SCI Questions & Case Study Key

Questions:

1. Predict what muscle function will be remaining in the following situations. A client with
transection of the cord at:

o C3: No voluntary movement; may have varying degrees of head and neck movement
and sensation. May be independent of mechanical ventilation for short periods only.

o A client with injury at C6: Some shoulder strength, elbow flexion, wrist extension or
dorsiflexion and good control of head and neck; some ability to grasp objects and eat
independently or with minimal assistance.

o A client with transection of the cord at TI0: Full control of upper extremities; some
degree of control/partial balance with use of abdominal and trunk muscles. Manual
wheelchair, independent breathing & eating.

o A client with injury at L2: Full control of upper extremities, abdominal and trunk
muscles; will likely have hip flexion & abduction, knee extension, and ankle
dorsiflexion; ambulation with leg braces/assistance possible. Independent
dressing/eating/elimination.

2. Complete each of the statements below by selecting the appropriate word within the
parentheses.
o Individuals with a spinal cord injury at the level of C4 (will/will not) be able to
breathe without ventilator support.
o Loss of the intercostal muscles interferes with expansion of the (rib cage/diaphragm)
decreasing alveolar ventilation.
o The accessory muscles are innervated from the spinal cord at the level of (C2-8/Tl-7).
o Studies show that continuous turning is (effective/ ineffective) in preventing pooling
of secretions in patients with spinal cord injury.
o Suctioning of the patient with SCI can result in profound (bradycardia/tachycardia)
Case Studies:

1. A 19-year-old patient sustained a spinal cord injury during an automobile accident. He

a. Which patient suffers from an upper motor neuron lesion, and which patient has a lower motor
neuron lesion? List the data that support your conclusion.

The data suggest that the first patient has an upper motor neuron injury as manifested by
spastic paralysis, hyperreflexia, and a spastic bladder. The reflex arc is not disturbed;
therefore reflex activity causes spasticity. The roommate’s lumbosacral injury has lower
motor neuron injury with impaired sacral reflex, which accounts for flaccid paralysis,
areflexia, muscle atrophy and flaccid bladder.

b. What aspects of care will be similar or different for these two patients? What are your nursing
interventions?

The patient with a flaccid bladder will likely require ongoing intermittent
catheterization. Bladder can become distended but pt. will not feel sensation, and
overflow incontinence may occur.

Although the patient with a spastic bladder can stimulate his bladder to empty by using
trigger points, initially he may need occasional catheterization because the bladder may
not empty completely. Can use bladder retraining/use a timed voiding schedule.

Both patients will require teaching about self-catheterization- teach sterile technique.
Both patients should be encouraged to increase their intake of foods and fluids that
increase urine acidity. This helps prevent stone formation. Both need to know how to
prevent and recognize bladder infection and prevent overdistention by regularly emptying
bladder.
2. A young man is being evaluated in the emergency department following a motorcycle
accident. Physical findings include flaccid paralysis and loss of sensation below C6, BP 92/58,
pulse 56, respirations 16 and shallow, and temperature 94° F. His skin is warm/dry, pedal pulses
diminished, bowel sounds absent, incontinent of bowel and bladder shortly after the accident.
Foley output over the past 2 hours equals 60 mL of concentrated urine.
Analyze these assessment findings. Determine which data, if any, support spinal neurogenic
shock. Is there any evidence of hypovolemia? If so, note indicators. Plan nursing interventions.

Spinal Neurogenic Shock: Flaccid paralysis, loss of all sensation below C6, hypothermia,
absent bowel sounds, bowel and bladder incontinence. Each of these clinical
manifestations reflects the loss of all reflex activity below the level of injury and is
referred to as spinal shock. Hypotension and bradycardia represent the loss of vasomotor
tone and interruption of sympathetic pathways referred to neurogenic shock.
Hypovolemia: A relative hypovolemia occurs with spinal shock because of the enlarged
vascular space occurring with loss of sympathetic tone and vasodilation. Fluid pools in
the venous system, which decreases blood return to the heart with a subsequent decrease
in cardiac output. Normally, patients who are hypovolemic will be hypotensive,
tachycardic and cool to touch because of low fluid volume. However, in this case,
because the sympathetic and parasympathetic nervous systems are not communicating,
the hypotension does not stimulate normal cardiac acceleration. Therefore not all
assessment findings will be consistent with typical hypovolemia. Other parameters that
do indicate low fluid volume are the patient’s low urine output and weak peripheral
pulses.

What are the signs that neurogenic shock is resolving? Return of reflexes, development of
hyperreflexia instead of flaccidity, return of ability to empty bladder (depending on level
of injury).
 3. A 28-year-old man is 6 months into a rehabilitation program following a complete
spinal cord injury at C6. The patient has a spastic bladder and has been able to trigger bladder
emptying. During range-of-motion exercises the nurse notes that the leg she is exercising appears
pale and feels cool, and the patient's face is flushed.
Discuss questions the nurse should ask the patient, and identify other assessments the nurse
should complete and describe/act out the interventions. What is happening? Prioritize a plan of
action.

Suspecting autonomic dysreflexia (exaggerated autonomic response to injury) the nurse

A. Immediately elevate the head of the bed and assess blood pressure, since
hypertension is the classic indicator and can be dangerously elevated. Also assess
pulse, since bradycardia is usually present as a result of vasodilation above the
level of injury.
B. Above the level of injury (C6), assess for sweating. Ask about nasal congestion,
headache or blurred vision.
C. Below the level of the injury, assess for cool, mottled skin and piloerection
(goosebumps).
D. Catheterize the bladder immediately even if the patient states he recently voided.
E. If catheterization does not improve the patient’s symptoms (decreased blood
pressure), the nurse should check the patient’s rectum for stool, using Nupercainal
ointment. If stool is present, steps to lower the blood pressure are usually taken
before removing the feces, since this stimulus could worsen the dysreflexia.
F. Notify the physician or use unit protocol to administer an antihypertensive and
monitor vital signs.
G. Other possible causes should be assessed if the above stimuli are not present (e.g.,
skin breakdown, urinary infection, tight-fitting shoes, ingrown toenail).
H. Assess for thrombophlebitis/Pulmonary embolism due to venous stasis (chest
pain, SOB, hypoxia, leg swelling). Check if on anticoagulation/prophylaxis.