Caring for patients with injuries Learn how to help stabilize patients and prevent complications of these devastating injuries.

(SCIs) are tinence, or retention SPINAL CORD INJURIES By Mark Bauman, MS, RN, CCRN, and a significant cause of disability, with Tammy Russo-McCourt, BSN, RN, CCRN • difficulty with balance and walking profound—and in many cases dev - • impaired breathing astating—consequences. According • abnormal bandlike sensations in to recent data, about 12,000 SCIs subluxation and hyperflexion or ex - the thorax, with pain and pressure occur annually in the United States, tension injury. • unusual lumps on the head or and up to 250,000 Americans are With an incomplete SCI, patients spine. living with SCIs. Most victims are retain some level of sensory func - SCI may be ruled out by check - aged 16 to 30; more than 80% are tion, motor function, or both below ing for criteria from the National males. In both genders, motor vehi - the injury level. They may be able Emergency X-Radiography Utiliza - cle accidents, falls, and gunshot to move one arm or leg more than tion Study. (See NEXUS criteria to wounds account for most SCIs; in the other or may have greater motor exclude SCI .) persons aged 65 and older, falls are or sensory function on one side of Patients with a suspected SCI the leading cause. The Centers for the body. Incomplete SCIs fall into must undergo a thorough examina - Disease Control and Prevention esti - several categories. (See Types of in - tion using a validated assessment mates that SCI-related medical costs complete SCIs . tool, such as the International Stan - amount to about $9.7 billion each dards for Neurological Classification year. (See Serious and deadly com - Clinical evaluation of from the plications of SCI .) Signs and symptoms of SCI include: American Spinal Injury Association Most SCIs result from direct trau - • extreme pain or pressure in the (ASIA) examination. This tool pro - ma to the vertebral column, affect - neck, head, or back motes appropriate evaluation of ing the spinal cord’s ability to send • tingling or sensation loss in the motor and sensory function and and receive messages to and from hands, fingers, feet, or toes classifies the degree of impairment the brain. The disruption impairs • partial or complete loss of con - as complete (type A) or incomplete the systems that control sensory, trol over any body part (types B through E). To learn motor, and autonomic functions be - • urinary or bowel urgency, incon - more about ASIA and access its re - low the injury level. sources, visit asia-spinalinjury.org This article differentiates the and elearnsci.org . types of SCIs and describes clinical CNE and diagnostic evaluation, treat - 1.55 contact Radiologic evaluation ment, and nursing care for patients hours Best practices for SCI evaluation in - with SCIs. It assumes readers have a clude use of computerized tomogra - LEARNING OBJECTIVES basic understanding of spinal cord phy (CT) when available. The anatomy and physiology. 1. Differentiate the types of spinal American Association of Neurologi - cord injuries (SCIs). cal Surgeons/Congress of Neurologi - 2. Describe the evaluation of pa - Types of SCIs tients with SCIs. cal Surgeons 2013 Joint Guidelines A complete SCI causes total loss of 3. Discuss treatment of patients with for the Management of Acute Cervi - all motor and sensory function be - SCIs. cal Spine and Spinal Cord Injury low the injury level, including the recommend traditional X-rays only The authors and planners of this CNE activity have lowest sacral segments. Complete disclosed no relevant financial relationships with if high-quality CT isn’t available. For cord transection is rare. Function any commercial companies pertaining to this patients with known or suspected activity. See the last page of the article to learn loss usually stems from a contusion how to earn CNE credit. SCIs, magnetic resonance imaging or compromised blood flow to the Expiration: 5/1/19 helps visualizes the spinal cord and injured part of the cord, as from detects ligamentous injury, blood

American Nurse Today Volume 11, Number 5 www.AmericanNurseToday.com 18 clots, and herniated discs or other Serious and deadly complications of SCI masses that may be compressing Patients with —a neurologically complete cervical spinal cord injury the cord. Providers should follow (SCI)—are at lifelong high risk for secondary medical complications. Pressure ul - their facility’s spinal-clearance proto - cers are the most common complications. In the first year after injury, 15% of cols for SCI detection. tetraplegic patients develop them; incidence rises steadily thereafter. The most common ulcer location is the sacrum. Other complications of tetraplegia include Treatment pneumonia and deep vein thrombosis. Treatment begins even before the Several factors influence mortality in patients with SCI. Perhaps the most sig - patient is admitted. Paramedics or nificant is severity of associated injuries. Due to the force needed to fracture the other emergency medical services spine, significant damage to the chest or abdomen may accompany SCIs, with po - tentially fatal consequences. In general, younger patients and those with incom - personnel carefully immobilize the plete SCIs have a better prognosis than older patients and those with tetraplegia. spine at the scene. In the emer - Respiratory diseases are the leading cause of death in SCI patients, with pneu - gency department (ED), immobiliza - monia accounting for 71% of these deaths. The second and third leading causes tion continues while the healthcare are heart disease and infections, respectively. The cumulative 20-year survival rate team identifies and addresses more for SCI patients is 70.6%, but given underreporting and cases lost in follow-up, immediate life-threatening problems. the actual death rate is probably higher. If the patient needs emergency sur - gery for trauma to the abdomen, chest, or other area, immobilization cluding reflexes, deep tendon func - respiratory muscles. and alignment must be maintained tion, and rectal tone. Be sure to es - Closely monitor the patient’s res - during the operation. tablish baseline findings and per - piratory rate, depth, and pattern, For many CSI patients, traction form serial assessments—usually staying alert for paradoxical breath - may be indicated to help bring the hourly or more often during the ini - ing. Also monitor breath sounds, spine into proper alignment and re - tial injury phase and less often as cough strength and effectiveness, store blood flow to the injured area. the injury stabilizes. Conduct addi - gas exchange adequacy, and arterial Occasionally, a surgeon may take tional assessments and document blood gas (ABG) results. Maintain the patient to the operating room findings each time the patient has continuous pulse oximetry; when immediately if the cord appears to been moved out of bed (for in - possible, use end-tidal capnography be compressed by a herniated disc, stance, for diagnostic tests) or if you as part of routine monitoring. blood clot, or other lesion. This suspect deterioration. Help the patient use incentive most often happens with an incom - Establishing a baseline helps spirometry to monitor inspiratory plete SCI or progressive neurologic caregivers promptly detect improve - lung volumes. Vital capacity below deterioration. Even if surgery can’t ment or deterioration. Assessment 1 L suggests decreased inspiratory reverse spinal cord damage, it may should be interprofessional, involv - muscle strength, which may result be needed to stabilize the spine to ing the provider, nurse, and physi - in atelectasis and, over time, respi - prevent future pain or deformity. cal therapist. ratory fatigue and failure. A weak or Always logroll the patient to ineffective cough may lead to re - Nursing care check for rectal tone as well as tained secretions and subsequent Nursing care can prevent or mitigate when repositioning, toileting, and pneumonia. further injury and promote the best performing skin care or chest phys - As indicated and ordered, provide possible patient outcome. Focus iotherapy (CPT). (See Quick guide adjunctive treatments, including CPT your care on: to nursing care for SCI patients .) and postural drainage, suctioning, • maintaining stable blood pressure bronchoscopy, intrapulmonary per - (BP) Respiratory management cussive ventilation (IPV) with aero- • monitoring cardiovascular func - Respiratory impairment is the most solized mucolytics and bronchodila - tion common complication of acute SCI. tors, and mechanical cough assist to • ensuring adequate ventilation The extent of impairment depends help mobilize and clear secretions. and lung function on injury level and severity. Take all An abdominal binder placed below • preventing and promptly ad - possible measures to protect the pa - the costal margin to support the vis - dressing infection and other com - tient’s airway and maintain ade - cera can aid breathing by bringing plications. quate respiration. High thoracic to the diaphragm into a better resting Use serial SCI assessments with a cervical SCIs put the patient at risk position. consistent grading tool to monitor for respiratory insufficiency. Lower Intubation. Patients with respira - and communicate motor and senso - spinal injuries have minimal conse - tory failure require mechanical ven - ry improvement or deterioration, in - quences for motor function of the tilation. If your patient needs intu -

www.AmericanNurseToday.com May 2016 American Nurse Today 19 Types of incomplete SCIs above) may develop neurogenic An incomplete spinal cord injury (SCI) leaves the patient with some motor or sen - shock. Caused by loss of sympathet - sory function below the injury level. Most incomplete SCIs fall into the following ic tone, this distributive shock state categories. results in vasodilation, profound bradycardia, and hypothermia. Hy - Anterior cord syndrome: The most common incomplete SCI, anterior cord syn - potension, temperature dysregula - drome usually stems from impact trauma with compression tion, venous stasis, and autonomic and ischemia to the motor and sensory pathways in the ante - rior parts of the cord. Although patients may feel gross sensa - dysregulation (AD) may occur. tion via intact pathways in the posterior part of the cord, they Hypotension. Hypotension predis - lose movement and fine sensation. poses the acute SCI patient to a sec - ondary injury from reduced blood Brown-Sequard syndrome: This rare disorder results from injury to one side of flow and poor spinal cord perfusion, the spinal cord, usually by direct insult to the spine, such as a possibly worsening neurologic out - penetrating injury. The defining characteristic is loss of pain come. Be sure to maintain continu - and temperature sensation on the side opposite the injury, ous heart rate and BP monitoring. because these pathways cross to the opposite side shortly af - Expect to manage hypotension ter entering the spinal cord. The patient loses movement and with volume resuscitation and vaso - some types of sensation below the injury level on the injured side. pressor therapy. The goal of therapy : This progressive neurologic syndrome results from in - is to sustain a mean arterial pressure jury to the cauda equina, a bundle of nerve roots arising from (MAP) of 85 mm Hg or higher for 7 the end of the spinal cord. It’s marked by lumbar pain, weak - days (an approach called hemody - ness or paralysis of the lower extremities (which may be asym - namic push), which studies suggest metrical), saddle anesthesia, and bowel and bladder inconti - may improve neurologic outcomes. nence. The most common cause of cauda equina syndrome is Once the patient is cleared for significant disc herniation. mobilization, neurogenic orthostatic hypotension may occur. Such strate - Central cord syndrome: Usually caused by trauma, central cord syndrome is gies as abdominal binder applica - linked to damage to the large nerve fibers that carry informa - tion, compression stockings, com - tion directly from the cerebral cortex to the cord. Signs and pression wrappings for the lower symptoms may include paralysis and loss of fine control of arm and hand movements, with far less impairment of leg extremities, and slow elevation of movement. Sensory loss below the SCI site and loss of bladder the head of the bed may help re - control also may occur. duce this risk. In patients whose hypotension Conus medullaris syndrome: This condition stems from injury to the conus persists despite these interventions, medullaris, the terminal end of the spinal cord. Patients typi - midodrine, pseudoephedrine, and cally present with sudden onset of lower back pain, bowel and salt tablets have been shown to bladder dysfunction, and symmetrical motor and sensory dys - have some effect, such as increased function. Distinguishing this syndrome from cauda equina heart rate and BP. Small studies sug - syndrome may be difficult. gest droxidopa also may raise BP. Images © Tammy Russo-McCourt Typically, patients adapt to a low - er BP over time; some may experi - bation, take care to maintain spinal • peptic ulcer disease prophylaxis ence bradycardia from unopposed alignment by using a cervical collar, • deep vein thrombosis (DVT) pro - vagal flow. Vasopressors that raise manual inline traction, or both. phylaxis. the heart rate may offer some bene - Be sure to initiate the ventilator Many patients with injuries at the fit during the initial hemodynamic bundle for these patients. The Insti - C3 vertebral level or higher are ven - push. Such medications as enteral tute for Healthcare Improvement’s tilator dependent. Those with an in - albuterol have been used to increase ventilator bundle includes five com - tact phrenic nerve may qualify for the heart rate in patients with per - ponents of care: diaphragmatic pacer implantation, sistent symptomatic bradycardia. • at least 30-degree elevation of which may allow weaning from me - Stimulation of the vasovagal re - the head of the bed chanical ventilation. flex may lead to cardiac arrest, re - • daily sedation interruption and quiring emergency atropine admin - assessment for readiness to extu - Cardiovascular management istration. To help prevent asystole bate Patients with significant cervical and episodes, hyperoxygenate the pa - • oral care with chlorhexidine high thoracic injuries (T6 level and tient before turning or suctioning

American Nurse Today Volume 11, Number 5 www.AmericanNurseToday.com 20 (unless contraindicated). Cardiac NEXUS criteria to exclude SCI pacing has been used in patients To rule out cervical spine injury in low-risk patients and eliminate the need for whose hypotension fails to resolve further cervical imaging or cervical spine stabilization after blunt trauma, clinicians over time or who require frequent can use these criteria from the National Emergency X-Radiography Utilization Group doses of anticholinergic drugs. (NEXUS): Temperature dysregulation. Inabil - • no posterior midline cervical spine tenderness ity to sweat or shiver (poikilother - • no evidence of intoxication mia) affects the patient’s temperature • normal alertness level regulation and can worsen bradycar - • no focal neurologic deficit dia. Poikilothermia is more likely to • no painful distracting injury. occur with higher-level SCIs and NSAID mnemonic more complete motor impairment. To remember these criteria, you can use the “NSAID” mnemonic below. But keep in Monitor environmental temperature, mind that “NSAID” refers to absence of NEXUS criteria. Thus, cervical spine injury as this can affect body temperature. can’t be ruled out in a patient who has any of the findings below. Hypothermia may worsen bradycar - N Neuro deficit dia and hypotension. Provide gentle S Spinal tenderness (midline) rewarming and monitor core tem - A Altered mental status (normal level of consciousness) perature continuously. I Intoxication (alcohol or drugs) Venous stasis. DVT and subse - D Distracting injuries quent venous thromboembolism are serious threats. In SCI, loss of vascu - In patients who complain of neck pain, aren’t fully awake, or have obvious weak - ness or other signs or symptoms of neurologic injury, keep the cervical spine in a lar and muscle tone causes venous rigid collar until appropriate radiologic studies are completed. stasis. Coupled with immobility and initiation of the clotting cascade (caused by trauma), venous stasis parasympathetic nervous system to the exact mechanism is unclear, puts patients at high risk for blood induce vasodilation and slow the some experts believe ileus stems clots—a risk that remains high for heart rate. Unfortunately, those mes - from loss of balance between up to 3 months after the injury. sages can’t descend below the in - branches of the autonomic nervous Venous stasis prophylaxis in - jury level to disrupt vasoconstric - system. Ileus typically resolves cludes immediate application of tion. As a result, pallor develops within the first week after injury. pneumatic compression sleeves, below the injury level while flush - Monitor the patient’s bowel along with subtherapeutic heparin ing, sweating, and pounding sounds and abdominal distention at or enoxaparin initiated 72 hours af - headache occur above it. least every 4 hours. If indicated and ter the injury, once the bleeding risk Many patients with higher-level ordered, insert a decompressive resolves. In cases of blood clot for - SCIs have a lower baseline BP. If gastric tube to reduce aspiration risk mation, the patient may receive an they have what’s commonly defined and restore diaphragm position and implantable filter in addition to con - as a “normal” BP, this actually may lung size to normal. ventional anticoagulant therapy. represent early AD. In some cases, The injury level determines whe- AD. This condition may arise elevated BP reaches levels of clini - th er the patient has a neurogenic when spinal shock starts to resolve cal emergency. Use rapid interven - (upper motor neuron) or aneuro - and reflexes return. A stimulus (typ - tions, such as sitting the patient genic (lower motor neuron) bowel. ically a noxious one) activates the upright to induce orthostasis (if pos - • Neurogenic bowel is marked by spinal reflex mechanism, causing sible) and administering fast-acting loss of voluntary control of the vasoconstriction below the injury antihypertensive agents (such as external rectal sphincter, tight re - level, which in turn causes BP to nifedipine) if ordered, to lower BP flexive sphincter tone, retained rise. Injuries at the T6 level and as the offending stimulus is identi - stool, and constipation. To aid higher involve the splanchnic vascu - fied and eliminated. The most com - bowel regulation, the patient lar bed, resulting in a “visceral mon culprits in AD are a full bowel may need a bowel regimen of squeeze,” which further increases and distended bladder. stool softeners and a high-fiber BP and boosts venous return to the diet along with low-volume ene - heart. Baroreceptors in the carotid GI management mas, glycerin, or bisacodyl sup - arteries and aortic arch detect the Acute GI problems in SCI patients positories or digital rectal stimu - critical rise in BP and send signals may include paralytic ileus with as - lation to cause reflexive to the brainstem, which responds sociated abdominal distention, gas - evacuation after the morning by sending messages via the tric ulcers, and constipation. While meal. (Gastric distention activates

www.AmericanNurseToday.com May 2016 American Nurse Today 21 Quick guide to nursing care for SCI patients The nursing interventions below can help promote optimal outcomes in patients with spinal cord injury (SCI). Body system Potential problem Nursing intervention

Respiratory • Respiratory insufficiency, failure, or both • Monitor respirations for signs of fatigue and impending failure. • Provide pulmonary toileting. • Administer bronchodilators, as ordered.

Cardiovascular • Acute hypotension • Maintain mean arterial pressure > 85 mm Hg for first 7 days after injury. • Bradycardia • Monitor heart rate • Administer medications for symptomatic bradycardia, as ordered. • Poikilothermia • Maintain normothermia. • Deep vein thrombosis • Minimize DVT risk. (DVT) • Initiate prophylaxis. • Orthostatic hypotension • Monitor for orthostatic hypotension. • Autonomic dysreflexia (AD) • Monitor for signs and symptoms of AD.

Genitourinary • Urinary retention • Decompress bladder via indwelling catheter insertion, as ordered. • Implement intermittent straight catheterization protocol when appropriate.

GI • Ileus • Monitor for abdominal distention. • Constipation • Maintain bowel elimination.

Musculoskeletal • Contractures • Provide frequent range-of-motion exercises. • Administer antispasmodics, as ordered.

Dermatologic • Skin breakdown • Perform meticulous skin care, frequently observing under splints and braces. • Reposition patient every 2 hours in bed. • Shift weight every 30 minutes when patient is out of bed in upright wheelchair.

bowel motility.) To reduce the placed to decompress the bladder catheterization protocol, as ordered. risk of constipation-induced AD, and allow close urinary output mon - The goal is to achieve a so-called perform a digital check of the itoring during the initial resuscitation balanced bladder, where fluid in - rectum for retained stool. and critical management phases. take approximates output. Because • In aneurogenic bowel, patients The patient may need the catheter overdistention can trigger AD, blad - have a slow colonic transport for the duration of the hemodynam - der volumes typically are targeted to time and lose both voluntary ic push period to prevent bladder 500 mL or less per catheterization. control and reflexive sphincter distention and bladder injury. Dur - SCI can cause neurogenic or tone. Fecal incontinence is com - ing the acute phase, fluid shifts may aneurogenic bladder. mon. Stool softeners, mini-ene - result from I.V. fluid administration • In neurogenic bladder, reflex-ini - mas, and digital stool removal coupled with use of vasopressors to tiated voiding may occur when may keep the rectum empty, re - support blood pressure. The cathe- the patient has a full bladder. ducing incontinence frequency. ter stays place until the patient • In aneurogenic bladder, such achieves hemodynamic stability, typ - voiding doesn’t occur, potentially Genitourinary management ically defined in intensive care envi - causing overflow urine leakage. A patient in neurogenic shock expe - ronments as when the patient no Planned intermittent catheteriza - riences abrupt loss of voluntary longer needs vasopressors. tion can reduce incontinence. Long- muscle control and reflexes, result - Once this period ends and if the term bladder management varies ing in acute urinary retention. An in - patient remains stable, restrict fluids with the patient’s bladder type, dwelling urinary catheter must be to 2 L/day and follow a straight needs, and lifestyle.

American Nurse Today Volume 11, Number 5 www.AmericanNurseToday.com 22 Musculoskeletal management the trochanters, sacrum, and bathe, dress, change position, and Patients with SCIs typically experi - heels perform other activities of daily living. ence muscle spasticity as spinal • using specialized support surfaces The profound, life-changing im - shock recedes and reflexes return. • minimizing moisture plications of SCI for both the patient Spasticity may take a flexor or ex - • frequently inspecting the skin un - and family warrant psychosocial, tensor pattern or a combination. der braces and splints emotional, and vocational support. Spasticity can reduce venous • using a custom-fit wheelchair Before discharge, provide consults pooling and stabilize the thoracic with pressure-relieving cushions for physical and occupational thera - and abdominal muscles used in res - • establishing a pressure-release py, social work, pastoral care, and piration. It’s also associated with regimen (manual or automated) financial counseling. Inform the pa - chronic pain syndrome, sleep distur - for wheelchair sitting tient and family about available bance, fatigue, joint contracture, • providing nutritional counseling community resources, such as SCI bone density loss, heterotopic ossifi - and patient education. support or advocacy groups. cation (presence of bone in soft tis - If skin breakdown occurs, con - sue where it normally doesn’t oc - sult specialized wound care services Preventing SCIs cur), and skin breakdown. for wound assessment and treat - While recent advances in emergency Nonpharmacologic strategies to ment. Treatment options may in - care and rehabilitation have in - manage spasticity include range-of- creased survivability after SCI, ap - motion exercises, positioning tech - proaches for reducing injury extent niques, weight-bearing exercises, and restoring function remain limit - electrical stimulation, and orthoses Recovery of function ed. No cure for SCI exists, but ongo - or splinting to prevent loss of mus - ing research to test surgical and drug cle length and contractures. Phar - depends on therapies continues to progress. In macologic therapy may include ba - severity clinical trials, researchers are explor - clofen, benzodiazepines, alpha 2- of the initial injury. ing drug treatments, decompression adrenergic agonists, and regional bot - surgery, nerve cell transplantation, ulism toxin or phenol injection. In nerve regeneration, stem cell thera - severe cases, surgical options (which clude both surgical and nonsurgical py, and complex drug therapies as are irreversible) may be used. interventions, depending on wound ways to overcome SCI effects. stage, location, and depth. With no cure for SCI available, Dermatologic management prevention remains key. To help A lifelong complication of SCI, pres - Neurologic improvement prevent behavior that can lead to sure ulcers may threaten not only Recovery of function depends on this devastating injury, educate the quality of life but also life itself. severity of the initial injury. Unfortu - public on how to prevent SCIs. Cau - Many factors contribute to tissue nately, patients with a complete SCI tion them to always wear seatbelts breakdown and eventual pressure are unlikely to regain function be - when in motor vehicles, drive sober, ulcers, including low BP, immobili - low the injury level. If some degree prevent falls by securing rugs and ty, friction and shearing forces, un - of improvement occurs, it usually cords, use appropriate safety equip - relieved pressure, moisture, poor manifests within the first few days ment during sports (such as helmets nutrition, and nonadherence with after injury. when cycling, skateboarding, or preventive strategies. Incomplete SCIs usually improve horseback riding), and avoid diving Prevention and early detection somewhat over time, but this varies in water less than 9' deep or if they are the cornerstones of pressure- with the specific injury. Although can’t see the bottom of murky water. ulcer management. Routinely inspect full recovery is rare, some patients An SCI can affect every aspect of the patient’s skin and use an estab - may be able to improve enough to life. But with treatment and rehabili - lished skin risk assessment tool, ambulate and control their bowel tation, many patients can lead pro - such as the Braden scale. To ad - and bladder functions. ductive, independent lives. dress identified risk factors, develop a plan of care. Risk-reduction inter - Supportive and rehabilitative Mark Bauman is a clinical educator at the University ventions include: care and treatment of Maryland Medical Center Midtown Campus in • turning the patient every 2 hours Once the patient is medically stable, Baltimore. Tammy Russo-McCourt is a senior clinical or more (depending on risk as - care and treatment shift to support nurse at the University of Maryland R Adams Cowley sessment findings) and rehabilitation. Family members, Shock Trauma Center in Baltimore. • avoiding positioning the patient nurses, or specially trained aides may Visit www.AmericanNurseToday.com/ on bony prominences, such as provide care, helping the patient ?p=22892 for a list of selected references. www.AmericanNurseToday.com May 2016 American Nurse Today 23 CNE Caring for patients with spinal cord injuries POST-TEST • CNE: 1.55 contact hours Earn contact hour credit online at http://www.americannursetoday.com/continuing-education/

Provider accreditation Post-test passing score is 80%. Expiration: 5/1/19 The American Nurses Association’s Center for Continuing Edu - ANA Center for Continuing Education and Professional Devel - cation and Professional Development is accredited as a opment’s accredited provider status refers only to CNE activi - provider of continuing nursing education by the American ties and does not imply that there is real or implied endorse - Nurses Credentialing Center’s Commission on Accreditation. ment of any product, service, or company referred to in this ANCC Provider Number 0023. activity nor of any company subsidizing costs related to the Contact hours: 1.55 activity. The author and planners of this CNE activity have dis - ANA’s Center for Continuing Education and Professional Devel - closed no relevant financial relationships with any commercial opment is approved by the California Board of Registered Nurs - companies pertaining to this CNE. See the banner at the top of ing, Provider Number CEP6178 for 1.86 contact hours. this page to learn how to earn CNE credit.

Please mark the correct answer online. 6. Which statement about avoiding c. Injuries at the T2 level and higher involve respiratory complications in patients with the splanchnic vascular bed, which leads 1. Significant disc herniation is the most SCI is accurate? to increased blood pressure (BP). common cause of which type of incomplete a. An abdominal binder placed below the d. A stimulus activates the spinal reflex spinal cord injury (SCI)? costal margin to support the viscera can mechanism, causing vasoconstriction be - a. Anterior cord syndrome aid breathing. low the injury level, which in turn raises BP. b. Brown-Sequard syndrome b. An abdominal binder placed above the c. Cauda equina syndrome costal margin to support the viscera can 12. Which statement about patients with d. Central cord syndrome aid breathing. aneurogenic bowel is true? c. Vital capacity above 1.5 L suggests a. They lose both voluntary control and 2. The most common type of incomplete decreased inspiratory muscle strength. reflexive sphincter tone. SCI is: d. Vital capacity above 2 L suggests b. They have tight reflexive sphincter tone a. anterior cord syndrome. decreased inspiratory muscle strength. and retained stool. b. Brown-Sequard syndrome. c. They may need a bowel regimen of stool c. cauda equina syndrome. 7. One component of the Institute for Health - softeners. d. central cord syndrome. care Improvement’s ventilator bundle is: d. They require a digital check of the a. avoiding prophylaxis for peptic ulcer rectum for retained stool. 3. Loss of pain and temperature sensation disease. on the side opposite the injury is the defining b. weekly sedation interruption to assess 13. Which statement about genitourinary feature of which type of incomplete SCI? readiness to extubate. management of SCI patients is correct? a. Anterior cord syndrome c. at least 15-degree elevation of the head a. Once the acute phase ends and the b. Brown-Sequard syndrome of the bed. patient is stable, restrict fluids to 1 L/day. c. Cauda equina syndrome d. oral care with chlorhexidine. b. Bladder volumes typically are targeted to d. Central cord syndrome 500 mL or less per catheterization. 8. A sign that might indicate a patient with c. In aneurogenic bladder, reflex-initiated 4. Which sign or symptom might eliminate SCI may be in neurogenic shock is: voiding may occur when the patient has the need for further cervical imaging or a. hyperthermia. a full bladder. cervical spine stabilization in a low-risk patient b. hypothermia. d. Planned intermittent catheterization with cervical spine injury after blunt trauma? c. heart rate of 70 beats/minute. does not help reduce incontinence. a. Weak hand grip d. heart rate of 100 beats/minute. b. Lumbar spinal tenderness 14. Strategies for managing spasticity in c. No posterior midline cervical spine 9. In SCI patients with hypotension, the patients with SCIs include: tenderness goal is to sustain a mean arterial pressure of: a. avoiding weight-bearing exercises. d. Unsteady gait when walking a. 60 mm Hg or higher for 3 days. b. opioid pharmacologic agents. b. 70 mm Hg or higher for 5 days. c. orthotics to reduce muscle length. 5. Which statement related to radiologic c. 85 mm Hg or higher for 7 days. d. electrical stimulation. evaluation of patients with possible SCI is d. 90 mm Hg or higher for 10 days. correct? 15. To help patients avoid skin breakdown, a. Magnetic resonance imaging is not 10. The most common complication of SCI is: the nurse should: helpful in detecting ligamentous injury a. respiratory impairment. a. reposition the patient in bed at least that may be compressing the cord. b. hypertension. every 4 hours. b. Magnetic resonance imaging does not c. sympathetic dysregulation. b. shift the patient’s weight every 60 provide valuable analysis of the spinal d. paralytic ileus. minutes when the patient is out of bed cord. in a wheelchair. c. Computerized tomography (CT) and 11. Which statement about autonomic c. shift the patient’s weight every 30 traditional X-rays are equally acceptable. dysregulation is correct? minutes when the patient is out of bed d. Traditional X-rays should be used only if a. Treatment includes slow-acting in a wheelchair. high-quality CT isn’t available. antihypertensive agents. d. reposition the patient in bed at least b. The most common cause is increased every 3 hours. urine output.

American Nurse Today Volume 11, Number 5 www.AmericanNurseToday.com 24