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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.
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.
What are the possible complications of a spinal cord injury?
- Autonomic Instability
- Breathing problems
- 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.
What could be going on with Mr. White?
- He may be developing autonomic dysreflexia
What things should you assess in order to determine the problem?
- 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.
What is going on with Mr. White, physiologically?
- 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.
What medications might be ordered for Mr. White? What other nursing interventions should you include?
- Medications – nitroglycerin, calcium channel blockers (nifedipine)
- Passive cooling (ice or cool cloths)
- 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.
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.
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.
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