Mr. White is a 17 year old male who was injured in a snowboarding accident 3 weeks ago. He sustained a vertebral fracture and complete spinal cord injury at T7. His fracture has been stabilized with rods and screws. The plan is for him to be discharged home in 3 days with home health and family care.
Critical Thinking Check
Bloom's Taxonomy: Comprehension
Considering the level of the spinal cord injury, do you anticipate any concern for respiratory weakness?
No, not typically. The diaphragm is innervated by C3-C5, which is when we would have the most concern. At T7, there MIGHT be some weakness of the intercostal muscles, but the majority of the intercostal muscle movement will still be intact, as well as the diaphragm.
Critical Thinking Check
Bloom's Taxonomy: Application
What are the possible complications of a spinal cord injury?
Clots or other circulatory issues (i.e. neurogenic shock)
Discomfort or neuropathic pain
Elimination problems
Functional ability is decreased – they need help with ADL’s
Grief – this is a huge alteration in life and can cause grief and possible even depression
The CNA reports to you that the bath has been completed, there was no BM or incontinence of urine. However, Mr. White’s blood pressure has risen to 189/100 with a heart rate of 56. You immediately go to the room to check on Mr. White.
Would need to assess him closer, get a temperature and ask him about symptoms
Assess bowels, bladder, and skin to see if there is a specific irritating source.
You note that Mr. White is warm to touch, his temp is 103.6°F. You palpate his abdomen, which is soft and nondistended throughout. His bladder is also nondistended. He tells you he’s starting to feel very anxious You ask the CNA to help you turn Mr. White and you find a washcloth had been left under his back.
Mr. White has autonomic dysreflexia caused by the washcloth being left under his back.
This irritation in his skin caused his sympathetic nervous system (fight or flight) to overreact because of the impaired signals. This overreaction causes elevated BP, elevated temp, reflex bradycardia, anxiety/restlessness, and warm, flushed skin.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What medications might be ordered for Mr. White? What other nursing interventions should you include?
Remove the source – fix sheets, reposition, catheter to empty bladder, digital rectal disimpaction or enema or suppository for constipation
Together with the CNA, you remove the cloth, straighten Mr. White’s sheets, and make him comfortable. You provide a cool cloth for his forehead, and place a small ice pack under each armpit. You administer Nitroglycerin 0.4 mg SL as ordered. In 5 minutes you recheck and his BP has come down to 142/90, and his HR is 70. He reports his anxiety is decreasing and his temperature has come down to 100.6°F.
Critical Thinking Check
Bloom's Taxonomy: Analysis
What would you discuss with the CNA to prevent this from recurring in the future?
I would first determine if the CNA understands why Mr. White’s body reacted the way it did. Then I would help them understand possible causes of Autonomic Dysreflexia.
I would encourage the CNA to help keep Mr. White safe not only by ensuring that sheets are free of wrinkles and that nothing is left under him, but also continuing to report abnormal vital signs or any anxiety in the patient.
Critical Thinking Check
Bloom's Taxonomy: Application
What education will be required for Mr. White and his family on discharge to prevent complications?
Mr. White’s family needs to know s/s autonomic dysreflexia to look for as well as the instructions and methods for treatment, including the use of sublingual nitroglycerin or chewable nifedipine.
His family should also be taught how to monitor his vital signs and how to prevent the development of Autonomic Dysreflexia
His family should also be taught how to perform range of motion exercises and proper turning and positioning to prevent contractures or pressure ulcers.
They should also know what to report to the provider, including signs of pneumonia, DVT, or pressure ulcers.
This nursing case study course is designed to help nursing students build critical thinking. Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process. To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs. If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding. In the end, that is what nursing case studies are all about – growing in your clinical judgement.
Miriam Wahrman, MSN/Ed, RNC-MNN 
Chance Reaves, MSN-Ed, RN 