In partial fulfillment of the Requirements in

Nursing Care Management 104.1: Medical Surgical Nursing

Xavier University- Ateneo de Cagayan

College of Nursing

A Concept Map on:

Spinal Cord Injury

Submitted to:

Mrs. Florence H. Baluran, RN, MAN

Mrs. Glenda P. De Vera, RN, MAN

Submitted by:

Azzissah Maunting Mua

November 14, 2017

 Spinal Cord Injury

Disease Condition

Spinal cord injuries include fractures, contusions, and compressions of the vertebral
column, usually as the result of trauma to the head or neck. The real danger lies in
spinal cord damage—cutting, pulling, twisting, or compression. Damage may involve
the entire cord or be restricted to a portion of it, and can occur at any level. Fracture
of the 5th, 6th, or 7th cervical, 12th thoracic and 1st lumbar vertebrae is most common.
These vertebrae are most susceptible because there is a greater range of mobility in
the vertebral column in these areas.

Predisposing and precipitating factors

The most common causes of SCIs are motor vehicle crashes (46%), falls (22%),
violence (16%), and sports (12%). The predominant risk factors for SCI include
young age, male gender, and alcohol and drug use. Males account for 80% of
patients with SCI and an estimated 50%-70% occur in those 15-35 years of age.
Males are approximately 4 times more likely than females to have spinal cord
injuries. Spinal cord injuries also occur more frequently during daylight hours, which
may be due to the increased frequency of motor vehicle accidents and of diving and
other recreational sporting accidents during the day.
Pathologic Process

Like head trauma, spinal cord trauma results from acceleration, deceleration, or other
deforming forces usually applied from a distance. Mechanisms involved with spinal
cord injury include:

 Hyperflexion injury when the head is suddenly and forcefully accelerated

forward, causing extreme flexion of the neck. This type of injury often occurs
in head-on collisions and diving accidents. Flexion injury to the lower thoracic
and lumbar spine may occur when the trunk is suddenly flexed on itself. The
posterior ligaments can be stretched, or torn, or the vertebrae may fracture or
dislocate. Either process may disrupt the integrity of the spinal cord, causing
hemorrhage, edema, and necrosis.
 Hyperextension injury occurring most often in automobile accidents in which
the client’s vehicle is struck from behind or during falls when the client’s chin
is struck. The head is suddenly accelerated and then decelerated. This
 stretches or tears the anterior longitudinal ligament, fractures or subluxates
the vertebrae, and perhaps ruptures an intervertebral disk.
 Rotation injuries caused by turning of the head beyond normal range.
 Penetrating injuries to the spinal cord are classified by the velocity of the
vehicle causing the injury. Low-velocity or low-impact injuries cause damage
directly at the site or localized damage to the spinal cord or spinal nerves. In
contrast, high-velocity injuries that occur from gunshot wounds cause both
direct and indirect damage.

Secondary injury exacerbates the primary injury and worsens morbidity:

 Neurogenic shock
 Vascular insult
 Hemorrhage
 Ischemia
 Fluid and Electrolyte Imbalance

Injury causes microscopic hemorrhage in the gray matter, pia mater, and arachnoid
mater. The hemorrhages gradually increase in size until some or all of the gray
matter is filled with blood, which causes necrosis. From the gray matter, the blood
enters the white matter, where it impedes the circulation within the spinal cord.
Ensuing edema causes compression and decreases the blood supply. Thus, the
spinal cord loses perfusion and becomes ischemic. The edema and hemorrhage are
greatest at and approximately two segments above and below the injury. The edema
temporarily adds to the patient’s dysfunction by increasing pressure and compressing
the nerves. Edema at or above the 3rd to 5th cervical vertebrae may interfere with
phrenic nerve impulse transmission to the diaphragm and inhibit respiratory function.

In the white matter, circulation usually returns to normal in approximately 24 hours.

However, in the gray matter, an inflammatory reaction prevents restoration of
circulation. Phagocytes appear at the site within 36-48 hours after the injury,
macrophages engulf degenerating axons, and collagen replaces the normal tissue.
Scarring and meningeal thickening leaves the nerves in the area blocked or tangled.

Complete spinal cord injuries occur when the spinal cord is fully compressed or
severed, completely eliminating the brain's ability to send signals below the point of
injury. A complete spinal cord injury removes the brain's ability to send signals down
the spinal cord below the site of the injury. Thus, a complete spinal cord injury in your
lumbar spinal cord might lead to paralysis below the waist though movement in your
arms and upper body is preserved.

Incomplete spinal cord injuries occur when the spinal cord is compressed or
injured, but the brain's ability to send signals below the site of the injury is not
completely removed. With an incomplete spinal cord injury, the spinal cord's
functions are only partially compromised. The effects of an incomplete spinal cord
injury, then, vary more widely. Someone with an incomplete spinal cord injury due to
an infection may retain significant function. But a gunshot wound survivor whose
injury is high on the spine but incomplete may face obstacles similar to those faced
by a complete spinal cord injury survivor.

Spinal shock is the temporary reduction of or loss of reflexes following a spinal cord
injury (SCI). Reflexes -- such as the ability to pull your hand away from a hot stove
without thinking -- are controlled by the autonomic nervous system. In general, the
more severe the injury, the more severe the autonomic dysfunction will be. However,
spinal shock alone cannot be used to determine prognosis or assess the severity of a
spinal cord injury. immediately following SCI, spinal shock occurs in the portion of the
spinal cord that is injured and results in a complete loss of all motor, sensory, reflex,
and autonomic function below the level of the injury. This loss is manifested in loss of
bowel and bladder tone and peripheral vascular tone, which result in bladder
distention, paralytic ileus, flaccid paralysis, and hypotension. After a period that
varies from hours to months, but which usually lasts for 1 to 6 weeks, the spinal
neurons gradually regain their excitability and the period of spinal shock ends. The
earliest indication is the return of the perianal reflexes. The bulbocavernous reflex
has returned if a slight muscle contraction follows squeezing of the glans penis or
pulling the indwelling catheter. The anal flex has returned if there a puckering of the
anal sphincter following a digital examination of the rectum, insertion of a rectal
thermometer, or a scratching of the skin around the anal area. The flaccid paralysis
during spinal shock is replaced by spastic paralysis during recovery. Muscle wasting
results from the long-term flaccid paralysis seen in clients with lower motor neuron
lesions. Incomplete lesions or upper motor neuron lesions may cause muscle
spasticity, which can lead to contractures after spinal shock has resolved.

Clinical Manifestations

Signs and symptoms of a spinal cord injury may present immediately or some
symptoms may be delayed as swelling and bleeding occur in or around the spinal
cord. One or more of the following symptoms may occur with a spinal cord injury:
  Pain and numbness, or burning sensation
 Inability to move the extremities or walk
 Inability to feel pressure, heat, or cold
 Muscle spasms
 Loss of bladder or bowel control
 Difficulty breathing
 Hypotension
 Hypothermia
 Bradycardia
 Tingling (paresthesia)
 Weakness (flaccid paralysis)
 Absence of reflexes
 Reduced sensation (hypoesthesia)
 Increased sensation (hyperesthesia)
There are three main areas in which a person may suffer spinal cord injury: cervical,
thoracic, and lumbar. The fourth section of the spine (sacral), does not contain spinal
cord tissue. Consequently, though you may cause damage to the sacral vertebrae or
nerves, you will not damage the cord at that level.
Cervical (C1-C8) - Damage to the spinal cord in the cervical spine is considered
the most severe because it can be life-threatening. Symptoms of cervical spinal cord
damage may affect the arms, legs, mid-body, and even the ability to breathe on one’s
own. The higher up in the cervical spine the damage occurs, the worse the injury.
Symptoms may be felt on one or both sides of the body.
Thoracic (T1-T12) - Damage to the spinal cord in the thoracic spine typically
affects the legs. Thoracic spinal cord damage high up in the area may affect blood
pressure.
Lumbar (L1-L5) - Damage to the spinal cord in the lumbar spine typically affects
one or both legs. Patients with lumbar spinal cord damage may also have trouble
controlling their bladder and/or bowel function.
As for spinal cord compression, slight compression may cause mild symptoms if it
disrupts only some nerve impulses going up and down the spinal cord. These
symptoms may include:
 Discomfort or pain in the back
 Slight muscle weakness
 Tingling
 Other changes in sensation
  In men, difficulty initiating and maintaining an erection (erectile dysfunction)
Pain may radiate down a leg, sometimes to the foot. If the cause is cancer, an
abscess, or a hematoma, the back may be tender to the touch in the affected area.
Sometimes sensation is lost. Reflexes, including the urge to urinate, may be lost. If
compression increases, symptoms may worsen. Substantial compression may block
most nerve impulses, causing
 Severe muscle weakness
 Numbness
 Retention of urine
 Loss of bladder and bowel control
If all nerve impulses are blocked, the following result:
 Paralysis
 Complete loss of sensation
Diagnostic Studies
 Spinal X-rays: most important diagnostic measure, detect most fractures
 Computed Tomography Scan: provides images of fracture
 MRI: reveals spinal cord edema and compression and may reveal a spinal
mass
 Urinalysis: check for presence of blood in urine after trauma
 ABG: monitor respiratory status for client at risk of respiratory insufficiency;
decreased O2 and increased CO2 and respiratory acidosis indicates
respiratory failure

Medical and Surgical Management

 Dextran: (plasma expander) increase capillary blood flow within the spinal
cord; prevent or treat hypotension
 Atropine Sulfate: treat bradycardia <50-6- bpm
 Naloxone and Thyrotropin-releasing hormone: improve spinal cord
blood flow
 4-AP Potassium channel blocker: improve spinal cord conduction
 Dantrolene and Baclofen: control severe muscle spasticity
 Intrathecal Baclofen Therapy: severe spasticity

Secondary Conditions

 Autonomic Dysreflexia (AD) is a serious and potentially life-threatening

emergency associated with SCI. AD causes over-activity of the autonomic
 nervous system. In other words, communication between the body and brain
is disrupted above the injury level. This means body functions, such as
breathing, blood pressure, and heart rate become unregulated. Drugs that
decrease heart rate and relax blood vessels may be used to treat AD.
 Respiratory infections may develop when chest and abdominal muscles are
weak, such as in cervical and thoracic SCI. Difficulty or inability to cough
contributes to the development of respiratory infection. Common infections
include the common cold, bronchitis, and pneumonia. Antibiotics may be
prescribed to clear the chest.
 Spasticity is characterized by stiff or rigid muscles that make movement,
such as walking or talking, difficult. Muscle relaxant and anti-spastic drugs
may be given.
 Pain caused by the injury, even in areas where there is no sensation or
feeling is limited, is common. SCI patients who use wheelchairs may develop
shoulder or arm pain (eg, tendonitis). Medication may include non-steroidal
anti-inflammatory drugs (NSAIDS), muscle relaxants, anti-depressants, and
painkillers (eg, narcotics).
 Chronic pain (eg, neurogenic, nerve pain) often accompanies paralysis.
Medication may include non-steroidal anti-inflammatory drugs (NSAIDS),
gabapentin (Neurontin), muscle relaxants, anti-depressants, and painkillers.
 Depression is common, but there are many medications that are used to
treat this disorder. Sometimes, anti-depressant medications are combined.
Some examples of anti-depressant medications are:
 Selective Serotonin Reuptake Inhibitors (SSRIs)
 Tricylic drugs
 Selective Serotonin and Norepinephrine Reuptake Inhibitors (SSNRIs)
 Anxiety medications

Cervical Injuries

 Fixed skeletal traction to realign vertebrae, facilitate bone healing,

prevent further injury
 Halo traction device and cervical tongs
 Rotational bed to allow frequent turning
Nursing diagnosis

1) Ineffective Tissue Perfusion to Spinal Cord r/t interruption of arterial flow

2) Ineffective Airway Clearance r/t weakness of intercostal muscles and

neuromuscular dysfunction

3) Ineffective breathing pattern r/t weakness or paralysis of abdominal and intercostal

muscles and inability to clear secretions

4) Impaired bed mobility r/t motor and sensory impairments

5) Impaired physical mobility r/t motor and sensory impairments

6) Impaired urinary elimination r/t sensory and motor impairment and inability to void
spontaneously

7) Constipation r/t presence of atonic bowel as a result of autonomic disruption

8) Autonomic dysreflexia r/t uninhibited sympathetic response of the nervous system

following SCI

9) Self-care deficit r/t decreased or absent muscle control

10) Impaired transfer ability r/t neuromuscular or musculoskeletal impairment

11) Sexual dysfunction r/t altered body function

12) Reflex urinary incontinence r/t neurological impairment above level of sacral or
pontine micturition center

13) Risk for impaired skin integrity r/t prolonged physical immobilization

14) Imbalanced nutrition: Less than body requirements r/t inability to absorb nutrients

15) Acute pain r/t physical injury

Nursing Management

1) Provide emergency treatment

 Do not move the client until adequate personnel and equipment are available
 Keep the neck aligned
 Immobilize the head and neck
  Maintain a patent airway; with cervical injury, ascending edema may cause
respiratory difficulty

2) Administer prescribed medications.

3) Assist with immobilization and reduction of dislocations and stabilization of

the cervical vertebral column by applying skeletal traction or halo traction

 By caring for the client on a Stryker frame or CircOlectric bed

 Ensure that weights hang freely and do not interfere with traction
 Clean tong insertion sites and assessing for signs of infection
 Take appropriate measures to prevent skin breakdown

4) Prevent complications of immobility.

 Perform Passive ROM exercises on paralyzed limbs to maintain joint mobility

 Provide nursing care to prevent complications such as DVT, pressure ulcers,
contractures, constipation, and pneumonia

5) Promote normal bowel and bladder elimination

 Promote measures to prevent constipation, and encourage the client to

establish a regular bowel routine: advise a client to set a schedule for
defecation preferably 15-20 mins after a meal and provide a warm liquid
before defecation time
 Provide bladder care to prevent urine stasis
 Maintain adequate fluid intake
 Identify and use triggering mechanisms that can stimulate voiding
 Perform intermittent bladder catheterization as appropriate.

6) Provide information on alternative means for achieving sexual satisfaction

as appropriate.
 REFERENCES

Benzel, E. (2015, September 14). Drugs and Medications for Spinal Cord Injury.
Retrieved from https://www.spineuniverse.com/conditions/spinal-cord-injury/drugs-
medications-spinal-cord-injury

Bonner, S., Smith, C., (2013). Continuing Education in Anaesthesia Critical Care &
Pain.

Dewit, S., Stromberg, H., Dallred, C. (n.d.) Medical-surgical Nursing: Concepts &
Practice

Eck, J. C. (2016, February 09). Spinal Cord Injury: Levels, Treatment, Symptoms,
Recovery.

Losey, P., Anthony, D. (2014). Impact of vasculature damage on the outcome of

spinal cord injury: a novel collagenase-induced model may give new insights into the
mechanisms involved. Vol. 9. Issue 20.

Rubin, M. (n.d.). Compression of the Spinal Cord - Brain, Spinal Cord, and Nerve
Disorders. Retrieved November 12, 2017, from
http://www.msdmanuals.com/home/brain,-spinal-cord,-and-nerve-disorders/spinal-
cord-disorders/compression-of-the-spinal-cord

Signs & Symtoms of Spinal Cord Injuries. (n.d.). Retrieved November 12, 2017, from
https://www.spinalcord.com/signs-symtoms-of-spinal-cord-injuries

Spinal Cord Compression. (n.d.). Retrieved November 12, 2017, from

https://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/
spinal_cord_compression_134,13

Villines, Z. (2015, December 30). Complete vs. Incomplete Spinal Cord Injuries.
Retrieved November 12, 2017, from https://www.spinalcord.com/blog/complete-vs.-
incomplete-spinal-cord-injuries

Villines, Z. (2017, February 15). Spinal Shock: What It Is and How You Treat It.
Retrieved November 12, 2017, from https://www.spinalcord.com/blog/spinal-shock-
what-it-is-and-how-you-treat-it