Introduction to Medical-Surgical Nursing, 6th ed.
29
Lesson Plans for
Spinal Cord Injury
CHAPTER LESSON PLANS & OBJECTIVES
Lesson 29.1:
2. Describe the diagnostic tests used to evaluate spinal cord injuries and related nursing responsibilities.
4. Describe the medical and surgical treatment during the acute phase of spinal cord injury.
Lesson 29.2:
6. Identify nursing diagnoses, goals, interventions, and outcome criteria for the patient with a spinal cord
injury.
8. Describe the nursing care for the patient undergoing a laminectomy.
CHAPTER TEACHING FOCUS
• In this chapter, students will be introduced to the effects of spinal cord injuries on patients, both
physically and emotionally.
• The chapter includes information on the diagnostic methods and nursing assessment of the patient with
CONCEPTS
The following conceptual themes and specific concepts match those presented in Giddens, J. R. (2013).
Concepts for nursing practice. St. Louis: Elsevier. The specific exemplars chosen and listed below for
each concept have been tailored specifically to correspond to the Linton textbook.
THEME: Protection and Movement
• Concept: Mobility
• Exemplar: Pathophysiology of Spinal Cord Injury, p. 513
• Figure 29-5: Mechanisms of spinal cord injury (SCI), p. 514
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Introduction to Medical-Surgical Nursing, 6th ed.
CHAPTER PRETEST
Have the students answer these questions prior to covering this chapter to understand where they stand
in relation to the content.
1) The most common causes of severe spinal cord injuries are __________.
a) assault and battery to the head and neck
b) osteoarthritis and degenerative changes of the vertebral column
c) the results of seat belts and inflated air bags
d) accidents involving motor vehicles, diving, or other sports
2) An imaging procedure that involves the injection of a radiopaque dye into the subarachnoid space is
a(n) __________.
a) computed tomogram
b) myelogram
c) electroencephalogram
d) pyelogram
3) Autonomic dysreflexia that occurs with a spinal cord injury __________.
a) causes vasodilation below the level of the injury
b) is a result of parasympathetic nerve stimulation
c) can be triggered by constipation or a full bladder
d) needs a cardiac defibrillator to be corrected
4) Which of the following devices rotates an immobile patient side to side to prevent pulmonary
complications?
a) Halo device
b) Gardner-Wells tongs
c) Roto-Rest bed
d) Philadelphia collar
5) The corticosteroid methylprednisolone achieves optimal results in spinal cord injury when given
within the first ______ hours of injury.
a) 8
b) 12
c) 24
d) 48
6) Any disruption in the blood supply to the spinal cord will __________.
a) result in cardiac damage
b) self-correct by an increase in blood pressure
c) result in neurologic damage
d) cause severe pain in the thoracic area
7) One example of an incomplete injury to the spinal cord is __________.
a) ankylosing spondylitis
b) Brown-Séquard syndrome
c) Down syndrome
d) Stevens-Johnson syndrome
8) Ineffective thermoregulation in a spinal cord–injured patient is the result of __________.
a) interruption of motor pathways
b) inability to turn, cough, and deep-breathe
c) bowel and bladder distention
d) disturbances in sensory input
9) Immediately after a spinal cord injury, the patient’s muscle strength is graded as 2 throughout both
lower extremities. This means that __________.
a) the muscles move when supported against gravity
b) the patient will never walk again
c) all sensation is probably absent
d) there will not be any long-term deficits
Introduction to Medical-Surgical Nursing, 6th ed.
10) Evidence for a nursing diagnosis of Ineffective coping in a patient with a spinal cord injury would be
__________.
a) urinary incontinence
b) the inability to do active range of motion (ROM)
c) the need for assistance with meals
d) refusal to do deep-breathing exercises
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Introduction to Medical-Surgical Nursing, 6th ed.
Chapter Pretest Answers
5) a
10) d
CHAPTER BACKGROUND ASSESSMENT
Discuss these questions with your students prior to covering this chapter to understand where they stand
in relation to the content.
Question: How is a diagnosis of incomplete spinal cord injury determined?
Question: What are possible psychosocial effects of a complete spinal cord injury?
Answer: A spinal cord injury causes a loss of physical independence that can lead to feelings of loss of
______________________________________________________________ Chapter 29 Spinal Cord Injury 5
Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 29.1
Instructor Preparation
Textbook Objectives Covered
1. Explain the impact of spinal cord injury.
3. Explain the physical effects of spinal cord injury.
4. Describe the medical and surgical treatment during the acute phase of spinal cord injury.
Lesson Preparation Checklist
• Prepare lecture from TEACH lecture slides available on Evolve.
• Guest speakers: representative from a spinal cord injury association
• Student performance evaluation of all entry-level skills required for student comprehension of
principles underlying spinal cord injury, including:
• The impact of spinal cord injury
• Diagnostic tests for spinal cord injury
• Acute care of spinal cord injury
Materials and Supplies
• computer and PowerPoint
projector
Key Terms
• autonomic dysreflexia
• spasticity (p. 516)
Student Preparation
Assignments 2 hours
1
READ – Textbook (pp. 509-517)
REVIEW
• Figure 29-5: Mechanisms of spinal cord injury (p. 514)
• Table 29-2: Incomplete Injuries and Related Neurologic Deficits (p. 515)
ANSWER – Text
ANSWER – Study Guide
• Part IA: 1-11 (pp. 171-172)
2
READ – Textbook (pp. 512-513)
REVIEW
ANSWER – Study Guide
• Part IIC: 8 (p. 173)
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 29.1
3
READ – Textbook (pp. 513-517)
REVIEW
• Figure 29-3: Degrees of loss and functional capability with injury (p. 515)
ANSWER Text:
• Review Questions for the NCLEX Examination: 2, 3, 4, 5 (p. 529)
ANSWER – Study Guide
• Part IIC: 1, 6, 9, 10 (pp. 172-173)
4
READ – Textbook (pp. 518-519)
REVIEW
• Figure 29-6: Gardner-Wells tongs (p. 518)
• Figure 29-7: The Halo device (p. 518)
ANSWER Text:
• Review Questions for the NCLEX Examination: 6, 7, 8, 9, 10 (pp. 529–530)
ANSWER – Study Guide
• Part IB: 2-4 (p. 172)
50-Minute Lesson Plan
Lecture Outline 20 minutes
Slide 1
Chapter 29
Spinal Cord Injury
1
Slide 2
Vertebral Column
• Consists of 33 vertebrae
• 7 cervical (C1 through C7)
• 12 thoracic (T1 through T12)
TALKING POINTS:
• The bony vertebral column consists of 33 vertebrae.
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 29.1
Slide 3
Vertebral Column (cont.)
• Each vertebra consists of a body and an arch
• The spinal cord passes through an opening in the center of each arch
Slide 4
• As we age, nucleus pulposus loses much of its water; less effective as a shock absorber
Disks
• Vertebrae separated by disks which serve as shock absorbers for the vertebral column
• Composed of anulus fibrosus and nucleus pulposus
• Anulus fibrosus: ring of tissue; encircles nucleus pulposus
TALKING POINTS:
• Who is at greater risk for back injuries and herniated disks?
• Intervertebral disks separate the vertebrae, each of which consists of a body and an arch.
Slide 5
Spinal Cord
• Extends from the brainstem to L2 in pelvic cavity
• Surrounded by three protective meningeal layers
• Dura mater
• Outermost layer
• Arachnoid
TALKING POINTS:
• The central canal is contiguous with which ventricle of the brain?
• The spinal cord extends from the medulla of the brainstem to the level of the second
lumbar vertebra.
Slide 6
cord.
Spinal Cord (cont.)
• Gray matter
• Consists of the bodies of nerve cells that control motor and sensory activities
• White matter
TALKING POINTS:
• Does the gray matter or the white matter form an H shape?
• Ascending tracts in the white matter carry sensory information from the spinal cord to the
brain.
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 29.1
Slide 7
Spinal Cord (cont.)
• Blood supply
• Major arterial supply to the spinal cord; consists of the vertebral arteries posteriorly
and the anterior spinal artery
• Reflexive activity
TALKING POINTS:
• Blood supply to the spinal cord is vital.
• What will be caused by a disruption in blood flow to the spinal cord?
Slide 8
Spinal Cord (cont.)
• Relay activity
• Stimulus enters spinal cord; travels up ascending tracts to relay sensory signals to the
TALKING POINTS:
• The descending white matter tracts also participate in the relay function of the spinal cord.
• They relay motor information, with messages being sent from the brain, down the cord, to
muscles, which affect various kinds of responses.
• What are four of the most important spinal cord tracts?
2
Slide 9
Diagnostic Tests and Procedures
• Neurologic examination
• Initial evaluation of the spinal cord: injured patient provides the nurse with a baseline
assessment of function and problems
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 29.1
Slide 10
Diagnostic Tests and Procedures (cont.)
• Imaging studies
• Radiography
• Detects vertebral compression, fractures, or problems with alignment
• Computed tomography (CT)
• Noninvasive examination of the specific levels of the spinal cord to be visualized,
TALKING POINTS:
• Radiography is repeated at intervals to evaluate the achievement of proper alignment with
treatment.
• The CT allows the physician to identify bony fractures, floating bone fragments,
3
Slide 11
Types of Injuries
• Location
• Cervical, thoracic, or lumbar
• Open or closed
• Closed: trauma in which the skin and meningeal covering that surround the spinal
cord remain intact
• Open: damage to the protective skin and meninges
TALKING POINTS:
• What are common causes of closed spinal cord injuries?
• Open injuries often result in either complete or partial transection (cutting across) of the
cord.
Effects of Spinal Cord Injury
• Factors include extent of cut and level of injury
TALKING POINTS:
• A complete injury cuts all descending and ascending tracts; the result is disruption of all
voluntary motor and sensory activity below the level of the injury.
• How does the reflex activity continue below the level of injury with a partial transection?
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 29.1
Effects of Spinal Cord Injury (cont.)
• The higher the level of injury, the more encompassing the neurologic dysfunction
• Injuries at or below T2 may cause paralysis of the lower part of the body
TALKING POINTS:
• What does the term tetraplegia mean?
Respiratory Impairment
• Injuries at or above the level of C5 may result in instant death because the nerves that
TALKING POINTS:
• Many patients with high cervical injuries die before reaching the hospital.
• What problems may occur with impairment of intercostal and abdominal muscles?
Slide 15
Spinal Shock
• An immediate, transient response to injury in which reflex activity below the level of the
injury temporarily ceases
TALKING POINTS:
Autonomic Dysreflexia
• Exaggerated response of autonomic nervous system to noxious (painful) stimuli
• With injury at or above the level of T6
TALKING POINTS:
• Autonomic dysreflexia is one of the most serious and potentially dangerous problems for
the spinal cord–injured patient.
• When does the risk of autonomic dysreflexia occur?
Slide 17
Autonomic Dysreflexia (cont.)
• Triggered by various stimuli including
• Distended bladder
• Constipation
• Renal calculi
TALKING POINTS:
• Many of these conditions can be prevented by a good nursing assessment.
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Introduction to Medical-Surgical Nursing, 6th ed.
LESSON 29.1
Slide 18
Spasticity
• Muscle spasms may be incapacitating for these patients, hampering efforts at
rehabilitation
TALKING POINTS:
• How is muscle tone evaluated?
Slide 19
Impaired Sensory and Motor Function
• Impaired motor function can affect the patient’s mobility and self-care and thus result in
complications from immobility
TALKING POINTS:
• The higher the level of the lesion, the more extensive the neurologic dysfunction.
Slide 20
Impaired Bladder Function
• During spinal shock, all bladder and bowel function ceases
• Once spinal shock resolves, reflex activity returns
TALKING POINTS:
• What medications may be used in the prevention of urinary tract infections?
Slide 21
Impaired Bowel Function
• Most spinal cord–injured patients can maintain bowel function because the large bowel
musculature has its own neural center that responds to distention by the fecal mass
TALKING POINTS:
• The absence of bowel activity in the first day or two after injury may require insertion of a
nasogastric tube for decompression.
• When does peristalsis usually return?
• To assist in evacuation of the bowel, the patient must take advantage of the abdominal
muscles; the patient must also have an appropriate diet.
Slide 22
Impaired Temperature Regulation
• May lose these regulatory mechanisms and be unable to adapt to temperature extremes
TALKING POINTS:
• What body responses normally help regulate temperature?
Slide 23
Impaired Sexual Function
• Spinal levels S2, S3, and S4 control sexual function, so injury at or above these levels
results in sexual dysfunction
• Ability to achieve erection and ejaculation is variable
TALKING POINTS:
• In females, menses resumes normally after injury.
• Can women with spinal cord injuries bear children?
12 Chapter 29 Spinal Cord Injury ______________________________________________________________
LESSON 29.1
Impaired Skin Integrity
• Because immobile patient cannot change positions, skin in sacral area and across bony
TALKING POINTS:
• Immobility and loss of sensation put the patient at risk for skin problems.
• What is one of the most common complications in the spinal cord–injured patient?
Slide 25
Altered Self-Concept and Body Image
• French and Phillips (1991) describe the effects of spinal cord injury on body image as
occurring in four phases: impact, retreat, acknowledgment, and reconstruction
TALKING POINTS:
• In the impact phase, the patient becomes aware of the devastating changes that have
taken place.
• The retreat phase is marked by depression and withdrawal as the patient considers the
implications of the injury.
4
Saving the Patient’s Life: Establish Airway
• Conventional head tilt–chin lift: inappropriate with spinal injury; increases risk of cord
Saving the Patient’s Life: Establish Airway (cont.)
• Once airway is open, administer 100% oxygen by mask and manual resuscitator
Slide 28
Preventing Further Cord Injury
• Traction
• Immobilization with skeletal traction manages cervical spinal cord injuries acutely
• Gardner-Wells tongs
TALKING POINTS:
• What is the purpose of traction with a cord injury?