all the questions.\

(For Related Learning Experience, please refer to your clinical instructor.)

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