DEFINITION OF THE DISEASE

Injuries affecting the spinal cord commonly results from trauma, gunshot
wounds and motor vehicle accidents. Many cases of SCI are caused by falls,
sports-related injury and minor trauma. The principal risk factors for SCI
include age, gender, and alcohol and drug use. Males are affected four times
more often than females. Over half of the victims are 16 to 30 years of age.
The most common vertebrae involved in SCI are the 5th, 6th and 7th cervical,
the 12th thoracic, and the 1st lumbar. These vertebrae are the most
vulnerable because there is a greater range of mobility in thevertebral
column in these areas. Damage to the spinal cord ranges from transient
concussion, to contusion, laceration and compression of the cord substance,
to complete transection of the cord.
Injury can be categorized as primary which is usually permanent or secondary
wherein nerve fibers swell and disintegrate as a result of ischemia, hypoxia,
edema, and hemorrhagic lesions. The type of injury on the other hand, refers
to the extent of injury to the spinal cord itself. Incomplete spinal cord lesions
are classified according to the area of spinal cord damage: central, lateral,
anterior, or peripheral. A complete spinal cord injury can result in paraplegia,
which is paralysis of the lower body or quadriplegia which is the paralysis of
all four extremities
Signs & Symptoms
Neurologic Level
The neurologic level refers to the lowest level of the injury of the cord.
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 below the neurologic level
Marked reduction of blood pressure 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
PATHOPHYSIOLOGY
DIAGNOSTIC EXAM
Diagnosis of SCI is based on physical examination, radiologic examination,
CT scan, MRI and myelography.
Diagnostic x-rays such as lateral cervical spine x-rays and CT scanning are
usually performed initially. An MRI scan may be ordered as a further work up
if a ligamentous injury is suspected, since significant spinal cord damage may
exist even in the ansence of bony injury. Continuous electrocardiographic
monitoring may be indicated if a cord injury is suspected since bradycardia
and asystole are common in acute spinal injuries.
NURSING CARE
Promoting Adequate Breathing
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.
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.
Discourage smoking.
Monitor respiratory status frequently.
Improving Mobility
Maintain proper body alignment; place patient in dorsal or supine position.
Turn patient every 2 hours; monitor for hypotension in patients with lesions above
the midthoracic level. Assist patient out of bed as soon as spinal column is
stabilized.
Do not turn patient who is not on a turning frame unless physician indicates that it
is safe to do so.
Apply splints to prevent footdrop ans trochanter rolls to prevent external rotation
of the hip joint; reapply every 2 hours.
Perform passive range-of-motion exercises within 48 to 72 hours after injury to
avoid complications such as contractures and atrophy.
Provide a full range of motion at least every four or five times daily to toes,
metatarsals, ankles, knees & hips.
Maintaining Skin Integrity
Change patients 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;
gently perform massage using a circular motion.
Teach patient about pressure ulcers and encourage participation in preventive
measures.
Promoting Urinary Elimination
Perform intermittent catheterization to avoid overstreatching 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, quality of urine, and any unusual feelings.
Promoting Adaptation to Disturbed Sensory Perception
Stimulate the area above the level of the injury through touch, aromas, flavorful
food, 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.
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 sound resume.
Administer prescribed stool softener to counteract effects of immobility and pain
medications, and institue a bowel program as early as possible.
Providing Comfort
Reassure patient in halo traction that he/she will adapt to steel frame.
Cleanse pin sites daily, and observe for redness, drainage, and pain; observe for
loosening; keep a torque screwdriver readily available.
Assess skull for signs of infection, including drainage around halo-vest tongs.
Check back of head periodically for signs of pressure. Massage at intervals, taking
care not to move the neck.
Shave hair around tongs to facilitate inspection. Avoid probing under encrusted
areas.
Inspect skin under halo vest for excessive perspiration, redness, and skin
blistering, especially on 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.