Chapter 60, Spinal Cord and Peripheral Nerve Problems

Which manifestations in a patient with a T4 spinal cord injury alerts the nurse to the possibility of autonomic dysreflexia?

Headache and increased BP Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic manifestations.

The nurse prepares a dietary teaching plan for a patient with a spinal cord injury and includes which information? Select all that apply.

Include two servings from the milk group. Eat three well-balanced meals each day. Include two or more servings from the meat group. For maintaining adequate nutrition in the patient with spinal cord injury, the nurse should instruct the patient to eat three well-balanced meals per day. Food items should be included from the milk and the meat group to increase protein intake. Beans should be avoided because they can cause formation of gas. Spicy food should also be avoided because it can cause gastrointestinal upset.

The nurse performs a respiratory assessment on a patient with uncomplicated tetraplegia and identifies that which finding is acceptable?

PaO2 >60 mm Hg A PaO2 >60 mm Hg and a PaCO2 <45 mm Hg are acceptable values in a patient with uncomplicated tetraplegia. A respiratory rate of 30 is tachypnea, which is not an acceptable finding. When bibasilar crackles are auscultated, the nurse should evaluate the patient for the need to be suctioned.

The nurse provides education about rehabilitation for a patient with a spinal cord tumor. Which statement made by the patient indicates effective learning?

"With rehabilitation, I will be able to function at my highest level of wellness." Rehabilitation is an interdisciplinary endeavor carried out with a team approach to teach and enable the patient to function at the patient's highest level of wellness and adjustment. It will be a lot of work for all involved and takes longer than two weeks. Progress may be slow. With neurologic dysfunction, the patient will not be able to do all the normal activities in the same way as before the lesion, so this statement should be discussed. The patient is expected to be involved in therapies and learn self-care for several hours each day.

A patient who is hospitalized with a spinal cord injury experiences poor dietary intake. Which measures does the nurse take to improve the patient's nutritional status? Select all that apply.

Allow adequate time to eat. Encourage intake of dietary fiber. Request a consult with the nutritionist. Provide a pleasant eating environment. Encourage the family to bring in special foods. General measures such as providing a pleasant eating environment, allowing adequate time to eat (including any self-feeding the patient can achieve), and encouraging the family to bring in special foods may be useful to improve nutrition of the patient. Increased dietary fiber should be included to promote bowel function. The nurse should request a consult with the nutritionist when a patient has increased metabolic needs and poor dietary intake. The nutritionist can provide recommendations for appropriate daily caloric intake and suggest supplements that will improve the nutritional status of the patient. Because there is severe catabolism taking place, a high-protein diet is necessary for energy and tissue repair.

A patient with spinal cord injury is suspected of having venous thromboembolism (VTE). Low-molecular-weight heparin is prescribed. Before initiating the drug, the nurse performs which assessments? Select all that apply.

Any history of recent surgeries Signs of any internal bleeding Low-molecular-weight heparin (e.g., enoxaparin) is used to prevent VTE unless contraindicated. Contraindications include internal bleeding and recent surgery. Low-weight heparin can be administered in the presence of any infection, respiratory problems, or gastroenteritis.

The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred?

Applying a rigid cervical collar and using a backboard to transport the patient Application of a rigid neck collar and use of a backboard will immobilize and stabilize the cervical spine to limit immediate injury to the spinal cord. Initiation of IV access is important but is not directly associated with limiting the SCI. Patient orientation will not stabilize a SCI. The airway must be maintained with the jaw thrust technique if SCI is suspected.

The nurse is caring for a patient with paraplegia who is at risk for developing venous thromboembolism (VTE). The nurse expects that the patient's care plan will include which interventions? Select all that apply.

Assess thighs and calves for signs of VTE. Administer prophylactic low-dose low-molecular-weight heparin. Regularly perform range-of-motion (ROM) exercises and stretching. Continue VTE prophylaxis for three months after injury. Nursing interventions in paraplegics should be aimed at preventing VTE. Assessment of the thighs and calves should be done every shift for signs of VTE. Low-molecular-weight heparin should be administered as a prophylactic measure to prevent thromboembolism. The patient should regularly perform ROM exercises and stretching. VTE prophylaxis should be continued for three months after injury. The nurse should remove the stockings every eight hours for skin care.

Which clinical manifestation does the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury?

Bradycardia Neurogenic shock is caused by the loss of vasomotor tone caused by injury and is characterized by bradycardia and hypotension. Loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

The nurse is providing care to a patient with a spinal cord injury as the result of a motor vehicle accident. The nurse notes that the patient feels no pain in the leg on the side opposite the injury. Which spinal cord syndrome does the nurse suspect?

Brown-Séquard syndrome Brown-Séquard syndrome results from damage to one half of the spinal cord. A contralateral (opposite side of the injury) loss of pain and temperature sensation below the level of the injury is a manifestation of the syndrome. Central cord syndrome is caused by damage to the central spinal cord. Motor weakness and sensory loss are the common manifestations of this syndrome. Anterior cord syndrome is caused by damage to the anterior spinal artery and often results in motor paralysis and loss of temperature and pain sensation below the level of the injury. Cauda Equina syndrome results from damage to the lowest portion of the spinal cord. Flaccid paralysis of the lower limbs and areflexic bladder and bowel are the common manifestations.

The nurse is providing care to a patient with a penetrating spinal cord injury. The patient experiences ipsilateral loss of motor function and position and vibratory sense vasomotor paralysis. Which syndrome does the nurse document in this patient?

Brown-Séquard syndrome Brown-Séquard syndrome results from damage to one half of the spinal cord. This syndrome is typically caused by a penetrating spinal cord injury and results in a loss of motor function on the same side as the injury. Central cord syndrome is caused by damage to the central spinal cord, resulting in motor weakness and sensory loss in both the upper and lower extremities. Anterior cord syndrome is caused by damage to the anterior spinal artery that results in compromised blood flow to the anterior spinal cord. Motor paralysis and loss of pain and temperature sensation are manifestations. Cauda Equina syndrome is damage to cauda equina (lumbar and sacral nerve roots); the patient experiences asymmetric distal weakness and patchy sensation in the lower extremities.

The nurse identifies that a patient is at risk for failure of the diaphragm when the patient experiences which level of spinal cord injury?

C3-C5 Patients with high cervical injury (C3-5) have respiratory insufficiency due to loss of phrenic nerve innervation to the diaphragm and decreases in chest and abdominal wall strength. Patients with complete SCI above C5 should be intubated at once. The thoracic and lumbar spinal nerves do not innervate the diaphragm.

The nurse is caring for a patient with paraplegia who is at risk for developing venous thromboembolism (VTE). The nurse expects that the patient's care plan will include which interventions? Select all that apply.

Continue VTE prophylaxis for three months after injury. Assess thighs and calves for signs of VTE. Administer prophylactic low-dose low-molecular-weight heparin. Regularly perform range-of-motion (ROM) exercises and stretching. Nursing interventions in paraplegics should be aimed at preventing VTE. Assessment of the thighs and calves should be done every shift for signs of VTE. Low-molecular-weight heparin should be administered as a prophylactic measure to prevent thromboembolism. The patient should regularly perform ROM exercises and stretching. VTE prophylaxis should be continued for three months after injury. The nurse should remove the stockings every eight hours for skin care.

A patient with paraplegia has been hospitalized for a week and is eating a very limited amount of food. The nurse identifies which potential causes of the patient's anorexia? Select all that apply.

Depression Hurried feeding by the caregiver Boredom with agency food Exhibiting a way of asserting control Patients with a spinal cord injury (SCI) may have anorexia due to depression, boredom with agency food, or discomfort at being fed (often by a hurried person). Some patients have a normally small appetite. Sometimes refusal to eat is a way of asserting control. Taste sensations are usually intact in patients with an SCI. A paraplegic patient has a thoracic or lumbar cord injury; therefore, dysphagia is not a common problem affecting eating.

The patient with a spinal cord injury (SCI) is admitted to the intensive care unit. The nurse recalls which information about medications used to treat SCI?

Dopamine has more complications than phenylephrine in SCI. Vasopressor agents (e.g., phenylephrine, norepinephrine) are used in the acute phase of injury as adjuvants to treatment. They maintain the mean arterial pressure (MAP) to improve perfusion to the spinal cord. Use of vasopressors has significant risk for complications. These include ventricular tachycardia, troponin elevation, metabolic acidosis, and atrial fibrillation. Dopamine has more complications than phenylephrine in SCI. In patients with SCI, MP is no longer approved by the Food and Drug Administration (FDA). Unless contraindicated, low-molecular heparin is given to prevent venous thrombolytic embolism (VTE). Vasopressor agents are prescribed in the acute phase of the injury to keep the MAP above 90 mm Hg and to improve perfusion to the spinal cord.y

A patient with a spinal cord injury experiences a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures does the nurse teach the patient and the caregiver about to assist with bowel evacuation? Select all that apply.

Eat 20 to 30 g of fiber per day. Consume 2 to 3 liters of fluid per day. The patient with a spinal cord injury and neurogenic bowel should eat 20 to 30 g of fiber and drink 1.8 to 2.8 L of water or juice each day. Milk may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless necessary. Bowel evacuation time is usually established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

The nurse provides postoperative care for a patient after a cervical spine stabilization surgery. The nurse recognizes that which interventions will help stabilize the spine? Select all that apply.

Ensure that the patient's body is correctly aligned. Use a sternal-occipital-mandibular immobilizer brace. Turn the patient as a unit. Proper immobilization of the neck involves the maintenance of a neutral position. After cervical fusion or other stabilization surgery, the patient may have a hard cervical collar or sternal-occipital-mandibular immobilizer brace. The nurse should always keep the patient's body in correct alignment. The patient should be turned as a unit (e.g., logrolling) to prevent movement of the spine.

A patient with a T2 spinal cord injury has begun to experience stress ulcers and intraabdominal bleeding. The nurse expects which assessment findings? Select all that apply.

Expanding abdominal girth Decreased hemoglobin Hypotension Intraabdominal bleeding may be hard to diagnose because the person with a spinal cord injury may not have pain or tenderness. Continued hypotension and decreases in hemoglobin and hematocrit may be the only signs of bleeding. Expanding abdominal girth may be seen. The hematocrit will be decreased. With a T2 level injury, it is unlikely that the patient would experience pain.A woman with a T4 level complete spinal cord injury (SCI) asks the nurse about the impact of the injury on her sexuality. Which information does the nurse provide? Select all that apply.

The nurse prepares a home care plan for a patient with a T3 level complete spinal cord injury. The nurse recognizes which rehabilitation potential for this patient? Select all that apply.

Independent self-care is possible. Independent wheelchair mobility is possible. The patient may be able to drive with hand controls. The patient will be able to have independent standing in a standing frame The patient with a T3 level spinal cord injury will have full innervation of the upper extremities, back, essential intrinsic muscles of the hands, full strength and dexterity of grasp, decreased trunk stability, and decreased respiratory reserve. Therefore, the patient may have the following potentials: full independence in self-care and in a wheelchair, ability to drive a car with hand controls, and independent standing in a standing frame. The patient will not able to climb stairs due to the injury.

The nurse provides a group of nursing students with education about Bell's palsy and includes which information?

It can affect any age group. Bell's palsy is a type of peripheral facial paralysis that can affect any age group, although it commonly is seen in the 20- to 60-year-old range. The cause is not well known; it may be theorized that Bell's palsy can be related to activation of herpes simplex virus (HSV-1). It has a good prognosis. It is characterized by facial-nerve inflammation (cranial nerve [CN] VII) on one side of the face, in the absence of any other disease such as stroke. Bell's palsy occurs on only one side of the face, and more than 40,000 Americans are afflicted each year.

The nurse is providing care to a patient with a spinal cord injury (SCI). The patient's assessment findings include varying control of legs and pelvis, instability of the lower back, and good sitting balance. The patient has full use of the wheelchair and can ambulate with long leg braces. Which level of spinal cord injury would have caused this manifestation?

L1 Injury to lumbar vertebra 1 results in paralysis below the waist. An LI-L2 injury results in varying control of legs and pelvis, instability of the lower back, and good sitting balance. With this type of injury, the patient has full use of the wheelchair and can ambulate with long leg braces. Injury to cervical vertebra 4 results in complete paralysis below the neck. Injury to cervical vertebra 6 results in partial paralysis of the hands and arms and of the lower body. Injury to thoracic vertebra 6 results in paralysis below the chest.

The nurse is assessing a patient with a T2 level spinal cord injury (SCI). The nurse notes that there is a kink in the catheter, the bladder is distended, and the BP is 220/100 mm Hg. Which interventions does the nurse implement? Select all that apply.

Monitor BP regularly. Notify the primary health care provider. Check for the presence of bowel impaction. Remove the kink in the catheter and drain the bladder. The patient is evidencing signs of autonomic dysreflexia (AD), which is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system (SNS). It involves stimulation of sensory receptors below the level of the SCI. The intact SNS below the level of injury responds to the stimulation with a reflex arteriolar vasoconstriction that increases BP. Nursing interventions in a serious emergency like AD include notifying the primary health care provider and determining the cause. The BP should be regularly monitored; administration of an α-adrenergic blocker or an arteriolar vasodilator is required. Contractions of the rectum are also a cause; therefore, the nurse should check for bowel impaction and treat it accordingly. The most common cause is bladder distention. If a catheter is present, then the presence of any kinks or folds should be checked. However, the most important nursing intervention in this case is elevating the head of the bed 45 degrees or higher to make the patient sit upright; this would lower the BP.

A patient with quadriplegia who has been hospitalized for one month is at a risk of developing pressure injury (PI). Which steps does the nurse take to prevent this complication? Select all that apply.

Monitor urinary incontinence. Evaluate the nutritional status of the patient. Check bony prominences for signs of pressure sores. Prevention of pressure ulcers and other types of injury to insensitive skin is essential for every patient with a spinal cord injury (SCI). Moisture from incontinence or any urine leakage can contribute to pressure ulcer development by macerating the skin and increasing friction injuries. Assess nutritional status regularly. A comprehensive visual and tactile examination of the skin should be done at least once daily, with special attention given to areas over bony prominences. The areas most vulnerable to breakdown include the ischia, trochanters, heels, and sacrum. Both body weight loss and weight gain can contribute to skin breakdown. When a patient is moved, it must be done in a way to prevent friction and shearing, because these forces will cause skin injury as readily as pressure. The patient must be lifted, not dragged, while repositioning, which also means that more than one person may be needed to move the patient. Pulling or dragging the patient will cause skin damage due to friction. Careful positioning and repositioning should be done every two hours.

The nurse creates a plan of care for an older male patient with a spinal cord injury who requires clean intermittent catheterization (CIC). Which interventions does the nurse include in the plan? Select all that apply.

Perform CIC four to six times daily. If the urine becomes cloudy, then send a specimen for culture. The patient may have benign prostatic hyperplasia, which may interfere with the ability to complete CIC. Bladder distention may cause autonomic dysreflexia (AD). CIC should be done four to six times daily to prevent bacterial overgrowth from urinary stasis. If the urine is cloudy or has a strong odor or if the patient develops symptoms of a urinary tract infection (UTI) (e.g., chills, fever, malaise), then the nurse should send a specimen for culture. The older male patient may have benign prostatic hyperplasia, which may interfere with the ability to complete CIC. Bladder distention is a trigger for AD. The urine residuals should be kept under 500 mL to prevent bladder distention.

A woman with a T4 level complete spinal cord injury (SCI) asks the nurse about the impact of the injury on her sexuality. Which information does the nurse provide? Select all that apply.

Protection against unplanned pregnancy is needed. The patient has the capacity to become pregnant. The injury does not affect the ability to deliver normally through the birth canal. Pregnancy is associated with a higher rate of autonomic dysreflexia (AD). The effect of SCI on female sexual response is less clear than with the male. A woman of childbearing age with SCI usually stays fertile. The injury does not affect the ability to become pregnant or deliver normally through the birth canal. If sexual activity is resumed, protection against unplanned pregnancy is needed. Pregnancy is associated with increased risk for diabetes and urinary tract infection (UTI) and higher rates of AD, pressure injury (PI), increased spasticity, and catheter-related issues. Menses may cease for as long as six months after injury.

A patient experiences a spinal cord injury as a result of a motor vehicle accident. The patient exhibits a loss of deep tendon and sphincter reflexes, loss of sensation, and flaccid paralysis below the level of injury. The nurse identifies that the findings are consistent with which condition?

Spinal shock Spinal shock may occur shortly after acute SCI. It is characterized by loss of deep tendon and sphincter reflexes, loss of sensation, and flaccid paralysis below the level of injury. This syndrome lasts days to weeks. Central cord syndrome is manifested by motor and sensory loss that is greater in the upper extremities than in the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. In contrast to spinal shock, neurogenic (vasogenic) shock can occur in cervical or high thoracic injury (T6 or higher). It occurs from unopposed parasympathetic response due to loss of sympathetic nervous system (SNS) innervation. It causes peripheral vasodilation, venous pooling, and decreased cardiac output.

Which is a priority nonoperative treatment following a spinal cord injury?

Stabilization Stabilization eliminates any damaging motion at the injury site to avoid worsening the patient's condition. Pain management is important, but it is a lower priority than stabilization. Spinal fusion is a surgical procedure. Cervical traction is a closed reduction with skeletal traction and is used for early realignment (reduction) of the injury; the patient should be stabilized before a care plan is implemented.

A patient with a spinal cord injury (SCI) at the C7 level experiences autonomic dysreflexia. Which signs and symptoms occur with this condition? Select all that apply.

Sweating above the level of the SCI Sudden onset of severe headache Autonomic dysreflexia is a condition that can occur in persons with SCI at the level of the sixth thoracic vertebra (T6) or higher. A sensory receptor (as with a distended bladder) is stimulated below the level of injury, and the sympathetic nervous system responds with vasoconstriction. This is not mediated by the parasympathetic nervous system but is caused by the SCI. Thus the patient develops severe hypertension, often with bradycardia. The causative factors also include rectal distension or skin stimulation. The causative factor must be alleviated as soon as possible. The sympathetic stimulation causes flushing of the skin and sweating above the site of the SCI. The rapid rise in BP gives the patient a severe headache. The patient does not have bowel function, so an involuntary bowel movement will not occur. The condition causes severe hypertension, not hypotension.

A patient who has been admitted to the hospital with a spinal cord injury at the upper thoracic level experiences neurogenic shock. How does the nurse explain the condition to the patient's family? Select all that apply.

There is loss of nervous control of the blood vessels. The amount of blood pumped out of the heart is reduced. There is pooling of blood in the veins of the extremities. Neurogenic shock is due to the loss of vasomotor tone caused by spinal cord injury. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. It is chiefly characterized by hypotension and bradycardia, not increased BP and heart rate. The blood vessels in the extremities dilate due to neurogenic shock.

The nurse is providing care for a patient with a C7 spinal cord injury (SCI). Which instructions does the nurse give to the patient to prevent skin breakdown? Select all that apply.

Use a special mattress to reduce pressure. Use wheelchair cushions to reduce pressure. Use pillows to protect bony prominences when in bed. For preventing skin breakdown in the patient with spinal cord injury, the nurse should teach the patient and caregivers to use special mattresses and wheelchair cushions to reduce pressure. Pillows should be used to protect bony prominences when in bed. If in a wheelchair, the patient should be instructed to lift up and shift weight every 15 to 30 minutes to promote circulation. If in bed, the position should be changed every two hours.

A patient with a T1 level spinal cord injury (SCI) is scheduled to be discharged from the hospital. The nurse creates a neurogenic bowel management plan and includes which information? Select all that apply.

Use of stool softeners Dietary choices for a high-fiber diet Use of suppositories for evacuation Instructions for how to perform digital stimulation of the rectum Careful management of bowel evacuation is necessary in the patient with SCI because voluntary control of this function may be lost. This condition is called neurogenic bowel. A stool softener such as docusate sodium can be used to regulate stool consistency. A digital stimulation (performed 20 to 30 minutes after suppository insertion) by the nurse or patient may be necessary. In addition, suppositories (bisacodyl or glycerin) or small-volume enemas can be used. The usual measures for preventing constipation include a high-fiber diet and adequate fluid intake. However, these measures by themselves may not be adequate to stimulate evacuation. The Valsalva maneuver requires intact abdominal muscles, so it is used in those patients with injuries below T12. A high intake of fluid is advised for easier bowel evacuation.

Which interventions does the nurse include in the teaching plan for a patient with paraplegia who is being discharged from a rehabilitation facility? Select all that apply.

Use pressure-relief devices while sitting. Change bed positions at least every two hours. Dress warmly in cold weather to prevent frostbite. Prevention of skin breakdown is the goal for patients with paraplegia (paralysis of the lower extremities). Because patients sit much of the time, pressure relief devices are needed, especially on wheelchairs. Skin that remains reddened after 30 minutes is showing signs of pressure damage. Minimally, patients need to change position every two hours to prevent pressure sore development. The patient should dress warmly in cold weather to prevent frostbite. Massaging the areas will add to the injury. A diet with adequate vitamins and adequate protein is needed to maintain skin integrity.