6.

5 Spinal Cord
Ian, Hana, Seans x 2, Rebekah
Patho/Etiology
Spinal cord injury (SCI) is an insult to the spinal cord
resulting in a change, either temporary or permanent, in its
normal motor, sensory, or autonomic function. The
International Standards for Neurological and Functional
Classification of Spinal Cord Injury is a widely accepted
system describing the level and extent of injury based on a
systematic motor and sensory examination of neurologic
function.
Destruction from direct trauma
Compression by bone fragments, hematoma, or disk material
Ischemia from damage or impingement on the spinal arteries
Interventions
Continually asses motor function spial shock or
edema
Provide means to summon help
Assist in range of motion exercises
Plan activities to provide uninterrupted rest periods
Reposition periodically to help maintain skin integrity
Provide therapeutic level of ana;geic medication
Medications
Analgesics
NSAIDS if indicated
Other prescribed medications related to past or
current medical history.
6.5 Spinal Cord
Ben Brown is a 21-year-old college junior who was
admitted to the ICU via the ED for evaluation and
treatment of a spinal cord injury (SCI) sustained in a
diving accident. Consider the type of fracture most
typical from this type of accident. He is accompanied
by his fiancée and his parents.
1. This morning Ben complained of an excruciating headache, and
his BP was 210/110 mm Hg. Identify the etiologic factors that
might cause these manifestations and the nursing interventions.
The return of reflexes after the resolution of spinal shock means that patients with an injury level at T6 or higher may develop
autonomic dysreflexia. Autonomic dysreflexia (also known as autonomic hyperreflexia) is a massive uncompensated cardiovascular
reaction mediated by the sympathetic nervous system. It occurs in response to visceral stimulation once spinal shock is resolved in
patients with spinal cord lesions. The condition is a life-threatening situation that requires immediate resolution. If resolution does
not occur, this condition can lead to status epilepticus, stroke, myocardial infarction, and even death.

The most common precipitating cause is a distended bladder or rectum, although any sensory stimulation may cause autonomic
dysreflexia. Contraction of the bladder or rectum, stimulation of the skin, or stimulation of the pain receptors may also cause
autonomic dysreflexia. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis
above the level of the lesion, bradycardia (30 to 40 beats/min), piloerection (erection of body hair), flushing of the skin above the
level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure blood
pressure when a patient with a spinal cord injury complains of a headache.

Nursing interventions in this serious emergency are elevation of the head of the bed 45 degrees or sitting the patient upright,
notification of the physician, and assessment to determine the cause. Since the patient already has a catheter in place, it should be
checked for kinks or folds. If plugged, small-volume irrigation should be performed slowly and gently to open a plugged catheter, or
a new catheter may be inserted. Stool impaction can also result in autonomic dysreflexia. A digital rectal examination should be
performed only after application of an anesthetic ointment to decrease rectal stimulation and to prevent an increase of symptoms.
The nurse should remove all skin stimuli, such as constrictive clothing and tight shoes. Blood pressure should be monitored
frequently during the episode. If symptoms persist after the source has been relieved, an α-adrenergic blocker or an arteriolar
vasodilator (e.g., nifedipine [Procardia]) is administered. Careful monitoring must continue until the vital signs stabilize.
2. Compare and contrast the sensory & motor deficits expected for various levels of SCI. Include C1-2, C4-6, T4-6, L1-5, S1-5 in your discussion. Identify the rehabilitation potential and
priority nursing actions for each of these categories.
Level of Injury
C1 - 3
Often fatal injury; Vagus nerve domination
of heart, respiration, blood vessels, & all
organs below injury
C4 - 6
Vagus nerve domination of heart,
respiration, blood vessels, & all organs
below injury
T4 - 6
Sympathetic innervation to heart, vagus
nerve domination of all vessels & organs
below injury.
L1 - 5
L1 – 2: Vagus nerve domination of leg
vessels.
L3 – 5: Partial vagus nerve domination of
leg vessels, GI & GU organs.
S1 - 5
S1 - 3: Heel & middle back of leg; back of
thighs; medial side of buttocks.
S4 - 5: Perineal region; skin immediately at
& adjacent to anus.
Movement Remaining
Movement in neck & above; loss of
innervation to diaphragm; absence of
independent respiratory function.
C4: Sensation & movement in neck &
above; may be able to breathe w/out a vent.
C5: Full neck, partial shoulder, back,
biceps; gross elbow, inability to roll over or
use hands; ↓ respiratory reserve
C6: Shoulder and upper back abduction
and rotation at shoulder, full biceps - elbow
flexion, wrist ext, weak grasp of thumb, ↓
respiratory reserve
Full innervation of upper extremities; back, Full independence in self-care and in WC; ability to
essential intrinsic muscles of hand; full
strength & dexterity of grasp; ↓ trunk
stability, ↓ respiratory reserve.
L1 – 2: Varying control of legs & pelvis,
instability of lower back.
L3 – 5: Quadriceps & hip flexors, absence
of hamstring function, flail ankles.
S1 – 5: Variable bowel/bladder/sexual
function; may have total preservation of leg
strength but complete bowel and bladder
paralysis as well as perineal anesthesia;
Some hip, knee and foot movement
depending on the level of injury. The lower
the injury, the more control over movement.
Rehabilitation Potential
Ability to drive electric WC equipped w/ portable vent
by using chin control/mouth stick; headrest to
stabilize head; computer use w/ mouth stick, head
wand, or noise control, 24-hr attendant care, able to
instruct others.
C4: Same as C1 – 3.
C5: Ability to assist with xfer & perform some self-
care; feed self w/ hand devices; push WC on smooth,
flat surface; drive adapted van from WC; ind. computer
use w/ adaptive equipment; attendant care 6 hr/day.
C6: Ability to transfer self to WC; roll over & sit up in
bed; push self on most surfaces; perform most self-
care; ind. use of WC; ability to drive car w/ powered
hand controls (in some pts); attendant care 0-6 hr/day
drive car with hand controls (in most pts); ind standing
in standing frame.
L1 – 2: Good sitting balance; full use of WC;
ambulation w/ long leg braces.
L3 – 5: Completely ind. ambulation w/ short leg braces
& canes; inability to stand for long periods.
S1 - 5: Manual WC may be used for everyday living,
w/ the ability to go over uneven ground; xfer
independently from bed - chair, & chair - car; it may be
possible to xfer from floor - chair depending on upper
body strength; based on level of injury, walking may
be possible w/ assistance or aids; ability to drive car
adapted w/ hand controls; ability to load WC into car
independently.
Priority Nursing Actions

Priority nursing actions for these categories are to sustain life and prevent further cord damage. Systemic
and neurogenic shock must be treated to maintain blood pressure. For injury at the cervical level, all
body systems must be maintained until the full extent of the damage can be evaluated.

Initial
• Ensure patent airway.
• Stabilize cervical spine.
• Administer oxygen via nasal canula or non- rebreather mask.
• Establish IV access with two large-bore catheters to infuse normal saline or lactated
Ringer's solution as appropriate.
• Assess for other injuries.
• Control external bleeding.
• Obtain cervical spine x-rays, CT scan, or MRI.
• Prepare for stabilization with cranial tongs and traction.
• Administer high-dose methylprednisolone if ordered.

Ongoing Monitoring
• Monitor vital signs, level of consciousness, oxygen saturation, cardiac rhythm, urine output.
• Keep warm.
• Monitor for urinary retention, hypertension.
• Anticipate need for intubation if gag reflex absent.
3. Identify the teaching on sexual function that is necessary for clients with SCI. When should this
teaching begin.

Sexual activities may require more planning and be less spontaneous than before the injury. For example, an attendant may
have to undress the patient and remove equipment. A relaxed atmosphere with music and perfume creates an attractive
environment. Ample time for caressing, fondling, and kissing is essential. The partners should be encouraged to explore
each other's erogenous areas, such as the lips, neck, and ears, which can arouse psychogenic erection or orgasm. Few
demands should be made initially.

Care should be taken not to dislodge an indwelling catheter during sexual activity. If an external catheter is used, it should
be removed before sexual activity and the patient should refrain from fluids. The bowel program should include evacuation
the morning of sexual activity. The partner should be informed that incontinence is always possible. The woman may need
a water-soluble lubricant to supplement diminished vaginal secretions and facilitate vaginal penetration.

Sexual rehabilitation for both men and women should begin informally after the acute phase of the injury has passed.
Questions such as, “Have you had an erection since your injury?” and “Have your menstrual periods continued since the
injury?” are nonthreatening ways to introduce the topic of sexual functioning. The male patient may pose a question such
as, “Can I ever be a man again?”

Open discussion with the patient is essential. This important aspect of rehabilitation should be handled by someone
specially trained in sexual counseling. A nurse or other rehabilitation professional with such expertise works with the
patient and partner to provide support, with the emphasis on open communication. The nurse's educational role requires
respect for every couple's personal standards of religious and cultural beliefs.
4. Identify the key nursing actions for clients in skeletal traction
for cervical injuries. Compare these nursing actions with
those given after treatment for these injuries.
Nursing Actions for Traction: 1) identify and know the
types skeletal vs skin 2) patient teaching 3)
maintaining the traction apparatus 4) assessing for
complications of immobility 5) for patients with
skeletal traction- caring for and assessing the pin
insertion sites.
5. Consider the risks and benefits of halo traction
versus spinal
fusion for the treatment of cervical injuries.
Halo traction is a way of keeping your head and neck still while you get better after an accident or operation to your
neck bones.  This will usually always be used in adults with broken necks if surgery is not performed immediately
post injury.  If surgery goes ahead and is successful post injury then there's usually no further need for halo traction. 
If surgery is ruled out then the halo traction will be used for up to two months on bed rest and then a further month
to three months attached to a specially made vest so the head is kept perfectly still whilst sitting.
 
The halo traction equipment is made up of three pieces:
a ring around your head and then or
a special vest
Weights attached to the halo at head end of bed over a pulley system
a set of four rods and two blocks.
 
Halo traction is attached to the head by titanium screws which are screwed into the skull bone.  The screws have to
be tightened periodically to ensure the halo is fitting correctly.  The halo traction vest when required will be made
just for the individual.
 
Cervical spinal fusion is a surgery that joins selected bones in the neck. The different methods are bone graphs,
insertion of metal rods, removal of vertebra or disc and fusing remaining bone. This surgery usually requires a short
stay in the hospital. One has to remember after a joint is fused one loses all movement in that joint which can affect
ones ADL’s.
6. Compare and contrast the nursing roles and priorities of the
acute or critical care nurse and the rehabilitation nurse in
caring for clients with SCI.
Acute care of spinal cord injury is focused on
preventing further damage and trying to restore as
much function as possible. Rehab focuses on therapy
aimed at improving neurocognitive function that has
been lost or diminished by disease or traumatic injury.
7. Compare and contrast the traumatic and nontraumatic disorders
that may result in SCI. Consider how the source of the
injury may influence nursing care.
7) Spinal cord injury refers to an injury to the spinal cord. It can cause myelopathy or
damage to nerve roots or myelinated fiber tracts that carry signals to and from the brain.
 
Causes traumatic and non traumatic:
Trauma such as automobile crashes, falls, gunshots, diving accidents, war injuries, etc.
Tumor such as meningiomas, ependymomas, astrocytomas, and metastatic cancer.
Ischemia resulting from occlusion of spinal blood vessels, including
dissecting aortic aneurysms, emboli, arteriosclerosis.
Developmental disorders, such as spina bifida, meningomyolcoele, and others
Neurodegenerative diseases, such as Friedreich's ataxia, spinocerebellar ataxia, etc.
Demyelinative diseases, such as Multiple Sclerosis.
Transverse myelitis, resulting from stroke, inflammation, or other causes.
Vascular malformations, such as arteriovenous malformation (AVM), dural
arteriovenous fistula (AVF), spinal hemangioma, cavernous angioma and aneurysm.
 
References
http://www.scribd.com/doc/14009149/Nursingcribco
m-Nursing-Care-Plan-Spinal-Cord-Injury