Question

The patient is a 20-year-old male construction worker who was building a house when he slipped and tripped on building materials and fell 30 feet from the roof. The patient hit the ground with a thud, and his co-workers went running to his aid and called EMS. The patient was moaning and conversing with one of his buddies, who continuously reminded him to be still and not to try to move. EMS arrived on the scene and found the patient alert and oriented and immediately stabilized his neck with a rigid cervical collar. At the scene, the patient stated he could not feel or move either of his legs and his left hand felt numb and tingly. Initial history and physical at the scene found the patient was a normal, healthy young adult male with no previous health history; respiratory rate and effort were adequate, pulses were palpable and strong in all four extremities, skin was warm and color normal with brisk capillary refill, left arm was painful to slight touch and gross motor movement was adequate (patient was able to wiggle fingers). Forearm deformity with associated pain without movement was noted. Paresthesia extended from between the nipple line and umbilicus, with no movement noted in bilateral lower extremities. His initial vital signs at the scene were reported to be HR 92, BP 128/86, RR 28 and SpO₂ 94%. The diagnosis of suspected spinal cord injury was made and a methylprednisolone loading dose of 30 mg/kg was initiated. The patient’s left arm was splinted. Report was called to the local hospital ED, and the patient was placed on a backboard and transported with no difficulties. On arrival to the hospital, the ED healthcare provider quickly assessed the patient and determined he was hemodynamically stable and should be emergently transferred to the regional spinal cord injury center for specialized medical care. Admission orders have been written.

Background:

Normal, healthy young adult male with no previous health history. The patient has no known drug allergies and is awake and alert.

Assessment:

Vital signs: HR 94, BP 122/84, RR 24, SpO₂ 94% on room air, Temp 36.8^oC

General Appearance: Generalized contusions and abrasions, rigid cervical collar in place, splint to left arm

Cardiovascular: Normal sinus rhythm on telemetry monitoring

Respiratory: Clear in all lung fields, respiratory rate and effort adequate

GI: Active bowel sounds, last ate at 0600 this morning before going to work

GU: A urinary catheter was inserted in the Emergency Department prior to transfer and is draining dilute pale yellow urine. 275 mL were emptied before transfer

Extremities: Pink, warm and with adequate turgor and brisk capillary refill; pulses palpable and strong in all four extremities; left arm painful to slight touch and gross motor movement adequate—he is able to wiggle his fingers. Noted left forearm deformity with associated pain without movement, left arm was splinted at site of injury. States he cannot feel or move either of his legs, left hand feels numb and tingly, paresthesia extends from between his nipple line and umbilicus with no movement noted in bilateral lower extremities. Skin: Warm, dry and pink

Neurological: Alert and oriented to person, place and time; pupils equal, round, reactive to light and accommodation

IVs: 20-gauge IV to saline lock in the right forearm, patent and non-reddened; methyprednisolone loading dose of 30 mg/kg was initiated; 0.9% Normal Saline infusing at 100 mL/hr via gravity infusion

Labs: CBC with differential, electrolytes, BUN, creatinine, glucose and ABG ordered on arrival to ICU

Fall Risk: High-risk for falls

Pain: Complains of left arm and hand pain that he rates 5/10

Recommendations:

Admit to ICU and monitor hemodynamic and neurological status.

Orders

Initial Healthcare Provider’s Orders:

Continuous ECG and SpO₂ monitoring

Vital signs and neurological assessment every 1 hour

Oxygen 2 LPM via nasal cannula; titrate to keep SpO₂ greater than 95%

Incentive spirometer every hour while awake

Cough and deep breathe every hour while awake

NPO

CBC with differential, Electrolytes, BUN Creatinine, Glucose, ABG on arrival and every AM

CT scan of the spine, no contrast

X-ray of left arm and shoulder

Chest x-ray on admission and every other AM

IV 0.9% NS at 80 mL/hour

Methylprednisolone 5.4 mg/kg continuous IV infusion for 24 hours

Strict bed rest; maintain spinal precautions, logroll only

Rigid cervical collar

Antiembolic stockings and sequential compression device for deep vein thrombosis (DVT) prophylaxis

Famotidine 20 mg IV twice daily

Morphine sulfate 1-2 mg IV every 1 hour prn for pain Notify healthcare provider for:

HR greater than 140 or less than 60

Systolic BP less than 90 or greater than 180

Temp greater than 38°C

SpO₂ less than 92%

Urine output less than 30mL/hour x 2 hours

Any neurologic changes

• What are the goals of nursing management of the patient with neurogenic shock?
• Identify three nursing diagnoses for the patient with spinal cord injury, focusing on the first 24 hours in the ICU.
• Identify three nursing diagnoses for the patient experiencing neurogenic shock.
• Discuss the collaborative management of the patient experiencing neurogenic shock.

Answer 1

Neurogenic shock means the hemodynamic change results from a sudden loss of autonomic tone due to spinal cord injury.

The major goals of nursing management include:

Assess airway, breathing and circulation and neurological.

Provide adequate ventilation.

Maintain proper alignment of spine without further spinal cord damage.

Proper positioning as evidenced by absence of contractures, foot drop.

Recognize sensory impairments.

Finding out behaviors to compensate for deficits.

Verbalize awareness of sensory needs and potential for deprivation.

NURSING DIAGNOSIS FOR SPINAL CORD INJURY:

1. Impaired physical mobility related to neuromuscular impairment as evidenced by paralysis.

Nursing intervention:

Passive range of motion exercises

Proper body alignment should be maintained at all times

log roll the patient as per doctors advice.

Encourage relaxation techniues

2. Acute pain related to physical injury.

Nursing Intervention:

  Provide analgesics and sedations as per doctors order.

Provide comfort measures (position changes, massage, ROM exercises, warm or cold packs, as indicated).

Promote mind deviation or relaxation methods like listening music.

Provide pleasant atmosphere.

3. Risk for urinary tract infection related to catheterisation.

Nursing interventions:

Assess vital signs hourly.

Encourage more fluids.

Provide proper catheter care.

NURSING DIAGNOSIS FOR NEUROGENIC SHOCK:

Risk for impaired breathing pattern related to impairment of innervation of diaphragm.

Risk for trauma related to instability of spinal column.

COLLABORATIVE MANAGEMENT:

It includes:

Nursing assessment:

Basic airway, breathing, circulation assessment while protecting the spine from any extra movement.

Neurologic assessment. Neurologic deficits should be identified.

The management includes:

Elevate head of bed.

Applying anti-embolism stockings and elevating the foot of the bed may help minimize pooling of the blood in the legs and prevent thrombus formation.

Passive range of motion helps to promote circulation.

Maintain patent airway.

Administer oxygen by appropriate method (nasal prongs, mask, intubation, ventilator).

Plan activities to provide uninterrupted rest periods and encourage involvement within individual tolerance and ability.

Monitor BP before and after activity in acute phases or until stable.

Assist patient to recognize and compensate for alterations in sensation.