JOSIP JURAJ STROSSMAYER UNIVERSITY OF OSIJEK

FACULTY OF MEDICINE OSIJEK

UNIVERSITY UNDERGRADUATE STUDY OF NURSING
ACADEMIC YEAR 2016/2017

Kovai Mihael
PROCESS OF NURSING HEALTHCARE IN PATIENTS WITH
SPINAL CORD INJURY
SEMINAR PAPER
(ENGLISH LANGUAGE 3)

Mentor: Lorna Dubac Nemet, MA, senior lecturer

Osijek, May 2017
Contents
INTRODUCTION ...................................................................................................................... 1

THE VERTEBRAL COLUMN AND SPINAL CORD ANATOMY ....................................... 2

Vertebral column .................................................................................................................... 2

The spinal cord ....................................................................................................................... 2

UNDERSTANDING THE SPINAL CORD INJURY............................................................... 3

EVALUATION AND TREATMENT ....................................................................................... 4

Evaluation ............................................................................................................................... 4

Treatment ................................................................................................................................ 4

NURSING MANAGEMENT .................................................................................................... 4

Assessment ............................................................................................................................. 4

Respiratory management ........................................................................................................ 4

Cardiovascular management................................................................................................... 5

Gastrointestinal management ................................................................................................. 6

Genitourinary management .................................................................................................... 6

Musculoskeletal management................................................................................................. 6

Dermatologic management ..................................................................................................... 7

Neurological improvement ..................................................................................................... 7

Nursing diagnoses................................................................................................................... 8

Evaluation ............................................................................................................................... 9

Home- and community-based care ......................................................................................... 9

Teaching patients self-care ................................................................................................. 9

Continuing care ................................................................................................................... 9

CONCLUSION ........................................................................................................................ 10

REFERENCES ......................................................................................................................... 11
INTRODUCTION

Spinal cord injury is low-incidency but high-repercussion injury caused by traumatic,

which is more frequent the cause, and non-traumatic experiences. Symptoms of it depend on
the extent of the injury or the cause, higher on the spine injury happened, bigger the possibility
that symptoms, complications and consequences will be more severe. Causes and symptoms
will be discussed further in this seminar paper. This seminar paper will run thru anatomy of the
spine, spinal cannal and spinal cord, causes of the injury, symptoms, consequences, treatment
and the main focus of this seminar paper- preoperative and postoperative surgical nursing care
of the patient with spinal cord injury. Nurses play a big part of the medical team, they are here
to motivate the patient, supervise, improve patient's self-image, improve physical function and
mobility of the patient's locomotoric system, assist patients to have independant lives and
educate them to cope better with their condition and how to manage a healthy and happy life,
especially since spinal cord injury often demands big alterations in one's lifestyle.

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THE VERTEBRAL COLUMN AND SPINAL CORD ANATOMY

Vertebral column
The vertebral column is physical support to the skull and trunk, allowing their movement,
absorbing stresses caused by physical movement and activity, protecting the spinal cord and
providing attachment for the limbs, ribs and muscle tendons.

It is made up out of 33 single bones called vertebrae and intervertebral fibrocartilage discs
placed between most of the vertebrae. One's vertebral column is 71 cm long in average and the
fun fact is, 23 of 33 vertebrae are accounting only one quarter of the length. Vetrebrae are are
divided in five groups: 7 cervical vertebrae, 12 thoracic, 5 lumbar, 5 sacral and 4 coccygeal
vertebrae. Vertebral column is slightly S-shaped with four bendings called the cervical,
thoracic, lumbar and pelvic curvatures. (1.)

The spinal cord

The spinal cord is a cylinder made out of nervous tissue starting from the brainstem at
the foramen magnum. It passes down the vertebral canal and reaches first lumbar vertebra. In
adults it is in average around 45 cm long and 2 cm thick. It gives rise to 31 pairs of spinal nerves
which give inervation to the entire body.

The spinal cord is divided into cervical, thoracic, lumbar and sacral region. Even tho cord does
not reach the sacrum, the sacrum contains roots of spinal nerves. At the end, the spinal cord
tapers to a point called the medullary cone (conus medullaris). And it ends with a bundle of
nerve roots reaching from second lumbar to fifth sacral vertebra and it is called the cauda
equina, named that way for it's resemblance to a horse's tail.(2.)

The spinal cord is wrapped with a loose-fitting sleeve made out of tough collagen as thick as a
rubber kitchen glove called dura mater, on the inside of the dura, there is arachnoidea mater
and on the inside of the arachnoid mater, there is pia mater.

The spinal cord has a central core of gray matter that appears in a butterfly shape in a cross
section. It consists of tho dorsal/posterior horns, and two thicker ventral/anterior horns. The
sides are connected by a gray commissure in the middle of which we find central canal. Near
it's attachment to the spinal cord, a spinal nerve branches into a dorsal root and ventral root.
The dorsal root carries sensory nerve fibers and ventral horns contain large somas of the somatic
motor neurons. In the thoracic and lumbar regions, an additional lateral horn is visible on each
side of the gray matter and it contains neurons of the sympathetic nervous system.

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The white matter of the spinal cord surrounds the gray matter. It consists of bundles of axons
that course up and down the cord and provides avenues of communication between different
levels of the central nervous system.(1.)

UNDERSTANDING THE SPINAL CORD INJURY

Spinal cord injury, later in this seminar paper refered as SCI, is a medically complex and
life-disrupting condition. Previously it has been associated with high mortality rates and today,
in developed countries, it is viewed more as a personal and social challenge that can be
successfully overcome.

Damage to the spinal cord may be traumatic or non-traumatic. Traumatic SCI can result from
many different causes including falls, road traffic injuries, occupational and sports injuries and
violence. Non-traumatic SCI usually involves an underlying pathology such as infectious
disease, tumour, musculoskeletal disease such, and congenital problems.

The symptoms of spinal cord lesion depend on the extent of the injury or non-traumatic cause,
but they can include loss of sensory or motor control of the lower limbs, trunk and the upper
limbs, as well as loss of autonomic (involuntary) regulation of the body. This can affect
breathing, heart rate, blood pressure, temperature control, bowel and bladder control, and sexual
function. In general, the higher up the spinal cord the lesion occurrs the more extensive the
range of impairments will be. Cervical SCI commonly causes sensory and motor loss (paralysis)
in the arms, body and legs- a condition called tetraplegia. Thoracic SCI commonly causes
sensory and/or motor loss in the trunk and legs, a condition called paraplegia. Lumbar SCI
typically causes sensory and motor loss in the hips and legs. All forms of SCI may also result
in chronic pain. The extent and severity of sensory, motor and autonomic loss from SCI depends
not only on the level of injury to the spinal cord, but also on whether the lesion is complete
or incomplete. An SCI is considered complete if there is no sensory and motor function at
S4S5. While some sensory and/or motor functions are preserved below the level of injury in
incomplete SCI, it is not less serious and can still result in severe impairments.(3.)

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EVALUATION AND TREATMENT

Evaluation
Best practice evaluation includes use of CT (computerized tomography) when available.
The American Association of Neurological Surgeons recommends traditional X-rays only if
high-quality CT isnt available. For patients with known or suspected SCIs, MRI (magnetic
resonance imaging) helps visualize the spinal cord and detect injury of the ligaments, trombi,
and herniated discs or other masses that may compress the cord.

Treatment
Treatment starts even before the patient is admitted. Paramedics carefully immobilize
the spine at the scene. In the emergency department, immobilization continues while the
healthcare team works on identifying and addressing more immediate life-endangering
problems. If the patient is in need of the urgent surgery, immobilization and alignment must be
maintained the entire time of the surgery.

For many SCI patients, traction is indicated to bring the spine into proper alignment and
restore blood flow to the injured area. Sometimes, a surgeon may take the patient to the
surgery immediately if the spinal cord appears to be compressed. Even if surgery cant reverse
damage, it may be needed to stabilize the spine to prevent pain or deformity in the future.(4.)

NURSING MANAGEMENT

Assessment
Continued assessment is crucial. Nurses assess for signs of diminished oxygenation, BP
instability, infections, disruption of skin integrity, gastrointestinal or nutrition and urinary
problems. A daily review of physical status is performed. Assessment of a tracheostomy tube,
traction devices, correct use of compression devices or compression stockings, indwelling
catheter, intravenous cannula, naso- and oro-gastric tube is essential to do in each shift.(5.)

Respiratory management
Respiratory impairment is the most commonly occurring complication when it comes to
acute SCI. The level and severity of the injury determine extent of the impairment. It is crucial
to protect the patients airway and maintain adequate respiration. High thoracic to cervical SCIs

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may even end up with respiratory insufficiency and lower injuries have minimal chances for
damaging the motor function of the respiratory muscles. (4.)

To promote adequate breathing and airway clearence nurse needs to:

Observe the patient, measure vital capacity, and monitor oxygen saturation through
pulse oximetry and arterial blood gas values to detect potential respiratory failure in
time.
Clear bronchial and pharyngeal secretions to prevent retention of secretions and
resultant atelectasis.
Suction with caution, because this procedure can cause bradycardia and cardiac arrest.
Assist coughing to mobilize secretions.
Supervise breathing exercises to increase strength and endurance of inspiratory muscles.
Ensure proper humidification and hydration to thin the secretions down.
Assess for cough, fever, and dyspnea which are signs of respiratory infection.
Monitor respiratory status frequently.(7.)

Cardiovascular management
SCI may result in vasodilation, difficult bradycardia, and hypothermia. Hypotension,
temperature dysregulation, venous stasis, and autonomic dysregulation (AD) may occurr.

Nurse has to be sure to monitor frequently heart rate and BP. The goal is to sustain arterial
pressure of 85 mmHg for 7 days, which improves neurologic outcomes.

Once the patient is allowed to walk, orthostatic hypotension may occurr. Nurse then applies
following to reduce the risk:

abdominal binder application,

compression stockings,
compression wrappings for the lower extremities,
and slow elevation of the head of the bed.
Midodrine, pseudoephedrine, and salt tablets can be administered if previous
intervention don't help.

Inability to sweat affects the patients temperature regulation and can worsen bradycardia.
Nurse has to monitor environmental temperature, as this affects body temperature. and provide
gentle rewarming and monitor core temperature frequently.

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Deep venous thrombosis and thromboembolism are a serious threat. Loss of vascular and
muscle tone causes venous stasis which puts the patient at high risk for blood clots.

Venous stasis prophylaxis includes:

immediate application of compression sleeves,

initiation of heparin or enoxaparin 72 hours after the injury,
and in cases of blood clot formation, the patient may receive an implantable filter.(4)

Gastrointestinal management
Paralytic ileus with associated abdominal distention, gastric ulcers, and constipation may
occurr. Ileus typically goes away within the first 7 days. To notice ileus occurring or changes
in already present ileus, nurse has to monitor every 4 hours the bowel sounds and abdominal
distention. If indicated and ordered by a doctor, nurse will insert a gastric tube to reduce
aspiration risk and restore diaphragm position and lung size to normal.(4.)

To prevent GI complications nurse will:

Monitor reactions to gastric intubation.

Provide a high-calorie, high-fiber, and high-protein diet.
Administer prescribed stool softener to conduct a bowel movement as early as
possible.(7.)

Genitourinary management
A patient experiences loss of reflexes and voluntary muscle control, resulting in acute
urinary retention.

To prevent further retention of fluids in the bladder and any further complications, nurse will:

Perform intermittent catheterization to avoid overstretching the bladder and infection.

If this is not doable, nurse will insert an indwelling catheter.
Show family members how to catheterize, and encourage them to participate.
Teach patient to record voiding pattern, characteristics of urine, fluid intake, amounts
of residual urine after catheterization, and any unusual feelings.(7.)

Musculoskeletal management
Patients experience muscle spasticity when spinal shock recedes and reflexes
return. Spasticity reduces venous pooling and stabilizes the muscles used respiration. It also

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causes chronic pain syndrome, fatigue, sleep disturbance, bone density loss, joint
contracture, and it threatens the skin integrity.(4.)

Immobility is a huge problem by it self, not to mention that it is cause of many other
complications including vascular, gastrointestinal, urinary and other. So to improve and
maintain mobility nurse will:

Maintain proper body alignment at all times.

Reposition the patient frequently and assist patient out of bed as soon as the spinal
column is stabilized.
Monitor BP when positions are changed since patients may not tolerate changes in
position.
Do not turn patient unless physician indicates that it is safe to do so.
Perform passive exercises as soon as possible after injury to avoid contractures and
atrophy.(7.)

Dermatologic management
Since patient needs to be immobilised it may lead to decubiti. Factors which combined
cause decubitus are low BP, immobility, unrelieved pressure, friction and shearing forces,
poor nutrition and moisture.

Nurse needs to routinely inspect the patients skin and use the Braden scale- a skin risk
assessment tool. Risk-reduction interventions nurse has to do include:

turn the patient every 2 hours

avoid positioning the patient on bony prominences
minimize moisture
using a custom wheelchair with cushions
providing patient education and nutritional counseling.
If skin breakdown occurrs, consult specialized wound care specialist for wound
assessment and treatment. Treatment options may include both nonsurgical and
surgical interventions, depending on wound location, stage, and depth.(4.)

Neurological improvement
Severity of the initial injury determines recovery of function. Patients with a complete
SCI are unlikely to regain function below the injury level. Incomplete SCIs usually
improve over time to a certain level but it also depends on the injury. (4.)

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To promote adaptation to disturbed sensory perception, nurse will:

Stimulate the area above the level of the injury through touch, flavorful food and
beverages, aromas, music and conversation.
Provide prism glasses to enable patient to see while lieing down.
Encourage use of hearing aids if suitable.
Teach patient strategies to compensate for or cope with sensory deficits and provide
emotional support.(7.)

Nursing diagnoses
''Nursing diagnoses appropriate for the patient with a spinal cord injury may include:

Impaired gas exchange related to paralysis, diaphragm fatigue, or retained secretions.

Impaired physical mobility related to vertebral column instability, disruption of the spinal
cord, and traction.

Decreased cardiac output related to hypotension and decreased muscle action causing
venous pooling.

Imbalanced nutrition: less than body requirements related to increased metabolic

demand from healing injuries, slowed gastrointestinal motility, and inability to feed self.

Impaired urinary elimination related to decreased innervation of the bladder.

Constipation related to loss of nerve stimulation to the bowel and immobility.

Risk for autonomic dysreflexia related to reflex stimulation of sympathetic nervous system.

Risk for skin impairment related to immobility and loss of sensation.

Risk for ineffective coping related to loss of control over bodily functions and altered
lifestyle secondary to paralysis.

Disturbed body image related to paralysis and loss of control over bodily functions.

Interrupted family processes related to change in role within the family because of
neurologic deficits.

Dysfunctional grieving related to neurologic deficits and changes in roles and lifestyle.''(4.,
Baumann, Russo-McCourt, 2016.)

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Evaluation
Evaluation is needed after every nurse process. And in evaluation it is expected that
patient in the best outcome possible does the following:

Demonstrates improvement in gas exchange and clearance of secretions,

Demonstrates optimal skin integrity,
Regains bowel function,
Moves within limits of dysfunction, and demonstrates completion of exercises within
functional limitations,
Demonstrates adaptation to sensory and perceptual alterations,
Regains urinary bladder function,
Reports absence of pain and discomfort,
Is free of complications.(7.)

Home- and community-based care

After patient is released from the hospital, nursing care does not stop. It is very important
to promote good home- and community-based care. And that is done by teaching patient self-
care and continuing care.

Teaching patients self-care

Planning is directed towards independence and the skills necessary for active daily life.
Initially, teach the patient on the injury and its effects on mobility, dressing, and bowel,
bladder, and sexual function. When the patient and family acknowledge the
consequences of the injury and the resulting disability, broaden the focus of teaching to
address issues necessary for taking charge of their lives.

Continuing care
Nurse has to support and assist patient and his family in taking responsibility for
increasing care and providing assistance in dealing with psychological impact.
Nurse also coordinates management team, and serve as intermediate with home care
agencies and rehabilitation centers.
Nurse will reassure female patients that pregnancy is not contraindicated and fertility is
somewhat unaffected, but that pregnant women with SCI represent unique medical
management challenges.
Refer for home care nursing support as indicated by a doctor or desired by the patient
or his family.
Refer patient to mental health care professional if indicated.(7.)

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CONCLUSION

Even tho spinal cord injury represent a life-threating state and can require a broad
spectrum of medical and nursing intervention, with a well organised team, problems can be
solved and complications prevented, all it takes is good communication within the team,
knowledge of the team members and a certain level of exprrience when it comes to dealing with
such patients. Nurses don't particularly participate in the medical aspect of it when it comes to
big decisions but nurses sure do play a huge role in following doctor's prescriptions and
preventing many complications that that occurr in the SCI patients and their families.

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REFERENCES

1. Saladin KS, McFarland RK. Human Anatomy 2nd ed. The McGraw-Hill Companies, Inc.,
New York, New York, United States of America, 2008.

2. Gray H. Anatomy of the Human Body, 20th ed. Lea & Febiger, Philadelphia, United States
of America, 2000.

3. International Perspectives on Spinal Cord Injury. World Health Organization, Valletta,

Malta, 2013.

4. Bauman M, Russo-McCourt T. Caring for patients with spinal cord injuries. American Nurse
Today, Vol. 11 No. 5, May 2016.

5. Chadwick AT, Oesting H. Carinf For Patients with Spinal Cord Injuries. Nursing, Volume
19- Issue 11- ppg 53-56, November 1989.

6. Sekhon L, Fehlings M. Epidemiology, Demographics, and Pathophysiology of Acute Spinal

Cord Injury. Spine, Volume 26- Issue 24S- pp S2-S12,December 2001.

7. Brunner, Suddarth. Medical Surgical Nursing 12th edition. Lippincot Willims & Wilkins,
Philadeplpia, United States of America, 2008.

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