1. Chapter 45
Care of Patients with Problems of the Central Nervous System: The Spinal Cord
A cross section of the spinal cord.

2. Lumbosacral BackPain (Low Back Pain)
Herniated nucleus pulposus

3. Health Promotion & Maintenance
Preventative measures
Good posture
Proper lifting
Exercise
Ergonomics
Equipment that can be used

4. Nonsurgical Management
Positioning
Drug therapy
Heat therapy
Physical therapy
Weight control
Complementary and alternative therapies

5. Surgical Management Minimally invasive surgery
Percutaneous lumbar diskectomy
Thermodiskectomy
Laser-assisted laparoscopic lumbar diskectomy
Conventional open surgical procedures
Diskectomy
Laminectomy
Spinal fusion

6. Postoperative Care Prevention/assessment of complications
Neurologic assessment; vital signs
Patient’s ability to void
Pain control
Wound care
CSF check
Patient positioning/mobility
Discharge teaching
Home care management
Community resources

7. Cervical Neck Pain Conservative treatment Soft collars
Surgical management
Anterior cervical diskectomy
Fusion

8. Spinal Cord Injuries Hyperflexion Hyperextension
Axial loading or vertical compression (e.g., caused by jumping)
Excessive head rotation beyond its range
Penetration (e.g., caused by bullet or knife)

9. Spinal Cord Injuries
Hyperflexion injury of the cervical spine.

10. Spinal Cord Injuries
Axial loading (vertical compression) injury of the cervical spine and the lumbar spine.

11. Common Spinal Cord Syndromes
Complete lesion
Anterior cord syndrome
Posterior cord lesion
Brown-Séquard syndrome
Central cord syndrome

12. Common Spinal Cord Syndromes

13. Spinal Cord Injury Initial Assessment
Airway, breathing pattern, circulation
Indications of intra-abdominal hemorrhage, or hemorrhage/bleeding around fracture sites
Level of consciousness: Glasgow Coma Scale
Level of injury: tetraplegia, quadriplegia, quadriparesis, paraplegia, paraparesis

14. Key Assessment Findings
Neurological system
Cardiovascular system
Respiratory system
Gastrointestinal system

15. Management of Spinal Cord Injuries
Nonsurgical management
Immobilization
Drug therapy
Surgical management
Community resources

16. Priority Problems for Long-Term Management
Difficulty breathing
Impaired physical mobility (safety)
Spastic or flaccid bladder and bowel
Impaired adjustment

17. Spinal Cord Tumors Types: Assessment findings
Primary
Intramedullary
Extramedullary
Assessment findings
Priority problems with interventions:
Surgical management—emergency surgery
Nonsurgical management—radiation, chemotherapy

18. Multiple Sclerosis Types: Assessment findings
Relapsing-remitting
Primary progressive
Secondary progressive
Progressive-relapsing
Assessment findings
Priority problems with interventions:
Compare/contrast with priority problems and interventions for SCI
Drug therapy

19. Amyotrophic Lateral Sclerosis (ALS)
Assessment findings
Priority problems with interventions:
Respiratory concerns
Swallowing concerns
Musculoskeletal concerns

20. Case Study
A 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?
Airway
Circulation
Level of consciousness
Sensory-motor
ANS: A
Even 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 Study
While the patient is monitored in the ED, which finding will you immediately report to the physician?
Unresolved headache
Blood pressure of 90/70 mm Hg
Neck pain of “5” on a 0-to-10 scale
Increase in the Glasgow Coma Scale score
ANS: B
Low 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 Study
The 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 syndrome
Brown-Séquard syndrome
Central cord syndrome
Posterior cord syndrome
ANS: A
With 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 Study
The 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: D
Manifestations 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 Study
Ten 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 status
Teaching self-care skills
Working on mobility skills
Bowel and bladder retraining
Airway, breathing, and circulation
ANS: B, C, D
During 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 45
Audience Response System Questions 25

26. Question 1
In 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: B
Rationale: 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 2
True or False: Smoking is a risk factor associated with the development of multiple sclerosis in women.
True
False
Answer: 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 3
A 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: A
Rationale: 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.