Spinal Cord Injury Case Study

Spinal Cord Injury Case Study
Patient Profile
Acute Phase
B.V., a 24-yr-old white man, is admitted to the emergency department with the diagnosis of a cervical
spinal cord injury (SCI). B.V. was swimming at a
neighbor’s backyard pool. He dove into the shallow
end, striking his head on the bottom of the pool. His
friends noticed that he did not resurface. They
rescued him and brought him to the side of the pool.
They maintained neck immobilization until the rescue
crews arrived.
Subjective Data
• Is awake and alert
• Is complaining of neck pain
• Is anxious and asking why he cannot move his legs
• Is asking to see his family
Objective Data
Physical Examination
• Weak biceps movement bilaterally
• No triceps movement bilaterally
• Gross elbow movement present bilaterally
• No movement in bilateral lower extremities
• Decreased sensation from the shoulders down
• No bladder or bowel control
• BP 85/50 mm Hg; pulse 56 beats/min; respirations 32 breaths/min and
labored
Diagnostic Studies
• CT C-spine shows C5 subluxation and compression fracture
• MRI C-spine shows a severe spinal cord compression at C5-6
Collaborative Care
• Intubated in the emergency department
• Started on mechanical ventilation
• Placed in tongs and traction on arrival to the ICU
Discussion Questions (Acute Phase)
1. Priority Decision: What nursing activities would be a priority on B.V.’s
arrival in the ICU?
2. What physiologic problems are causing B.V. to have hypotension and
bradycardia\
3. What would be the first line of treatment for B.V.’s hypotension and
bradycardia?
4. What signs and symptoms would indicate respiratory distress, and
what physiologic problem would cause respiratory distress in B.V.’s
injury state?
5. What can you do to decrease B.V.’s anxiety?
6. Priority Decision: Based on the assessment data provided, what
are the priority nursing diagnoses? Are there any collaborative
problems?
7. Delegation Decision: Identify activities that can be delegated to unlicensed assistive personnel (UAP).
Patient Profile
Rehabilitation Phase
B.V. is now 1 mo postinjury and is currently at a local inpatient SCI rehabilitation facility. He has since been extubated and uses a wheelchair to
mobilize. He eats three meals a day with assistance and is on a strict
bowel and bladder program.
Subjective Data
• Awake and alert but anxious
• Complaining of severe headache, blurred vision, and nausea
Objective Data
Physical Examination
• Flushed and diaphoretic above the level of injury
• No bowel movement for 2 days
• BP 235/106 mm Hg, pulse 32 beats/min, respirations 30 breaths/min
and labored
Discussion Questions (Rehabilitation Phase)
1. Priority Decision: What initial priority nursing interventions would be
appropriate?
2. What physiologic problem is causing B.V.’s hypertension and
bradycardia?
3. Once the physician has been notified, what other interventions would
be appropriate?
4. Priority Decision: Based on the assessment data provided, what are
the priority nursing diagnoses?
5. Patient and family involvement in the rehabilitation process is vital.
What teaching will you provide about bowel management?
6. Evidence-Based Practice: B.V. and his family are concerned about the
potential risk of autonomic dysreflexia. What information would you
provide the patient and