The initial injury causes a release of glutamate, which causes cellular damage and petechial hemorrhages at the injury site. Calcium influx into the neuron is caused by thrombus formation. This alteration in calcium triggers the arachidonic acid cascade to be initiated, thus leading to free radical formation, lactic acidosis, and lipid peroxidation. This final series of events hastens ischemia of the white matter and microvasculature destruction, with resultant neuronal damage and permanent neurological deficit. This series of physiological and chemical events associated with acute SCI lead to the permanent neurological deficit. With aggressive medical interventions and nursing management, approximately 90% of patients with acute SCI survive.
SCI can be classified by a variety of methods: complete and incomplete cord injury, mechanism of injury, and the level of injury. In a complete SCI, the patient loses all function below the neurological injury level (the lowest neurological segment with intact motor and sensory function). In an incomplete SCI, some motor or sensory function below the neurological injury level remains intact.
Nursing care plan assessment and physical examination
Determine the mechanism of injury in addition to taking a detailed report from prehospital professionals about the patient with an acute SCI. Question the prehospital care provider, significant others, or witnesses about the situation surrounding the injury. If the patient was in an MVC, determine the speed and type of the vehicle, whether the patient was restrained, the patient’s position in the vehicle, and if the patient was thrown from the vehicle on impact. If the patient fell, the distance of the fall is important to know during the initial assessment and evaluation phase. A key component of the history in the patient with a suspected acute SCI is information about the patient’s motor and sensory function at the scene of the injury.
Assess the patient as soon as possible after the primary injury and again each hour during the acute period. Neurological assessments usually include the Glasgow Coma Scale and pupil reflexes. The initial assessment is conducted at the injury site. This primary survey generally takes about 30 seconds and focuses on assessing airway, breathing, and circulation and implementing life-saving intervention. Stabilizing the cervical spine prevents an incomplete SCI from progressing to a complete one. The secondary survey is a complete head-to-toe assessment. Sometime during the first 48 hours, a tertiary survey is performed to discover any subtle injuries that may have been missed during the initial assessment.
Assess the patient’s injury level. Test the patient’s ability to distinguish a pinprick from dull pain at each level of the dermatomes. Rectal examination helps determine if the sphincter tone is normal and if the SCI is complete or incomplete. Normal sphincter tone and anal winking indicate an incomplete SCI. Evaluate the patient’s motor strength to help determine the injury level. Test the patient’s motor movement.
Examine the patient for signs of neurogenic shock, which usually occurs within 30 to 60 minutes after the SCI when sympathetic nerves have lost their normal connections to the central nervous system (CNS). Signs to look for include decreased heart rate and pronounced hypotension (systolic pressure below 90 mm Hg).
Acute SCI is catastrophic and alters not only the lives of patients but also the lives of their families, friends, and the community they live in. Physiological alterations are significant in patients with acute SCIs, as are the psychosocial adjustments. Ongoing assessment of the patient’s and family’s coping skills is critical in planning meaningful support and interventions to assist the patient in reaching her or his functional potential.
Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to hypoventilation or airway obstruction.
Nursing care plan intervention and treatment plan
Maintenance of airway, breathing, and circulation is the highest priority in patients with SCI. The patient with a cervical or high thoracic injury is at risk for developing pulmonary insufficiency, problems with airway clearance, and ineffective breathing patterns. The patient may require endotracheal intubation or tracheostomy with mechanical ventilation. Assess tidal volume and vital capacity every 2 hours in the patient who is not endotracheally intubated. Hydration may be provided by intravenous (IV) crystalloid fluids or by dextran, a plasma expander that may be used to increase capillary blood flow.
The benefits of early spinal stabilization are decreased morbidity and decreased length of hospital stay, but the neurological benefits are controversial. Although this is a temporary intervention, external stabilization may be accomplished by Gardner-Wells tongs, which can be applied until surgical stabilization can be performed. A halo apparatus can be applied either as a primary intervention or to protect a surgical repair. This device immobilizes the cervical spine but allows the patient increased mobility. Patients with stable thoracolumbar spine fractures require only support with a rigid external brace for several months. Timing for surgical (internal) stabilization of cervical spine injuries is controversial. Some suggest that early surgical stabilization enhances neurological recovery and decreases morbidity, but others believe that early stabilization may increase biochemical alterations and vascular instability.
Patients with unstable thoracolumbar spine fractures are managed with metal rods and surgical decompression. Neurological outcome may be improved by postponing surgery until spinal cord edema is decreased.
Postoperative patients may require a rigid cervical collar or rigid external brace to protect the surgical repair. Patients with acute SCI from penetrating trauma may require surgical intervention for débridement and closure of the dura, if cerebrospinal fluid leakage persists. If x-ray films demonstrate that a bullet or other foreign body is within the spinal cord, surgical removal may be recommended to decrease the likelihood of chronic radicular pain.
The most critical nursing intervention for the patient with an acute SCI is to maintain airway, breathing, and circulation. Maintain cervical alignment and immobilization. An abdominal binder may be beneficial in patients with SCIs to provide additional support of the abdominal musculature, a major contributor to respiratory excursion. A potentially life-threatening complication associated with acute SCI is autonomic dysreflexia. This dysfunction may occur after the acute phase and is characterized by a hypersympathetic response to some noxious stimuli; this response is commonly found in patients with SCIs above the T8 level. Deep vein thrombosis may also occur. Apply sequential compression devices or foot pumps as prescribed.
Check bony prominences and areas under the brace or jacket for skin breakdown. Aggressive physical and occupational therapy early in the acute phase may be beneficial to the patient’s overall rehabilitation. Joint range-of-motion exercises prevent contractures and severe muscle wasting. Some patients may require splints for the upper and lower extremities to prevent flexion contractures and footdrop.
Prevent urinary tract infections by instituting an intermittent catheterization protocol early. Protocols vary, but most begin with catheterizing every 4 hours. Monitor the residual urine volume; when it is less than 400 mL, catheterization can be done every 6 hours. Record the amount of urine voided and the postvoid residuals. As the amount of residual volume decreases, increase the time intervals between catheterizations. Before catheterization, assist the patient in emptying the bladder by Crede’s method or by gently tapping or percussing the bladder. Establish bowel continence early in the acute phase.
When the patient is eating by mouth or is being tube fed, administer stool softeners as ordered. If the patient has not had a bowel movement, administer bisocodyl (Dulcolax) suppository. If the patient is NPO (nothing by mouth), administer bisocodyl every other night. Digital stimulation is used in conjunction with the bowel program. Adequate fluid volume status is important for a successful bowel and bladder program.
Provide diversionary activities to help pass the time. Arrange for the patient or family to consult with a clinical nurse specialist, chaplain, or social worker to assist in coping with anxiety and stress, if it is deemed necessary. If the patient has little hope for recovery, consider speaking with the family about donating the patient’s organs, if appropriate.
If the patient is scheduled for discharge, teach the patient and family about the recommended activity level and rehabilitative exercises. Explain how to recognize the signs and symptoms of infection or a deteriorating level of consciousness. Instruct the patient and family in the name, dosage, action, and potential adverse effects of all prescribed medications. Show them the proper care for wounds and lacerations. Make sure the patient and family are aware of the schedule for follow-up medical care.
Nursing care plan discharge and home health care guidelines
Encourage the patient to participate in therapies. Instruct the patient to communicate any abnormalities that are recognized. Explain the use of compression stockings as prescribed, with correct application. Teach the patient to maintain the bowel and bladder program. Verify that the patient and family understand the causes and symptoms of autonomic dysreflexia. Be sure the patient understands any medication prescribed. Verify that the patient and family have demonstrated safe use of all assistive devices: wheelchair, transfers, adaptive feeding equipment, and toileting practices. Review with the patient and family all follow-up appointments that are arranged. Verify that all at-home arrangements have been completed.
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