SCI
what gender is it more common males or females?
what is the common cause ?
Motor vehicle crashes
The nurse recognizes which of the following as common triggers for autonomic dysreflexia? (Select all that apply.)
A. Bladder distention
B. Tight clothing
C. Wrinkled bed sheets
D. Pain or discomfort
E. Increased intracranial pressure
Correct Answers: A, B, C, D
Rationale: AD is caused by noxious stimuli below the level of injury such as bladder distention, tight clothing, wrinkled sheets, or pain.
Increased ICP (E) is not a trigger — it’s a different neuro condition.
fill in the blank.
Crutchfield tongs are attached to ______ and nurse should turn pt every __ hours
Crutchfield tongs are attached to bed and nurse should turn pt every 2 hours
What are the priority assessments of a patient with a spinal cord injury?
motor and sensory NOT REFLEXES
what's the difference between complete vs incomplete injury?
complete - total motor and sensory loss below injury
incomplete - mixed loss of voluntary motor activity and sensation
Which vertebral areas are the most commonly injured?
lumbar and cervical
A client with a T4 spinal cord injury suddenly complains of a severe, throbbing headache and nasal congestion. The nurse notes flushed skin above the level of injury and pale, cool skin below.
Which action should the nurse take first?
A. Administer prescribed antihypertensive medication
B. Check the client’s bladder for distention
C. Notify the healthcare provider
D. Reposition the client flat in bed
B. Check the client’s bladder for distention
Rationale: These are classic signs of autonomic dysreflexia, a medical emergency seen in T6 or higher injuries.
The priority after elevating the head of bed is to remove the trigger, most often bladder distention from a full or kinked catheter.
What are the interventions with a bowel regimen in a spinal cord patient?
use of fiber and stool softeners
rectal stimulation
daily, consistent toilet routine
A spinal cord injury to which area would warrant close monitoring of vital signs?
cervical
give me 4 diagnostic test you'll do for spinal cord injury?
x ray, ct, mri & ABGs
what is primary injury vs secondary injury?
initial impact
ongoing problem above or below the injury site
Which nursing intervention represents the immediate and highest priority safety measure for a patient who has sustained trauma with a suspected head and neck injury?
A.
Administering a dose of Methylprednisolone.
B.
Placing the patient on a spinal backboard and immobilizing the head in a neutral position.
C.
Assessing capillary refill and distal pulses.
D.
Checking for a weak or absent gag reflex.
B.
Placing the patient on a spinal backboard and immobilizing the head in a neutral position.
That's right!
The critical priority is to assume SCI is present until ruled out and to prevent further damage by maintaining immobilization and neutral alignment.
A patient with a T6 spinal cord injury suddenly develops a blood pressure of 190/100 mmHg, a pounding headache, and profuse diaphoresis (sweating) on the face and neck. The patient's skin is pale and cool below the level of injury. What complication does the nurse suspect?
A. neurogenic shock.
B.Spinal shock.
C.Paralytic ileus.
D.Autonomic Dysreflexia (AD).
D.
Autonomic Dysreflexia (AD).
That's right!
The triad of severe hypertension, throbbing headache, and flushing/diaphoresis above the injury with paleness below is the classic presentation of Autonomic Dysreflexia.
Which device is preferred in the immobilization of a cervical injury?
halo vest
hyperflexion
hyperextension
compression/axial load
rotational
head hits windshield
chin hit table
diving
falling backwards
tell me everything about halo vest
Purpose: Keeps the cervical spine stable after injury or surgery.
Structure: Metal halo ring with 4 pins (2 front, 2 back) attached to a vest.
Nursing Care:
Do not move or lift the patient by the halo.
Check neuro status (movement, sensation, strength).
Make sure the vest isn’t too tight (fit one finger under).
Inspect skin for redness or pressure.
Provide sterile pin care as ordered.
Patient Teaching:
Show how to clean pins and vest.
Report infection signs (redness, drainage, fever).
Offer emotional support for body image changes.
Watch for:
Autonomic dysreflexia (injury above T6): sudden headache, ↑BP, ↓HR, sweating, goosebumps → emergency.
tell me everything about neurogenic shock
Cause: Loss of sympathetic tone → massive vasodilation.
Effects:
Blood pools in vessels.
Decreased tissue perfusion.
Impaired cellular metabolism (cells don’t get enough oxygen).
Key Signs:
Low BP (hypotension)
Bradycardia (slow HR)
Warm, dry skin (from vasodilation)
A nurse is assessing a client with a T4 spinal cord injury who suddenly reports a severe, throbbing headache. Which additional findings should the nurse expect if the client is experiencing autonomic dysreflexia?
A. Hypotension and bradycardia
B. Flushed skin above the level of injury and pale skin below
C. Warm, dry skin over entire body
D. Decreased blood pressure with tachycardia
Correct Answer: B. Flushed skin above the level of injury and pale skin below
Rationale:
Autonomic dysreflexia is caused by overstimulation of the sympathetic nervous system in clients with T6 or higher injuries.
Key S/S include:
Severe headache
Flushed skin and diaphoresis above injury
Cool, pale skin below injury
Hypertension and bradycardia
A spinal cord injury pt. states they have a terrible headache, the nurse's first action is:
raise the head of the bed
clinical manifestation
c1-c3:
c4:
c5-c6:
t6-l4:
no independent breathing
poor cough, hypoventilation, vent assist
decrease respiratory reserve high risk for pneumonia
functional
why would a pt with SCI take
1. methylprednisolone
2. dextran
3.vasopressors
4. atropine
5. baclofen
1. decrease edema, increase blood flow
2.Plasma expander used to increase capillary blood low within the spinal cord and to prevent or treat hypotension
3.maintain BP MAP 80-90 mmHg
4. for bradycardia
5. for sever spasticity
fill in the blank
Spinal shock is a __________ condition causing a sudden __________ in reflexes below the lesion, leading to __________ and __________ muscles. It can last __________ to __________ and requires __________ support.
temporary, decrease, paralysis, flaccid, days, weeks, emotional
After elevating the HOB for a client experiencing autonomic dysreflexia, what should the nurse do next?
A. Administer antihypertensive medication
B. Check the bladder for distention or kinks in the catheter
C. Call the provider immediately
D. Reassure the patient and continue to monitor
Correct Answer: B. Check the bladder for distention or kinks in the catheter
Rationale:
The most common cause is bladder distention, so the nurse should palpate the abdomen and perform a bladder scan before giving meds or calling the provider.
Which intervention should be questioned in a patient with increased ICP?
turn, cough, deep breathe