Spinal cord injuries: trauma from hyperextension, hyperfleon, aal compression, lateral fleon, or shearing of the spine.

Types:

C-l and C-2 injury level - resulting deficit:

Phrenic nerve involvement.
Diaphragmatic paralysis.
Respiratory difficulties (require permanent ventilatory support).
Possible quadriplegic.
Possible death.

C-4 through T-l injury level - resulting deficit: possible quadriplegic.
Thoracic-lumbar injury level - resulting deficit: possible paraplegic.

Pathophysiology: trauma —> vertebral dislocation or fractures —>cord trauma, compression, or severance of the cord.
Risk factors:

Motor vehicle accidents.
Diving, surfing, contact sports.
Falls.
Gunshot wounds.

Assessment:

Subjective data:
1. Pain at the level of injury.
2. Numbness/weakness, loss of sensation below level of injury.
3. Psychological distress related to severity of injury and its effects.
Objective data:

Symptoms depend on extent of injury to spinal cord/spinal nerves.
Paralysis: motor, sphincter.

Initially a period of flaccid paralysis and loss of reflexes, called spinal or neural shock.
Incomplete injuries may lead to loss of voluntary movement and sensory deficits below injury level (symptoms vary depending on injury).
Complete injury leads to loss of function and all voluntary movement below level of injury.

Respiratory distress.
Alterations in temperature control.
Alterations in bowel and bladder function.
Involved muscles become spastic and hyperreflec within days or weeks.

Analysis/nursing diagnosis:

Ineffective breathing pattern related to highlevel injury.
Impaired physical mobility related to injuries affecting lower limbs.
Fear related to uncertain future health status.
Anety related to loss of control over own activities of daily living.
Bathing/hygiene self-care deficit related to injuries above T-l.
Impaired home maintenance management related to possible quadriplegia and paraplegia.
Risk for altered body temperature related to absence of sweating below level of injury.
Risk for injury related to equipment necessary for daily activities.
Tactile sensory/perceptual alterations related to injury level.
Body image disturbance related to permanent change in physical status.

Nursing care plan/implementation:

Goal: maintain patent airway.

Suction, cough, tracheostomy care, prn.
Oxygen, ventilator care.
Monitor blood gas levels.

Goal: prevent further damage.
1. Immobilize spine.
2. Firm mattress, Stryker frame, Foster frame, CircO-electric bed, traction, braces.
3. Skeletal traction via tongs: Crutchfield, Gardner-Wells.
4. Halo traction.
Goal: relieve edema: anti-inflammatory medications, corticosteroids.
Goal: relieve discomfort: analgesics, sedatives, muscle relaxants.
Goal: promote comfort:
1. Maintain fluid intake: PO/IV, I&O.
2. Increase nutritional intake
3. Prevent contractures and decubiti.
4. Assist patient to deal with psychosocial issues, e.g., role changes.
5. Begin rehabilitation plan.
Goal: prevent complications.
1. Monitor for spinal shock during initial phase of injury.
2. Monitor for hyperreflexia with severed spinal cord injuries.
Goal: health teaching.
1. Self-care techniques for highest level of independence; include significant others in teaching.
2. How to use ambulation assistive devices (battery-operated wheelchair controlled by mouthpiece or hand controls, depending on level of paralysis).
3. Identify community resources for followup care and career counseling.
4. Signs and symptoms of autonomic hyperreflexia .
5. Methods to prevent skin breakdown, infections of respiratory, urinary tract.
6. Bowel, bladder program.

Evaluation/outcome criteria:
1. Complications avoide
2. Accomplishes self-care to greatest level for injury.
3. Participates in rehabilitation plan.
4. Grieves over loss and begins to integrate self into society.

Clinical Pathway: Posterior Spinal Fusion (PSF)

/ /	/ /	/ /	/ /	/ 1	Discharge Outcomes
Day 3	Day 4	Day 5	Day 6	Day 7	Date
Verbalizes pain at acceptable level Uses PGA appropriately w/o basal + takes po pain medication around the clock	verbalizes patn at acceptable level; on PO pm pain medication	Pain at acceptable level with PO medication prn	Pain at acceptable level with PO medication pm	Pain 8t acceptable level with PO medication pm	Pain al acceptable level with PO medication prn
Lofitois, minimal-moderate assistance Dancies 2 times, moderate assistance Stands 8-10 minutes for brace mold	Gets intout of bed, moderate assistance Sits in chair (or meals 1-2 times Walks In room, moderale-maximal	Gets in/out of bod. minimal assistance Sits In chair 2-3 times Walks to hall, moderate assistance 3x Wearing brace as ordered Reports need for adjustment of brace	Gets In/out ol bed Sits in chair 2-3 times Walks in hall minimal assistance times 3	Gets in/out of bed Independently Sits In chair 2-3 times Walks, Independently 3 times Reports brace correctly fitting	lodep-ndent in/out of bod Walking on level and up/ doMtstiifS of reached goal PafenWam-y demonstrate crVotf brace tethrioue
CSM status ai baselire	CSM status at baseline	CSM status al baseline	CSM status at baseline	CSM status at baseline	CSM status at baseline
C. T. 6 DB Uses ICS q 2’ volume_______ O2 sat >94% on room air Respiratory system WNL	Uses ICS Independently volume____ Respiratory system WNL	Uses ICS independently volume____ Respiratory system WNL	Uses ICS independently volume____ Respiratory system WNL	Respiratory system WNL	Respiratory system WNL
WNL skin warm, dry and Intact. Normal color and turgor PURV_	WNL skin warm, dry and Intact. Normal color and turgor.	WNL: skin warm, dry and intact. Normal color and turgor	WNL: skin warm, dry and Intact. Normal color and turgor. PURV_____	WNL: skin warm, dry and Intact. Normal color and turgor.	Skin cleaa, de/, and tniacl; wound well-approximated without rednes&'swe'Lng
Receives and verbalizes understanding of information booklet Participates In care Anxiety reduction strategies Able to group requests Exhibits decreased anxiety	Verbalizes understanding of Information Participates in care Abie to use anxiety reduction strategies	Verbalizes understanding of information Participates In care Able to make decisions	Participates in care Discusses plans lor going home Makes decisions	Participates In care Verbalizes ability to manage at home Makes decisions	Verbalizes ability to manage at home and/or with continuing care arrangements
Voiding without difficulty Bcwel sounds present Abdomen non-tender Passing flatus 01 has a bowel movement	Voiding without difficulty Bowel sounds present Abdomen non-tender Passing Hates. or na? a bowel movement	Voiding Bowel sounds present Abdomen ngn-tender Passing flatus, or has a bowel movement	Voiding Bowel sounds present Abdomen non-tender Passing flatus, and has a bowel movement	Voiding Bowel sounds present Abdomen non-tender Passing flatus, or has a bowel movement	Voiding Had BM during hospitalization
Systems WNL	Systems WNL	Systems WNL	Systems WNL	Systems WNL	Systems WNL
Washes areas m reach Feeds sell	Washes areas In reach Feeds sett	Bathes sell with minimal assistance	Battves and toilets self with minimal assistance	Independent in self care or reaches goal	Indepemterii in sc ! ca:e or reaches goal
65 or older......................1 Mental status limitations........5 History ot fails.....................5 Mobility limitations.............4 Elimination problems...............2 Medications .....................1 Total Score.....................’	65 or Older... .................1 Mental states limitations .5 History of falls ...............5 Mobility limitations........ ...4 Elimination probterns...........2 Medications.....................1 Toial Scene.............. *	65 or older........................1 Mental status limitations ..5 History of falls..................5 Mobility limitations..............4 Elimination problems..............2 Medications.......................1 Total Score.......................*	65 or older —......................1 Menial status limitations..........5 History of tails..................5 Mobility limitations..............4 Elimination problems..............2 Medications.......................1 Total Score....................... *	65 or older.......................1 Mental status limitations.........5 History of (alls..................5 Mobility limitations..............4 Elimination problems..............2 Medications.......................1 Total Score....................... *	No falls