Agunod, Wengel M.

BSN – III
Maitim, Princess Anne M. Calamba Group 1
Paner, Alliah Loideen V. NCM 32116L
Parayno, Christine Kaye G.
Redondo, Bless A.

CASE STUDY/ANALYSIS

1. Make a brief discussion in relation to the case presented to include its causes and pathophysiology.

Spinal cord injury occurs when there is any damage to the spinal cord that blocks communication between the brain and the body. After

a spinal cord injury, a person’s sensory, motor and reflex messages are affected and may not be able to get past the damage in the spinal cord.

In general, the higher on the spinal cord the injury occurs, the more dysfunction the person will experience. Injuries are referred to as complete

or incomplete, based on whether any movement and sensation occurs at or below the level of injury.

In the initial medical assessment, the blood pressure of the patient drops reveals hypotension and has the possibility of having neurogenic

shock following acute spinal injury. It is due to disruption of autonomic pathway and loss of the sympathetic tone to the heart. There will be a

widespread vasodilatation with a decrease in systemic vascular resistance due to injury to the descending sympathetic system.

The X-ray reveals unstable C6 Compression Fracture or Axial Loading Injury (Burst Fracture)and thus the patient can’t able to move his

extremities or has a complete quadriplegic and is required to be intubated to manage respiratory function.

The ABG analysis in PH reflects acidosis due to the result which is lesser that the normal value. PaO2 reveals hypoxemia. PaCO2 indicates

Respiratory Acidosis and SPO2 were lesser than the normal value.

The most important and sometimes frustrating thing to know is that each person’s recovery from spinal cord injury is different.
CAUSES:

Traumatic injuries

Motor vehicle accidents Football

Falls Gymnastics
Violence Diving into shallow water
Spinal cord injuries affect more men than women. The majority of people who sustain a spinal cord injury are young adults between the ages of

16 and 30 because of riskier behaviors.

PATHOPHYSIOLOGY:

The pathophysiology of spinal cord injury can be categorized as acute impact or compression. Acute impact injury is a concussion of the

spinal cord. This type of injury initiates a cascade of events focused in the gray matter, and results in hemorrhagic necrosis. The initiating event

is a hypoperfusion of the gray matter. Increases in intracellular calcium and reperfusion injury play key roles in cellular injury, and occur early

after injury. The extent of necrosis is contingent on the amount of initial force of trauma, but also involves concomitant compression, perfusion

pressures and blood flow, and administration of pharmacological agents. Preventing or quelling this cascade of events must involve

mechanisms occurring in the initial stages. Spinal cord compression occurs when a mass impinges on the spinal cord causing increased

parenchymal pressure. The tissue response is gliosis, demyelination, and axonal loss. This occurs in the white matter, whereas gray matter

structures are preserved. Rapid or a critical degree of compression will result in collapse of the venous side of the microvasculature, resulting in

vasogenic edema. Vasogenic edema exacerbates parenchymal pressure, and may lead to rapid progression of disfunction. Treatment of

compression should focus on removal of the offending mass.

2. Discuss the reasons, its implications, all the diagnostic/laboratory tests, and medical management performed to the client.

 The leading reasons or causes of having a spinal cord injury are when the area of the spine or neck is bent or compressed:

o Example given are: road traffic accident, sports related injuries, violence like gunshot or stab wounds, and falls.

 There are many implications that can be associated with spinal cord injury, and it can lead to life threatening or risk in developing

secondary conditions, (e.g. are urinary tract infection, muscle spasms, osteoporosis, chronic pain and even respiratory complications). It

can also lead to paralysis and loss of function depending on what side or part of the body that is affected.

 Patient with spinal cord injury, may experience low in blood pressure, reduced body control of temperature and the inability to sweat

below the injury.

➢ When a patient experiences spinal cord injury, the doctor required to diagnostics test to determine which part of the body is affected.

THE DIAGNOSTIC TESTS:

 X-rays – in this test it can reveal which spinal column tumors, fracture and degenerative changes in spine.

 CT Scan – in this test it scans images that can define bone and disk problems.

 MRI – this test is very helpful in looking for spinal cord because it can identify herniated disks, blood clots and other masses that may be

compressing the spinal cord.

 CT Spine – is a diagnostic imaging test used to determine spinal column damage in injured patients.

 Reflex test – are performed quickly to confirm the integrity of spinal cord to know the location of the spinal cord injury.

 Sensation – it is used to determine the areas where abnormal sensation occurs and the severity and type of sensory impairment and the

extent of the involvement

 CT brain scans – to provide detailed information about the brain tissue and structures related to the injuries of the patient.

Laboratory/Diagnostic Tests
  The patient's laboratory results he has unstable C6 compression fracture or axial loading injury (burst fracture) that found bone

fragments in his C5-6 spinal canal, that means a type of compression fracture related to high-energy axial loading spinal trauma that

results in disruption of the posterior vertebral body cortex with retropulsion into the spinal canal. This typically occur following a fall from

height (often landing on feet) like what happen to patient who hit his head from high falling – where in this case, the patient hit a sand

bank. That can cause the patient unable to move his extremities due to nerve paralysis and no voluntary control of bowel or bladder, but

may be able to manage on their own with special equipment. The patient can speak and use diaphragm, but his breathing will be

weakened; like the said result, he has decreased lung expansion upon inhalation and mild pulmonary edema due to the water he

inhaled. Due to the said situation that the patient hit his head, this caused mild frontal contusion which causes his brain to bleed and

swell.

Blood Gas

 The patient is experiencing acute respiratory acidosis, where his lungs is unable to remove enough carbon dioxide produced by the

body. This is causing the decreased lung expansion upon inhalation and having a pulmonary edema.

Medical Management

 Management of neurogenic shock is not easy. The condition is best managed by an interprofessional team that includes the emergency

department physician, neurosurgeon, orthopedic surgeon, trauma specialist, neurologist, and intensivist. Neurosurgery-specialized

intensive care unit nurses usually monitor these patients. They will restore sympathetic tone of the spinal cord, administer IV fluids to

stabilize the patient’s blood pressure, and traction may be needed to stabilize the spine to bring it to proper alignment. The patient was

intubated to managed his decreased lung expansion and mild pulmonary edema.
Surgery

 The patient underwent surgery of spinal fixation at C4-C8 with spinal decompression, opens the bony canals through which the spinal

cord and nerves pass, creating more space for them to move freely. Surgery may be recommended again if symptoms do not improve

with physical therapy and medications. The patient was experiencing paralysis in his extremities, where he complained that he cannot

feel his arms and legs. He also was experiencing decreased lung expansion as sign of C5-6 injury. This surgery is does not guarantee

the patient will go back to his normal life, he still need some rehabilitation and assistance to improve his condition.
3. 3 Nursing Care Plans

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EXPECTED OUTCOMES

Nursing Interventions Rationale
Subjective Data:
Impaired physical mobility Short Term Goal: Independent:
“I couldn’t move my related to neuromuscular The patient will
After 8 hours of nursing demonstrate
legs.” As verbalized by impairment as evidenced  Assess patient’s  To have a
intervention, the patient
the patient. by flaccid lower motor function baseline data understanding regarding
will be able to
extremities. demonstrate and evaluate techniques that enable
understanding regarding the status of resumption of activity and
Objective Data: techniques that enable patient. the patient will increase
resumption of activity. strength of affected and
 Flaccid lower  Perform and assist  Enhances unaffected body parts.
extremities with full ROM circulation,
exercises on all restores and
 (-) or absent of Long Term Goal: extremities and maintains
muscle stretch joints muscle tone
reflexes in the After rendering and joint
upper and interventions, the patient mobility. This
will be able to increase
lower also prevents
strength of affected and
extremities unaffected body parts. muscle
atrophy.
 Patient couldn’t
raise either arm  Promote safety by  To ensure the
against gravity raising the side patient is
rails. protected and
there will be
no accidents
like falls and
injury.

 Patient is at
 Inspect for
risk for
localized
developing
tenderness or
deep vein
edema.
thrombosis
(DVT).

 Reduce
 Support patient’s
pressure
body parts by
ulcers.
using foot
supports, gel
 pads, etc.

 Plan activities to  Prevents

provide fatigue,
uninterrupted rest allowing
periods. opportunity for
Encourage maximal
involvement within efforts and
individual participation
tolerance and by patient.
ability.

 Encourage use of  Helps the

relaxation client to relax
techniques. and to reduce
muscle
tension.

 Assess if the client  Development

experience of pulmonary
dyspnea. emboli may be
“silent”
because pain
perception is
altered and
DVT is not
readily
recognized.

 Inspect skin daily.  Altered

circulation
may result in
pressure
ulcers.

 Advise the client  To prevent

to do deep risk for
breathing pulmonary
exercises. infection due
to immobility.
 Dependent:

 Administer  Centrally
Tizanidine as acting
ordered. [alpha]2-
adrenergic
agonist
reduces
spasticity.
Short duration
of action
requires
careful dosage
monitoring to
achieve
maximum
effect.

Collaborative:

 Refer to physical  Other

therapist healthcare
professionals
may help
patient by
assisting in
performing
ROM
exercises.

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EXPECTED OUTCOMES

Nursing Interventions Rationale
Subjective Data: Disturbed sensory Short Term Goal: Independent:
perception related to The patient will verbalize
“I don’t feel anything.” After 8 hours of nursing  To assess awareness of sensory
destruction of sensory  Evaluate sensory
intervention, the patient
As verbalized by the tracts as evidenced by awareness such degree of needs. The patient will
will be able to verbalize
client when the loss of sensory across his awareness of sensory as stimulus of hot impairment. also identify behaviours to
paramedics assessed chest. needs and potential for or cold, and dull compensate for deficits.
and touched his chest. deprivation/overload. and sharp.

 Determine  To assess if
response to the response
Long Term Goal:
Objective Data: painful stimuli. to stimulus is
After rendering delayed or
 (-) or absent intervention, the patient immediate.
bilateral will be able to identify
sensation on behaviors to  Provide safety  To prevent
chest compensate for deficits. measures as injury and
needed. complication.
 Reduced
sensation in  Protect from bodily  Patient may
arms harm such as falls, not sense pain
burns, positioning or be aware of
 Cannot localize of arm or objects. body position.
touch or
describe  Assist patient to  May help
texture with any recognize and reduce anxiety
consistency at compensate for of the
the site alterations in unknown and
sensation. prevent injury.

 Explain  To enhance
procedures before patient’s
and during care, perception.
identifying the
body part
involved.

 Provide tactile  Touching

stimulation conveys
caring and
fulfils a normal
physiological
and
psychological
 need.

 Reduces
 Provide sensory
uninterrupted overload.
sleep and rest
periods.
 To assist
 Interpret stimuli client to
and offer separate
feedback. reality from
fantasy.

 To prevent
 Avoid isolation of sensory
client. deprivation
and limit
confusion.

Collaborative:

 Collaborate with  To achieve

other healthcare maximal gains
team members. in function and
psychosocial
well being.

ASSESSMENT NURSING DIAGNOSIS PLANNING IMPLEMENTATION EXPECTED OUTCOMES

Nursing Interventions Rationale
Subjective Data: Ineffective breathing Short Term Goal: Independent:
pattern related to The patient will
“I can’t breathe well.” After 8 hours of nursing  Injuries at C5 demonstrate appropriate
impairment of innervation  note client’s level
intervention, the patient behaviors to support the
As verbalized by the of diaphragm as of injury when can result in
will be able to respiratory effort and will
client evidenced by respiratory demonstrate appropriate assessing variable loss
maintain adequate
rate of 32 with shallow behaviors to support the respiratory of respiratory ventilation as evidenced
breathing. respiratory effort. function. Note function, by absence of respiratory
presence of depending on distress and ABGs within
absence of the phrenic acceptable limits.
Objective Data: spontaneous effort nerve
and quality of involvement
Long Term Goal:
 RR: 32 bpm respiration. and
After rendering diaphragmatic
 Shallow interventions, the patient function but
breathing will be able to maintain generally
adequate ventilation as cause
 PaO2 60 evidenced by absence of decreased
respiratory distress and
mmHg vital capacity
ABGs within acceptable
limits and inspiratory
 HCO# 25.3 effort.
mEq/L
 ausculatte breath  Hypoventilatio
 SPO2 89% sounds. Note n is common
areas of absent or and leads to
 pH 7.27 decreased breath accumulation
sounds or of secretions,
development of atelectasis,
adventitious and
sounds. pneumonia.

 Maintain airway by  Clients with

keeping the head high cervical
in neutral position. injury and
Elevate the head impaired
slightly if tolerated, cough reflex
and use airway needs
adjunct as assistance in
indicated. preventing
aspiration or
maintaining
patent airway.
 Assist client in  Breathing may
taking control of no longer be a
respirations as totally
indicated. Instruct involuntary
and encourage activity but
deep breathing require
focusing attention conscious
on steps of effort,
breathing. depending on
level of
injury/involve
ment of
respiratory
muscles.

 Advise the client  Assist client to

to use slow and deal with the
deep respirations. physiologic
effects of
hypoxia which
may be
manifested as
anxiety and
fear.

 Reposition/turn  Enhances
periodically. ventilation of
Avoid/limit prone all lung
position when segments,
indicated. mobilizes
secretions,
reducing risk
of infection.
Note: prone
position
significantly
decreases
vital capacity,
and increase
risk of resp.
compromise
failure.
4. What are your discharge plans to the client?

DISCHARGE INSTRUCTIONS:

Rehab therapies:

The goal of rehab is to help learn to take care of self as much as possible. A team of healthcare providers will help to teach to function. Ask for

more information on any of the following rehab treatments:

 Skin care helps prevent pressure sores. Specialists will help to teach how to keep skin healthy.

 A physical therapist teaches exercise to help improve movement and strength. Physical therapists help to teach ways to stay active.

They will teach how to use a wheelchair and how to move from a bed to a chair or toilet.

 An occupational therapist teaches skills to help with daily activities, such as getting dressed or bathing. Occupational therapists also

teach work-related skills.

 Bowel and bladder programs help manage when urinating or have a bowel movement.

Moving back into daily life

After discharge, it is common to feel overwhelmed. To help cope during this time:

 Stays involved in care and keep all appointments with healthcare and rehab team. Continue using the skills learned during rehab. When

faced a new task or situation, remember how to manage challenges during initial recovery.

 Take large tasks and break them into smaller, more reasonable goals. As the patient reach each goal, set a new one. In this way, patient

will build the skills needed to face even the biggest challenges.
 Stay positive. Take note of every success, met goal, and step in the right direction, no matter how small. Think of these anytime feeling

discouraged.

 Use the daily self-care skills learned during rehab. These are the tasks needed to do every day to keep body healthy. Follow treatment

care plan, including bowel and bladder care, transfers, and taking medicines.

 Structure the day. This can help make transition from the facility easier. Make schedules for self around the care plan.