13 Spinal Cord Injury Initial Assessment Airway, breathing pattern, circulationIndications of intra-abdominal hemorrhage, or hemorrhage/bleeding around fracture sitesLevel of consciousness: Glasgow Coma ScaleLevel of injury: tetraplegia, quadriplegia, quadriparesis, paraplegia, paraparesis
14 Key Assessment Findings Neurological systemCardiovascular systemRespiratory systemGastrointestinal system
20 Case StudyA 19-year-old man who was involved in a motor vehicle accident is brought to the ED. The patient was stopped at a red light when he was hit from behind by another vehicle traveling at 15 mph. The patient was placed in a cervical immobilizer by the paramedics. He is alert and oriented, states that his neck hurts, and is in no apparent distress. He currently rates his neck pain as a “5” on a 0-to-10 scale.Which assessment will you perform first?AirwayCirculationLevel of consciousnessSensory-motorANS: AEven if the patient is in no apparent distress, airway must always be assessed first. Circulation, level of consciousness, and the sensory-motor system can be assessed after the airway.
21 Case StudyWhile the patient is monitored in the ED, which finding will you immediately report to the physician?Unresolved headacheBlood pressure of 90/70 mm HgNeck pain of “5” on a 0-to-10 scaleIncrease in the Glasgow Coma Scale scoreANS: BLow systolic blood pressure can indicate a decrease in perfusion to the spinal cord, which could worsen the patient’s condition. A headache may linger. Neck pain is the chief concern, but it is unlikely to resolve completely while in the ED. An increase in the GCS score indicates improvement in a patient’s condition.
22 Case StudyThe patient is admitted to the orthopedic unit. On assessment, you find the following manifestations: loss of motor function, pain, and temperature sensation below the level of injury; sensations of touch, position, and vibration are intact.Which spinal cord syndrome do you suspect?Anterior cord syndromeBrown-Séquard syndromeCentral cord syndromePosterior cord syndromeANS: AWith anterior cord syndrome, a decrease in blood supply to the anterior gray and white matter results in a loss of motor function, pain, and temperature sensation below the level of injury. However, sensations of touch, position, and vibration remain intact. In some of these patients, motor control is recovered.
23 Case StudyThe next morning, the patient’s heart rate is 48/min and blood pressure is 78/66. His skin is warm and dry.What is your best first action?Increase the IV rate from 50 to 75 mL/hr.Raise the head of bed to 45 degrees.Apply oxygen at 2 L per nasal cannula.Notify the provider immediately.ANS: DManifestations of neurogenic shock include severe bradycardia, warm and dry skin, and severe hypotension. The physician should be notified immediately because this is an emergency. It is best treated by restoring fluids to the circulating blood volume. While increasing the IV rate is a good intervention, going from 50 to 75 mL/hr will not be enough, and a physician’s order is needed to make this change.
24 Case StudyTen days later the patient is to be discharged to a rehabilitation facility.What are priorities of care during rehabilitation? (Select all that apply.)Returning to pre-injury statusTeaching self-care skillsWorking on mobility skillsBowel and bladder retrainingAirway, breathing, and circulationANS: B, C, DDuring rehabilitation, patients learn about self-care, mobility skills, and work on bowel and bladder retraining. A typical stay is 1 to 2 months. A return to pre-injury status may not be a realistic goal. ABCs should always be monitored; however, the patient should be stable in these areas prior to transfer to a rehabilitation facility.
25 Audience Response System Questions Chapter 45Audience Response System Questions25
26 Question 1In assessing a patient with low back pain, an important question to ask is:“How does your back pain affect your activities of daily living?”“Tell me about your pain and what interventions are helpful in managing your pain.”“How long have you had back pain?”“Have you ever had magnetic resonance imaging to find a cause for your back pain?”Answer: BRationale: Obtaining a thorough assessment of the patient’s pain level and effective interventions to treat pain is an important element of the nursing assessment.
27 Question 2True or False: Smoking is a risk factor associated with the development of multiple sclerosis in women.TrueFalseAnswer: A (True)Rationale: Women who smoke are 1.6 times more likely to develop MS than women who are non-smokers. Additionally, individuals with MS who smoke appear to be at a much greater risk of experiencing a quicker progression of their disease.(Source: Accessed August 12, 2011, from
28 Question 3A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. His blood pressure is 190/100 mm Hg, and heart rate is 52 beats/min. What is the nursing priority intervention?Place the patient in a sitting position.Page/notify the health care provider.Check the urinary catheter tubing for kinks or obstruction.Check the patient for fecal impaction.Answer: ARationale: Autonomic dysreflexia is an excessive, uncontrolled sympathetic output and is a neurologic emergency in patients with spinal cord injury T6 and above. The first priority of care is to place the patient in a sitting position. Then contact the health care provider to treat the increased blood pressure. The cause of this syndrome is a noxious stimulus—most often a distended bladder or constipation. Rapid treatment is essential to prevent a stroke.