NCLEX-RN: Medical–Surgical Nursing

 Medical–Surgical Nursing: Spinal Cord Injury

Focus topic:  Medical–Surgical Nursing

Definition: Partial or complete disruption of nerve tracts and neurons resulting in paralysis, sensory loss, altered reflex activity, and autonomic nervous system dysfunction.

 Medical–Surgical Nursing: Characteristics

Focus topic:  Medical–Surgical Nursing
A. The mechanisms of trauma associated with spinal cord injury (SCI) are usually related to vertebral fracture; resulting injuries include flexion, hyperflexion, hyperextension, flexion–rotation, rotation beyond normal range, axial-loading/compression, and penetrating injury.

  • Most common causes of abnormal spinal cord movements.
    a. Acceleration—when an external force is applied in rear-end collision, upper torso and head are forced backward and then forward.
    b. Deceleration—in a head-on collision, the external force is applied from the front.
  • Direction of motion.
    a. Hyperflexion.
    b. Hyperextension.
    c. Axial loading.
    d. Excessive rotation.

B. Common traumas.

  • Automobile and motorcycle accidents.
  • Sports and industrial injuries.
  • Falls and crushing injuries, stab wounds, bullets.

C. Other conditions associated with spinal cord pathology.

  • Infections, tumors.
  • Disruption of blood supply to cord—thrombus.
  • Degenerative diseases.
  • Congenital or acquired anomalies—spina bifida, myelomeningocele.

D. Improper handling and transport may result in extension of cord damage.
E. Vascular disruption, biochemical changes, and direct tissue damage cause pathology associated with trauma.

  • Inflammatory process leads to edema and neuronal dysfunction.
  • Ischemia and hypoxia due to vasoconstriction, edema, and hemorrhage.
  • Hypoxia of gray matter stimulates release of catecholamines, which increases hemorrhage and necrosis.

Medical–Surgical Nursing

 Medical–Surgical Nursing: Classification of Cord Involvement

Focus topic:  Medical–Surgical Nursing
A. Functional deficiencies.

  • Level of spinal cord involvement dictates consequences of the cord injury.
  • Quadriplegia (tetraplegia): All four extremities functionally involved—cervical injuries (C1 through C8).
  • Paraplegia: Both lower extremities functionally involved—thoracic–lumbar region (T1 through L4).

B. Transection of the cord.

  • Complete cord transection.
    a. All voluntary motor activity below injury is permanently lost.
    b. All sensation dependent on ascending pathway of segment is lost.
    c. Reflexes may return if blood supply to cord below injury is intact.
  • Incomplete injuries.
    a. Motor and sensory loss varies and is dependent on degree of incompleteness.
    b. Extent of reflex dysfunction dependent on location of neurological deficit.

C. Types of injuries.

  • Central cord syndrome—leg function returns, arm function does not, as damage has occurred to peripheral cord, which innervates arms.
    a. More common in older adults.
    b. Motor weakness in both upper and lower extremities—greater in upper extremities than lower.
    (1) Sensory dysfunction varies according to site of injury.
    (2) Bladder dysfunction is variable.
    c. Frequently a result of hyperextension of osteoarthritic spine.
  • Brown–Séquard syndrome—one side of cord damaged, resulting in paralysis on one side of body and loss of sensation on the other side.
    a. Transection or lesion of half of spinal cord.
    b. Usually caused by penetrating injuries (e.g., gunshot, stabbing).
    c. Characteristics.
    (1) Loss of motor function (paralysis), position and vibratory sense, vasomotor paralysis on the same side (ipsilateral) and below the hemisection.
    (2) Loss of pain and temperature sensation on the opposite side—contralateral (below the level of the lesion or hemisection).
  • Anterior cord syndrome—paralysis below the level of injury, loss of temperature and pain sensation below the level of injury.
    a. Often caused by a flexion injury.
    b. Lesion on anterior two-thirds of cord.
    c. Compression caused by disk or bony fragment.
    d. May be caused by spinal artery occlusion.
    e. Characteristics.
    (1) Complete motor paralysis from site of injury and below.

(2) Hypoesthesia—decreased pain sensation and loss of temperature below the injury.
(3) Because posterior cord tracts are not injured, sensation of touch, position, vibration, and motion remains intact.

  • Posterior cord syndrome—weakness in isolated muscle groups, tingling, pain, decreased or absent reflexes in the involved area.
    a. Associated with hyperextension trauma.
    b. Results from compression or damage to the posterior part of the spinal cord.
    c. Loss of proprioception.
    d. Pain, temperature sensation, and motor function below the level of the lesion remain intact.
  • Horner’s syndrome—ipsilateral ptosis of the eyelid, constricted pupil, and facial anhidrosis (inability to perspire).

D. Upper and lower motor neuron damage.

  • Upper motor neuron originates in cerebral cortex and terminates at anterior horn cell in cord.
    a. Postspinal shock reflexes return, resulting in spastic paralysis. No reflex return if blood supply to cord is lost.
    b. Spasms and reflexes used to retrain activities of daily living—bowel evacuation and bladder control.
  • Lower motor neuron begins at anterior horn cell and becomes part of peripheral nerve to muscle, motor side of reflex arc.
    a. Areflexia continues, flaccid paralysis.
    b. Usually cauda equina injuries.

 Medical–Surgical Nursing: Assessment

Focus topic:  Medical–Surgical Nursing
A. Level of injury. The last cord segment in which normal motor, sensory, and reflex activity can be demonstrated is labeled level of injury (e.g., “C5, level of injury” means neurofunction is intact for C5 but not C6).
B. Degree of sensory, motor, and reflex loss depends upon severity of cord damage.
C. Respiratory insufficiency or failures occur in injuries above C4 due to lack of diaphragm innervation.
D. Assess general sensory function in all extremities: touch, pressure, pain.

E. Assess motor response to command.

  • Pattern of motor dysfunction yields information about anatomic location of lesions, independent of level of consciousness.
  • Appropriate response—spontaneous movement to stimulus or command.
  • Absent response—hemiplegia, paraplegia, quadriplegia.
  • Use minimal amount of stimulus necessary to evoke a response.

F. Assess for bladder control.

  • Reflex (autonomic or spastic) bladder occurs when reflexes are still present and, with stimulation, the bladder involuntarily empties.
  • Spastic bladder responds to minor stimulus and empties before it is full.

G. Evaluate bowel control.

  • Observe ability to evacuate stool.
  • Assess consistency and number of stools.
  • Identify need for bowel training program.

Medical–Surgical Nursing

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 Medical–Surgical Nursing: Implementation

Focus topic:  Medical–Surgical Nursing
A. Complete a head-to-toe neurological examination to determine motor, sensory, and reflex loss due to spinal cord injury.
B. Provide emergency care—suspect spinal cord injury if neurological deficits present in extremities.

  • Immobilize entire body, especially head and neck; do not flex head; stabilize cervical spine.
  • Transport in log fashion with sufficient help.
  •  Maintain open airway and adequate ventilation—high cervical injuries can cause complete paralysis of muscles for breathing; observe for signs of respiratory failure.

C. Immobilize client, as ordered, to allow fracture healing and prevent further injury.

  • Special beds (Stryker frame) permit change of position between prone and supine.
    a. Maintain optimal body alignment.
    b. Place client in center of frame without flexing or twisting.
    c. Position arm boards, footboards, canvas.
    d. Turn; reassure client while turning.
    e. Free all tubings; secure bolts and straps.
  • Regular hospital beds used in many rehabilitation centers. (Some use Roto-Rest beds or Foster frame.)
  • Halo traction with body cast allows for early mobilization. (See also page 376.)
    a. Consists of a circular headpiece with four pins: two anterior, two posterior. These are inserted into client’s skull, and then halo jacket or cast is applied.
    b. Once fracture is stable, the headpiece can be attached to halo vest.
    c. Assess client’s neurological status for decreased strength or changes in movement.
    d. Never turn or move the client by pulling on the halo traction.
    e. Assess for tightness of the jacket. Be sure one finger can fit under the jacket.
    f. Assess skin integrity to be sure there are no pressure areas from the cast or jacket; protect with fleece or foam.
    g. Provide care to the pin sites.
    h. Keep correct-size wrench available at all times for any emergency situation that may occur and require removal of the device.
    i. If client requires cardiopulmonary resuscitation, the anterior portion of the vest will be loosened and the posterior portion will remain in place to provide stability.
  • Soft and hard collars and back braces used about 6 weeks postinjury.
  • Maintain skeletal traction if part of treatment.
    a. Cervical tongs for hyperextension (Crutchfield, Gardner–Wells, Vinke).
    (1) Traction is applied to vertebral column by attaching weights to pair of tongs.
    (2) Tongs are inserted into outer layer of parietal area of skull.
    b. Facilitates moving and turning of client while maintaining spine immobilization.
    c. Observe site of insertion for redness or drainage, alignment and position of traction, and pressure areas.

D. Complete frequent neurological assessment: Note changes in muscle tone, motor movement, sensation, bladder and bowel function, presence or absence of sweating, temperature, and reflexes.

E. Monitor for autonomic nervous system disturbances.

  • Heart, lung, and bowel sounds for complications, such as embolus, ileus.
  • Temperature fluctuations—unable to adapt to environmental changes or infection-related.
    a. Excessive perspiration causes dehydration.
    b. Absence of perspiration leads to hyperthermia.

F. Prevent postural hypotension and syncope, which occur when head is elevated.

  • Apply Ace bandage or TED elastic hose.
  • Administer ephedrine PO 30 minutes before client is to get up.

G. Monitor for autonomic dysreflexia. (See page 191.)

  • Signs and symptoms: extreme hypertension, flushing, bradycardia, headache (usually occipital), sweating, diplopia, convulsions.
  • rovide immediate treatment.
    a. Catheterize bladder; manually evacuate bowel.
    b. May administer parasympatholytic (Banthine [propantheline bromide]) or ganglionic blocking agent (Hyperstat [diazoxide], Apresoline [hydralazine]).
    c. If client is lying down and fracture status permits, immediately elevate the head of bed or elevate client to sitting position.
  • Control factors that precipitate episode to prevent recurrence.
    a. Set up regular bowel and bladder programs.
    b. Apply Nupercainal (dibucaine) ointment prior to rectal stimulation.
    c. Administer alpha-adrenergic blocking agents [Dibenzyline (phenoxybenzamine)] bid.

H. Prevent infections.

  • Administer prophylactic antibiotics while client is on catheterizations.
  • Evaluate client with elevated temperature for urinary or respiratory infection.

I. Prevent circulatory complications.

  • Turn entire body every 2 hours. Give range- of-motion exercises to extremities.
  • Apply Ace bandages and TED elastic hose to legs.
  • Monitor for edema, thrombus, and emboli; provide prompt anticoagulant therapy if needed.
  • Do not overhydrate based on blood pressure (normal BP is 100/60 or below).

J. Maintain optimal positioning.

  • Logroll with firm support to head, neck, spine, and limbs; do not allow neck flexion.
  • Maintain good body alignment with 10-degree flexion of knees, heels off mattress or canvas, and feet in firm dorsiflexion.
  • During convalescence, provide cervical collar, tilt table, wheelchair, braces, parallel bars.

K. Promote optimal physical activity.

  • Provide physical therapy, exercises, range of motion.
  • Encourage independent activity.
  • Provide extensive program of rehabilitation and self-care.

L. Maintain integrity of the skin.

  • Turn client every 2 hours and check skin.
  • Do not administer IM medication below the level of the lesion due to impaired circulation and potential skin breakdown.
  • Provide elastic stockings to improve circulation in legs.
  • Later, instruct client how to look for and prevent injury; reinforce the necessity for self-care.
  • Provide prompt treatment of pressure areas.

M. Promote adequate nutrition, fluid and electrolyte balance.

  • Provide diet adequate in protein, vitamins, calories, and bulk; limit milk.
  • Avoid citrus juices, which alkalize the urine; give cranberry juice and vitamin C tabs to acidify urine.
  • Avoid gas-forming foods.
  • Monitor calcium, electrolytes, and hemoglobin.
  • Restrict fluids if client is on intermittent catheterization; otherwise, encourage fluids—3000 mL+ per day.

N. Provide psychological support to client and family.

  • Support client and family through grief process.
  • Promote sustained therapeutic relationships.
  • Provide diversionary activities, socialization.
  • Promote independence; teach client to problem solve.
  • Give encouragement and reassurance but never false hope.
  • Encourage family involvement in care.
  • Provide sexual counseling if needed.
    a. Client should be aware of his or her sexual abilities postinjury.
    b. Role perception may need expansion.
  • During rehabilitation stage, provide employment counseling if needed.

O. Establish individualized rehabilitation program for client.

  • Based on level of injury.
  • Determined by willingness of client to adapt to new body image.
  • Availability of family and community support services.

P. Optimal bladder function.

  • During spinal shock, bladder is atonic with urinary retention; danger of overdistention, stretching.
  • Possible reactions.
    a. Hypertonic, retention with overflow—sacral reflex center injury (lower motor neuron).
    b. Hypertonic, sudden reflex voiding—injury above sacral area (upper motor neuron).
  • Check for bladder distention, voiding, incontinence, and symptoms of infection.
  • Provide aseptic intermittent catheterizations—prophylactic antimicrobials (Nitrofuran [nitrofurantoin]).
  • Prevent urinary tract infection, calculi.
    a. Monitor urinary residuals.
    b. May have periodic bladder and kidney function studies—intravenous pyelogram (IVP), cystogram.
  • Initiate bladder retraining.
    a. Hypertonic—sensation of full bladder, trigger areas, regulation of fluid intake.
    b. Hypotonic—manual expression of urine (Credé maneuver).
  • Administer medications to treat incontinence.
    a. Hypertonic—propantheline bromide, diazepam.
    b. Hypotonic—bethanechol chloride.

Q. Optimal bowel function.

  • Incontinence and paralytic ileus occur with spinal shock; later, incontinence, constipation, impaction.
  • For severe distention, administer neostigmine methylsulfate and insert rectal tube, which decompresses intestinal tract.
  • Give enema only if necessary. Excessive amount of fluid distends bowel. Manual evacuation is preferred.
  •  Initiate bowel retraining.
    a. Record bowel habits before and after injury.
    b. Provide well-balanced diet with high-fiber foods—fruits, vegetables, grains (bran), and legumes.
    c. Encourage fluid intake—2000 to 3000 mL per day.
    d. Provide stool softeners, bulk producers, mild laxative.
    e. Encourage the development of muscle tone.
    f. Administer suppository (glycerin or Dulcolax [bisacodyl]) as indicated.

R. Pharmacology.

  • Corticosteroids—high-dose steroid protocol using Medrol (methylprednisolone) must be given intravenously within 8 hours of injury to be effective. It is used to prevent secondary spinal cord damage from edema and ischemia. Initial loading dose given, followed by a maintenance dose over the next 23 hours.
    a. Criteria for selection.
    (1) Spinal cord injury less than 8 hours old.
    (2) Spinal lesion cannot be below L2 or be a cauda equina lesion.
    b. Special considerations.
    (1) Pregnant client.
    (2) Client less than 13 years old.
    (3) Client with penetrating spinal cord lesion.
    (4) Client with fulminating infection like tuberculosis (TB), AIDS, or severe diabetes mellitus.
  • Vasopressors—used in the immediate critical care period to treat bradycardia or hypotension due to spinal shock.
  • Antispasmodics—used to treat spasms. They depress the central nervous system and inhibit transmission of impulse from spinal cord to skeletal muscle (not always effective).
    a. Lioresal (baclofen).
    b. Paraflex (chlorzoxazone).
    c. Flexeril (cyclobenzaprine hydrochloride).
    d. Valium (diazepam).
    e. Norflex (orphenadrine citrate).
    f. Dantrium (dantrolene sodium).
  • Analgesics.
    a. Nonsteroidal anti-inflammatory drugs (NSAIDs).
    b. Opioids, nonopioids.
    c. Tricyclic antidepressants [Elavil (amitriptyline), Tofranil (imipramine)].
    d. Anticoagulant—heparin or low-molecularweight heparin for deep vein thrombosis (DVT) prophylaxis.
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