(T3) SCI and GB CHTP 60 (Test 3)

Muscular Spinal:
Spinal Cord Injuries,

Guillain Barre’ &
Peripheral Nerve
Problems
Chapter 60 _ Lewis
pp. 1419-1441
Copyright © 2017,
Elsevier Inc. All Rights
Reserved.
Actor Christopher Reeves, 1995
Actor Christopher Reeve, best known for

his role as Superman, is paralyzed and
cannot breathe without the help of a
respirator after breaking his neck in a
riding accident. Reeve suffered fractures to
the top two vertebrae, considered the
most serious of cervical injuries, and ...
Copyright © 2017, Elsevier Inc. All Rights Reserved.

... It takes a Village
◼Keesler Rehabilitation Center in New

Jersey
◼It was the nurses who mainly kept
him alive, as breathing tube became
disconnected many times
◼Glen Miller helped him learn how to
independently take showers via
powered wheelchair
... 10 year survival

Prevention Needs to be the
Objective
◼Increased survival: No Cure
▪ restored function REMAINS limited
▪ Good rehab and ER care to reducing extent of injury
▪ FUTURE: nerve transplant, improved decompression
surgery
▪ Stem cell therapy/research
▪ “Complex” Drug therapies
◼PREVENTION is KEY

Autonomic Nervous System
◼the part of the nervous system

responsible for control of the bodily
functions not consciously directed,
such as breathing, the heartbeat, and
digestive processes.

STUDY RECOMMENDATIONS
• Inclusion of your Anatomy and

Physiology materials
• Lewis Med-Surg
• Taber's dictionary
• The internet ..........
Word of God .... To whom much is given__
much is required__Lu 12:48

The Spine
◼ There are 33 individual Vertebrae

bones that interlock to form
the spinal column.
◼Regions: cervical, thoracic, lumbar,
sacrum, and coccyx
◼The top 24 bones are moveable; the
◼vertebrae of the sacrum and coccyx are
fused.
Spinal Cord Injury (SCI)
◼ Trauma or damage to spinal cord

◼Cervical, thoracic, lumbar, or sacral
◼ 12,500 new SCIs each year
◼ 276,000 Americans living with SCI
◼ Highest in men ages 16-30
◼ ↑ In older adults

Question
You are monitoring the neurologic status on a

patient with a progressive spinal cord compression.
Which finding will indicate compression above the
level of the C7-C8 injury?
A. Urinary retention.
B. Gastric distention.
C. Loss of grip strength.
D. Decrease in resp. rate.

Question
You are monitoring the neurologic status on a
patient with a progressive spinal cord compression.
Which finding will indicate compression at or above
the level of the C8 injury?
A. Urinary retention. Thoracic
B. Gastric distention. Thoracic
C. Loss of grip strength.
D. Decrease in resp. rate._ C4-C5
pp.-1421 1423

Rationale
◼At C8 injury pt grasp ability dec. in upward
extension and flexion causing loss of grip
strength.
◼Resprate will increase due to trying to compensate for
the hypoventilation.
◼Both urinary retention and gastric retention already
present bc of vagus nerve stimulation (parasympathetic)
BELOW the level of the injury pp. 1421-1423

Spinal Cord Injury (SCI)
◼ Trauma or damage to spinal cord

◼Cervical, thoracic, lumbar, or sacral
◼ 12,500 new SCIs each year
◼ 276,000 Americans living with SCI
◼ Highest in men ages 16-30
◼ ↑ In older adults

Question
What symptoms will the nurse assess in a

client diagnosed with neurogenic shock?
(select all that apply).
a. Bradycardia.
b. Flaccidity
c. Hypotension
d. Loss of reflexes
e. Absent thermoregulation
Question
What symptoms will the nurse assess in a

client diagnosed with neurogenic shock?
a. Bradycardia. The other
symptoms are
b. Flaccidity related to spinal
shock_pp. 1420
c. Hypotension Know the
d. Loss of reflexes difference
e. Absent thermoregulation
Question
◼What other symptoms accompany

neurogenic shock besides
(bradycardia & hypotension)?

Note: Review SNS
◼What does the
◼Inc. HR
Sympathetic
Nervous System ◼Goose bumps
do? ◼Dilated pupils
◼Constrict blood
vessels
Fight or flight
◼Inc. peristalsis
response

Question
◼Which activities can the nurse delegate to an
unlicensed personnel on a c-spine injury pt?
A. Monitor intake and output.
B. Turn side to side every 2 hours
C. Assess lung sounds bilaterally.
D. Test stool specimen for hemoccult bld
E. Remove and reapply compression stockings.

Question
◼Which activities can the nurse delegate to an
unlicensed personnel? (select all that apply).
A. Monitor intake and output.
B. Turn side to side every 2 hours
C. Assess lung sounds bilaterally.
D. Test stool specimen for hemoccult bld
E. Remove and reapply compression stockings.

Prevention:
◼1. Reduction of driving speeds

◼2. Use of seat belts and
shoulder harness
◼3. Wearing of helmets by
motorcyclist and bikers
◼4. Education programs on
driving drunk
Prevention:
◼5. Water safety instruction

◼6. Better availability of
handrails in areas where elderly
may fall
◼7. Improved sports protective
equip and proper usage
◼8. Community education
Etiology
◼ Causes
▪ 38% motor vehicle
collisions
▪ 30% falls
▪ 14% violence
▪ 9% sports injuries
▪ 9% other
miscellaneous cases

Etiology and Pathophysiology
Primary Injury
◼ SCI due to cord compression by
▪ Bone displacement
▪ Interruption of blood supply
▪ Traction from pulling on cord
◼ Penetrating trauma → tearing and
transection

Secondary Injury
▪ Ongoing, progressive damage that
occurs after initial injury
▪ Several theories exist on what causes
ongoing damage

Secondary Injury
◼ Within 24 hours, permanent damage
may occur because of edema
◼ ongoing inflammatory response >
limited tissue expansion > compression
of spinal cord > ischemia to area > poss.
cell/tissue death
◼Worsening could be up to 72 hrs

Secondary Injury
▪ Extent of damage and prognosis for
recovery most accurately determined
72 hours or more after injury
◼ Greatest improvement occurs in first 3
to 6 months following injury

Classification of SCI
◼ SCI is classified by
▪ Mechanism of injury
▪ Level of injury
▪ Degree of injury

Mechanisms of SCI
◼1. Transection complete or partial

◼2. hyperflexion
◼3. hyperextension
◼4. flexion-rotation
◼5. Compression
◼6. Secondary injury Cord Infarction -
ischemia or edema Loss of blood
supply to cord
Hyperflexion
Hyperextension
Compression
The Cord
TABLE 60-1 (p. 1422)
◼Anterior cord syndrome: This type of
injury, to the front of the spinal cord,
damages the motor and sensory
pathways in the spinal cord. Victim may
retain some sensation, but struggle with
movement.

Anterior Cord
◼Anterior cord syndrome: This
type of injury, to the front of the
spinal cord, damages the motor
and sensory pathways in the spinal
cord. You may retain some
sensation, but struggle with
movement.
Central Cord Syndrome
◼Central cord syndrome: This injury is
an injury to the center of the cord, and
damages nerves that carry signals
from the brain to the spinal cord.
Loss of fine motor skills, paralysis of
the arms, and partial impairment—
usually less pronounced—in the legs
are common.
◼Some survivors also suffer a loss of
bowel or bladder control, or lose the
ability to sexually function

Brown-Sequard Syndrome
◼Brown-Sequard syndrome:
damage to one side of the spinal
cord; movement may be
impossible on the right side, but
may be fully retained on the left.
The degree to which Brown-
Sequard patients are injured
greatly varies from patient to
patient.

SYMPTOMS:
Immediate or Delayed
▪ Pain and numbness, ▪ Loss of bladder or bowel
or burning sensation control
◼Inability to move or ◼Difficulty breathing
walk ◼Inability to feel
◼Muscle spasms pressure, heat, or cold

DIAGNOSTICS
◼CT or MRI or
PET or
◼CT angiogram
▪ Nursing do pt
education
▪ Preparing pt
Charles Krauthammer
FOX News Anchor
◼ Paralyzed since 22;

Harvard University
◼ tragic swimming accident
◼ Cervical vertebrae
severed the SC
◼ “Two books at poolside
when they picked up my
effects,” Krauthammer
stated. “One was ‘The
Anatomy of the Spinal
Cord’ and the other one
[was] ‘Man’s Fate’ by
André Malraux.”..

It’s not over till God says so...
Joni Eareckson Tada

FYI
◼Symptoms of a spinal cord injury
corresponding to C5 vertebrae include:
▪ Ability to speak and breathe on their own,
but breathing will be weak.
▪ Paralysis in torso, legs, wrists, and
hands. Paralysis may be experienced on one
or both sides.
▪ Patients may be able to raise
their arms and/or bend their elbows.

Pathophysiology Primary Injury
◼ SCI due to cord compression by

▪ Bone displacement
▪ Interruption of blood supply
▪ Traction from pulling on cord
◼ Penetrating trauma → tearing and
transection
◼Stretching and tearing or laceration of
axons > primary injury
Pathophysiology Secondary Injury
◼ Several theories on what causes ongoing

damage at cellular levels
▪ Vascular changes-hemorrg, thrombosis,
inflammatory process, ischemia, edema
▪ Free radical formation
▪ Lipid peroxidation
▪ Release of glutamate
▪ Uncontrolled calcium influx neuron death
▪ dec. spinal cord bld flow
Secondary Injury
◼ Apoptosis (programmed cell death)
for weeks after injury
◼ Lead to scar tissue formation,
irreversible nerve damage, and
permanent neurologic deficit

Secondary Injury
◼ Within 24 hours, permanent damage
may occur because of edema
◼ Extent of damage and prognosis for
recovery most accurately determined
72 hours or more after injury
◼ Greatest improvement occurs in first 3
to 6 months following injury

Events Leading to Second Injury
(Modified from Marciano FF, Greene KA, Apostolides PJ, et al: Pharmacologic management of spinal cord injury: review of the
literature, BNI Q 11[2]:11, 1995. In McCance KL, Huether SE, editors: Pathophysiology: the biologic basis for disease in adults
and children, ed 5, St Louis, 2006, Mosby.) Copyright © 2017, Elsevier Inc. All Rights Reserved.
Case Study
(©Comstock/Thinkstock)
• J.N.’s cervical spine x-rays and CT reveal

fractured C7-8 vertebrae.
• Physical exam demonstrates total loss

of reflexes, sensation, and movement
below the level of injury.

Case Study
• You recognize these symptoms as being

caused by spinal shock. (p. 1420)
• What is spinal shock and how does it

differ from neurogenic shock?

Spinal Shock
◼ Characterized by
▪ ↓ Reflexes
▪ Loss of sensation
▪ Absent thermoregulation
▪ Flaccid paralysis below level of injury
◼ Lasts days to weeks

Neurogenic Shock
◼ Characterized by
▪ Hypotension
▪ Bradycardia
◼ Loss of SNS innervation
▪ Peripheral vasodilation
▪ Venous pooling
▪ ↓Cardiac output
◼ T6 or higher injury
COMPARISON
◼SPINAL ◼NEUROGENIC
◼Dec reflexes ◼Hypotension
◼Loss sensation ◼Bradycardia
◼Flaccid paralysis below ◼Loss of SNS
level of injury innervation
◼ absent ▪ Dec COP
thermoregulation? ▪ Venous pooling

◼ Major mechanisms of injury are

▪ Flexion
▪ Hyperextension Which one is
▪ the most
Flexion-rotation-
unstable?
▪ Extension-rotation
▪ Compression

Flexion Rotation Injury
◼ Major mechanisms of injury are
▪ Flexion
▪ Hyperextension
▪ Flexion-rotation
▪ Extension-rotation
▪ Compression

◼Flexion rotation because the
ligaments that stabilize the spine are
torn.
◼Severe neurologic deficits
◼Usually trauma related
▪ MVC, sporting, falls, diving, etc

Level of Injury p. 1420
◼ Skeletal vs. neurologic level
◼Skeletal (vertebral) Neurological (lowest
segment of cord
◼ Level of injury may be
▪ Cervical, thoracic, lumbar, or sacral _ the lower
the level the better the come back
◼ Tetraplegia (quadraplegia)
◼Cervical spine
◼ Paraplegia
◼Thoracic, lumbar, or sacral

INCOMPLETE SPINAL CORD INJURY
SYNDROMES: Table 60-1
◼Central Cord Syndrome

◼Anterior Cord Syndrome
◼Brown-Sequard Syndrome

Incomplete SCI
Central Cord Syndrome
◼ Damage to central spinal cord
◼ Most commonly cervical region
◼ More common in older adults
◼ Motor weakness and sensory loss
◼ Lower extremities are not usually
affected
◼ Dysesthetic burning pain in upper
extremities
Incomplete SCI
Anterior Cord Syndrome
◼ Damage to anterior spinal artery →
compromised blood flow
◼ Typically results from flexion injury
◼ Motor paralysis and loss of pain and
temperature sensation below level of
injury

Incomplete SCI
Brown-Séquard Syndrome
◼ Damage to one-half of cord
◼ Typically results from penetrating
injury
◼ Ipsilateral loss of motor function
and pressure, position, and vibration
sense
◼ Contralateral loss of light touch,
pain, and temperature sensation
Clinical Manifestations
◼ Related to level and degree of injury

◼ Incomplete → variable
◼ Sequelae more serious with higher
injury

Manifestations of
Incomplete Spinal Cord
injury depend on the
level

ASIA Impairment Scale (1422)
◼Helps determine severity

of injury
◼Combines motor &
sensory function to
determine (1)neurological
status and completeness of
injury (2) and Rehab goals
(From American Spinal Injury Association.)

Respiratory System
CORRESPONDS TO THE LEVEL OF INJURY
◼ Above level of C4
▪ Total loss of respiratory muscle function
▪ Below level of C4
▪ Phrenic nerve important for breathing
▪ Diaphragmatic breathing → respiratory
insufficiency
▪ Hypoventilation &
▪ Dec. in vital capacity and Tidal volume
Respiratory System
◼ Cervical and thoracic injuries
▪ Paralysis of abdominal and intercostal
muscles → ineffective cough → risk for
aspiration, atelectasis, pneumonia
◼ Risk for neurogenic pulmonary
edema > inc. stim. of SNS >bld shunts
to lungs > pulm. edema

Cardiovascular System
◼ Injury above T6 leads to dysfunction of
sympathetic nervous system
◼ Leads to neurogenic shock
◼ Bradycardia
◼ Peripheral vasodilation
◼Dec. cardiac output >
◼ Hypotension
◼ Relative hypovolemia because of ↑ in capacity of
dilated veins
◼ Reduced venous return decreasing cardiac output
◼ALSO WATCH for HEMORRHAGIC SHOCK
Urinary System
◼ Neurogenic bladder
▪ Bladder dysfunction related to abnormal or
absent bladder innervation
▪ No reflex detrusor contractions (flaccid,
hypotonic)
▪ Hyperactive reflex detrusor contractions
(spastic)
▪ Lack of coordination between detrusor
contraction and urethral relaxation (dyssynergia)
▪ FLACCID > SPASTIC > DYSSYNERGIA

Urinary System
◼ Acute phase
▪ Urinary retention
▪ Bladder atonic, over-distended, fails to
empty ... UTIs
▪ Indwelling catheter
◼ Post-acute phase
▪ Bladder may become hyperirritable
▪ Loss of inhibition from brain
▪ Reflex emptying and failure to store urine
▪ keep pt clean

Gastrointestinal System
◼ Decreased GI motor activity
◼ Gastric distention
◼ Development of paralytic ileus
◼ Gastric emptying may be delayed
◼ Excessive release of HCl may cause stress
ulcers
◼ Dysphagia may be present
◼ Intra-abdominal bleeding may be
difficult to diagnose (s/s)?
Integumentary System
◼ Potential for skin breakdown
◼ Poikilothermism
▪ Interruption of SNS
▪ ↓Ability to sweat or shiver below the level
of injury
▪ More common with high cervical injury.
▪ High cervical injuries have greater inability
to reg. temp than thoracic or lumbar

Metabolic Needs
◼ NG suctioning → metabolic
alkalosis
◼ Monitor electrolytes WHICH ONES?
◼ ↑Nutritional needs
◼ Nutritional support to focus on caloric
and nitrogen needs
◼ Prevent skin breakdown, reduce
infection, decrease muscle atrophy

◼Can nutritional status impact
skin integrity?
▪ Needs High protein, high
calorie due to severe
catabolism 72hr after injury
▪ If cannot take p.o. begin
enteral feedings

Peripheral Vascular Problems
◼ Venous thromboembolism (VTE)
▪ Deep vein thrombosis (DVT) may be
difficult to detect
◼ Pulmonary embolism
▪ Leading cause of death

Pain
◼ Nociceptive/Musculoskeletal Pain
▪ Dull or aching, worsens with movement
▪ Visceral pain in thorax, abdomen, pelvis -
dull, tender, or cramping
◼ Neuropathic Pain
▪ Located at or below level of injury
▪ Hot, burning, tingling, pins and needles, cold,
shooting
▪ May be extremely sensitive to stimuli
Diagnostic Studies
◼ CT scan
◼ Cervical x-rays
◼ MRI
◼ Comprehensive neurologic
examination
◼ CT angiogram
◼PET SCAN
Interprofessional Care
Prehospital
◼ Immediate goals
▪ Patent airway
▪ Adequate ventilation/breathing
▪ Adequate circulating blood volume
▪ Prevent extension of spinal cord
damage

Prehospital
◼ Immobilization
◼ Rigid cervical collar
◼ Backboard with straps
◼ Spinal immobilization with penetrating
trauma not recommended (p. 1424-25)
◼ Maintain systolic BP >90mm Hg
◼STABILIZING PATIENT FIRST BEFORE
SURGERY INTERVENTION
OBSELETE!
◼Spinal immobilization with
sandbags and tape is
insufficient, and is not
recommended.

Initial “Acute” Care
◼ Initial care
◼ Cervical injury requires more intense support
◼Resp. Issue and Hemodynamic Issue
◼bradycardia, and hypotension
◼Thoracic and lumbar level not as severe
◼ Obtain history, emphasizing incident
◼ Assess extent of injury and “how” it occurred
◼ERS persons or Paramedics
◼ Initial assessment __ usually in ER
◼ Managing ABCs and vital signs _ ER
◼O2 sat 90% or greater, SBP- > 90,
◼ Medical interventions and diagnostics
◼ Complete neurologic assessment using ASIA tool
Spinal Cord Injury/Cervical Cord
Injury Can Result In:
◼ Brain injury and/or Vertebral artery
injury
▪ History of unconsciousness
▪ Signs of concussion
▪ ICH
▪ Musculoskeletal injuries
▪ Trauma to internal organs:
▪ s/s ??????
Acute Care
◼ Move the patient in alignment as a
unit (logroll)
◼ Monitor respiratory, cardiac,
urinary, GI functions

Non-Operative Stabilization
◼ Stabilization of injured spinal
segment
◼ Eliminates damaging motion
◼ Prevent secondary damage
◼ Decompression
◼ Traction or realignment What type nsg
◼ Early realignment care for
decompression &
◼ Closed reduction realignment?
◼ Cranio-cervical traction
Surgical Therapy
◼ Used following acute SCI to fix
instability and decompress the spinal
cord
◼What is decompression of SC?
◼ Surgery within first 24 hours associated
with improved neurologic outcome
◼ Posterior approach
◼ Anterior approach
◼ Fusion (autograft or allograft)

Decompression of SC
◼ Opening or removal of bone to

relieve pressure and pinching of the
spinal nerves. discectomy: a type
of surgery in which
herniated disc material is removed so
that it no longer irritates and
compresses the nerve root.

Surgical Therapy (con’t)
◼Surgery within first 24 hours
associated with improved neurologic
outcome
◼ Posterior approach
◼ Anterior approach
◼ Fusion

Drug Therapy
◼ Low-molecular-weight heparin
◼ Prevent VTE
◼ Vasopressor agents
▪ Maintain mean arterial pressure >85-90
mm Hg
▪ Significant risk of complications

Nursing Assessment
◼ Objective Data
▪ Poikilothermism
▪ What is it?
▪ Loss of sexual function
▪ Warm, dry skin (neurogenic shock)
▪ Respiratory difficulties
▪ Bradycardia, hypotension
▪ Decreased or absent bowel sounds
▪ Abdominal distention
▪ Constipation, incontinence, impaction

Nursing Assessment
◼ Objective Data
▪ Urinary retention
▪ Flaccid or spastic bladder
▪ Priapism
▪ Paralysis
▪ Hyperactive deep tendon reflexes
▪ Muscle atony, contractures

Nursing Diagnoses
◼ Ineffective breathing pattern
◼ Imbal nutrition: > than body
requirements
◼ Ineffective periph tissue perfusion
◼ Impaired skin integrity
◼ Impaired urinary elimination
◼ Constipation
◼ Risk for autonomic hyperreflexia
(dysreflexia) interchangeable
◼SNS (too much)
Planning for SCI
◼ Overall Goals
▪ Optimal level of neurologic functioning
▪ Minimal to no complications from
immobility
▪ Learn skills, gain new knowledge, and
acquire new behaviors to care for self
▪ Return to home at optimum level of
functioning

Acute Care
◼ Immobilization
◼ Maintain neutral position
◼ Stabilize to prevent lateral rotation
▪ Hard cervical collar
▪ Backboard
◼ Keep body in correct alignment
◼ Turn as a unit (logrolling)

Case Study
• How does cervical traction help a

client diagnosed with a cervical
fracture?

Immobilization
◼ Skeletal traction
▪ Realignment or reduction of injury
▪ Crutchfield, Gardner-Wells, or halo
▪ Rope, pulley, and weights
▪ Traction maintained at all times
▪ If displacement occurs, hold head in
neutral position and get help

Immobilization
Cervical Tx Device
◼head brace is fixed to the
patient’s head and neck.
Then, using a
counterweight attached to
a pulley system, the head is
stretched away from the
shoulders, relieving disc
compression and spinal
pain.

SOMI Brace after C-Fusion Surg
▪ Candidates:
▪ Minimally
unstable cervical
fx’s;
▪ C5-C7
◼Controls flexion
◼Leverages more
on thorax

Halo Brace/ Vest: Non-surgical
◼A metal brace that circles &
attaches to skull. keeps
cervical spine from moving.
◼Pins screwed into the skin
above your eyebrows. Metal
rods connect the halo to a
plastic vest worn over your
chest and back.

Pin Site Care
◼ Potential for infection at sites of

tongs or halo pin insertion
▪ Preventive care based on hospital
protocol
▪ Common protocol involves:
▪ Cleansing with ½ strength peroxide and
normal saline twice a day
▪ Applying antibiotic ointment

Immobilization
◼ Kinetic therapy Bed

▪ Continual side-to-side rotation
▪ Prevent pulmonary complications
▪ Prevent pressure ulcers

RotoRest

Immobilization
◼ “STABLE” thoracic or lumbar spine

injuries
▪ Custom thoracolumbar orthosis (TLSO or
body jacket)
▪ Jewett brace
◼ Immobilization good “BUT” Profound
effects of immobility
▪ Meticulous skin care critical
▪ Fit immobilizers properly
Respiratory Dysfunction
◼ Spinal cord edema may increase

during first 48 hours
◼ May need intubation and
mechanical ventilation
◼ ↑ Risk for pneumonia and
atelectasis

Respiratory Dysfunction
◼ Regular assessment
◼ Intervene to maintain ventilation
◼ Administer oxygen
◼ Provide ventilator support
◼ Chest physiotherapy
◼ Assisted (augmented) coughing
◼ Tracheal suctioning
◼ Incentive spirometry
◼ Appropriate pain management

Respiratory Dysfunction (con’t)
Assisted/Augmented Cough
◼Whether spinal cord injury or
neuromuscular disease an individual may
require assistance to cough using manual
techniques or a medical device.
Manual assisted cough is the
compression of the diaphragm by
another person to replace the work of
abdominal muscles in order to facilitate
a cough.
Cardiovascular Instability
◼ Risk for bradycardia and cardiac

arrest
◼ Chronic low blood pressure with
postural hypotension
◼ ↑ Risk for DVT
◼ Dysrhythmias may occur

◼ Frequently assess vital signs
◼ Anticholinergic drug/pacemaker
◼block acetylcholine from binding nerve cells. They inhibit
parasympathetic nerve impulses
◼ Fluid replacement, vasopressor agent
◼ If blood loss_Monitor H/H
◼ Possible blood administration
◼ Assess orthostatic BP
◼ Abdominal binders/compression stockings
◼Light headed, faint, blurry, weakness, confusion
◼ Drug therapy

◼ Assess for signs of DVT

◼ Prophylactic low-dose heparin
◼ SCDs and/TEDs
◼ Assess thighs and calves every shift
◼ Range-of-motion exercises and
stretching

Fluid and Nutritional Maintenance
◼ Paralytic ileus may occur 1st 48-72 hrs

past injury, requiring NG tube
◼ Monitor fluid and electrolytes
◼ Nutrition should be started within 72
hours (NG, g-tube, or j-tube)
◼ Individualized solutions/additives
◼ High-protein, high-calorie diet
◼ Possible parenteral nutrition
111
◼If cannot take nutrition via (NG, g-

tube, or j-tube) then ...
◼Parenteral Therapy – due to pts
experiencing high catabolic or
hypermetabolic processes:
◼ Individualized solutions/additives
◼ High-protein, high-calorie diet

112
◼ Inadequate nutritional intake

▪ Assess for cause
▪ General measures
▪ Pleasant eating environment
▪ Adequate time
▪ Calorie count
▪ Dietary supplements
▪ Increased dietary fiber *
Neurogenic Bladder
Management
◼ Neurogenic bladder initially (urinary
retention) ___ because of autonomic and
reflex bladder control
◼ Indwelling urinary catheter
◼ Strict aseptic technique
▪ ↑Fluid intake
◼ Intermittent catheterization program
▪ Every 4-6 times daily
▪ Monitor for signs and symptoms of urinary tract
infections

Bowel Function
Management
◼ Neurogenic bowel initially
◼No voluntary/involuntary reflex evacuation
◼ Bowel program started in acute care
▪ Daily rectal stimulant
▪ Suppository or small-volume enema
▪ Digital stimulation or manual evacuation
▪ Adequate fluid and fiber intake
▪ Increased activity and exercise

Temperature Control
◼ No vasoconstriction, piloerection, or
heat loss through perspiration below
level of injury
◼ Temperature control is external
◼ Monitor environment and body
temperature
◼ Do not use excessive covers or
unduly expose patient
Stress Ulcers
◼ ↑Risk secondary to severe trauma and

physiologic & psychologic stress
◼ Monitor stool, gastric contents, and
hematocrit
◼ Prophylactic medications

Pain Management
◼ Musculoskeletal nociceptive pain_ dull, aching,
throbbing; aggravated w/ moving
▪ Antiinflammatory drugs
▪ Opioids
◼ Visceral nociceptive pain
▪ Diagnostic imaging to evaluate cause
◼ Neuropathic pain_abnormal sensation pain, abnormal sense
of touch; burning; pins & needles
▪ Gabapentin (Neurontin) or pregabalin (Lyrica)
▪ Teach about pain triggers and relaxation therapy

Reflexes
◼ Return of reflexes may complicate
rehabilitation
▪ lack of control
▪ Hyperactive
▪ Exaggerated responses
▪ Penile erections
▪ Spasms
◼ Patient teaching
◼ Antispasmodic drugs

Case Study
• Some of J.N.’s reflexes have returned.

• You walk into her room one morning to
find her pale and diaphoretic.
• She is complaining of a pounding
headache.
• You assess her vital signs and find her BP
is 206/100 mm Hg and her heart rate is
56 bpm.
Case Study
• What do you suspect is going on with

J.N.?

Autonomic Dysreflexia
(aka hyperrelexia)
◼ Massive uncompensated
cardiovascular reaction mediated by
sympathetic nervous system
▪ SNS responds to stimulation of sensory
receptors – parasympathetic nervous
system unable to counteract these
responses.
▪ Hypertension and bradycardia
Case Study
• What would be the most likely cause

of autonomic dysreflexia in J.N.?

◼ Most common precipitating factor is
distended bladder or rectum
◼ Manifestations
▪ Hypertension (up to 300 mm Hg systolic)
▪ Throbbing headache
▪ Marked diaphoresis above level of injury
▪ Bradycardia (30 to 40 beats/minute)

◼ Manifestations
▪ Piloerection
▪ Flushing of skin above level of injury
▪ Blurred vision or spots in visual field
▪ Nasal congestion
▪ Anxiety
▪ Nausea

Case Study
• What are appropriate nursing

interventions for J.N. at this point?

◼ Nursing interventions
▪ Elevate head, sit upright
▪ Notify HCP
▪ Assess for and remove cause
▪ Immediate catheterization
▪ Remove stool impaction if cause
▪ Remove constrictive clothing/tight shoes
▪ Monitor and treat BP
▪ Patient and caregiver teaching
Rehabilitation and Home Care
◼ Complex
◼ Goal highest level of wellness
◼ Interprofessional team effort
◼ Guide to self care
◼Be aware very, very stressful
◼Be encouraging

Respiratory Rehabilitation
◼ Mechanical ventilation for injury

above C3
◼ Round-the-clock caregiver
◼ Respiratory hygiene
◼ Tracheostomy care
◼ Phrenic nerve stimulator
◼ Diaphragmatic pacemaker
◼ Mobile ventilators
Neurogenic Bladder
TABLE 60-8)
◼ Areflexic (flaccid), hyper-reflexic
(spastic), or dyssynergia
uncoordinated & abrupt movements
◼ Common problems
▪ Urgency, frequency, incontinence,
inability to void, and high bladder
pressures resulting in reflux of urine into
kidneys
Neurogenic Bladder
TABLE 60-8)
◼ Once pt stable
◼Urodynamic Testing
◼Urine culture
◼Residuals
◼Major concern: urine reflux back into
kidney pelvis

Neurogenic Bladder
◼Bladder Management Program
◼Drug therapy _ several; see your text
▪ Anticholinergic drugs
▪ α-Adrenergic blockers (vasopressors)
▪ Antispasmodic drugs
◼ Drainage methods
▪ Bladder reflex training
▪ Indwelling, intermittent, external catheterization
▪ Urinary diversion surgery

Neurogenic Bowel
◼ Voluntary control may be lost

◼ High-fiber diet
◼ Adequate fluid intake
◼ Suppositories
◼ Small-volume enemas
◼ Digital stimulation
▪ Mandatory for upper motor neuron
injury
Neurogenic Bowel
◼ Stool softener
◼ Oral stimulant laxatives
◼Do this sparingly; not on regular basis
◼ Valsalva maneuver with manual
stimulation
◼ Timing to not interrupt therapy

Spasticity p. 1434
◼ Can be both beneficial and undesirable
▪ Can you explain?
◼ Ashworth and modified Ashworth
scales
◼ Treatment _ How can nurses assist?
▪ ROM exercises
▪ Antispasmodic drugs
▪ Botulinum toxin injections

Neurogenic Skin (1)
◼ Prevention essential
◼ Comprehensive daily exam
◼ Teach to reposition
◼ At least every 2 hours while in bed
◼ Every 15 to 20 minutes when in a chair
◼ Pressure-relieving cushion or mattress
◼ Adequate nutrition
◼ Protect from thermal injury

Neurogenic Skin (2)
◼Protect the skin by avoiding thermal
injury. Burns can be caused by hot food or
liquids, bath or shower water that is too
warm, radiators, heating pads, and
uninsulated plumbing.
◼ Thermal injury also can result from
extreme cold (frostbite). Injuries may not
be noticed until severe damage has
occurred. Anticipatory guidance about
potential risks is essential

Pain Management
◼ Acute pain
▪ Assess, evaluate, and treat routinely
▪ Analgesics
▪ Massage and repositioning
◼ Chronic pain
▪ May be result of overuse of muscles
▪ Sleep may be disrupted
▪ May refer to pain management specialist

Sexuality
◼ Important issue regardless of

patient’s age or gender
◼ Nurse must
▪ Have an awareness and an acceptance
of personal sexuality
▪ Have knowledge of human sexual
responses
▪ Use medical terminology

Sexuality
◼ Fertility not usually affected

▪ Pregnancy complicated
▪ Risk for precipitous delivery
◼ Female sexual activity
◼ Urinary catheterization
◼ Planning for bowel evacuation prior
▪ Incontinence

Depression and Adjustment
◼Adjustment of change and

acknowledging limitations
◼ Wide fluctuation in emotions
◼ Allow mourning but encourage
during the rehabilitative phase

Adjustment and Support
◼ Sympathy not helpful

◼ Encourage patient participation
◼ Consistency of care
◼ Psychiatric consult if needed
◼ Caregiver and family counseling
◼ Support group

Evaluation
◼ Adequate ventilation
◼ Adequate circulation and BP
◼ Intact skin
◼ Adequate nutrition
◼ Bowel management
◼ Bladder management
◼ No autonomic hyperreflexia
Gerontologic Considerations
◼ Increased incidence
◼ Increased complications
◼ Hospitalized linger
◼ Increased mortality rates
◼ Health promotion and screening
◼ Rehabilitation lengthened

Guillane-Barre’
◼An auto-immune disorder that may

follow a bacterial infection
◼Acute Inflammatory Demyelinating
Polyneuropathy
▪ Acute
▪ Ascending
▪ Symmetric and Progressive weakness of
limbs >>> respiratory sys. impacted

Guillane-Barre’
◼Most serious complication:

▪ Resp Failure due to Thoracic denervation

Guillane-Barre’
Nursing Management
◼Needs all hands on deck/Interprofessional
◼Ventilatory support
◼Hemodynamic monitoring
◼Plasmaphoresis
▪ Removes the antibodies; separation of blood
components results in a filtered plasma product.
The filtering of plasma from whole blood can be
accomplished via centrifugation
◼IV Ig (used the most; more available)
▪ Attacking the causative antigen

Guillane-Barre’
Nursing Management
◼Assess Resp and Cardiac
◼Nutritional Needs
▪ Delayed gastric emptying
▪ Aspiration
▪ ileus
◼Therapy: Occupational, Speech,
Physical Therapy, Care giver Support

See TABLE 60-2

THE END

(T3) SCI and GB CHTP 60 (Test 3)

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Muscular Spinal:

Spinal Cord Injuries,

Actor Christopher Reeve, best known for

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◼Keesler Rehabilitation Center in New

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◼the part of the nervous system

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• Inclusion of your Anatomy and

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◼ There are 33 individual Vertebrae

◼ Trauma or damage to spinal cord

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You are monitoring the neurologic status on a

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◼ Trauma or damage to spinal cord

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What symptoms will the nurse assess in a

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