amyotrophic lateral sclerosis (ALS) A progressive neurodegenerative disease that affects neurons in the brain and spinal cord that is likely caused by genetic mutations.
autonomic dysreflexia (AD) (sometimes referred to as autonomic hyperreflexia) A potentially life-threatening condition in which noxious visceral or cutaneous stimuli cause a sudden, massive, uninhibited reflex sympathetic discharge in people with high-level spinal cord injury.
cough assist A technique in which an assistant places both hands on the patient’s upper abdomen over the diaphragm and below the ribs. Hands are placed one over the other, with fingers interlocked and away from the skin while the patient takes a breath and coughs during expiration. The assistant locks elbows and pushes inward and upward as the patient coughs.
diplopia Double vision.
dysarthria Difficulty speaking due to slurred speech.
dysmetria The inability to direct or limit movement.
dysphagia Difficulty swallowing.
ergonomics An applied science in which the workplace is designed to increase worker comfort (thus reducing injury) while increasing efficiency and productivity.
heterotopic ossification (HO) Bony overgrowth, often into muscle; a complication of immobility.
hyperesthesia Increased sensory perception.
hypoalgesia A decreased sensitivity to pain.
hypoesthesia Decreased sensory perception.
intention tremor A tremor, usually of the arm and hand, that occurs while performing an activity.
log rolling A position change in which the patient turns as a unit while the back is kept as straight as possible.
multiple sclerosis (MS) A chronic disease caused by immune, genetic, and/or infectious factors that affects the myelin and nerve fibers of the brain and spinal cord.
neurogenic shock A type of shock that can occur in clients who have severe spinal cord injury; dilation of blood vessels leads to decreased perfusion to vital body organs.
nystagmus An involuntary condition in which the eyes make repetitive uncontrolled movements.
paraparesis Weakness that affects only the lower extremities, as seen in lower thoracic and lumbosacral injuries or lesions.
paraplegia Paralysis that affects only the lower extremities, as seen in lower thoracic and lumbosacral injuries or lesions.
progressive multifocal leukoencephalopathy (PML) An opportunistic viral infection of the brain that leads to death or severe disability.
quadriparesis Weakness involving all four extremities, as seen with cervical cord and upper thoracic injury.
radiculopathy Spinal nerve root involvement.
scotomas Changes in peripheral vision, often in patients with multiple sclerosis.
spinal cord stimulation An invasive technique that provides pain relief by applying an electrical field over the spinal cord.
spinal shock A syndrome that occurs immediately as the cord’s response to injury in which the patient has complete but temporary loss of motor, sensory, reflex, and autonomic function. It typically lasts less than 48 hours but may continue for several weeks.
spinal stenosis Narrowing of the spinal canal, nerve root canals, or intervertebral foramina typically seen in people older than 50 years of age.
tetraplegia (also called quadriplegia) Paralysis of all four extremities, as seen with cervical cord and upper thoracic cord injury.
tinnitus Ringing in the ears.
vertigo Dizziness.
http://evolve.elsevier.com/Iggy/
Priority and Interrelated Concepts
The priority concepts for this chapter are:
• Immunity
• Mobility
The Immunity concept exemplar for this chapter is Multiple Sclerosis.
The Mobility concept exemplar for this chapter is Spinal Cord Injury.
The interrelated concepts for this chapter are:
• Sensory Perception
• Cognition
• Sexuality
• Pain
The spinal cord relays messages to and from the brain. Besides injuries, the spinal cord can develop inflammatory and autoimmune diseases, such as multiple sclerosis (MS) and tumors, both benign and malignant. The spinal cord itself may be damaged, or the spinal nerves leading from the cord to the extremities may be affected. In some cases, both the spinal cord and the nerves are involved. Adult spinal health conditions may be acute or chronic and often can be managed in the community. End-of-life care is not needed unless the patient has a large, inoperable cancerous spinal cord tumor or spinal metastatic disease.
Signs and symptoms of spinal cord health conditions vary but often include problems with immunity, mobility, sensory perception, cognition, and sexuality. Interprofessional health care team members with expertise in symptom management collaborate to improve quality of life, promote a safe environment, and prevent complications from spinal cord health conditions. Chapter 3 briefly reviews each of these nursing and health concepts in detail.
Immunity Concept Exemplar: Multiple Sclerosis
Multiple sclerosis (MS) is a chronic disease caused by immune, genetic, and/or infectious factors that affects the myelin and nerve fibers of the brain and spinal cord. It is one of the leading causes of neurologic disability in young and middle-age adults.
Pathophysiology Review
Multiple sclerosis is characterized by periods of remission and exacerbation (flare). Patients progress at different rates and over different lengths of time. However, as the severity and duration of the disease progress, the periods of exacerbation become more frequent. Patients with MS can have a normal life expectancy as long as the effects of the disease are managed effectively.
As described in Chapter 35, myelin is responsible for the electrochemical transmission of impulses between the brain and spinal cord and the rest of the body; demyelination can result in slowed or stopped impulse transmission. MS is characterized by demyelination (loss of myelin sheaths). Diffuse random or patchy areas of plaque in the white matter of the central nervous system (CNS) are the definitive findings (Rogers, 2023). Initially, remyelination takes place to some degree, and clinical symptoms decrease. However, over time, new lesions develop and neuronal injury and muscle atrophy occur. The areas particularly affected include optic nerves, spinal pyramidal tracts, spinal posterior columns, brainstem nuclei, and the ventricular region of the brain. The four major types of MS include (National Multiple Sclerosis Society, 2020.):
• Clinically isolated syndrome (CIS)
• Relapsing-remitting
• Primary progressive
• Secondary progressive
The CIS is an episode of neurologic symptoms often attributed to MS that lasts for at least 24 hours. An MRI may or may not show evidence of MS, so a diagnosis is not yet possible. A little over half of patients diagnosed with CIS develop MS within 10 years, and disease-modifying therapies are often started to prevent or delay the onset. Radiologically isolated syndrome (RIS) is often diagnosed incidentally in a person having an MRI for another problem, such as headache or head trauma. It is characterized by isolated lesions that are similar to those of MS in a person who does not have a past or current history of symptoms of the disease (National Multiple Sclerosis Society, 2020).
Relapsing-remitting multiple sclerosis (RRMS) occurs in most cases of MS. The course of the disease may be mild or moderate, depending on the degree of disability. Symptoms develop and resolve in a few weeks to months, and the patient returns to baseline. During the relapsing phase, the patient reports loss of function and the continuing development of new symptoms. The majority of patients are diagnosed with this type initially (Rogers, 2023).
Primary progressive multiple sclerosis (PPMS) involves a steady and gradual neurologic deterioration without remission of symptoms. The patient has progressive disability with no acute attacks. Patients with this type of MS tend to be between 40 and 60 years of age at onset of the disease.
Secondary progressive multiple sclerosis (SPMS) begins with a relapsing-remitting course that later becomes steadily progressive. Many people with RRMS develop SPMS within 10 years. The current addition of disease-modifying drugs as part of disease management may decrease the development of SPMS.
Progressive-relapsing multiple sclerosis (PRMS) is an older label for an uncommon type of MS characterized by frequent relapses with partial recovery but not a return to baseline. This type of MS is seen in only a small percentage of patients. Progressive, cumulative symptoms and deterioration occur over several years (Rogers, 2023).
Etiology and Genetic Risk
The cause of MS is very complex and involves multiple immune, genetic, and/or infectious factors, although changes in immunity are the most likely etiology. The environment may also contribute to its development. For example, the disease is seen more often in the colder climates of the northeastern, Great Lakes, and Pacific northwestern states and in Canada (National Multiple Sclerosis Society, 2020).
Patient-Centered Care: Genetics/Genomics
Familial Patterns of Multiple Sclerosis
Large genome studies of families have helped identify familial patterns of multiple sclerosis (MS). For example, having a first-degree relative such as a parent or sibling with MS increases a person’s risk for developing the disease. Research also confirms the association of MS with over 100 gene variants, including interleukin (IL)-7 and IL-2 receptor genes (Rogers, 2023; National Multiple Sclerosis Society, 2020). These findings have helped guide the development of targeted drug therapies that are important in current disease management.
Incidence and Prevalence
MS usually occurs in people between the ages of 20 and 50 years, but cases may occur at any age. Nearly 1 million people in the United States have MS. The disease affects over 2.3 million people worldwide (National Multiple Sclerosis Society, 2020). About 90,000 Canadians have MS (MS Society of Canada, 2020).
Patient-Centered Care: Gender Health
Women and Multiple Sclerosis
MS affects women two to three times more often than men, suggesting a possible hormonal role in disease development. Some studies show that the disease occurs up to four times more often in women than men. However, the exact reason for this difference is not known (National Multiple Sclerosis Society, 2020).
Interprofessional Collaborative Care
Recognize Cues: Assessment
History
Multiple sclerosis (MS) often presents like other neurologic diseases, such as amyotrophic lateral sclerosis (ALS), which can make the diagnosis difficult and prolonged. ALS is also a progressive neurodegenerative disease that affects neurons in the brain and spinal cord and that is likely caused by genetic mutations. Unlike MS, there is no established treatment or cure for ALS, which is 100% fatal. Recently, a combination drug, sodium phenylbutyrate and taurursodiol, has been approved to slow physical function decline for patients who have ALS. Table 37.1 compares these two neurologic health conditions.
Patients often visit many primary health care providers and undergo a variety of diagnostic tests and treatments to obtain the correct diagnosis. Obtaining a thorough history is essential for accurate diagnosis. Ask the patient about a history of vision, mobility, and sensory perception changes, all of which are early indicators of MS. Symptoms are often vague and nonspecific in the early stages of the disease and may disappear for months or years before returning. Many patients have a single isolated clinical episode that lasts for 24 hours or more. These neurologic symptoms then disappear and occur later.
Ask about the progression of symptoms. Pay particular attention to whether they are intermittent or are becoming progressively worse. Document the date (month and year) when the patient first noticed these changes.
Next, ask about factors that aggravate the symptoms, such as fatigue, stress, overexertion, temperature extremes, or a hot shower or bath. Ask the patient and the family about any personality or behavioral changes that have occurred (e.g., euphoria [very elated mood], poor judgment, attention loss). In addition, determine whether there is a family history of MS or autoimmune disease.
Patient-Centered Care: Culture and Spirituality
Race and Multiple Sclerosis
MS has historically been thought to occur most often in White individuals. However, a recent study shows that MS is nearly as prevalent in the Black population as in the White population. A study of 3863 people in Southern California diagnosed with MS showed estimated prevalence rates (based on census and study data) to be very similar at 226/100,000 for Blacks and at 238/100,000 in Whites (Langer-Gould et al., 2022).
TABLE 37.1
Comparison of Multiple Sclerosis and Amyotrophic Lateral Sclerosis
Multiple Sclerosis (MS) Amyotrophic Lateral Sclerosis (ALS)
Pathophysiology and etiology Chronic neurologic disease that affects the brain and spinal cord due to immune-mediated demyelination and nerve injury; characterized by remissions and exacerbations Chronic neurologic disease of unknown cause (genetic and environmental factors identified), causing progressive muscle weakness and wasting and leading to paralysis of respiratory muscles
Populations affected Commonly occurring disease that affects people (women twice as often as men) between the ages of 20 and 50 yr; most often affects Whites Uncommon disease that affects people (more men than women) between the ages of 40 and 60 yr; incidence increases with each decade of life
Signs and symptoms
Fatigue
Muscle spasticity
Blurred or double vision (diplopia)
Scotomas
Nystagmus
Paresthesias
Areflexic (flaccid) or spastic bladder
Decreased sexual function
Intention tremors
Gait changes
Fatigue
Muscle atrophy (including tongue)
Muscle weakness
Twitching of face and tongue
Dysarthria
Dysphagia
Stiff and clumsy gait
Abnormal reflexes
Interprofessional collaborative care
Multiple immunomodulating and antineoplastic drugs available
Collaborative care to promote and maintain optimal functioning
Symptom management to achieve maximal function
Psychosocial support
Supportive care to promote optimal function
Palliative care for symptom management at end of life
Psychosocial support
Physical Assessment/Signs and Symptoms
MS produces a wide variety of signs and symptoms, as listed in Box 37.1. Therefore, each patient may present differently. Some patients with RRMS also report pain. Perform a complete pain assessment as described in Chapter 6 for all patients with MS.
Psychosocial Assessment
A major concern reported by most patients is how long it takes to establish a diagnosis of MS. Many patients go to several primary health care providers, are given varying diagnoses and treatment, and/or are told that their symptoms are related to stress and anxiety. Often, young adults present with weakness, fatigue, or changes in vision and are diagnosed with exhaustion and advised to get more sleep. The patient and family are relieved to have a definite diagnosis but may express anger and frustration that it took a long time to start appropriate treatment. Therefore, establish open and honest communication with patients and allow them to share frustrations, anger, and anxiety.
After the initial diagnosis of MS, the patient is often anxious. Apathy and emotional lability are common problems that occur later. Depression may occur at the time of diagnosis and can also occur later with disease progression. The patient may be euphoric either as a result of the disease itself or because of the drugs used to treat it. Assess the patient’s previously used coping and stress-management skills in preparing for a chronic, potentially debilitating disease. Secondary depression is the most frequent mental health disorder diagnosed in patients with MS.
Assess the patient for mental status changes. Changes in cognition are usually seen late in the course of the disease and can include decreases in short-term memory, concentration, and the ability to perform calculations; inattentiveness; and impaired judgment.
Assess the impact of bowel and bladder problems. Managing urinary or fecal incontinence or constipation can be time consuming and embarrassing.
Box 37.1 Key FeaturesMultiple Sclerosis
Common Symptoms and Conditions
• Muscle weakness and spasticity
• Fatigue (usually with continuous sensitivity to temperature)
• Flexor muscle spasms
• Numbness or tingling sensations (paresthesia)
• Visual changes such as diplopia, nystagmus (involuntary eye movements), decreased visual acuity, scotomas (changes in peripheral vision)
• Bowel and bladder dysfunction (flaccid or spastic)
• Alterations in sexual function, such as erectile dysfunction
• Cognitive changes, such as memory loss, impaired judgment, and decreased ability to solve problems or perform calculations
• Depression
• Dysesthesia (“MS hug”) squeezing sensation around the torso, often one of the first symptoms of the disease or a relapse
• Difficulty walking (including dysmetria [inability to direct or limit movement and ataxia])
• Vertigo (dizziness)
• Pain and itching
• Emotional changes
Less Common Symptoms and Conditions
• Intention tremor (tremor when performing an activity)
• Hypoalgesia (decreased sensitivity to pain)
• Dysarthria (difficulty speaking due to slurred speech)
• Dysphagia (difficulty swallowing)
• Decreased hearing acuity
• Tinnitus (ringing in the ears)
• Loss of taste
• Seizures
Sexuality can be affected in people with MS, and sexual dysfunction can have a major impact on quality of life. Assess the patient’s fatigue level and pattern, since fatigue contributes to sexual dysfunction. Be sensitive when asking about the patient’s sexual practices and orientation. Women often report impaired genital sensation, diminished orgasm, and loss of sexual interest. Men most often report difficulty in achieving and maintaining an erection and delayed ejaculation.
Laboratory Assessment
No single specific laboratory test is definitively diagnostic for MS. However, the collective results of a variety of tests are usually conclusive. Abnormal cerebrospinal fluid (CSF) findings include elevated proteins (oligoclonal bands) and an increase in the white blood cell (WBC) count. CSF electrophoresis reveals an increase in the myelin basic protein and the presence of increased immunoglobulins, especially immunoglobulin G (IgG) (Pagana et al., 2022). Newer tests are being developed to identify biomarkers for MS.
Other Diagnostic Assessments
An MRI of the brain and spinal cord that demonstrates the presence of plaques in at least two areas is considered diagnostic for MS. MRIs with contrast may show active plaques and reveal older lesions not associated with current symptoms (Fig. 37.1).
Evoked potential testing, usually the visual evoked response (VER), may be performed for patients suspected of having MS. This noninvasive test can identify impaired transmission along the optic nerve pathway. Chapter 35 discusses this test in more detail.
NCLEX Examination Challenge 37.1
Physiological Integrity
The nurse is caring for a client recently diagnosed with multiple sclerosis. Which of the following common client findings would the nurse expect? Select all that apply.
A. Muscle weakness
B. Memory loss
C. Visual changes such as diplopia
D. Hallucinations
E. Muscle spasticity
F. Fatigue
Analyze Cues and Prioritize Hypotheses: Analysis
The priority collaborative problems for patients with multiple sclerosis include:
1. Impaired immunity due to the disease and drug therapy for disease management
2. Decreased or impaired mobility due to muscle spasticity, intention tremors, and/or fatigue
3. Decreased visual acuity and cognition due to dysfunctional brain neurons
Generate Solutions and Take Actions: Planning and Implementation
The purpose of management is to modify the disease’s effects on the immune system, prevent exacerbations, manage symptoms, improve function, and maintain quality of life. As with other spinal cord conditions, care of the patient with MS requires the collaborative efforts of the interprofessional health care team.
Managing Impaired Immunity
Planning: Expected Outcomes
The patient with MS is expected to be free from episodes of secondary infection due to impaired immunity from the disease or from drug therapy used to manage the illness.
Interventions
As with any chronic disease, clients who have been diagnosed with MS are at an increased risk for infection. Teach these patients to avoid large crowds and anyone who is sick. Remind them to wash their hands frequently and use hand sanitizer when soap and water are not readily available.
Drug Therapy
The patient with MS is treated with a variety of drugs to treat and control disease progression. Medications can be administered orally, by injection, or by infusion. Many of these drugs are immunomodulators or antiinflammatory medications that can alter immunity and place patients at risk for secondary infection. Teach patients receiving drug therapy for MS to avoid crowds and anyone with an infection. If signs and symptoms of an infection occur, remind them to contact their primary health care provider for prompt management and medical observation. Other medications are used to control symptoms, such as bladder or bowel dysfunction, fatigue, itching, pain, sexual problems, spasticity, tremors, or gait disturbances.
FIG. 37.1 Typical plaques (arrows) seen in brain CT images of patient with multiple sclerosis. From Herring, W. [2020]. Learning radiology. [4th ed.]. St. Louis: Elsevier.
Examples of drugs used for treatment of relapsing types of MS include (Burchum & Rosenthal, 2022):
• Interferon-beta preparations (interferon beta-1a and beta-1b drugs), immunomodulators that modify the course of the disease and also have antiviral effects
• Glatiramer acetate, a synthetic protein that is similar to myelin-based protein
• Mitoxantrone, an IV antineoplastic antiinflammatory agent used to resolve relapses but with risks for leukemia and cardiotoxicity
• Natalizumab, the first IV monoclonal antibody approved for MS that binds to white blood cells (WBCs) to prevent further damage to the myelin
• Fingolimod, teriflunomide, ponesimod, and diroximel fumarate, oral immunomodulating drugs
Nursing Safety Priority
Drug Alert
The interferons and glatiramer acetate are subcutaneous injections that patients can self-administer. Teach patients how to give and rotate the site of injections because local injection site (skin) reactions are common. The first dose of these drugs is given under medical supervision to monitor for allergic response, including anaphylactic shock. Teach patients receiving them to avoid crowds and people with infections because these drugs can cause bone marrow suppression. Remind them to report any sign or symptom associated with infection immediately to their primary health care provider.
Instruct patients about flulike reactions that are very common for patients receiving any of the interferons. These symptoms can be minimized by starting at a low drug dose and giving acetaminophen or ibuprofen. Adverse effects of glatiramer are not common (Burchum & Rosenthal, 2022).
Natalizumab, a humanized monoclonal antibody, can cause many adverse events. It is usually given as an IV infusion in a specialty clinic under careful supervision. The patient is monitored carefully for allergic or anaphylactic reaction when each dose is given because the drug tends to build up in the body. Patients receiving this drug are at risk for progressive multifocal leukoencephalopathy (PML). This opportunistic viral infection of the brain leads to death or severe disability. Monitor for neurologic changes, especially changes in mental state, such as disorientation or acute confusion. PML is confirmed by MRI and by examining the cerebrospinal fluid for the causative pathogen (Burchum & Rosenthal, 2022). Natalizumab can also damage hepatic cells. Carefully monitor liver enzymes, and teach patients to have frequent laboratory tests to assess for changes.
Mitoxantrone, a chemotherapy drug, has been shown to be effective in reducing neurologic disability. It also decreases the frequency of clinical relapses in patients with secondary progressive, progressive-relapsing, or worsening relapsing-remitting MS.
Fingolimod was the first oral immunomodulator approved for the management of MS. The capsules may be taken with or without food. Teach patients to monitor their pulse every day because the drug can cause bradycardia, especially within the first 6 hours after taking it. Several other immunomodulating drugs have been approved for MS. Like fingolimod, these drugs inhibit immune cells and have antioxidant properties that protect brain and spinal cord cells. Teach the patient that the two most common side effects of all the oral drugs are facial flushing and GI disturbances (Burchum & Rosenthal, 2022). Remind the patient to keep follow-up appointments for laboratory monitoring of the WBC count because the oral drugs can cause a decrease in WBCs, which can predispose the patient to infection.
Patient-Centered Care: Health Equity
Health Equity Issues for Patients Who Have Multiple Sclerosis
MS is an expensive disease to treat. Bebo et al. (2022) found that the average annual cost for an individual living with MS is $88,487. Medications, particularly disease-modifying drugs, account for the largest amount of that cost. When compared to White patients who have MS, Black patients have a lower median income and less coverage for health insurance. These social determinants of health may explain the higher mortality rate of Black patients who have MS when compared to White patients because Black patients may be unable to afford the most effective drugs (Amezcua et al., 2021). All nurses should advocate for policy changes that make drugs needed for MS affordable for all those who have the disease (Bebo et al., 2022).
Medical Marijuana (Cannabis)
The National Multiple Sclerosis Society supports the use of medical marijuana (cannabis) for symptom management. Studies have shown that cannabis can reduce neuropathic pain, muscle stiffness, and spasticity for some patients with MS (Clark, 2021). Consistent availability of quality cannabis in a legalized-use state gives patients more options about the type of product that may be effective.
Stem Cell Therapy
Stem cell therapy is being researched as a promising treatment to manage MS (Cona, 2021; Drillinger, 2021). Stem cells may be derived from adults or embryonic tissue, although embryonic stem cells are preferred because they are often more effective. This therapy may slow the progression of the disease and decrease symptoms. (See the Legal/Ethical Considerations box.)
Legal/Ethical Considerations
Stem Cell Research
Human embryonic stem cell research remains ethically and politically controversial because human embryos are destroyed. The embryos, which are obtained through the in vitro fertilization (IVF) process, are between 3 and 5 days old (blastocysts), and are no longer needed for transfer into the uterus to create a pregnancy. Individuals who believe that life begins at conception oppose stem cell therapy when embryos are terminated. Nurses must respect the beliefs, morals, and values of all individuals regardless of their own personal feelings about the research and use of stem cells as regenerative therapy.
Improving Mobility
Planning Expected Outcomes
The patient with MS is expected to have optimal mobility as a result of successful interprofessional management and self-care interventions.
Interventions
The symptoms of MS that affect mobility include spasticity, tremor, pain, and fatigue. Referral to rehabilitative services, such as physical and occupational therapy, can help manage functional deficits from MS symptoms. An interprofessional team approach is important to attain patient-centered outcomes for care.
To lessen muscle spasticity (which often contributes to pain), the primary health care provider may prescribe baclofen or tizanidine (Burchum & Rosenthal, 2022). Severe muscle spasticity may also be treated with intrathecal baclofen (ITB) administered through a surgically implanted pump. Paresthesia may be treated with carbamazepine or tricyclic antidepressants. Propranolol hydrochloride and clonazepam have been used to treat cerebellar ataxia.
In collaboration with physical and occupational therapists, plan an exercise program that includes range-of-motion (ROM) exercises and stretching and strengthening exercises to manage spasticity and tremor. If needed as a last resort, neurosurgery (e.g., thalamotomy or deep brain stimulation) may provide some relief from tremors.
Emphasize the importance of avoiding rigorous activities that increase body temperature. Increased body temperature may lead to increased fatigue, diminished motor ability, and decreased visual acuity resulting from changes in the conduction abilities of the injured axons.
In collaboration with the case manager and occupational therapist, assess the patient’s home before discharge for any hazards. Any items that might interfere with mobility (e.g., scatter rugs) are removed. In addition, care must be taken to prevent injury resulting from vision problems. Teach the patient and family to keep the home environment as structured and free from clutter as possible. As the disease progresses, the home may need to be adapted for wheelchair accessibility. Adaptation in the kitchen, bedroom, and bathroom may also be needed to promote self-management. Any necessary assistive-adaptive device should be readily available before discharge from the hospital.
The patient with MS is often weak and easily fatigued. Teach the patient the importance of planning activities and allowing sufficient time to complete activities. For example, patients should check that all items needed for work are gathered before leaving the house. Items used on a daily basis should be easily accessible. A recent study showed beneficial effects of brief mindfulness training for hospitalized patients to manage their fatigue (Sauder et al., 2021).
If the patient experiences dysarthria as a result of muscle weakness, refer the patient to the speech-language pathologist (SLP) for evaluation and treatment. It is not unusual for the patient with dysarthria also to have dysphagia. The SLP performs a swallowing evaluation, but further diagnostic testing may be indicated. Monitor the patient to determine whether there are problems swallowing at mealtime that increase the risk of aspiration. In some cases, thickened liquids may be necessary.
Managing Decreased Visual Acuity and Cognition
Planning: Expected Outcomes
The patient with MS is expected to maintain optimal visual acuity and cognition with use of available drug treatment and supportive services.
Interventions
Alterations in visual acuity and cognition can occur at any time during the course of the disease process. Areas affected include attention, memory, problem solving, auditory reasoning, handling distractions, and visual perception.
Nursing Safety Priority
Action Alert
For the patient with MS who has impaired cognition, assist with orientation by using a single-date calendar. Give or encourage the patient to use written lists or recorded messages. To maintain an organized environment, encourage the patient to keep frequently used items in familiar places. Applications for handheld devices such as mobile phones and electronic tablets can also be used for reorientation, reminders, and behavioral cues.
An eye patch that is alternated from eye to eye every few hours usually relieves diplopia (double vision). For peripheral visual deficits, teach scanning techniques by having the patient move the head from side to side. Changes in visual acuity may be helped by corrective lenses.
Complementary and Integrative Health
Patients with MS often report that complementary therapies are successful in decreasing their symptoms and managing anxiety and/or depression. Some of the integrative therapies used by patients with MS are:
• Reflexology
• Massage
• Yoga
• Relaxation and meditation
• Acupuncture
• Aromatherapy
Care Coordination and Transition Management
Patients usually are able to live independently with their disease, but some may need assistance. To help the patient maintain maximum strength, function, and independence, continuity of care by an interprofessional team in the rehabilitation and/or home setting may be needed. In severe disease, placement in an assisted-living or long-term care facility may be the best alternative. The population of young and middle-age residents in these settings is increasing as people with physical disabilities live longer.
The primary health care provider explains to the patient and family the development of MS and the factors that may exacerbate the symptoms. Emphasize the importance of avoiding overexertion, stress, extremes of temperatures (fever, hot baths, use of sauna baths and hot tubs, overheating, and excessive chilling), humidity, and people with infections. Explain all medications to be taken on discharge, including the time and route of administration, dosage, purpose, and side effects. Teach the patient how to differentiate expected side effects from adverse or allergic reactions, and provide the name of a resource person to call if questions or problems occur. Provide written instructions as a resource for the patient and caregivers at home.
The physical therapist develops an exercise program appropriate for the patient’s tolerance level at home. The patient is instructed in techniques for self-care, daily living skills, and the use of required adaptive equipment such as walkers and electric carts. Include information related to bowel and bladder management, skin care, nutrition, and positioning techniques. Chapter 7 describes in detail these aspects of chronic illness and rehabilitation.
Teach patients about conservation strategies that balance periods of rest and activity, including regular social interactions. Remind them to use assistive devices and modify the environment to avoid fatigue. Explore strategies to manage stress and avoid undue stress. Often patients are anxious and worry about how long the remission will last or when the disease will progress.
MS affects the entire family because of the unpredictability and uncertainty of the course of the disease. Chronic fatigue may also prevent the patient from participating in family and community activities. Assess coping strategies of family members or other caregivers, and help them identify support systems that can assist them as they live with the patient with MS.
Because personality changes are not unusual, teach the family or significant others strategies to enable them to cope with these changes. For example, the family may develop a nonverbal signal to alert the patient to potentially inappropriate behavior. This action avoids embarrassment for the patient.
Sexual dysfunction may occur as a result of fatigue, nerve involvement, and/or psychological reasons. Therefore, some patients may benefit from counseling. If able, answer the patient’s questions or refer the patient to a counselor or urologist with experience in the field of sexuality, intimacy, and disability.
Prostaglandin-5 inhibitors (sildenafil, vardenafil, tadalafil) can be used to help men with erectile dysfunction. Penile prostheses are also used for men. The EROS Clitoral Therapy Device is a U.S. Food and Drug Administration (FDA)–approved therapy for women with impaired sexual response.
Refer the patient and family members or significant others to the local chapter of the National Multiple Sclerosis Society (www.nationalmssociety.org) or the MS Society of Canada (https://mssociety.ca). Other community resources include meal-delivery services (e.g., Meals on Wheels), transportation services for the disabled, and homemaker services.
Evaluate Outcomes: Evaluation
Evaluate the care of the patient with MS on the basis of the identified priority problems. The expected outcomes are that the patient:
• Remains free of infection as a result of drug therapy affecting immunity or the disease process
• Maintains optimal mobility and function as a result of managing fatigue and pain
• Maintains adequate visual acuity and cognition to function independently
Mobility Concept Exemplar: Spinal Cord Injury
Spinal cord injury (SCI) can occur at any level of the spine. Potential survivors of acute SCI experience injury below the third cervical level (C3). SCI is the leading cause of paralysis and results in a physical disability. Many health issues experienced by patients who live with SCI are related to impaired mobility (Smeltzer, 2021).
Pathophysiology Review
Spinal cord injuries can be classified as complete or incomplete. A complete SCI is one in which the spinal cord has been damaged in a way that eliminates all innervation below the level of the injury. Injuries that allow some function or movement below the level of the injury are described as an incomplete SCI. Incomplete SCIs are more common than complete injuries. Loss of or decreased mobility, sensory perception, and bowel and bladder control often result from an SCI.
Mechanisms of Injury
When enough force is applied to the spinal cord, the resulting damage causes many neurologic deficits. Sources of force include direct injury to the vertebral column (fracture, dislocation, and subluxation [partial dislocation]) or penetrating injury from violence (gunshot or knife wounds). Although in some cases the cord itself may remain intact, at other times it undergoes a destructive process caused by a contusion (bruise), compression, laceration, or transaction (severing of the cord, either complete or incomplete).
The causes of SCI can be divided into primary and secondary mechanisms of injury. Five primary mechanisms may result in an SCI (Rogers, 2023):
• Hyperflexion: a sudden and forceful acceleration (movement) of the head forward, causing extreme flexion of the neck (Fig. 37.2). This is often the result of a head-on motor vehicle collision or diving accident. Flexion injury to the lower thoracic and lumbar spine may occur when the trunk is suddenly flexed on itself, such as occurs in a fall on the buttocks.
• Hyperextension occurs most often in vehicle collisions in which the vehicle is struck from behind or during falls when the patient’s chin is struck (Fig. 37.3). The head is suddenly accelerated and then decelerated. This stretches or tears the anterior longitudinal ligament, fractures or subluxates the vertebrae, and perhaps ruptures an intervertebral disk. As with flexion injuries, the spinal cord may easily be damaged.
• Axial loading or vertical compression injuries resulting from diving accidents, falls on the buttocks, or a jump in which a person lands on the feet can cause many of the injuries attributable to axial loading (vertical compression) (Fig. 37.4). A blow to the top of the head can cause the vertebrae to shatter. Pieces of bone enter the spinal canal and damage the cord.
• Excessive rotation results from injuries that are caused by turning the head beyond the normal range.
• Penetrating trauma is classified by the speed of the object (e.g., knife, bullet) causing the injury. Low-speed or low-impact injuries cause damage directly at the site or local damage to the spinal cord or spinal nerves. In contrast, high-speed injuries that occur from gunshot wounds (GSWs) cause both direct and indirect damage.
Secondary Injury
Secondary injury worsens the primary injury and may result in death. Secondary injuries include (Rogers, 2023):
FIG. 37.2 Hyperflexion injury of the cervical vertebrae. From Leonard, P. C. [2022]. Building a medical vocabulary: With Spanish translations. [11th ed.]. St. Louis: Elsevier.
An illustration labeled, hyperflexion injury of the cervical spine shows head of a driver striking forward on the steering wheel in a moving vehicle with forward curved force which causes damage to spinal cord, anterior dislocation, and ruptured posterior longitudinal ligament.
FIG. 37.3 Hyperextension injury of the cervical vertebrae. From Leonard, P. C. [2022]. Building a medical vocabulary: With Spanish translations. [11th ed.]. St. Louis: Elsevier.
An illustrations labeled, hyperextension injury of the cervical spine shows head of a driver hitting back due to collision by a car hitting from back with backward curve force resulting in ruptured anterior longitudinal ligament and compression of spinal cord.
• Hemorrhage
• Ischemia (lack of oxygen, typically from reduced/absent blood flow)
• Hypovolemia (decreased circulating blood volume)
• Impaired tissue perfusion from neurogenic shock (a medical emergency)
• Local edema
Hemorrhage into the spinal cord may manifest with contusion or petechial leaking into the central gray matter and later into the white matter. Systemic hemorrhage can result in shock and decreased perfusion to the spinal cord. Edema occurs with both primary and secondary injuries, contributing to capillary compression and cord ischemia. In neurogenic shock, loss of blood vessel tone (dilation) after severe cord injury may result in hypoperfusion (Rogers, 2023).
Patients who have SCI have a decreased life expectancy, owing to complications of immobility or, more often, some type of infection. The major causes of death are pneumonia and septicemia.
Etiology and Genetic Risk
Trauma is the leading cause of spinal cord injuries (SCIs), with more than a third resulting from vehicle crashes. Other leading causes are falls, acts of violence (usually gunshot wounds [GSWs]), and sports- or recreation-related accidents. SCIs from falls are particularly likely among older adults. Spinal cord damage in older adults can also result from nontraumatic vertebral fracture and diseases such as tumors or degenerative conditions (Rogers, 2023).
Incidence and Prevalence
About 18,000 new SCIs occur every year in the United States. However, an estimated 300,000 or more individuals live with an SCI as a physical disability. Almost 80% of all SCIs occur in young males, with the majority being White. Cervical cord injuries are more common than thoracic or lumbar cord injuries (Rogers, 2023). The most common neurologic level of injury is C5. For patients with paraplegia, T12 and L1 are the most common levels. The average age of patients who have SCI is 43 years (Rogers, 2023).
Patient-Centered Care: Veteran Health
Veterans and Spinal Cord Injury
SCI is more prevalent among veterans who served in combat in Iraq and Afghanistan when compared to those who served in previous wars. Most of those SCIs resulted from blunt trauma caused by blast injuries. Be aware that veterans who experience an SCI from blast injury typically have other polytraumatic injuries, including traumatic brain injury and amputation of one or more limbs (Elliott et al., 2021). These additional injuries may take priority over attending to the problems related to the SCI and present a major challenge in managing care.
Health Promotion/Disease Prevention
Because trauma is the leading cause of SCI, teach people to avoid taking risks, if possible, by ensuring adequate protective measures (e.g., padding and helmets) for sports and recreational activities. Remind them to wear seat belts at all times when driving and to avoid impaired driving caused by alcohol, marijuana, and other substances. Instruct them on the danger of diving into shallow pools or other water when the depth is unknown. Water should be at least 9 feet deep before diving is attempted.
FIG. 37.4 Vertical compression of the cervical spine and the lumbar spine. From Leonard, P. C. [2022]. Building a medical vocabulary: With Spanish translations. [11th ed.]. St. Louis: Elsevier.
An illustration on left shows a man falling on his pelvis with downward force acting on his spine resulting in compression fracture of the lumbar spine and a man on right hitting his head on the stone while diving in water with downward force acting on his neck, resulting in compression fracture of the cervical spine.
Interprofessional Collaborative Care
Recognize Cues: Assessment
History
When obtaining a history from a patient with an acute SCI, gather as much data as possible once the patient is stabilized about how the accident occurred and the probable mechanism of injury. Important data include:
• Location and position of the patient immediately after the injury
• Symptoms that occurred immediately with the injury
• Changes that have occurred subsequently
• Type of immobilization devices used and whether any problems occurred during stabilization and transport to the hospital
• Treatment given at the scene of injury or in the emergency department (ED) (e.g., medications, IV fluids)
• Medical history, including osteoporosis or arthritis of the spine, congenital deformities, cancer, and previous injury or surgery of the neck or back
• History of any respiratory problems, especially if the patient has experienced a cervical SCI
Physical Assessment/Signs and Symptoms
Initial Assessment
The initial and priority assessment focuses on the patient’s ABCs (airway, breathing, and circulation). After an airway is established, assess the patient’s breathing pattern. The patient with a cervical SCI is at high risk for respiratory compromise because cervical spinal nerves (C3-5) innervate the phrenic nerve controlling the diaphragm.
Evaluate pulse, blood pressure, and peripheral perfusion such as pulse strength and capillary refill. Multiple injuries may contribute to circulatory compromise from hemorrhagic hypovolemic shock. Assess for indications of hemorrhage. All symptoms of circulatory compromise or hypovolemic shock must be treated aggressively to preserve tissue perfusion to the spinal cord. Shock is discussed in detail in Chapter 31.
Use the Glasgow Coma Scale (see Chapter 35) or other agency-approved assessment tool to assess the patient’s level of consciousness (LOC). Cognitive impairment as a result of an associated traumatic brain injury (TBI) or substance use disorder can occur in patients with traumatic SCIs.
Spinal shock, also called spinal shock syndrome, occurs immediately as the cord’s response to the injury. The patient has complete but temporary loss of motor, sensory, reflex, and autonomic function that often lasts less than 48 hours but may continue for several weeks. Common symptoms include decreased heart rate, increased blood pressure, and pale/ash gray or flushed skin (Rogers, 2023). Spinal shock is not the same as neurogenic shock.
Sensory Perception and Mobility Assessment
Perform a detailed assessment of the patient’s mobility and sensory perception status to determine the level of injury and establish baseline data for future comparison. The level of injury is the lowest neurologic segment with intact or normal motor and sensory function. Tetraplegia, also called quadriplegia (paralysis), and quadriparesis (weakness) involve all four extremities, as seen with cervical cord and upper thoracic injury. Paraplegia (paralysis) and paraparesis (weakness) involve only the lower extremities, as seen in lower thoracic and lumbosacral injuries or lesions.
Neurologic level defined by the American Spinal Injury Association (ASIA) refers to the highest neurologic level of normal function and is not the same as the anatomic level of injury. The neurologic level is determined by evaluating the zones of sensory and motor function, known as dermatomes (area of skin in which sensory nerves derive from a single spinal nerve root) and myotomes (set of muscles innervated by a spinal nerve). The patient may report a complete sensory loss, hypoesthesia (decreased sensory perception), or hyperesthesia (increased sensory perception).
Nursing Safety Priority
Critical Rescue
In acute SCI, monitor for a decrease in sensory perception from baseline, especially in a proximal (upward) dermatome and/or new loss of motor function and mobility. The presence of these changes is considered an emergency and requires immediate communication with the Rapid Response Team or primary health care provider, using SBAR or other agency-approved protocol for notification. Document these assessment findings in the electronic health record.
The primary health care provider may also test deep tendon reflexes (DTRs), including the biceps (C5), triceps (C7), patella (L3), and ankle (S1). It is not unusual for these reflexes, as well as all mobility or sensory perception, to be absent immediately after the injury because of spinal shock. After spinal shock has resolved, the reflexes may return.
Cardiovascular and Respiratory Assessment
Cardiovascular dysfunction results from disruption of sympathetic fibers of the autonomic nervous system (ANS), especially if the injury is above the sixth thoracic vertebra. Bradycardia, hypotension, and hypothermia occur because of loss of sympathetic input. These changes may lead to cardiac dysrhythmias. A systolic blood pressure below 90 mm Hg requires treatment because lack of perfusion to the spinal cord could worsen the patient’s condition.
A patient with a cervical SCI is at risk for breathing problems resulting from an interruption of spinal innervation to the respiratory muscles. In collaboration with the respiratory therapist (RT), if available, perform a complete respiratory assessment, including pulse oximetry for arterial oxygen saturation, at least every 8 to 12 hours, more often in the acute stage. An oxygen saturation of 92% or less and adventitious breath sounds may indicate a complication such as atelectasis or pneumonia.
Autonomic dysreflexia (AD), sometimes referred to as autonomic hyperreflexia, is a potentially life-threatening condition in which noxious visceral or cutaneous stimuli cause a sudden, massive, uninhibited reflex sympathetic discharge in people with high-level SCI. The signs and symptoms of AD are listed in Box 37.2. Severely elevated blood pressure can cause a hemorrhagic stroke, discussed in Chapter 38.
Box 37.2 Key FeaturesAutonomic Dysreflexia
• Sudden, significant rise in systolic and diastolic blood pressure, accompanied by bradycardia
• Profuse sweating above the level of lesion—especially in the face, neck, and shoulders; rarely occurs below the level of the lesion because of sympathetic cholinergic activity
• Goose bumps above or possibly below the level of the lesion
• Flushing of the skin above the level of the lesion—especially in the face, neck, and shoulders
• Blurred vision
• Spots in the patient’s visual field
• Nasal congestion
• Onset of severe, throbbing headache
• Feeling of apprehension
The causes of AD are typically GI, gynecologic-urologic (GU), and vascular stimulation. Specific risk factors are bladder distention, urinary tract infection, epididymitis or scrotal compression, bowel distention or impaction from constipation, or irritation of hemorrhoids. Pain; circumferential constriction of the thorax, abdomen, or an extremity (e.g., tight clothing); contact with hard or sharp objects; and temperature fluctuations can also cause AD. Patients with altered sensory perception are at great risk for this complication (Rogers, 2023).
Gastrointestinal and Genitourinary Assessment
Assess the patient’s abdomen for symptoms of internal bleeding, such as abdominal distention, pain, or paralytic ileus. Hemorrhage may result from the trauma, or it may occur later from a stress ulcer or the administration of steroids. Monitor for abdominal pain and changes in bowel sounds. Paralytic ileus may develop within 72 hours of hospital admission. During the period of spinal shock, peristalsis decreases, leading to a loss of bowel sounds and to gastric distention. This disruption of the autonomic nervous system may lead to a hypotonic bowel.
After the first few days, when edema subsides, the spinal reflexes that innervate the bowel and bladder usually begin to establish function, depending on the level of the injury. Patients with cervical or high thoracic SCIs have upper motor neuron damage that spares lower spinal reflexes, causing a spastic bowel and bladder. Patients with lower thoracic and lumbosacral injuries usually have damage to their lower spinal nerves and therefore have a flaccid bowel and bladder.
Assessment of Patients for Long-Term Complications
Patients with complete SCI are at a high risk for complications that result from prolonged impaired mobility, including pressure injuries and venous thromboembolism (VTE). Assess skin integrity with each turn or repositioning. Monitor for signs of VTE with vital signs, including lower extremity deep vein thrombosis (DVT). More detailed information on prevention and management of these complications may be found elsewhere in this text.
Bones can become osteopenic and osteoporotic without weight-bearing exercise, placing the long-term SCI patient at risk for fractures. Another complication of prolonged immobility is heterotopic ossification (HO) (bony overgrowth, often into muscle). Assess for swelling, redness/hyperpigmentation, warmth, and decreased range of motion (ROM) of the involved extremity. The hip is the most common place where HO occurs. Changes in the bony structure are not visible until several weeks after initial symptoms appear.
Psychosocial Assessment
Patients experiencing an SCI may have significant behavioral and emotional reactions as a result of changes in functional ability, body image, role performance, and self-concept. Many of these patients are young men who may feel guilty for engaging in high-risk behaviors such as diving into shallow water or racing a vehicle that caused the injury. Some patients with SCI are war veterans. Assess patients for their reaction to the injury and provide opportunities to listen to their concerns. Be realistic about their abilities and projected function, but offer hope and encouragement. Aggressive rehabilitation can help most patients live productive and independent lives.
Laboratory and Imaging Assessment
The primary health care provider may request basic laboratory studies for the patient with an SCI to establish baseline data. A spine CT and MRI are performed to determine the degree and extent of damage to the spinal cord and detect the presence of blood and bone within the spinal column. In addition, patients may have a series of x-rays of the spine to identify vertebral fractures, subluxation, or dislocation.
Analyze Cues and Prioritize Hypotheses: Analysis
The priority collaborative problems for patients with an acute spinal cord injury (SCI) include:
1. Potential for respiratory distress/failure due to aspiration, decreased diaphragmatic innervation, and/or decreased mobility
2. Potential for cardiovascular instability (e.g., shock and autonomic dysreflexia) due to loss or interruption of sympathetic innervation or hemorrhage
3. Potential for secondary spinal cord injury due to hypoperfusion, edema, or delayed spinal column stabilization
4. Decreased mobility and sensory perception due to spinal cord damage and edema
In addition, the patient with a long-term SCI is at risk for multiple problems caused by prolonged immobility or impaired mobility. These problems are discussed in fundamentals textbooks and reviewed in Chapter 7.
Generate Solutions and Take Actions: Planning and Implementation
Caring for a patient with an SCI requires both a patient- and family-centered collaborative approach and involves every health care team member to help meet the patient’s expected outcomes. Optimally, patients with a new SCI are quickly transported to an SCI Model System Center. Because of the complexity of an SCI, discharge planning, including the rehabilitation team, needs to begin on the day of admission.
The desired outcomes of patient-centered collaborative care following acute SCI are to stabilize the vertebral column, manage damage to the spinal cord, and prevent secondary injuries.
Managing the Airway and Improving Breathing
Planning: Expected Outcomes
The patient with an SCI is expected to not experience respiratory distress as evidenced by a patent airway and adequate ventilation.
Interventions
Airway management is the priority for a patient with cervical spinal cord injury! Patients with injuries at or above T6 are especially at risk for respiratory distress and pulmonary embolus during the first 5 days after injury. These complications are caused by impaired functioning of the intercostal muscles and disruption in the innervation to the diaphragm. Depending on the level of injury, intubation or tracheotomy with mechanical ventilation may be needed.
Nursing Safety Priority
Action Alert
Assess breath sounds every 2 to 4 hours during the first few days after SCI, and document and report any adventitious or diminished sounds. Monitor vital signs with pulse oximetry. Watch for changes in respiratory pattern or airway obstruction. Intervene per agency or primary health care provider protocol when there is a decrease in oxygen saturation (SpO2) to below 95%.
FIG. 37.5 “Cough assist” technique for patient with high spinal cord injury.
An illustration shows a man coughing while sitting on a wheel chair. A nursing assistant stands in front of man applying pressure with both hands on the chest of man. Hands are placed one over the other, with fingers interlocked and away from the skin.
Respiratory secretions are managed with manually assisted coughing, pulmonary hygiene, and suctioning. Implement strategies to prevent ventilator-associated pneumonia (VAP) when the patient needs continuous mechanical ventilation as discussed in Chapter 26. Encourage the non–mechanically ventilated patient to use an incentive spirometer. The nurse and respiratory therapist perform a respiratory assessment at least every 8 hours to determine the effectiveness of these strategies. In some cases, it may be necessary to perform oral or nasal suctioning if the patient cannot effectively clear the airway of secretions.
Teach the patient who is tetraplegic to coordinate cough effort with an assistant. The nurse, or other assistant, places both hands on the upper abdomen over the diaphragm and below the ribs. Hands are placed one over the other, with fingers interlocked and away from the skin (Fig. 37.5). If the patient is obese, an alternate hand placement is one hand on either side of the rib cage. Have the patient take a breath and cough during expiration. The assistant locks the elbows and pushes inward and upward as the patient coughs. This technique is sometimes called assisted coughing, quad cough, or cough assist. Repeat the coordinated effort, with rest periods as needed, until the airway is clear.
Monitoring for Cardiovascular Instability
Planning: Expected Outcomes
The patient is expected to not develop neurogenic or hypovolemic shock due to hemorrhage and is expected to be free from episodes of autonomic dysreflexia (AD). If any of these potentially life-threatening complications occur, the patient is expected to receive prompt interventions with positive outcomes.
Interventions
Maintain adequate hydration through IV therapy and oral fluids as appropriate, depending on the patient’s overall condition. Carefully observe for manifestations of neurogenic shock, which may occur within 24 hours after injury, most commonly in patients with injuries above T6. This potentially life-threatening problem results from disruption in the communication pathways between upper motor neurons and lower motor neurons.
Dextran, a plasma expander, may be used to increase capillary blood flow within the spinal cord and prevent or treat hypotension. Atropine sulfate is used to treat bradycardia if the pulse rate falls below 50 to 60 beats/min. Hypotension, if severe, is treated with continuous IV sympathomimetic agents such as phenylephrine, dopamine, or other vasoactive agent. Chapter 31 discusses in detail the care of patients experiencing or at risk for shock.
Nursing Safety Priority
Critical Rescue
Monitor the patient with acute spinal cord injury at least hourly for indications of neurogenic shock:
• Temperature dysregulation, including warm, flushed skin
• Symptomatic bradycardia, including reduced level of consciousness and deceased urine output
• Hypotension with systolic blood pressure (SBP) <90 or mean arterial pressure (MAP) <65 mm Hg
Notify the Rapid Response Team or primary health care provider immediately if these symptoms occur because this is an emergency! Similar to interventions for any type of shock, neurogenic shock is treated symptomatically by providing fluids to the circulating blood volume, adding vasopressor IV therapy, and providing supportive care to stabilize the patient. In addition, respiratory compromise (pulse oximetry [SpO2] <95% or symptoms of aspiration [e.g., stridor, garbled speech, or inability to clear airway]) may be treated with intubation or bronchial endoscopy.
In addition to observing the patient for shock or hypotension, monitor the patient who has a high-level SCI injury for the additional risk of autonomic dysreflexia (AD). AD is a neurologic emergency and must be promptly treated to prevent a hypertensive stroke! Be sure to reduce potential causes for this complication by preventing bladder and bowel distention, managing pain and room temperature, and monitoring for infections (Harmison et al., 2023).
Nursing Safety Priority
Critical Rescue
If the patient experiences AD, raise the head of the bed immediately to help reduce the blood pressure as the first action. Notify the Rapid Response Team or primary health care provider immediately for drug therapy to quickly reduce blood pressure as indicated. Determine the cause of AD, and manage it promptly as described in Box 37.3.
NCLEX Examination Challenge 37.2
Safe and Effective Care Environment
A client who experienced a recent T1 spinal cord injury appears flushed and diaphoretic in the face and neck and is reporting “seeing spots.” Which action would the nurse take first?
A. Notify the primary health care provider.
B. Perform a bedside bladder scan.
C. Raise the head of the client’s bed.
D. Obtain and document vital signs.
Preventing Secondary Spinal Cord Injury
Planning: Expected Outcomes
The patient with an acute SCI is expected to have adequate spinal cord stabilization as evidenced by no further deterioration in neurologic status.
Interventions
During the immediate care of the patient with a suspected or confirmed cervical spine injury, a hard cervical collar, such as the Miami J or Philadelphia collar, is placed to stabilize the spine until a specific order indicates that it can be removed (Fig. 37.6). Padding at pressure points beneath and at the edges of the collar, particularly at the occiput, may be necessary to maintain skin integrity. Until the spinal column is stabilized, a jaw-thrust maneuver is preferable to a head-tilt maneuver to open the airway should the patient need an airway intervention. Maintain spinal alignment at all times, with log rolling to change position from supine to side-lying.
FIG. 37.6 Patient with spinal cord injury wearing a hard cervical (Miami J) collar. Found in Ostendork, W. R., Perry, A. G., & Potter, P. A. [2020.] Nursing interventions & clinical skills. [7th ed.] St. Louis: Elsevier. From Össur Americas.
Box 37.3 Best Practice for Patient Safety and Quality CareEmergency Care of the Patient Experiencing Autonomic Dysreflexia: Immediate Interventions
• Place patient in a sitting position (first priority!), or return to a previous safe position.
• Assess for and remove/manage the cause:
• Check for urinary retention or catheter blockage.
• Check the urinary catheter tubing (if present) for kinks or obstruction.
• If a urinary catheter is not present, check for bladder distention, and catheterize immediately if indicated. (Consider using anesthetic ointment on the tip of the catheter before catheter insertion to reduce urethral irritation.)
• Determine if a urinary tract infection or bladder calculi (stones) are contributing to genitourinary irritation.
• Check the patient for fecal impaction or other colorectal irritation, using anesthetic ointment at rectum; disimpact if needed.
• Examine skin for new or worsening pressure injury symptoms.
• Monitor blood pressure every 10 to 15 minutes.
• Give nifedipine or nitrate as prescribed to lower blood pressure as needed. (Patients with recurrent autonomic dysreflexia may receive clonidine or another centrally acting alpha-agonist agent prophylactically [Burchum & Rosenthal, 2022].)
If the patient has a fractured vertebra, the primary concern of the health care team is to reduce and immobilize the fracture to prevent further damage to the spinal cord from bone fragments. Nonsurgical techniques include external fixation or orthotic devices, but surgery is often needed to better stabilize the spine and prevent further spinal cord damage. Typical surgical procedures include spinal fusion to manage cervical injuries. Metal wiring is used to secure bone chips taken from the patient’s hip or other source of bone grafting, such as donor bone tissue. Chapter 9 discusses general postoperative nursing care.
After surgical spinal fusion, assess the patient’s neurologic status and vital signs at least every hour for the first 4 to 6 hours and then, if the patient is stable, every 4 hours. Assess for complications of surgery, including worsening of motor or sensory function at or above the site of surgery. Document your assessments carefully and in detail. Failure to do so may prevent other staff members from quickly recognizing deterioration in neurologic status.
The patient may be placed in fixed skeletal traction to maintain vertebral alignment, facilitate bone healing, and prevent further injury, often after surgical stabilization. The most commonly used device for immobilization of the cervical spine is the halo fixator device, also called a halo crown, which is worn for 6 to 12 weeks. This static device is affixed by four pins (or screws) into the outer aspect of the skull and is connected to a vest or jacket (Fig. 37.7). For patients not having surgery, the addition of traction helps reduce the fracture.
Nursing Safety Priority
Action Alert
Never move or turn the patient by holding or pulling on the halo device. Do not adjust the screws holding it in place. Check the patient’s skin frequently to ensure that the jacket is not causing pressure. Pressure is avoided if one finger can be inserted easily between the jacket and the patient’s skin. Monitor the patient’s neurologic status for changes in movement or decreased strength. A special wrench is needed to loosen the vest in emergencies such as cardiopulmonary arrest. Tape the wrench to the vest for easy and consistent accessibility. Do not use sharp objects (e.g., coat hangers, knitting needles) to relieve itching under the vest; skin damage and infection will slow recovery.
Common complications of the halo device are pin loosening, local infection, and scarring. More serious but less common complications include osteomyelitis (cranial bone infection), subdural abscess, and instability. Hospital policy is followed for pin-site care, which may specify the use of solutions such as saline. Vaseline dressings may also be used. Monitor the patient for indications of possible infection (e.g., fever, purulent drainage from the pin sites), and report any changes to the primary health care provider immediately.
For thoracic and lumbar fusions, metal or steel rods (e.g., Harrington rods) are used to keep the bone ends in alignment after fracture reduction. After surgery the patient usually wears a molded plastic support (cervical or thoracic-lumbar or both) to keep the injured and operative areas immobilized during recovery. Postoperative care is similar to that described in Chapter 9.
Because SCI is a physical trauma, the patient is started on a proton pump inhibitor, such as pantoprazole, to help prevent the development of stress ulcers. This drug may be administered IV or orally. Oral doses may be taken with or without food (Burchum & Rosenthal, 2022). An anticoagulant may be given as part of the VTE prevention protocol. Bulk-forming laxatives or stool softeners are given to prevent constipation.
FIG. 37.7 Halo fixation device with jacket.
Other drugs to prevent or treat complications of immobility may be needed later during the rehabilitative phase. For example, celecoxib may be prescribed to prevent or treat heterotopic ossification (bony overgrowth). However, recall that the adverse effects of this drug include an increased risk of myocardial infarction and stroke. Calcium and bisphosphonates may prevent the osteoporosis that results from lack of weight-bearing or resistance activity. Osteoporosis can cause fractures in later years. Early and continued exercise may help decrease the incidence of these complications.
Centrally acting skeletal muscular relaxants may help control muscle spasticity. Intrathecal baclofen (ITB) therapy may be prescribed to treat muscle spasms without incurring the drowsiness and sedation often seen with oral medications (Burchum & Rosenthal, 2022). This drug is administered through a programmable, implantable infusion pump and intrathecal catheter directly into the cerebrospinal fluid. The pump is surgically placed in a subcutaneous pouch in the lower abdomen. Monitor for common adverse effects, which include sedation, fatigue, headache, hypotension, and changes in mental status (Burchum & Rosenthal, 2022). Seizures and hallucinations may occur if ITB is suddenly withdrawn.
NCLEX Examination Challenge 37.3
Safety and Infection Control
A nurse is caring for a client with a spinal cord injury being treated with a halo fixator with vest. Which action by the nurse is most important for client safety?
A. Assess the pin sites daily.
B. Ensure that the wrench is taped to the vest.
C. Provide straws for ease of drinking.
D. Keep the client in a sitting position.
Managing Decreased Mobility
Planning: Expected Outcomes
The patient with an SCI is expected to be free from complications of decreased mobility and perform ADLs as independently as possible with or without assistive-adaptive devices.
Interventions
Patients with an SCI are especially at risk for pressure injuries due to altered sensory perception of pressure areas on skin below the level of the injury. They are also at risk for venous thromboembolism (VTE), contractures, orthostatic hypotension (especially in patients with high SCI), and fractures related to osteoporosis due to impaired mobility. Frequent and therapeutic positioning not only helps prevent complications but also provides alignment to prevent further SCI or irritability. Reposition patients frequently (every 1 to 2 hours). Assess the condition of the patient’s skin, especially over pressure points, with each turn or repositioning. Turning may be performed manually, or the patient may be placed on an automatic rotating bed. Reduce pressure on any reddened area, and monitor it with the next turn. When sitting in a chair, patients are repositioned or taught to reposition themselves more often than every hour. Paraplegic patients usually perform frequent “wheelchair push-ups” to relieve skin pressure. Use a pressure-reducing mattress and wheelchair or chair pad to help prevent skin breakdown. Prevent pressure injuries by using best practices as described in Chapter 21. The prevention of VTE includes the interventions of intermittent pneumatic compression stockings and low–molecular-weight heparin (LMWH).
Patients with cervical cord injuries especially are at high risk for orthostatic (postural) hypotension, but anyone who is immobilized may have this problem. If the patient changes from a lying position to a sitting or standing position too quickly, the patient may experience hypotension, which could result in dizziness and falls. Because of interrupted sympathetic innervation caused by the SCI, the blood vessels do not constrict quickly enough to push blood up into the brain. The resulting vasodilation causes dizziness or light-headedness and possible falls with syncope (“blackout”).
In collaboration with the rehabilitation team, teach or reinforce teaching for bed mobility skills and bed-to-chair transfers. Patients with paraplegia are usually able to transfer from the bed to chair or wheelchair with minimal or no assistance unless balance is a problem (seen in patients with high thoracic injuries). Techniques to improve balance are usually taught by occupational or physical therapists. Tetraplegic patients may learn how to transfer using a slider, also called a sliding board. This simple boardlike device allows the patient to move from the bed to chair or vice versa by creating a bridge. When using the slider, remind patients to lift the buttocks while moving incrementally and slowly across the board. Patients with severe muscle spasticity have more challenges when learning transfer skills, and contractures are common. Contractures may be prevented or minimized with splints and range-of-motion exercises. Managing decreased mobility requires communication and coordination among multiple members of the health care team, as described in Box 37.4.
Box 37.4 Interprofessional CollaborationCare of Patients With Spinal Cord Injury
Consult with the physical therapist (PT) and occupational therapist (OT) to ensure positive patient outcomes. Coordinate care with the rehabilitative team to ensure collaborative care. According to the Interprofessional Education Collaborative (IPEC) Expert Panel’s Competency of Interprofessional Communication, be sure to use language that is easily understood by the patient when coordinating care. Avoid discipline-specific terminology when possible (IPEC, 2016; Slusser et al., 2019).
All patients with an SCI require bowel and bladder retraining, including adequate fluids (1.5 to 2 L each day) and stool softeners to prevent constipation from immobility and the injury itself. Those with upper motor neuron lesions (usually cervical and high thoracic injuries) have spastic bowel and bladder function with an intact spinal reflex for elimination. However, voiding patterns may be uncontrollable and require long-term indwelling or external catheters, leading to frequent urinary tract infections (Elliott et al., 2021). An implanted intraurethral device may be an option for some female SCI patients (Schimke & Connolly, 2020). Rectal suppositories are often successful to promote regular bowel elimination.
The patient with a lower motor neuron lesion has a flaccid bowel and bladder. Intermittent urinary catheterizations, manual pressure over the bladder area, and bowel disimpaction on a regular basis help to establish a routine. Chapter 7 describes bowel and bladder training in more detail.
In patients with established or long-term SCI, assess baseline ability, and encourage their participation in self-care and management. Encourage family members’ participation in care, and support their effort to keep the patient engaged in family life.
Care Coordination and Transition Management
Rehabilitation Phase
Rehabilitation after an acute SCI begins in the acute or critical care unit when patients are hemodynamically stable. They are usually transferred from the acute care setting to a rehabilitation setting, where they learn more about self-care, mobility skills, and bladder and bowel retraining. The primary purpose of rehabilitation for a SCI is to enable patients to function independently in their communities. However, physical barriers still exist in some communities that prevent the patient in a wheelchair from finding a parking place, using sidewalks, and attending activities or accessing resources (Smeltzer, 2021) (Fig. 37.8). Chapter 7 describes nursing care and the role of rehabilitative services in detail.
One new but promising therapy in rehabilitation is functional electrical stimulation (FES). FES uses small electrical pulses to paralyzed muscles to restore or improve their function. It is commonly used for exercise, but it is also used to assist with breathing, grasping, transferring, standing, and walking. The occupational therapist instructs the patient in the correct use of all adaptive equipment and therapies.
FIG. 37.8 Community physical barrier example: A curb prevents the patient in a wheelchair from getting onto the sidewalk.
Wearable robotic exoskeletons have also shown promise in improving quality of life in patients with spinal cord injury (Chis et al., 2020). These battery-powered devices typically fit over the hips and lower extremities, allowing clients to “walk” at home and in the community.
Living with a Spinal Cord Injury in the Community
A full-time caregiver or personal assistant is sometimes required when the patient with tetraplegia returns home from rehabilitation. The caregiver may be a family member or a nursing assistant employed to help provide care and companionship. A patient who is paraplegic is usually able to provide self-care without assistance after an appropriate rehabilitation program. Abu-Baker et al. (2021) conducted a study to determine which specific factors contribute to high self-care ability and quality of life for patients with SCI living in the community (see the Evidence-Based Practice box).
In addition to self-care ability, sexual function after SCI also depends on the level and extent of injury. Incomplete lesions allow some control over sensory perception and mobility. Complete lesions disconnect the messages from the brain to the rest of the body and vice versa. However, men with injuries above T6 are often able to have erections by stimulating reflex activity. For example, stroking the penis will cause an erection. Ejaculation is less predictable and may be mixed with urine. However, urine is sterile, so the patient’s partner will not get an infection. To prevent autonomic dysreflexia (AD), prophylactic administration of a vasodilator may be needed before intercourse.
Women with an SCI have a different challenge because they have indwelling urinary catheters more commonly than men. Some women do become pregnant and have full-term children. For others, ovulation stops in response to the injury. In this case, alternate methods for pregnancy, such as in vitro fertilization, may be an option. Some women also report vaginal dryness. Recommend a water-soluble lubricant for both partners to promote comfort during intercourse.
Evidence-Based Practice
What Factors Predict a High Quality of Life for Patients Who Have a Spinal Cord Injury?
Abu-Baker, N. N., Al-Zyoud, N. H., & Alshraifeen, A. (2021). Quality of life and self-care ability among individuals with spinal cord injury. Clinical Nursing Research, 30(6), 883–891.
The researchers studied a convenience sample of 152 individuals living with a spinal cord injury in the community to identify their self-care ability, quality of life, and related factors. Two tools were used to collect data—the Modified Barthel Index of ADL and the World Health Organization Quality of Life—BRIEF. The results showed that 55.3% of the sample reported moderate dependence on others to support self-care, 48% reported a good quality of life, and 65.8% were satisfied with their health. Having paraplegia or an incomplete SCI at any level significantly predicted the highest self-care ability. The highest quality of life was reported by males who had a high educational level, paraplegia, an incomplete spinal injury, and no pressure injuries.
Level of Evidence: 4
This was a descriptive study that used a convenience sample.
Implications for Nursing Practice and Research
Nurses need to recognize that many patients with spinal cord injury can enjoy a high level of independence and quality of life. This research indicates that educated men who have incomplete paraplegia and no complications of mobility would likely have the best quality of life when compared to other individuals who have SCI. More research is needed to determine what factors prevent women from having the same quality of life as their male counterparts. Research is also needed using a larger study sample.
About 25% of the U.S. population lives with a disability, including those who have an SCI. Research has shown that disabled individuals are less likely than those without a disability to seek preventive health care services.
Meeting Healthy People 2030 Objectives
Preventive Health and Disability
One major goal of Healthy People 2030 is to increase the health and well-being of people living with disabilities. Barriers such as difficulty in obtaining health care access or inadequate financial ability to pay for preventive services contribute to the lack of health promotion. Nurses should help patients locate affordable local community resources for preventive health to improve their overall health and well-being.
Many individuals have had their SCI for many years and continue to function successfully as productive members of the community. Teach patients what they need to know about health and aging, especially when living with an SCI (see Patient-Centered Care: Older Adult Health box).
Patient-Centered Care: Older Adult Health
What Patients Need to Know About Aging With Spinal Cord Injury
Health Teaching Rationale
Follow guidelines for adult vaccination, particularly influenza and pneumococcus vaccination recommendations. Respiratory complications are the most common cause of death after spinal cord injury (SCI).
For women, have Papanicolaou (Pap) smears and mammograms as recommended by the American Cancer Society or your primary health care provider. Limitations in movement may make breast self-awareness difficult.
Take measures to prevent osteoporosis, such as increasing calcium and vitamin D intake, avoiding caffeine, and not smoking. Exercise against resistance can maintain muscle strength and slow bone loss. Women older than 50 years often lose bone density, which can result in fractures. Men can also have osteoporotic fractures as a result of immobility.
Practice meticulous skin care, including frequent repositioning, using pressure-reduction surfaces in bed and chairs/wheelchairs, and applying skin protective products. As a person ages, skin becomes dry and less elastic, predisposing the patient to pressure injuries.
Take measures to prevent constipation, such as drinking adequate fluids, eating a high-fiber diet, adding a stool softener or bowel stimulant daily, and establishing a regular time for bowel elimination. Constipation is a problem for most patients with SCI, and bowel motility can slow, contributing to constipation later in life.
Modify activities if joint pain occurs; use a powered rather than a manual wheelchair. Ask the primary health care provider about treatment options. Arthritis occurs in more than half of people older than 65 years. Patients with SCI are more likely to develop arthritis as a result of added stress on the upper extremities when using a wheelchair.
Unfortunately, some patients living with SCIs living in the community are periodically admitted to the acute care or long-term care setting for complications of immobility, such as pressure injuries or fractures resulting from osteoporosis. Pressure injuries contribute to local or systemic infection, including osteomyelitis and septicemia. Priorities in care may need to be reevaluated as complications occur and resolve.
Refer patients and their families to local, state or province, and national organizations for more information and support for patients with SCI. These organizations include the United Spinal Association (www.unitedspinal.org) in the United States and Spinal Cord Injury Canada (www.sci-can.ca). Many excellent consumer-oriented books, journals, and DVDs are also available. Support groups may help the patient and family adjust to a changed lifestyle and provide solutions to commonly encountered problems.
Patient-Centered Care: Veteran Health
Health Care Resources for Veterans With Spinal Cord Injury
The U.S. Veterans Health Administration services is the largest provider of SCI care in the world (Elliott et al., 2021). The Paralyzed Veterans of America (PVA) (www.pva.org) can assist with educational materials, caregiver services, medical equipment, and support groups. The PVA also sponsors spinal cord research and raises money to help veterans with a variety of needs. It also supports wheelchair-sports teams composed of veterans with an SCI or diseases that affect the spinal cord.
The Independence Program of the Wounded Warriors Project is designed to help veterans with neurologic health conditions such as SCI and traumatic brain injury to progress toward independent living. This nonprofit program offers services such as wellness, life skills, and social and recreational activities (Elliott et al., 2021).
Evaluate Outcomes: Evaluation
Evaluate the care of the patient with an SCI based on the identified priority patient problems. The expected outcomes are that the patient:
• Exhibits no deterioration in neurologic status
• Maintains a patent airway, a physiologic breathing pattern, and adequate ventilation
• Does not experience a cardiovascular event (e.g., shock, hemorrhage, autonomic dysreflexia) or receives prompt treatment if an event occurs
• Does not experience secondary complications, including VTE and heterotopic ossification
• Is free from complications of decreased mobility
• Performs mobility skills and basic ADLs as independently as possible with or without the use of assistive-adaptive devices
Low Back Pain (Lumbosacral Back Pain)
Back pain affects most adults at some time in their life. It can be recurrent, and subsequent episodes tend to increase in severity. The lumbosacral (lower back) and cervical (neck) vertebrae are most commonly affected because these are the areas where the vertebral column is the most flexible. Acute back pain is usually self-limiting and lasts less than 12 weeks. If the pain continues for 12 weeks (3 months) or more, the patient has chronic back pain (National Institute of Neurologic Disorders and Stroke, 2021).
Pathophysiology Review
Low back pain (LBP) occurs along the lumbosacral area of the vertebral column. Acute pain is caused by muscle strain or spasm, ligament sprain, disk (also spelled “disc”) degeneration (osteoarthritis), or herniation of the center of the disk, the nucleus pulposus. A herniated nucleus pulposus (HNP) in the lumbosacral area can press on the adjacent spinal nerve (usually the sciatic nerve), causing burning or stabbing pain down into the leg or foot, which in some cases can be severe (Fig. 37.9). Herniated disks occur most often between the fourth and fifth lumbar vertebrae (L4-L5) but may occur at other levels. The specific area of symptoms depends on the level of herniation.
FIG. 37.9 Spinal ligaments, degenerative disk, and herniated disk. (A) Ligaments of the spine. (B) Bulging disk with spinal nerve compression and degenerative disk showing collapse of vertebral body. (C) Herniated disk with spinal nerve compression. From Rogers, J. L. [2023]. McCance & Huether’s Pathophysiology: The biologic basis for disease in adults and children. [9th ed.]. St. Louis: Elsevier.
Left panel, A. The illustration shows the lateral view of the spine and identifies the following ligaments, from the top to the bottom: anterior longitudinal ligament, posterior longitudinal ligament, supraspinous ligament, ligamentum flavum, invertebral foramen, interspinous ligament, spinous process, inferior articular process, superior articular process, and transverse process. Middle panel, B. The illustration shows the lateral view of a section of the spinal cord, identifying a building disk at the top and a degenerative disk at the bottom. Right panel, C. The illustration shows the superior view of a herniated disk and identifies the spinal compression (foraminal stenosis).
In addition to acute or persistent pain, there may be both muscle spasm and numbness and tingling (paresthesia) in the affected leg because spinal nerves have both motor and sensory fibers. The HNP may press on the spinal cord itself, causing leg weakness. Bowel and bladder incontinence or retention may occur with motor nerve involvement because sacral spinal nerves have parasympathetic fibers that help control bowel and bladder function (Rogers, 2023).
Back pain may also be caused by spinal stenosis, which is a narrowing of the spinal canal, nerve root canals, or intervertebral foramina typically seen in people older than 50 years. This narrowing may be caused by infection, trauma, herniated disk, arthritis, and disk degeneration. Most adults older than 50 years have some degree of degenerative disk disease, although they may not be symptomatic.
LBP is most prevalent during the third to sixth decades of life but can occur at any time. Women have a higher incidence of LBP compared to men (Pfieffer, 2020). Acute back pain usually results from injury or trauma, such as during a fall or vehicular crash or when lifting a heavy object. The mechanisms of injury include repetitive flexion and/or extension and hyperflexion or hyperextension with or without rotation. Obesity places increased stress on the vertebral column and back muscles, contributing to risk for injury. Smoking has been linked to disk degeneration, possibly caused by constriction of blood vessels that supply the spine. Congenital spinal conditions such as scoliosis (an abnormal lateral curvature of the spine) can also lead to LBP at any age.
Patient-Centered Care: Older Adult Health
Older Adults and Low Back Pain
Older adults are at high risk for acute and chronic LBP. Vertebral fracture from osteoporosis contributes to LBP. Petite, older White women are at high risk for both bone loss and subsequent vertebral fractures. Specific factors that can cause LBP in the older adult include (Touhy & Jett, 2022):
• Spinal stenosis
• Hypertrophy of the intraspinal ligaments
• Osteoarthritis
• Osteoporosis
• Changes in vertebral support structures and malalignment with deformity
• Scoliosis
• Lordosis (an inward abnormal curvature of the lumbar spinal area)
• Vascular changes
• Diminished blood supply to the spinal cord or cauda equina caused by arteriosclerosis
• Blood dyscrasias
• Intervertebral disk degeneration
Vertebral compression fractures are discussed in Chapter 42.
Health Promotion/Disease Prevention
Many of the problems related to back pain can be prevented by recognizing the factors that contribute to tissue injury and taking appropriate preventive measures to prevent pain. For example, proper posture and exercise can significantly decrease the incidence of LBP. Box 37.5 summarizes various ways to help prevent LBP.
The U.S. Occupational Safety and Health Administration (OSHA) has mandated that all industries develop and implement plans to decrease musculoskeletal injuries among their workers. One way to meet this requirement is to develop an ergonomic plan for the workplace. Ergonomics is an applied science in which the workplace is designed to increase worker comfort (thus reducing injury) while increasing efficiency and productivity. An example is a ceiling lift designed to help nurses assist patients to get out of bed. A variety of equipment can be used to decrease injury related to moving patients. Professional guidelines and legislative rules promote safe patient handling and mobility for health care workers (ANA, 2022).
Box 37.5 Patient and Family EducationPrevention of Low Back Pain and Injury
• Use safe manual handling practices, with specific attention to bending, lifting, and sitting.
• Assess the need for assistance with your household chores or other activities.
• Participate in a regular exercise program, especially one that promotes back strengthening, such as swimming and walking.
• Do not wear high-heeled shoes.
• Use good posture when sitting, standing, and walking.
• Avoid prolonged sitting or standing. Use a footstool and ergonomic chairs and tables to lessen back strain. Be sure that equipment in the workplace is ergonomically designed to prevent injury.
• Keep weight within 10% of ideal body weight.
• Ensure adequate calcium intake. Consider vitamin D supplementation if serum levels are low.
• Stop smoking. If you are not able to stop, cut down on the number of cigarettes or decrease the use of other forms of tobacco.
Nurse Well-Being Reminder!
Remember: Avoid lifting patients or equipment to prevent back injury. Be sure that every patient area is equipped with an appropriate mechanical or electric lift. Follow best practices for safe patient handling and mobility, including ensuring that agency furniture is ergonomically designed to promote comfort while reducing injury.
Interprofessional Collaborative Care
Recognize Cues: Assessment
Physical Assessment/Signs and Symptoms
The patient’s primary concern is continuous pain. Some patients have so much pain that they walk in a stiff, flexed posture, or they may be unable to bend at all. They may walk with a limp, indicating possible sciatic nerve impairment. Walking on the heels or toes often causes severe pain in the affected leg, the back, or both.
Conduct a complete pain assessment as discussed in Chapter 6. Record the patient’s current pain score and the worst and best score since the pain began. Ask about precipitating or relieving factors, such as symptoms at night or during rest. Determine whether a recent injury to the back has occurred. It is not unusual for the patient to say, “I just moved to do something and felt my back go out.”
Inspect the patient’s back for vertebral alignment and tenderness. Examine the surrounding anatomy and lower extremities for secondary injury. Patients will often describe pain as stabbing and continuous in the muscle closest to the affected disk. They often describe a sharp, burning posterior thigh or calf pain that may radiate to the ankle or toes along the path of one or more spinal nerves. Pain usually does not extend the entire length of the limb. Patients may also report the same type of pain in the middle of one buttock or hip. The pain is often aggravated by sneezing, coughing, or straining. Driving a vehicle is particularly painful.
Ask whether paresthesia (tingling sensation) or numbness is present in the involved leg. Both extremities may be checked for sensory perception by using a cotton ball and a paper clip for comparison of light or dull and sharp touch. The patient may feel sensation in both legs but may experience a stronger sensation on the unaffected side. Ask about urinary and fecal continence and difficulty with urination or having new-onset constipation.
If the sciatic nerve is compressed, severe pain usually occurs when the patient’s leg is held straight and lifted upward. Foot, ankle, and leg weakness may accompany LBP. To complete the neurologic assessment, evaluate the patient’s muscle tone and strength. Muscles in the extremity or lower back can atrophy as a result of severe persistent back pain. The patient has difficulty with movement, and certain movements create more pain than others.
Ask patients whether they have frequent feelings of sadness or have considered suicide. For many patients, persistent pain can cause depression and/or suicidal ideation.
Imaging Assessment
Imaging studies for patients who report mild nonspecific back pain may not be done, depending on the nature of the pain. Patients with severe or progressive motor or sensory perception deficits or who are thought to have other underlying conditions (e.g., cancer, infection) require complete diagnostic assessment. To determine the exact cause of the pain, a number of diagnostic tests may be used, including:
• Plain x-rays (show general arthritis changes and bony alignment)
• CT scan (shows spinal bones, nerves, disks, and ligaments)
• MRI (provides images of the spinal tissue, bones, spinal cord, nerves, ligaments, musculature, and disks)
• Bone scan (shows bone changes after injection of radioactive tracers, which attach to areas of increased bone production or show increased vascularity associated with tumor or infection)
Electrodiagnostic testing, such as electromyography (EMG) and nerve-conduction studies, may help distinguish motor neuron diseases from peripheral neuropathy and radiculopathy (spinal nerve root involvement). These tests are especially useful in chronic diseases of the spinal cord or associated nerves. Chapter 35 describes these tests in more detail.
Take Actions: Interventions
Management of patients with low back pain varies with the severity and chronicity of the problem. If acute pain is not treated or managed effectively, persistent pain may occur. Most patients with acute LBP experience spontaneous resolution of pain and other symptoms in less than 3 months.
Some patients need only a brief treatment regimen of at-home exercise or physical therapy to manage pain. In general, return to work, if safe, is beneficial for recovery and well-being. Some patients have continuous or intermittent chronic pain that must be managed for an extended period. Referral to an interprofessional team that specializes in pain or back pain can provide expert long-term management.
Nonsurgical Management
For patients with acute, nonspecific LBP, nonpharmacologic measures are often the first-line treatment, although a recent clinical guideline published by the North American Spine Society (NASS, 2020) found insufficient evidence to support many of the most commonly recommended treatments. A short period of back rest with heat or ice may be prescribed; heat has been shown to offer some short-term benefits. Physical therapy can help strengthen surrounding muscles, and the therapist can educate the patient on preventing further injury. The NASS work groups could not find conclusive evidence to endorse ultrasound treatments, transcutaneous electrical nerve stimulation (TENS), laser therapy, traction, dry needling or acupuncture, bracing, or massage therapy, although individual patients may get relief from any of these modalities.
The patient should begin stretching exercises and resume normal daily activities as soon as possible, including returning to work, if safe to do so. Aerobic exercise has good evidence to support its use when the patient is able (NASS, 2020). Most patients also find that they need to change position frequently. Prolonged standing, sitting, or lying down increases back pain. If the patient must stand for a long time for work or other reasons, shoe insoles or special floor pads may help decrease pain.
The Williams position is typically more comfortable and therapeutic for the patient with acute LBP from a bulging or herniated disk. In this position, the patient lies in semi-Fowler’s position with a pillow under the knees to keep them flexed or sits in a recliner chair. This position relaxes the muscles of the lower back and relieves pressure on the spinal nerve root.
Many patients worry that their back pain will not resolve, and in some cases the pain can convert to a chronic condition. Other patients will have no further reoccurrences. The nurse should provide honest information and reassure patients that with care, another episode might never occur. NASS (2020) recommends that psychosocial and workplace factors, pain severity, prior episodes of back pain, and functional impairment be considered when assessing risk of chronicity. NASS was unable to find conclusive evidence that sleep quality, smoking, or obesity were predictive of a chronic condition.
Patients with chronic LBP are also initially managed with nonpharmacologic interventions. In addition to the measures described earlier, patients may benefit from complementary and integrative therapies, such as stress reduction, mindfulness, progressive muscle relaxation, and yoga. Pain catastrophizing has been shown to cause increased distress (Conti et al., 2020). Cognitive-behavioral therapy in addition to physical therapy had strong evidence to support its use in patients whose pain continues beyond 12 months (NASS, 2020).
If medications are needed, nonselective NSAIDs, such as aspirin, ibuprofen, and naproxen, are helpful. Although antidepressants and antiepileptics such as gabapentin are often prescribed, NASS does not recommend them in the treatment of LBP. On the other hand, patients with chronic pain may become depressed; in that case, antidepressants are appropriate. NASS also found insufficient evidence for treatment with steroids, either oral or IV. Opioids have a very limited role in the treatment of back pain; they are used sparingly and for a very short time if needed for acute pain. Topical capsicum provides good pain relief on a short-term basis; there is no evidence that lidocaine patches provide significant relief (NASS, 2020). Ziconotide is a potent analgesic sometimes used for patients who have severe persistent pain.
Muscle spasms can occur for which the provider may prescribe centrally acting muscle relaxants. Commonly used medications include diazepam, cyclobenzaprine, metaxalone, carisoprodol, and tizanidine.
Nursing Safety Priority
Drug Alert
All centrally acting muscle relaxants can cause sedation, dizziness, or light-headedness. Most muscle relaxants have anticholinergic properties (dry mouth, urinary retention, blurred vision, constipation, and tachycardia). These side effects, plus sedation, increase an older adult’s fall risk and should, therefore, be avoided in this population. All patients taking these medications should be advised to avoid driving or other potentially hazardous activities, drinking alcohol, or taking other CNS depressants. Metaxalone can cause liver damage (Burchum & Rosenthal, 2022).
Ziconotide should not be given to patients with severe mental health/behavioral health problems because it can cause psychosis. If symptoms such as hallucinations and delusions occur, teach patients to stop the drug immediately and notify their primary health care provider (Burchum & Rosenthal, 2022).
A physical therapist (PT) works with the patient to develop an individualized exercise program. The type of exercises prescribed depends on the location and nature of the injury and the type of pain. McKenzie exercises are often utilized to help reposition the misaligned vertebral disks, strengthen surrounding muscles, and teach the patient how to manage back (or neck) pain themselves (Mann et al., 2021). These exercises include extension and flexion positions to centralize the back pain. The patient does not begin exercises until acute pain is reduced by other means. Water therapy combined with exercise is helpful for some patients with chronic pain. The water also provides muscle resistance during exercise to prevent atrophy.
Weight reduction may help reduce persistent LBP by decreasing the strain on the vertebrae caused by excess weight. If the patient’s weight exceeds the ideal by more than 10%, caloric restriction is considered, although NASS found insufficient evidence that BMI is a predictor of recurrent back pain (NASS, 2020). Health care professionals must be sensitive when discussing weight reduction and include behavioral approaches to weight loss and positive reinforcement as part of the plan.
Surgical Management
Surgery may be performed if conservative measures fail to relieve persistent back pain or if neurologic deficits continue to progress. An orthopedic surgeon and/or neurosurgeon perform these surgeries. Two general surgical methods are used, depending on the severity and exact location of pain: minimally invasive surgery (MIS) and conventional open surgical procedures. MIS is not done if the disk is pressing into the spinal cord (central cord involvement).
Preoperative Care
Preoperative care for the patient preparing for lumbar spinal surgery is similar to that for any patient undergoing surgery (see Chapter 9). Teach the patient about postoperative expectations, depending on surgical method, including:
• Techniques to get into and out of bed
• Turning and moving in bed
• Immediately reporting new sensory perception, such as numbness and tingling, or new motor impairment that may occur in the affected leg or in both legs
• Home care activities and restrictions, if any
As part of preoperative teaching, make sure that patients understand the type of procedure they are having and the postoperative care that will be needed. A recent randomized controlled trial found that the knowledge of patients about their surgical procedures was inadequate. There was no significant difference between the knowledge of patients who had routine preoperative education and of patients who had specific preoperative education on their spinal surgical procedures (Kesänen et al., 2019).
Newer surgical procedures allow many patients to have same-day surgery. Other patients are discharged to home within 23 to 48 hours after surgery. Therefore, teach family members or other caregivers how to assist the patient and what restrictions the patient must follow at home before surgery occurs.
Operative Procedures
Minimally invasive surgery (MIS) using endoscopy or percutaneous instrumentation results in minimal muscle injury, decreased blood loss, and decreased postoperative pain. Therefore, the primary advantages of MIS procedures are a shortened hospital stay, less pain, and the possibility of an ambulatory care (same-day) procedure. Spinal cord and nerve complications are also less likely. Several specific procedures are commonly performed.
A microdiskectomy involves microscopic surgery directly through a 1-inch incision using an endoscope. This procedure allows easier identification of anatomic structures, improved precision in removing small fragments, and decreased tissue trauma and pain. A special cutting tool or laser probe is threaded through the cannula for removal or destruction of the disk pieces that are compressing the nerve root. This process is also called a percutaneous endoscopic diskectomy (PED). A newer procedure combines the PED with laser thermodiskectomy to also shrink the herniated disk before removal. Inpatient hospitalization is not necessary for this procedure.
Laser-assisted laparoscopic lumbar diskectomy combines a laser with modified standard disk instruments inserted through the laparoscope using an umbilical (“belly button”) incision. The procedure may be used to treat herniated disks that are bulging but do not involve the vertebral canal. The primary risks of this surgery are infection and nerve root injury. The patient is typically discharged in 23 hours but may go home sooner.
The newest addition to MIS procedures is robot-assisted spinal surgery. This procedure requires additional training and experience for the surgeon and is currently limited to assistance with hardware placement (Staub & Sadrameli, 2019).
The most common open surgical procedures are diskectomy, laminectomy, and/or spinal fusion. Artificial disk replacement may also be part of this type of surgery. These procedures involve a surgical incision to expose anatomic landmarks for extensive muscle and soft-tissue dissection. The location and length of incision depends on the procedure and on surgeon preference and training.
As the name implies, a diskectomy is removal of a herniated disk. A laminectomy involves removal of part of the laminae and facet joints to obtain access to the disk space. A spinal fusion connects two or more vertebrae to stabilize the spine and release compression on spinal nerves. In an interbody cage fusion surgery, a titanium mesh device is implanted into the space where the disk was removed, and several screws ensure stabilization.
When repeated laminectomies are performed or the spine is unstable, the surgeon may perform a spinal fusion (arthrodesis) with bone graft to stabilize the affected area. Chips of cadaver bone are ground and grafted between the vertebrae for support and to strengthen the back. Metal implants (usually titanium pins, screws, plates, or rods) may be required to ensure the fusion of the spine. The surgeon may give an intrathecal (spinal) or epidural dose of long-acting morphine to decrease postoperative pain.
Postoperative Care
Postoperative care depends on the surgical method and procedure that was performed. In the postanesthesia care unit (PACU), vital signs and level of consciousness are monitored frequently, as for any surgery. Best practices for PACU nursing care are discussed in Chapter 9. Patients who have a minimally invasive spinal surgery go home the same day or the day after surgery with one or more wound closure tapes over the small incision. Those having a microdiskectomy may also have a clear or gauze dressing over the bandage. Most patients notice less pain immediately after surgery, but mild oral analgesics are needed while nerve tissue heals over the next few weeks to promote patient comfort. Teach the patient to follow the prescribed exercise program, which begins immediately after discharge. Patients should start walking routinely every day. Complications of MIS are rare.
Early postoperative nursing care focuses on preventing and assessing complications that might occur in the first 24 to 48 hours for patients having conventional open surgeries. Major complications for open traditional lumbar spinal surgery include nerve injuries, diskitis (disk inflammation), and dural tears (tears in the dura covering the spinal cord). Table 37.2 highlights major complications of open conventional back surgery, nursing assessment, and interventions to manage each complication.
As for any patient undergoing surgery, take vital signs at least every 4 hours during the first 24 hours to assess for fever, hypotension, or severe pain. Perform a neurologic assessment every 4 hours. Of particular importance are movement, strength, and sensory perception in the lower extremities.
Carefully check the patient’s ability to void after urinary catheter removal. Acute back pain and a flat position in bed make voiding difficult, especially for men. An inability to void may indicate damage to the sacral spinal nerves, which control the detrusor muscle in the bladder. The patient with an open traditional diskectomy, laminectomy, and/or traditional open spinal fusion typically gets out of bed with assistance on the evening of surgery, which may help with voiding.
Table 37.2
Assessing and Managing the Patient With Major Complications of Open Traditional Lumbar Spinal Surgery
Complication Assessment and Interventions
Cerebrospinal fluid (CSF) leakage
Observe for clear fluid on or around the dressing.
If leakage occurs, place patient flat.
Report CSF leakage immediately to the surgeon. (The patient is usually kept on flat bed rest for several days while the dural tear heals.)
Fluid volume deficit
Monitor intake and output; assess for dehydration, including vital signs and skin turgor.
Monitor vital signs carefully for hypotension and tachycardia.
Acute urinary retention
Assist the patient to the bathroom or a bedside commode as soon as possible after surgery or urinary catheter removal.
Help male patients stand at the bedside as soon as possible after surgery or urinary catheter removal.
Paralytic ileus
Monitor for flatus or stool.
Assess for abdominal distention, nausea, and vomiting.
Fat embolism syndrome (more common in people with traditional open spinal fusion)
Observe for and report chest pain, dyspnea, anxiety, and mental status changes (more common in older adults).
Note petechiae around the neck, upper chest, buccal membrane, and conjunctiva.
Monitor arterial blood gas values for decreased PaO2.
Persistent or progressive lumbar radiculopathy (nerve root pain)
Report pain not responsive to analgesics.
Document the location and nature of pain.
Administer analgesics as prescribed.
Infection (e.g., wound, diskitis, hematoma)
Monitor the patient’s temperature carefully (a slight elevation is normal). Increased temperature elevation or a spike after the second postoperative day may indicate infection.
Report increased pain or swelling at the wound site or in the legs.
Give antibiotics as prescribed if infection is confirmed.
Nursing Safety Priority
Critical Rescue
For the patient after back surgery, inspect the surgical dressing for blood or any other type of drainage. Clear drainage may mean cerebrospinal fluid (CSF) leakage. Blood and CSF may be mixed on the dressing, with the CSF being visible as a “halo” around the outer edges of the dressing. The loss of a large amount of CSF may cause the patient to report having a sudden headache. If a CSF leak is suspected, keep the patient on bed rest and lower the head of the bed immediately to slow the loss of fluid! Report signs of any drainage on the dressing to the surgeon or Rapid Response Team. Bulging at the incision site may be due to a CSF leak or a hematoma, both of which should also be reported immediately.
Correct turning of the patient in bed who is recovering from open traditional lumbar spinal injury is especially important. Do not place an overhead trapeze on the bed to assist the patient with mobility skills. This apparatus can cause more back pain and damage the surgical area. Teach the patient to log roll every 2 hours from side to back and vice versa. In log rolling, the patient turns as a unit while the back is kept as straight as possible. A turning sheet may be used for obese patients. Either turning method may require additional assistance, depending on how much the patient can assist. Instruct the patient to keep the back straight when getting out of bed. The patient should sit in a straight-back chair with the feet resting comfortably on the floor. As with all surgical patients, prevent atelectasis and hypostatic pneumonia with deep breathing and incentive spirometry.
Core Measures
Prevention of VTE
Follow best practices to avoid venous thromboembolism (VTE) after surgery with early mobility, intermittent sequential compression or pneumatic devices, and an anticoagulant/antiplatelet drug per The Joint Commission’s Core Measures.
When a lumbar spinal fusion is performed in addition to an open laminectomy, more care is taken with positioning. The nurse or assistive personnel (AP) assist with log rolling the patient every 2 hours while in bed. Remind the patient to avoid prolonged sitting or standing. Be sure to check with the surgeon or surgeon’s prescription regarding whether to place the orthotic device or brace on the patient before or after getting the patient out of bed.
Care Coordination and Transition Management
The patient with back pain who does not undergo surgery is typically managed at home. If back surgery is performed, the patient is usually discharged to home with support from family or significant others. For older adults without a community support system, a short-term stay in a nursing home or transitional care unit may be needed. Collaborate with the case manager or discharge planner, patient, and family to determine the most appropriate placement.
Patients having any of the MIS procedures or a lumbar interbody fusion may resume normal activities within a few days up to 3 weeks after surgery, depending on the specific procedure and the condition of the patient. The patient may take a shower on the third or fourth day after surgery. Teach the patient to leave the wound closure tapes in place for removal by the surgeon or until they fall off. Instruct the patient to contact the primary health care provider immediately if clear drainage seeps from the incision. Clear drainage usually indicates a dural tear and that cerebrospinal fluid is leaking.
After conventional open lumbar surgery, the patient may have activity restrictions and recommendations for the first 4 to 6 weeks, such as:
• Limit daily stair climbing.
• Restrict or limit driving.
• Do not lift objects heavier than 5 lb.
• Restrict pushing and pulling activities (e.g., dog walking).
• Avoid bending and twisting at the waist.
• Take a daily walk.
While the bone graft heals for an open spinal fusion, the patient may wear a back orthotic device for 4 to 6 weeks or longer after surgery. Provide information about the importance of wearing the brace as instructed during the healing process, how to take it off and put it on while maintaining spinal alignment, and how to clean it.
The duration of home-based recovery depends on the nature of the patient’s job and the extent and type of surgery. Most patients return to work after 2 to 6 weeks; some patients having more complex open spinal procedures may not return for several months if their jobs are physically strenuous.
The primary health care provider may want the patient to continue taking antiinflammatory drugs or, if muscle spasm is present, to take muscle relaxants. Remind the patient and family about the possible side effects of drugs and what to do if they occur.
In a few patients, back surgery is unsuccessful. This situation, referred to as failed back surgery syndrome (FBSS), is a complex combination of organic, psychological, and socioeconomic factors. Repeated surgical procedures often discourage these patients, who must continue aggressive pain management after multiple operations. Nerve blocks, implantable spinal cord stimulators (neurostimulators), and other modalities may be needed on a long-term basis to help with persistent pain. A newer alternative is lysis of epidural adhesions, if present, through a minimally invasive technique (Geudeke et al., 2021).
Spinal cord stimulation is an invasive technique that provides persistent pain relief by applying an electrical field over the spinal cord. A trial with a percutaneous spinal cord stimulator is conducted to determine whether permanent placement is appropriate. If the trial is successful, electrodes are surgically placed internally in the epidural space and connected to an external or implanted programmable generator. The patient is taught to program and adjust the device to maximize comfort. Spinal cord stimulation can be extremely effective in select patients, but it is reserved for intractable (unrelenting and continuous) neuropathic pain syndromes that have been unresponsive to other treatments.
Nursing Safety Priority
Critical Rescue
For patients who have a spinal cord stimulator implanted in the epidural space, assess neurologic status below the level of insertion frequently. Monitor for early changes in sensory perception, movement, and muscle strength. Ensure that the patient can void without difficulty. If any changes occur, document and report them immediately to the surgeon!
Cervical Neck Pain
Cervical neck pain most often results from a bulging or herniation of the nucleus pulposus (HNP) in a cervical intervertebral disk, illustrated in Fig. 37.1. The disk tends to herniate laterally where the annulus fibrosus is weakest and the posterior longitudinal ligament is thinned.
Pathophysiology Review
The result of cervical HNP is spinal nerve root compression with motor and sensory manifestations and moderate to severe pain, typically in the neck, upper back (over the shoulder), and down the affected arm. The disk between the fifth and sixth cervical vertebrae (C5-C6) is affected most often.
If the disk does not herniate, nerve compression may be caused by osteophyte (bony spur) formation from osteoarthritis. The osteophytes press on the intervertebral foramen, which results in a narrowing of the disk and pressure on the nerve root. As with sciatic nerve compression, the patient with cervical nerve compression may have either continuous or intermittent chronic pain. When the disk herniates centrally, pressure on the spinal cord occurs and requires prompt surgery to prevent paresis or paralysis.
Cervical pain—acute or persistent— can also occur from muscle strain, ligament sprain resulting from aging, poor posture, lifting, tumor, rheumatoid arthritis, osteoarthritis, or infection. The typical history of the patient includes a report of pain and numbness or tingling when moving the neck, which radiates to the shoulder and down the arm. The pain may interrupt sleep and may be accompanied by a headache or numbness and tingling in the affected arm. To determine the exact cause, plain x-rays and imaging studies may be used. Electromyography/nerve conduction studies are used to help differentiate cervical radiculopathy, ulnar or radial neuropathy, carpal tunnel syndrome, or other peripheral nerve problems.
Interprofessional Collaborative Care
Conservative treatment for acute neck pain is the same as described for low back pain except prescribed exercises focus on the shoulders and neck. The physical therapist teaches the patient the correct techniques for performing “shoulder shrug,” “shoulder squeeze,” and “seated rowing.” Some primary health care providers prescribe a soft collar to stabilize the neck, especially at night. Using the collar for longer than 10 days can lead to decreased muscle strength and range of motion. For that reason, many providers do not recommend collars for cervical disk problems. Therapeutic manipulation (chiropractic interventions) alone or in combination with other interventions does not appear to cause harm for most patients but does not consistently reduce pain or disability.
If conservative treatment is ineffective, surgery may be required—either minimally invasive surgery or conventional open surgery. A neurosurgeon usually performs this surgery because of the complexity of the nerves and other structures in that area of the spine. For open procedures and depending on the cause and the location of the disk herniation, either an anterior or a posterior surgical approach is used.
One of the most commonly performed procedures is the anterior or lateral interbody cervical fusion (AICF or LICF). In these procedures, a titanium mesh device is implanted into the space where the cervical disk was removed, and several screws ensure stabilization. For clients who have multiple cervical disk herniations, a traditional anterior cervical diskectomy and fusion (ACDF) with bone grafting may be performed. This surgery is much more complex and causes more postoperative complications than the AICF or LICF. The patient having traditional ACDF usually wears a soft collar for about 2 to 3 weeks after surgery. Other general preoperative and postoperative care nursing interventions are the same as described in Chapter 9.
Nursing Safety Priority
Critical Rescue
The priority for care in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the patient has no problem with breathing. Swelling from the surgery can narrow the trachea, causing a partial obstruction. Surgery can also interfere with cranial innervation for swallowing, resulting in a compromised airway or aspiration. If these changes occur, open the patient’s airway, sit the patient upright, suction if needed, and provide supplemental oxygen. Promptly notify the surgeon or Rapid Response Team using SBAR, and document your assessment and interventions. Box 37.6 summarizes best practices for postoperative care and discharge planning.
Box 37.6 Best Practice for Patient Safety and Quality CareCare of the Patient After a Traditional Anterior Cervical Diskectomy and Fusion
Postoperative Interventions
• Assess airway, breathing, and circulation (first priority!).
• Check for bleeding and drainage at the incision site.
• Monitor vital signs and neurologic status frequently.
• Check for swallowing ability.
• Monitor intake and output.
• Assess the patient’s ability to void (may be a problem secondary to opiates or anesthesia).
• Manage pain adequately.
• Assist the patient with ambulation within a few hours of surgery, if able.
Discharge Teaching
• Be sure that someone stays with the patient for the first few days after surgery.
• Review drug therapy.
• Teach care of the incision.
• Review activity restrictions:
• No lifting
• No driving until surgeon permission received
• No strenuous activities
• Walk every day.
• Call the surgeon if symptoms of pain, numbness, and tingling worsen or if swallowing becomes difficult.
• Wear collar per the primary health care provider’s prescription.
Some patients are candidates for minimally invasive surgery (MIS), such as percutaneous cervical diskectomy (PCD) through an endoscope, with or without laser thermodiskectomy, to shrink the herniated portion of the disk. The care for these patients is very similar to that for the patient with low back pain who has MIS (see the discussion of surgical management of patients with low back pain earlier in this chapter).
Many patients have positive clinical outcomes after interbody fusion (ADIF or LDIF) procedures, reducing the need for more complex fusions with bone grafting (ACDF). The patient has a small incision and is able to return to work in a few weeks. Complications of these procedures are not common.
Patients may also benefit from the placement of an artificial disk, a surgical option that preserves movement of the vertebrae. Artificial disks are approved by the FDA. Although there is evidence of their safety, the long-term effects on patient health are not yet established.
GET READY FOR THE NEXT-GENERATION NCLEX® EXAMINATION!
Essential Nursing Care Points
Mastery Questions
1. A client with a C6 fracture recently underwent external fixation with a halo device. What statement by the client indicates the need for the nurse to provide immediate follow-up?
A. “This device feels as if it will be too heavy to get up.”
B. “My arms and shoulders feel different than they did earlier.”
C. “I don’t know if I want to wear this thing as long as they say I should.”
D. “My feet and toes still feel numb, even after this was put on.”
2. The nurse is teaching a client who will be taking an interferon beta-1a drug for multiple sclerosis. Which of the following instructions would the nurse include in the teaching for the client? Select all that apply.
A. “Take your pulse once a day.”
B. “Avoid crowds and people who are sick.”
C. “Notify your provider immediately if you get confused.”
D. “Rotate the injection site daily.”
E. “Take acetaminophen if you get body aches.”
F. “Monitor your weight daily.”
3. The nurse is providing education to a community group on preventing back injury. Which of the following recommendations would the nurse provide? Select all that apply.
A. “If you smoke, try to cut down or quit altogether.”
B. “Ask if your workplace has ergonomic evaluations.”
C. “Maintain a healthy weight.”
D. “Use good posture when sitting or standing.”
E. “Turn yourself in bed by log rolling.”
F. “Avoid prolonged sitting or standing.”
NGN Challenge 37.1
37.1.1
The nurse is caring for a 21-year-old client who was admitted for a C7 spinal cord injury.
History and Physical Nurses’ Notes Imaging Studies Laboratory Results
1315: Client admitted to rehabilitation unit this morning with cervical SCI after spinal fusion and halo fixator with vest. Alert and oriented × 4; lung sounds clear; S1S2 present; BS present × 4; indwelling urinary catheter draining large amount of yellow clear urine. Vital signs: T 98.2°F (36.8°C); HR 76 beats/min; RR 20 breaths/min; BP 146/82 mm Hg; SpO2 97% on RA. Client’s goals are to increase mobility skills, control bowel and bladder, participate in self-care, and remain sexually active.
1435: Reports new-onset throbbing frontal headache with blurred vision and feeling very sleepy. Skin on face and neck flushed with profuse sweating. Vital signs: T 99°F (37.2°C); HR 58 beats/min; RR 22 breaths/min; BP 184/95 mm Hg; SpO2 95% on RA.
Select the 5 client findings that would require immediate follow-up.
○ Placement of a halo fixator with vest
○ New-onset throbbing frontal headache
○ Flushed skin on face and neck
○ Profuse sweating
○ Temperature of 99°F (37.2°C)
○ HR 58 beats/min
○ RR 22 breaths/min
○ BP 184/95 mm Hg
○ SpO2 95% on RA
37.1.2
The nurse is caring for a 21-year-old client who was admitted for a C7 spinal cord injury.
History and Physical Nurses’ Notes Imaging Studies Laboratory Results
1315: Client admitted to rehabilitation unit this morning with cervical SCI after spinal fusion and halo fixator with vest. Alert and oriented × 4; lung sounds clear; S1S2 present; BS present × 4; indwelling urinary catheter draining large amount of yellow clear urine. Vital signs: T 98.2°F (36.8°C); HR 76 beats/min; RR 20 breaths/min; BP 146/82 mm Hg; SpO2 97% on RA. Client’s goals are to increase mobility skills, control bowel and bladder, participate in self-care, and remain sexually active.
1435: Reports new-onset throbbing frontal headache with blurred vision and feeling very sleepy. Skin on face and neck flushed with profuse sweating. Vital signs: T 99°F (37.2°C); HR 58 beats/min; RR 22 breaths/min; BP 184/95 mm Hg; SpO2 95% on RA
For each client finding listed below, determine if the finding is consistent with the health conditions of spinal shock, neurogenic shock, or autonomic dysreflexia. Each finding may support more than 1 condition.
Client Findings Spinal Shock Neurogenic Shock Autonomic Dysreflexia
Profuse sweating
Flushed skin
Drowsiness
Elevated blood pressure
Bradycardia
Frontal headache
Blurred vision
37.1.3
The nurse is caring for a 21-year-old client who was admitted for a C7 spinal cord injury.
History and Physical Nurses’ Notes Imaging Studies Laboratory Results
1315: Client admitted to rehabilitation unit this morning with cervical SCI after spinal fusion and halo fixator with vest. Alert and oriented × 4; lung sounds clear; S1S2 present; BS present × 4; indwelling urinary catheter draining large amount of yellow clear urine. Vital signs: T 98.2°F (36.8°C); HR 76 beats/min; RR 20 breaths/min; BP 146/82 mm Hg; SpO2 97% on RA. Client’s goals are to increase mobility skills, control bowel and bladder, participate in self-care, and remain sexually active.
1435: Reports new-onset throbbing frontal headache with blurred vision and feeling very sleepy. Skin on face and neck flushed with profuse sweating. Vital signs: T 99°F (37.2°C); HR 58 beats/min; RR 22 breaths/min; BP 184/95 mm Hg; SpO2 95% on RA.
Complete the following sentence by selecting from the list of word choices below.
The priority at this time is to manage the client’s[Word Choice] to prevent[Word Choice].
Word Choices
Tachypnea
Elevated blood pressure
Fever
Stroke
Infection
37.1.4
The nurse is caring for a 21-year-old client with a C7 spinal cord injury.
History and Physical Nurses’ Notes Imaging Studies Laboratory Results
1315: Client admitted to rehabilitation unit this morning with cervical SCI after spinal fusion and halo fixator with vest. Alert and oriented × 4; lung sounds clear; S1S2 present; BS present × 4; indwelling urinary catheter draining large amount of yellow clear urine. Vital signs: T 98.2°F (36.8°C); HR 76 beats/min; RR 20 breaths/min; BP 146/82 mm Hg; SpO2 97% on RA. Client’s goals are to increase mobility skills, control bowel and bladder, participate in self-care, and remain sexually active.
1435: Reports new-onset frontal headache with blurred vision and feeling very sleepy. Skin on face and neck flushed with profuse sweating. Vital signs: T 99°F (37.2°C); HR 58 beats/min; RR 22 breaths/min; BP 184/95 mm Hg; SpO2 95% on RA.1450: Checked urinary catheter—no kinks and draining large amount of yellow clear urine. Notified primary health care provider. Vital signs: T 98.8°F (37.7°C); HR 56 beats/min; RR 20 breaths/min; BP 192/98 mm Hg; SpO2 95% on RA. Headache pain 8/10 and “feeling worse.”
The nurse begins to plan care for the client. Determine whether the following potential nursing actions are indicated or not indicated for the client at this time.
Potential Nursing Actions Indicated Not Indicated
Assess skin for new or worsening pressure injury
Monitor blood pressure every hour
Administer supplemental oxygen
Check for fecal impaction
Place the client in a flat supine position
Remove the client’s urinary catheter
37.1.5
The nurse is caring for a 21-year-old client with a C7 spinal cord injury.
History and Physical Nurses’ Notes Imaging Studies Laboratory Results
1315: Client admitted to rehabilitation unit this morning with cervical SCI after spinal fusion and halo fixator with vest. Alert and oriented × 4; lung sounds clear; S1S2 present; BS present × 4; indwelling urinary catheter draining large amount of yellow clear urine. Vital signs: T 98.2°F (36.8°C); HR 76 beats/min; RR 20 breaths/min; BP 146/82 mm Hg; SpO2 97% on RA. Client’s goals are to increase mobility skills, control bowel and bladder, participate in self-care, and remain sexually active.
1435: Reports new-onset frontal headache with blurred vision and feeling very sleepy. Skin on face and neck flushed with profuse sweating. Vital signs: T 99°F (37.2°C); HR 58 beats/min; RR 22 breaths/min; BP 184/95 mm Hg; SpO2 95% on RA.1450: Checked urinary catheter—no kinks and draining large amount of yellow clear urine. Notified physician. Vital signs: T 98.8°F (37.7°C); HR 56 beats/min; RR 20 breaths/min; BP 192/98 mm Hg; SpO2 95% on RA. Headache pain 8/10 and “feeling worse.”
1515: BP 188/92 mm Hg; headache starting to throb and reports pain of 9/10. Physician in to evaluate client.
The nurse plans interventions to manage the client’s condition. Which of the following nursing actions would the nurse plan to implement? Select all that apply.
○ Place the client in a sitting position.
○ Administer nifedipine per protocol.
○ Monitor the client’s headache pain intensity.
○ Observe client for any neurologic changes.
○ Monitor the client’s blood pressure every 10 to 15 minutes.
37.1.6
The nurse is caring for a 21-year-old client with a C7 spinal cord injury.
History and Physical Nurses’ Notes Imaging Studies Laboratory Results
1315: Client admitted to rehabilitation unit this morning with cervical SCI after spinal fusion and halo fixator with vest. Alert and oriented × 4; lung sounds clear; S1S2 present; BS present × 4; indwelling urinary catheter draining large amount of yellow clear urine. Vital signs: T 98.2°F (36.8°C); HR 76 beats/min; RR 20 breaths/min; BP 146/82 mm Hg; SpO2 97% on RA. Client’s goals are to increase mobility skills, control bowel and bladder, participate in self-care, and remain sexually active.
1435: Reports new-onset frontal headache with blurred vision and feeling very sleepy. Skin on face and neck flushed with profuse sweating. Vital signs: T 99°F (37.2°C); HR 58 beats/min; RR 22 breaths/min; BP 184/95 mm Hg; SpO2 95% on RA.1450: Checked urinary catheter—no kinks and draining large amount of yellow clear urine. Notified physician. Vital signs: T 98.8°F (37.7°C); HR 56 beats/min; RR 20 breaths/min; BP 192/98 mm Hg; SpO2 95% on RA. Headache pain 8/10 and “feeling worse.”
1515: BP 188/92 mm Hg; headache starting to throb and reports pain of 9/10. Physician in to evaluate client.
1550: Client reports headache pain of 5/10 after fecal disimpaction and nifedipine. Vital signs: T 98°F (36.7°C); HR 68 beats/min; RR 18 breaths/min; BP 132/82 mm Hg; SpO2 97% on RA. Skin remains slightly flushed.
Based on the Nurses’ Note entry at 1550, complete the following sentence by selecting from the lists of options below.
The most recent assessment findings indicate that the client’s condition has1[Select]as evidenced by2[Select] and 3[Select].
Options for 1 Options for 2 Options for 3
Worsened Continued headache pain Less headache pain
Improved Decreased temperature Increased oxygen saturation
Not changed Decreased blood pressure Continued skin flushing