Pathophysiology Normal Spinal Cord

Spinal cord begins at the foramen magnum in the cranium

Cord ends at the L1L2 vertebra level Spinal nerves continue to the last sacral vertebra The Human Spine

Spinal Cord
Gray matter- cell

bodies of voluntary and autonomic motor neurons

White matter

axons of ascending and descending motor fibers

Normal Spinal Cord

White tracts send

messages to and from the brain Ascending Tracts carry into higher levels

of CNS touch, deep pressure,vibration, position, temperature

Descending Tracts impulses for voluntary muscle movement

PyramidalVoluntary movements Posterior column (Dorsal)- touch, proprioception, and vibration sense Lateral spinothalamic tract- pain and temperature sensation (only tract that crosses within the cord) voluntary movement

Upper Motor Neurons UMN Originate in cerebral cortex Project downward Result in skeletal muscle movement Injury = SPASTIC paralysis Lower Motor Neurons LMN Originate at each vertebral level Project to specific parts of the body Result in movement /sensation Injury = FLACCID paralysis

Normal Spinal Cord

Reflex Arc
Involuntary response to a

stimulus
Where sensory and motor

nerves arise from cord Sensory fibers enter posterior Synapse in the grey matter Motor fibers leave anterior Once outside cord join form spinal nerve

reflex movement

Normal Spinal Cord

Dermatones
Skin innervated by sensory

spinal nerves Myotome- muscle group innervated by motor neurons

Nervous System and the Spinal Cord

ANS can be affected by

SCI Sympathetic chains on both sides of the spinal column (T1-L2) Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4)

Spinal Cord Protection

Bones- vertebral column 7 Cervical 12 Thoracic 5- Lumbar 5- Sacral Discsbetween vertebra

Spinal Cord Protection

Internal and external

ligaments Dura Meninges CSF in subarachnoid space allow for movement within spinal canal

Etiology of Traumatic SCI

MVA- most common cause
Other: falls, violence, sport injuries SCI typically occurs from indirect injury from vertebral

bones compressing cord SCI frequently occur with head injuries Cord injury may be caused by direct trauma from knives, bullets, etc

Etiology of Traumatic SCI

78% people with SCI are male
Typically young men 16-30 Number of older adults rising (>61 yr) Greater complications Life Expectancy 5 years less than same age without

injury 90% go home

Spinal Cord Injury- SCI

Compression
Interruption of blood supply Traction Penetrating Trauma

Spinal Cord Injury

Primary
Initial mechanism of injury

Secondary
Ongoing progressive damage

Ischemia Hypoxia Microhemorrhage Edema

Spinal Cord Injury

Hemorrhage and edema occur in the cord post injury,

causing more damage to cord

Extension of the cord injury from cord edema can

occur over the first few days

watch the phrenic nerve!

Initially SCI experience spinal shock depression of all cord & ANS function below injury. Lasts from few min to wks

Spinal and Neurogenic Shock

Spinal Shock Decreased reflexes and loss of sensation below the level of injury Motor loss- flaccid paralysis below level injury Sensory loss- loss touch, pressure, temperature pain and proprioception perception below injury
Lasts days to months

Spinal and Neurogenic Shock

Neurogenic shock Due to loss of vasomotor tone SNS loss results in parasympathetic dominance with vasomotor failure Loss of SNS innervation causes peripheral pooling and decreased cardiac output Hypotension and Bradycardia Orthostatic hypotension and poor temperature control (poikilothermic)

How do you know spinal shock is over?

Clonus is one of the first signs Hyperreflexia of foot Test by flexing leg at knee &

quickly dorsiflex the foot Rhythmic oscillations of foot against hand clonus

Classifications of SCI
Mechanism of Injury
Skeletal and Neurologic Level Completeness (degree) of Injury

Mechanism of Injury Flexion Hyperextension Compression Flexion /Rotation

Classifications of SCI Mechanism of Injury

Flexion (hyperflexion)
Most common because of

natural protection position. Generally cause neck to be unstable because stretching of ligaments

Classifications of SCI Mechanism of Injury

Hyperextention
Caused by chin hitting a

surface area, such as dashboard or bathtub Usually causes central cord syndrome symptoms

Classifications of SCI Mechanism of Injury

Compression
Caused by force from above,

as hit on head Or from below as landing on butt Usually affects the lumbar region

Classifications of SCI Mechanism of Injury

Flexion/Roatation
Most unstable Results in tearing of

ligamentous structures that normally stabilize the spine Usually results in serious neurologic deficits

 Skeletal level Vertebral level where the most damage to the bones Neurologic level The lowest segment of the spinal cord with normal sensory and motor function on both sides of the body Levels of Function in Spinal Cord Injury

Classification of SCILevel of Injury

Spinal cord level
When referring to spinal

cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level. sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone

the thoracic, lumbar &

Classifications of SCI Completeness (Degree) of Injury

Complete Incomplete Central cord syndrome Anterior Cord syndrome Brown-Sequard Syndrome Posterior Cord Syndrome Cauda Equina and Conus Medullaris

Classification of SCI Completeness (degree) of Injury

Complete (transection)
After spinal shock: Motor deficits spastic paralysis below

level of injury Sensory loss of all sensation perception Autonomic deficitsvasomotor failure and spastic bladder

Classification of SCI Completeness (degree) of Injury

Incomplete Central Cord Syndrome
Injury to the center of the

cord by edema and hemorrhage

Motor weakness and

sensory loss in all extremities Upper extremities affected more

Classification of SCI Completeness (degree) of Injury

Incomplete Brown-Squard Syndrome
Hemisection of cord Ipsilateral paralysis Ipsilateral superficial

sensation, vibration and proprioception loss Contralateral loss of pain and temperature perception

Classification of SCI Completeness (degree) of Injury

incomplete
Anterior Cord Syndrome Injury to anterior cord Loss of voluntary motor,

pain and temperature perception below injury Retains posterior column function (sensations of touch, position, vibration, motion)

Classification of SCI Completeness (degree) of Injury

incomplete
Posterior Cord Syndrome

Least frequent syndrome

Injury to the posterior

(dorsal) columns Loss of proprioception Pain, temperature, sensation and motor function below the level of the lesion remain intact

Classification of SCI Completeness (degree) of Injury

incomplete
Conus Medullaris
Injury to the sacral cord

(conus) and lumbar nerve roots Cauda Equina Injury to the lumbosacral nerve roots Result- areflexic (flaccid)bladder and bowel, flaccid lower limbs

Clinical Manifestations of SCI

Skin: pressure ulcers
Neuro: pain sensory loss upper/lower motor deficits autonomic dysreflexia

Cardio: dysrhythmias spinal shock loss of SNS control over blood vessels orthostatic hypotension, poikilothermic

 Respiratory decrease chest expansion, cough reflex & vital capacity diaphragm functionphrenic nerve GI stress ulcers paralytic ileus bowel- impaction & incontinence

GU upper/lower motor bladder Impotence sexual dysfunction Musculoskeletal joint contractures bone demineralization osteoporosis muscle spasms muscle atrophy pathologic fractures para/tetraplegia

Common Manifestation/Complications
Upper and Lower Motor Deficits
Upper motor deficits result in

spastic paralysis
Lower motor deficits result in

flaccid paralysis and muscle atrophy

Common Manifestations/Complications
Spinal cord injuries are described by the level of the injury the cord

segment or dermatome level Such as C6; L4 spinal cord injury

Terms used to describe motor deficits
Prefix:

para- meaning two extremities tetra- or quadra- all four extremities Suffix : -paresis meaning weakness -plegia meaning paralysis

Quadraparesis means what?

Common Manifestations/Complications
C1-3 usually fatal Loss of phrenic innervation

ventilator dependent No B/B control Spastic paralysis Electric w/c with chin/mouth control

Common Manifestations/Complications
C6- weak grasp Has shoulder/biceps to

transfer & push w/c No bowel/bladder control.

Considered level of

independence

Common Manifestations/Complications
T1-6- full use of upper

extremity Transfer Drive car with hand controls and do ADLs No bowel/bladder control

Immediate Care
Emergency Care at Scene, ER & ICU
Transport with cervical collar Assess ABCs; O2;

tracheotomy/vent IV for life line NG to suction Foley

Diagnostic Studies for SCI

X-ray of spinal column CT/MRI Blood gases

Therapeutic Interventions
Medications

IV methylprednisolone (Solu-Medrol) within 8 hrs to decrease cord edema

Therapeutic Interventions
Medications
To control or to prevent complications of SCI and immobility:
Vasopressors to maintain perfusion Histamine H2 blockers to prevent stress ulcers Anticoagulants Stool softeners Antispasmodics

Therapeutic Interventions
Stabilization/ Immobilization TractionGardner-wells tongs Halo Casts Splints Collars Braces

Therapeutic Interventions
Surgery for SCI

Manipulation to correct dislocation or to unlock vertebrae Decompression laminectomy Spinal fusion Wiring or rods to hold vertebrae together

Nursing Management Assessment

HEALTH HISTOY
Description of how and when injury occurred Other illnesses or disease processes

Ability to move, breathe, and associated injury such as a head injury, fractures

Nursing Management Assessment

PHYSICAL EXAM
LOC and pupils- may have indirect SCI from head injury Respiratory status- phrenic nerve (diaphragm) and intercostals; lung sounds Vital signs Motor Sensory Bowel and bladder function

Nursing Management Assessment

Motor Assessment Upper Extremity

Movement, strength and

symmetry
Hand grips

Flex and extend arm at

elbow- with and without resistance

Nursing Management Assessment

Motor Assessment Lower Extremity

Flex and extend leg at

knee with and without resistance Planter and dorsi flexion of foot Assess for Clonus

Nursing Management Assessment

Sensory assessment
With the sharp and dull ends

of a paperclip have the individual, with their eyes closed identify

Use the dermatome as

reference to identify level

C6 thumb; T4 nipple; T10

naval

Nursing Problems/Interventions
1.Impaired mobility 2.Impaired gas exchange 3. Impaired skin integrity 4. Constipation 5. Impaired urinary elimination 6. Risk for autonomic dysreflexia 7. Ineffective coping

1. Impaired Physical Mobility

Log roll as a single unit; provide assistance as needed

to keep alignment; teach patient Care traction, collars, splints, braces, assistive devices for ADLs Flaccid paralysis- use high top tennis shoes or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)

1. Impaired Physical Mobility

Spastic Paralysis
Prevent spasms by avoiding; sudden movements or

jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigue Treat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmodic medications

Assess skin break down thrombophlebitis; remove TED hose at least every shift

1. Impaired Physical Mobility

Prevent/treat orthostatic hypotension
Abdominal binder, calf compressors, TED hose when

individual gets up Assess BP, especially when rising

Teach use of transfer board

Assist Physical Therapy with tilt table as individual

gradually gets use to being in an upright position

2. Impaired Gas Exchange

Phrenic nerve (C3-5) controls the diaphragm

bilaterally. If nerve is nonfunctioning then individual is ventilator dependent. Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing

2. Impaired Gas Exchange

Respiratory rate, rhythm, depth,

breath sounds, respiratory effort, ABGs, O2 saturation

Signs of impending extension of

SCI up cord to phrenic nerve level (C3-5) Need for ventilatory assistance tracheotomy, ventilator
Quad cough (assistive cough) as

needed

3. Impaired Skin Integrity

Change position frequently Protection from extremes in temperature Inspect skin at least 2x/day especially over boney

prominences Avoid shearing and friction to soft tissue with transfers Removal of TED hose every 8 hours Nutritional status

4. Constipation
Bowels rely more on bulk than on nerves Stimulate bowels at the same time each day. Best after

a meal when normal peristalsis occurs Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation Assess bowel sounds prior to giving food for the first time paralytic ileus!

5. Impaired Urinary Elimination

Flaccid bladder (lower motor neuron lesion)

No reflex from S2,3,4 Automatic empting of bladder Urine fills the bladder and dribbles out Need Foley or freq intermittent self catheterization
Spastic bladder (upper motor neuron lesion) Reflex arc but no connection to or from brain Reflex fires at will Bladder training- trigger points to stimulate empting; self catheterization

5. Impaired Urinary Elimination

Use bladder scan to see amount of urine in bladder
Goal- residual <100ml/20% bladder capacity Some individuals may need suprapubic catheter

Assess effectiveness of medication

Urecholine to stimulate bladder contraction Urinary antiseptic

6. Risk for Autonomic Dysreflexia

SCI above T6
Results in loss of normal compensatory mechanisms

when sympathetic nervous system is stimulated Life threatening- if goes unchecked BP can result in cerebral hemorrhage
Vasodilatation symptoms above SCI

Vasoconstriction symptoms below SCI

The cause of SNS stimulation

6. Risk for Autonomic Dysreflexia

Elevate head of bed- causes orthostatic hypotension Identify cause/alleviate- if full bladder- cath; if skin-

remove pressure, if full bowel- empty, etc Remove support hose/abdominal binder Monitor blood pressure- can get > 300 S Give PRN medication to lower BP If above not effective call physician

7. Ineffective Coping/ Grief and Depression

Assess thoughts on quality of life; body image; role

changes Physical and psychological support Most common SCI is 15-30 yeas old and generally a risk taker this greatly affects their perception of life and rehabilitation

7. Ineffective Coping/sexuality
Male
UMN lesion reflexogenic (S2,3,4) erections LMN lesion psychogenic erections (psychological stimulation)

Female
hormones more than nerves

regarding fertility. C-section because of chance for autonomic dysreflexia during labor. Lack of sensation/movement affects sexual performance

Ejaculation/fertility may be

affected

7. Ineffective Coping/sexuality
Assess readiness/knowledge/your ability
Use proper terminology Suggestions: empty bladder before sex withhold fluids and antispasmodics certain positions may increase spasms explore new erogenous zones penile implants Refer to specially trained counselor

Home Care
Assess psychological, physiological resources
need for rehabilitation (in-house or out patient) need for community resources Home assessment

Whats new in SCI treatment?

Superman breather YouTube - Superman breather USA

Kevin Everett hypothermia treatment for SCI Standing Tall Travis Roy- 11 Seconds
Stem Cell treatment for SCI Lipitor for SCI

 Case study- Jim Valdez 1. Why does Jim have flaccid paralysis on admission to

ICU? 2. What symptoms indicate that he is in spinal shock? What was done about these symptoms? 3. How will we know when he is out of spinal shock? 4. How does progressive mobilization assist with orthostatic hypotension? What else can be done? 5. What are realistic functional goals for Jim?

Spinal Cord Anatomy

Function of disc is to allow

for mobility of the spine and act as shock absorber spinal cord anatomy

Pathophysiology/Etiology
Located between vertebral bodies Composed of nucleus pulposus a gelatinous

material surrounded by annulus fibrosis- a fibrous coil Spinal nerves come out between vertebra

Herniated Disc
Herniated nucleus pulposus, (HNP) slipped disc,

ruptured disc HNP- annulus becomes weakened/torn and the nucleus pulposus herniates through it. Risk Factors Standing erect Aging changes Poor body mechanics Overweight Trauma

Common Manifestations/Complications
HNP compresses
Spinal nerve (sensory or

motor component) as it leaves the spinal cord Or the cord itself- the white tracts within the cord- rare

Common Manifestations/Complications
Sensory root or nerve usually affected
pain, parenthesis, or loss of sensation

Motor root or nerve may be affected

paresis or paralysis

Manifestations
depend on what nerve root, spinal nerve is being

compressed which dermatomes Radiculopathy pathology of the nerve root

Common Manifestations/Complications Lumbar HNP

Most common site for HNP
L4-5 disc- the 5th lumbar nerve root

posterior sensory nerve or root compressed

Classic symptoms low back sciatica pain pain increases with increase in intrathoracic pressure

herniated disc L4-L5

Other Symptoms Lumbar HNP:

Postural changes
Urinary/male sexual function changes Paresis or paralysis

Foot drop
Paresthesias Numbness

Muscle spasms
Absent cord reflexes

Common Manifestations/Complications Cervical HNP

C5-C6 disc- affects the 6th cervical nerve root
Pain- neck, shoulder, anterior upper arm to thumb

Absent/diminished reflexes to the arm

Motor changes- paresis or paralysis Sensory- paresthesias or pain

Muscle spasms

Therapeutic Interventions- Diagnostic Tests

X-ray
identify deformities

and narrowing of disk space CT/MRI Mylogram p1336 Nerve conduction studies (EMG) detect electrical activity of skeletal muscles

Treatment- Conservative
Bed rest with firm mattress
log roll side lying position with knees bent and pillow between

legs to support legs Avoid flexion of the spine brace/corset, cervical collar to provide support Medications non-narcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers

Treatment- Conservative
Heat/cold therapy to decrease muscle spasms Break the pain-spasm-pain cycle Ultrasound, massage, relaxation techniques Progressive mobilization with approved exercise program includes abdominal/thigh strengthening Teaching good body mechanics Weight loss TENS unit

Treatment- Surgery
Laminectomy removal of a portion of the lamina to relieve

pressure and to get to the herniated nucleus pulposus that is protruding out herniated disc repair Foraminotomy
Enlargement of the bony overgrowth at the opening

which is compressing the nerve

Treatment- Surgery
Microdiskectomy
Use of electron microscope through a small incision to

remove a portion of the HNP that is displaced

If cervical HNP, usually use the anterior approach in

the neck
anterior cervical fusion

Treatment- Surgery
Spinal fusion
removes most of the disc and replaces it with bone

usually from the patient iliac crest Fusion also with rods, pins, synthetic protein Flexibility is lost at the site- requires longer hospital stay

spinal fusion Artificial Disc Combination of metal and plastic Attached to vertebrae above and below

Prevention of HNP
Back school approach Causes of HNP Learn how to prevent Good body mechanics Exercises to strengthen leg and abdominal muscles

Change in life-style or occupation

Nursing Assessment Specific to HNP Health History

Assess for risk factors The cumulative effect of standing erect and daily stress Aging changes in disc/ligaments Poor body mechanics Overweight

Trauma
Employment History of pain and other neuro changes

Nursing Assessment Specific to HNP Physical Exam

Use similar methods to assess as utilized SCI
Muscle strength and coordination

Sensation
sharp/dull of paperclip using dermatome as reference

Pain evaluation- pain scale

Pre/Post-op assessment

Post-Op Assessment for HNP

Sensory/motor assessment- care not to injure op site Assess for CSF drainage or bleeding from op site Encourage turn (log roll, cough, deep breath) Assess for postural hypotension
especially if client was on bed rest for several days/weeks

prior to surgery

Post-op Assessment for HNP

If Anterior Cervical Assess injury to the carotid, esophagus, trachea,

laryngeal nerve (speech- hoarseness) Assess respiration, neck size, swallowing and speech

If Post-Op Lumbar Assess bowels sounds, voiding. Minimize stress of post-op site- flat with pillow between

knees, log roll, etc

Nursing Problems/Interventions 1. Acute Pain

Post surgery the individual may have similar pain as pre-op due to lack of resiliency of the spinal nerves to bounce back quickly Donor site (illiac crest) may cause more pain than laminectomy Individual may be in a pain-spasm-pain cycle, therefore may need both antispasmodic as well as analgesic

2. Chronic Pain
Surgery may not relieve pain
Nonpharmalogical methods

to control pain
Pain clinic

3. Constipation
As a result of bed rest and decreased mobility and fear of pain with straining of stool
Constipation prevention methods fluids, diet, etc

4. Home Care
When riding in a car, take frequent stops to move and stretch
Prevention Back school approach May have to deal with pain as a chronic condition May need to make life/job changes

Spinal Cord Tumors

CNS is made up of neural

tissue and support tissue

These tissues undergo

changes and result in spinal cord tumors

Blood vessels and bone

also can be part of the tumor

Intramedullary- arise from neural tissues of the spinal cord Extramedullary- arise from tissues outside the spinal cord may be benign or malignant Intradural-from the nerve roots or meninges in subarachnoid space Extradural- from the epidural tissue or vertebra

Classification by origin
Primary- originating in the

spinal cord or meninges

Secondary- metastases from

other parts of the body Most spinal cord tumors are found in the thoracic region
Spinal cord tumors can

compress (benign), invade the neural tissue, or cause ischemia to the area because of vascular obstruction

Common Manifestations/Complications
Symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected
Pain that is not relieved by bed rest is the most common presenting symptom Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor

Common Manifestations/Complications
Manifestations of thoracic cord tumor
Paresis & spasticity of one leg then the other Pain back & chest, not relieved by bedrest

Sensory changes
Babinski reflex Bowel (ileus); bladder dysfunction (UMN in

type)

Therapeutic Interventions
Diagnostic tests include:
X-ray of the spinal column Myelogram

Lumbar puncture with CSF analysis

Therapeutic Interventions
Medications spinal tumors
Control pain- narcotic analgesics, epidural

catheter, PCA, NSAIDs

Reduce cord edema and tumor size

Steroids- high dose Dexamethasone

Therapeutic Interventions
Surgery for spinal cord tumors
Laminectomy to remove or to decrease the size

(decompression laminectomy) of the spinal cord tumor Spinal fusion or the insertion of rods if several vertebra involved and the column is unstable
Radiation to reduce size and control pain

Nursing Assessment
Health history Pain, motor and sensory changes, bowel and bladder changes, Babinski reflex.
Physical exam Similar to physical assessment for HNP

Nursing Problems/Interventions
1. Anxiety
Metatastic tumor vs benign spinal cord tumor Education and support system

2. Risk for constipation

From spinal cord compression, narcotics, bed rest Adjust fluid and diet

Nursing Problems/Interventions
3. Impaired physical mobility
From bed rest and motor involvement Basic nursing- ROM, etc

4. Acute pain
From compression or invasion of tumor Assess and treat

5. Sexual dysfunction
Male sacral reflex arc (S 2,3,4) interference Similar care as discussed with SCI

Nursing Problems/Interventions
6. Urinary retention
Reflex arc (S2,3,4) interference can cause neurogenic

bladder as discussed with SCI

7. Home care
Rehabilitation Home evaluation

Support groups
case study

 A 30-year-old was admitted to the progressive care unit

with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?
Bladder distension
Neurological deficit Pulse ox readings

The clients feelings about the injury

 While in the ER, a client with C8 tetraplegia develops a

blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?
Autonomic dysreflexia
Hemorrhagic shock Neurogenic shock

Pulmonary embolism

 A 22-year-old client with quadriplegia is apprehensive

and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
Place the client flat in bed Assess patency of the indwelling urinary catheter

Give one SL nitroglycerin tablet

Raise the head of the bed immediately to 90 degrees

 The nurse is caring for an elderly client diagnosed with a

herniated nucleus pulposus of L4-L5. Which scientific rationale explains the incidence of a ruptured disc in the elderly?
The client did not use good body mechanics when lifting an

object. There is an increased blood supply to the back as the body ages. Older clients develop atherosclerotic joint disease as a result of fat deposits. Clients develop intervertebral disc degeneration as they age.

 A client is admitted with a spinal cord injury at the

level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?
Acetazolamide (Diamox)
Furosemide (Lasix) Methylprednisolone (Solu-Medrol) Sodium bicarbonate

 A client with a cervical spine injury has Gardner-Wells

tongs inserted for which of the following reasons?

To hasten wound healing To immobilize the surgical spine To prevent autonomic dysreflexia To hold bony fragments of the skull together

 Which of the following interventions describes an

appropriate bladder program for a client in rehabilitation for spinal cord injury?
Insert an indwelling urinary catheter to straight

drainage Schedule intermittent catherization every 2 to 4 hours Perform a straight catherization every 8 hours while awake Perform Credes maneuver to the lower abdomen before the client voids.

 A client has a cervical spine injury at the level of C5.

Which of the following conditions would the nurse anticipate during the acute phase?
Absent corneal reflex
Decerebate posturing Movement of only the right or left half of the body

The need for mechanical ventilation

 The nurse is evaluating neurological signs of the male

client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
Positive reflexes Hyperreflexia

Inability to elicit a Babinskis reflex

Reflex emptying of the bladder

 Your T1 spinal cord injured patient complains of a

headache. You should

Give him prn Tylenol Disimpact his bowels Call the doctor Take his blood pressure

 What can the nurse do to best speed the patients

recovery from a laminectomy of L5?

Keep patient flat in bed Teach the back school approach Medicate for pain q2 hours Ambulate as soon as orders permit

 Your patient has a malignant metastatic lesion at T8

and is in for palliative radiation. What is your main goal with this patient?
Teach patient self catheterization
Ensure patient receives pain medication as needed Encourage patient to discuss fears

Ambulate twice a shift