Transcript File

By: Brittney Mathis RN, BSN
 Transient
concussion=full recovery
 Contusion
 Laceration
 Compression
 Complete
transection (SEVERING)-patient
paralyzed below level of injury
 Primary
injury-from initial insult and permanent
 Secondary-ischemia, hypoxia, edema, and
hemorrhagic lesions=destruction of myelin and
axons
Unstable burst fracture of the
atlas caused by severe axial
compression (C1)
Cause-diving injury
Associated injuries may include
damage to the vertebral artery
traversing the foramen
transversarium
 Causes-motor
vehicle crashes and
diving
 Disrupt ligaments of posterior column,
displacing vertebral body posteriorly
into spinal canal
 Neurologic injury common
 Quadriplegia, loss of pain, and
temperature sensation
 Most common at C5

A


B


Incomplete: Motor function is preserved below the neurologic level, and
more than half of key muscles below the neurologic level have a muscle
grade of less than 3
D


Incomplete: Sensory but not motor function is preserved below the
neurologic level, and includes the sacral segments S4 to S5
C


Complete: No motor or sensory function is preserved in the sacral
segments S4 to S5
Incomplete: Motor function is preserved below the neurologic level, and
at least half of key muscles below the neurologic level have a muscle grade
of 3 or greater
E

Normal: Motor and sensory function are normal
 Frequent
Neurological Exams q1-2 hours or as ordered
 Continuous Cardiac Monitor-bradycardia and asystole
common
 IV steroids


Pepcid/Prevacid/Protonix
Blood sugar monitoring <140
 Increased



blood pressure MAP >85
Dopamine
Phenylephrine
NEVER Norepinephrine (Levophed)!
(Department of Orthopaedic Surgery, 2011)
 Respiratory



Management
Continuous oxygen saturation monitoring
I.S. use and education
Aggressive coughing and deep breathing
 DVT
prophylaxis
 Foley with strict I&O
 Bowel Regimen
 From
loss of autonomic nervous system
 Hypotension-decreased
cardiac output, venous
pooling in extremities, peripheral vasodilation
 Bradycardia
 Thermodysregulation
(Krassioukov et al., 2007)
Spinal
back board
Head in neutral position
Cervical collar
Log rolling
 While
awaiting long term cervical spinal
stabilization, such as Aspen Collar, Philadelphia
Collar, or halo, patient should remain on flat
surface in neutral position.
 If patient’s head of bed needs to be elevated,
place patient in reverse Trendelenburg.

1. This is a 4 (minimum) or 5 person technique depending on the needs of
the patient
1 to hold to the patient’s head (in charge of the log roll)
2 (or 3) to support the chest, abdomen and lower limbs
1 to carry out the planned activity (pressure care)

2. Prepare the patient
Explain the procedure to the patient regardless of conscious state
Request that they lay still and resist assisting
Secure all lines, drains and tubes
Ensure that the patient is in neutral alignment (straight)
3. Prepare your environment
Ensure that the current collar is well fitting prior to the log roll
Assemble all necessary equipment i.e. hygiene equipment, wedge for side
lying etc
Ensure that the log rolling team is correctly positioned
 1. Person 1 supports upper body hands on shoulder and hip
 2. Person 2 supporting abdomen and lower legs hands on hip and lower legs
 3. If 3rd person required more support can be given to lower body

(The Royal Melbourne Hospital, 2013)
 Should


be preformed every four hours
Assess for skin breakdown and pressure points
Wash and completely dry skin under collar with each
assessment
 Male
patients need to be regularly shaved to
prevent skin irrigation
(The Royal Melbourne Hospital, 2013)
(Aspen Medical Products, 2004)
 Maintain
head in desired position. Place the
sizing guide against head at the highest point of
the shoulder muscle. Draw an imaginary line
from chin bottom to sizing guide then select
collar size.
(Aspen Medical Products, 2004)
 Roll
up the back panel
 Roll the front panel sides inward
(Aspen Medical Products, 2004)
 Flare
sides of the front panel outward. Place
chin piece directly under the chin. Generally, the
chin should not extend beyond the edge of the
plastic.
 Push the sides of the front panel up over
shoulder muscles around the neck (Aspen Medical Products, 2004)
 While
holding the front panel with one hand, center
the back panel and attach both sides to the front.
 While holding the front panel in place with one
hand, pull outward then secure the back panel
Velcro straps to the front of the collar.
(Aspen Medical Products, 2004)
 The
patient’s chin should be flush with the end of the
collar chin piece. The inner trach bar should not be
touching the airway. If it does, refit with the next taller
size.
 All slack should be removed from the collar back. The
back panel should be centered. From the front the back
Velcro straps should be symmetrical.
(Aspen Medical Products, 2004)
Which of the following should be the nurse’s
primary concern when caring for a client
who had a recent C4 injury?
 A. Spinal shock
 B. Paralytic ileus
 C. Stress ulcer
 D. Respiratory compromise
D. Using the airway, breathing, and circulation (ABC)
priority setting framework, the greatest risk to the
client with an SCI at the level of C4 is respiratory
compromise secondary to involvement of the phrenic
nerve. Maintenance of an airway and provision of
ventilator support, as needed, is the priority
intervention. Spinal shock, paralytic ileus, and stress
ulcers are also of concern, but are not the highest
priority.
A nurse is caring for a college student who experienced a
T12 fracture while playing football resulting paraplegia.
The client has no muscle control of his lower limbs,
bowel, bladder, or genital area. The client is 1 week
postoperative following spinal stabilization surgery.
During the acute phase following SCI prevention of
which of the following should be the nurse’s highest
priority when planning care for the client?
 A.
Further damage to the spinal cord
 B. Contractures of the hands and extremities
 C. Skin breakdown of areas that lack sensation
 D. Postural hypotension when placing the client in a
wheelchair
A. The greatest risk to the client during the acute
phase of a SCI is further damage to the spinal cord.
Therefore, when planning care the priority should
be the prevention of further damage to the spinal
cord. This should be done through the use of
corticosteroids, minimal movement of the client
until spinal stabilization is accomplished through
either traction or surgery, and adequate oxygenation
of the client to decrease ischemia of the spinal cord.
Preventing contractures, skin breakdown, and
postural hypotension are important, but they are
not the highest priority.
A patient with a C7 spinal cord injury
undergoing rehabilitation tells you he must
have the flu because he has a bad headache
and nausea. What is your initial action?
A. Call the physician.
B. Check the patient's temperature.
C. Take the patient's blood pressure.
D. Elevate the head of the bed to 90 degrees
C. Take the patient's blood pressure.
Autonomic dysreflexia is a massive, uncompensated
cardiovascular reaction mediated by the sympathetic
nervous system. Manifestations include hypertension (up
to 300 mm Hg systolic), throbbing headache, marked
diaphoresis above the level of the lesion, bradycardia (30
to 40 beats/minute), piloerection, flushing of the skin
above the level of the lesion, blurred vision or spots in
the visual fields, nasal congestion, anxiety, and nausea.
It is important to measure blood pressure when a patient
with a spinal cord injury complains of a headache.
A nurse is caring for client who experienced
a cervical spine injury 24 hr ago. Which of
the following types of medications prescribed
for the client by the provider should the
nurse question?
 A. Glucocorticoids
 B. Plasma expanders
 C. H2 antagonists
 D. Muscle relaxants
 D.
The client will still be in spinal shock
24 hr following the injury. The client
will not experience muscle spasms until
after the spinal shock has resolved,
making muscle relaxants unnecessary at
this time. The other medications are
appropriate to provide at this time.
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Aspen Medical Products. (2004, October). Aspen collar sizing guide. Retrieved from
http://www.aspenmp.com/images/product-downloads/aspen-collar/aspen-collarsizing-guide.pdf
Department of Orthopaedic Surgery. (2011). Cervical spine injury management
guidelines. Retrieved from http://orthosurg.ucsf.edu/oti/patientcare/divisions/spine/resources/cervical-spine-injury-management-guidelines/
Krassioukov, A. V., Karlsson, A., Wecht, J. M., Wuermser, L., Mathias, C. J., &
Marino, R. J. (2007). Assessment of autonomic dysfunction following spinal cord
injury: Rationale for additions to international standards for neurological
assessment. Journal of Rehabilitation Research & Development, 44(1), 103-112.
Retrieved from
http://www.rehab.research.va.gov/jour/07/44/1/pdf/Krassioukov.pdf
Pellico, L. H. (2013). Nursing management: Patients with chest and lower
respiratory tract disorders. In Focus on adult health medical-surgical nursing3
(pp. 312-322). China: Wolters Kluwer: Lippincott Williams & Wilkins.
Pimentel, L., & Diegelmann, L. (2010). Evaluation and management of acute
cervical spine trauma. Emergency medicine clinics of north america, 28(4), 719738. doi:10.1016/j.emc.2010.07.003
The Royal Melbourne Hospital. (2013). cervical spine guideline. Retrieved from
http://clinicalguidelines.mh.org.au/brochures/TRM03.01.pdf