CASE STUDY SPINAL CORD INJURY

Spinal Cord Injury

Ben Brown is a 21-year-old college junior who was admitted to the intensive care unit via the emergency
department for evaluation and treatment of a spinal cord injury (SCI) sustained in a diving accident. Consider
the type of fracture most typical from this type of accident. He is accompanied by his fiancée and his parents.

Admission Orders

Admit to ICU
Routine vital signs
Neurologic checks every hour for 24 hours
Bed rest; may logroll side to side
Maintain position of hard cervical collar
NPO status
Foley catheter with dependent drainage
IV dexamethasone (Decadron) 10 mg now and 4 mg q 4 hr
No sedation
Computed tomography (CT) scan of head and neck without contrast agent

Skeletal tongs are applied at the bedside, and cervical traction is instituted.

Nursing Admission Assessment

Mr. Brown is awake, alert, and cooperative. He has no known allergies. He states that he is an engineering
major in college and is planning to be married this spring. His fiancée is an elementary education major. During
the assessment, Mr. Brown makes several jokes and does not talk about or ask about his lack of sensation or
movement below the nipple line. Consider the level of spinal injury that would be reflected by these
manifestations.

Nursing Physical Examination

Height: 6 feet, 2 inches

Weight: 170 lb (77.3 kg)
Vital signs: BP 150/90; TPR 97.6, 90, 22
LOC: Alert and oriented × 3
EENT: PERRLA
Cardiac: Sinus rhythm without ectopic beats; S1 and S2 readily audible without rubs or murmur
Pulmonary: Lung sounds clear bilaterally; diminished from the mid-lung fields to the bases
Abdominal: Abdomen is flat with active bowel sounds in all four quadrants
Genitourinary: Foley catheter in place and draining clear, straw-colored urine
Peripheral pulses: 2/2, without edema noted

The CT scan reveals a compression fracture at C6 with multiple bone fragments in the spinal canal. There is no
evidence of transection of the spinal cord. Consider the alternatives available to Mr. Brown for treatment of this
type of injury. Mr. Brown continues to display lack of sensation and movement below the nipple line.
Yesterday, Mr. Brown pushed his lunch tray on the floor and threw a flower vase at the wall. Mr. Brown's
fiancée left the room in tears and stated, "The wedding is off." Consider the stage of grieving in which these
manifestations might occur.

Mr. Brown is fitted for a halo brace and is scheduled to be transferred to a regional rehabilitation facility at the
end of the week. He states, "Oh, great—I'm being turfed to the freak ward." Consider the possible responses to
this remark that Mr. Brown's nurse could make.

Discharge Criteria and Post-Treatment Considerations

• Average length of stay: 4.6 days in acute care facility followed by rehabilitation stay as dictated by
client's rehabilitation potential
• Client transfer sheet: Include most current assessment, medical treatment plan, previous laboratory
work, and radiology reports
• Community referrals: SCI support group; social services referral for home care or assisted living
arrangements after discharge

ANSWER THE FOLLOWING QUESTIONS

1. This morning Mr. Brown complained of an excruciating headache, and his blood pressure was 210/110 mm
Hg. Identify the etiologic factors that might cause these manifestations and the nursing interventions.

2. Compare and contrast the sensory and motor deficits expected for various levels of spinal cord injury (SCI).
Include C1-2, C4-6, T4-6, L1- 5, and S1-5 in your discussion. Identify the rehabilitation potential and priority
nursing actions for each of these categories.

3. Identify the key nursing actions for clients in skeletal traction for cervical injuries. Compare these nursing
actions with those given after treatment for these injuries.

Answer the following questions and state the rationale for your answer.

1. Because Mr. Brown has been diagnosed with compression fracture at C6, motor or sensory
manifestations he will exhibit include
a. no motor function because the injury is above C7.
b. ability to lift shoulders, elbows, wrists, and some hand function.
c. sensation in the perianal area, calf, heel, and small toes.
d. return of function as edema decreases.
1. Rehabilitation for Mr. Brown begins
a. as soon as he can tolerate exercise and physical therapy.
b. as soon as it is known what rehabilitation he will receive.
c. in preparation for discharge to a rehabilitation facility.
d. on admission to the health care facility.
1. Mr. Brown is to receive Decadron 10 mg IV now and 4 mg every 4 hours. He asks "Why do I need
steroids?" The nurse explains that Decadron is given to
 a. help repair the spinal cord.
b. decrease the edema in the spinal cord.
c. promote reflex action by the nerves.
d. deter muscle wasting.
1. Mr. Brown tells his nurse that he and his fiancée are having "a rough go of it" and he states that "I can't
get married now." Select the most supportive nursing response.
a. Suggest Mr. Brown discuss his sexual capabilities with his physician.
b. Volunteer to talk to Mr. Brown's fiancée about his concerns.
c. Refer Mr. Brown to a sex therapist for counseling.
d. Remind Mr. Brown of the availability of erotica for sexual stimulation.
1. With a C6 injury, Mr. Brown can expect to achieve functional goal(s) of
a. dressing his upper trunk and self-catheterization.
b. no trunk control but transfer to and from tub.
c. self-feeding and total dressing independence.
d. limited ambulation with bilateral braces.
1. During the acute period, pressure ulcer development is significantly associated with
a. immobilization for a number of hours.
b. poor nutrition and lack of appetite.
c. inability to perceive pain.
d. improper positioning.
1. Improvement in quality of life for Mr. Brown following his spinal cord injury should include discussion
of
a. relationships, finances, job, and productivity.
b. pain management, medications, and spiritual distress.
c. importance of gaining control of injury and assertiveness.
d. vocational training, diversional activity, and sexuality.
1. The most important principle in caring for a client in traction is
a. preventing constipation.
b. avoiding social isolation.
c. maintaining skin integrity.
d. maintaining proper body alignment.
With the following nursing diagnosis state your nursing interventions & state your respective rationale
for Mr. Brown. What are you Outcomes of nursing care?

Nursing Diagnoses:

1. Impaired Physical Mobility related to neuromuscular impairment resulting in inability to walk.

2. Risk for Disuse Syndrome related to paralysis.
3. Risk for Infection related to chronic disease, surgical wounds, and stasis of body fluids.
4. Sexual Dysfunction related to altered body function and knowledge deficit resulting in alteration in
perceived sexual role.