3.4 SCI Acute Nursing Care, Mobilization & Complications

Acute Nursing Care and Complication Management

The nursing management of a patient with a spinal cord injury requires meticulous attention to detail across all body systems. Because the injury alters mobility, sensation, and autonomic function, patients are at high risk for a multitude of life-threatening complications. Care is focused on preserving function, preventing secondary complications, and initiating early rehabilitation.

Respiratory Management

Respiratory complications, particularly pneumonia and pulmonary embolism, are the leading causes of morbidity and mortality in SCI patients. The level of injury directly dictates respiratory compromise.

• C1-C3 Injuries: Total loss of respiratory muscle function. The phrenic nerve (C3-C5), which innervates the diaphragm, is disconnected from the brainstem. These patients require immediate intubation and lifelong mechanical ventilation. Diaphragmatic pacing may be an option later.
• C4-C5 Injuries: May have variable diaphragmatic function. Patients often require mechanical ventilation initially but may be successfully weaned. However, they lack intercostal and abdominal muscle function, severely impairing their vital capacity and ability to cough.
• C6-T11 Injuries: Diaphragm is intact, but varying degrees of intercostal and abdominal muscle loss limit forced expiration and cough strength.

Nursing Interventions:

• Vigilant monitoring of vital capacity, oxygen saturation, and arterial blood gases.
• Aggressive pulmonary hygiene: incentive spirometry, chest physiotherapy, and quad coughing (assisted coughing where the nurse applies upward and inward pressure on the abdomen during expiration to simulate abdominal muscle function).
• Early mobilization and frequent turning.

Venous Thromboembolism (VTE) Prophylaxis

Patients with SCI are at an exceptionally high risk for Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) due to Virchow's triad being met: venous stasis (from paralysis), endothelial injury (from the trauma), and hypercoagulability (a systemic response to severe trauma). The risk is highest in the first three months post-injury.

Nursing Interventions:

• Pharmacological Prophylaxis: Low-molecular-weight heparin (LMWH), such as enoxaparin, is the standard of care unless contraindicated by active bleeding.
• Mechanical Prophylaxis: Sequential compression devices (SCDs) or pneumatic compression boots must be applied immediately and worn continuously. Graduated compression stockings may also be used.
• Assessment: Daily inspection of the lower extremities for unilateral swelling, warmth, or redness. Note that due to sensory loss, the patient will not experience the classic calf pain associated with a DVT.

Heterotopic Ossification (HO)

Heterotopic ossification is the abnormal formation of true bone within extraskeletal soft tissues, usually around large joints like the hips and knees. The exact mechanism is unknown but is linked to the inflammatory response following trauma. It restricts range of motion and can cause severe pain (if sensation is intact) or trigger autonomic dysreflexia.

Assessment and Management:

• Signs include localized swelling, warmth, decreased range of motion, and elevated serum alkaline phosphatase levels.
• Management includes gentle range-of-motion exercises, nonsteroidal anti-inflammatory drugs (NSAIDs), or bisphosphonates to inhibit bone calcification. Surgical excision may be necessary if joint ankylosis occurs.

Neurogenic Bowel and Bladder

Loss of voluntary control over elimination requires the establishment of rigorous, individualized bowel and bladder programs to prevent complications like UTI, renal failure, impaction, and autonomic dysreflexia.

Neurogenic Bladder

The bladder behaves differently depending on the injury level, generally classified into two types:

1. Spastic (Hyperreflexic) Bladder: Occurs with upper motor neuron (UMN) injuries (typically above T12). The reflex arc is intact, but brain control is lost. The bladder empties spontaneously when it reaches a certain volume, but sphincter coordination is often poor (detrusor-sphincter dyssynergia), leading to high pressures and incomplete emptying.
   • Management: Intermittent catheterization (IC) every 4-6 hours, anticholinergic medications (e.g., oxybutynin) to suppress detrusor contractions, and condom catheters for males to manage incontinence between ICs.
2. Flaccid (Areflexic) Bladder: Occurs with lower motor neuron (LMN) injuries (T12 and below). The reflex arc is destroyed. The bladder fills continuously without contracting, leading to massive distention and overflow incontinence.
   • Management: Strict intermittent catheterization program or, in some cases, a suprapubic catheter. Credé maneuver (manual pressure over the bladder) or Valsalva maneuver may be used carefully.

Neurogenic Bowel

Similar to the bladder, bowel function is categorized into two patterns:

1. Upper Motor Neuron (Spastic) Bowel: Defecation reflex is intact. Stool moves through the colon, but voluntary control of the external sphincter is lost.
   • Management: Daily bowel program utilizing the gastrocolic reflex (timing after meals). Includes digital stimulation to trigger the reflex, often aided by suppositories (e.g., bisacodyl or glycerin). Diet high in fiber and adequate fluid intake are crucial.
2. Lower Motor Neuron (Flaccid) Bowel: Defecation reflex is lost. Peristalsis is sluggish, and the sphincter is flaccid, leading to a high risk of impaction and continuous seepage of stool.
   • Management: Manual disimpaction on a regular schedule. Suppositories are less effective because the reflex arc is absent. Firm stool consistency is desired to prevent seepage.

Skin Integrity

Denervated skin is highly susceptible to breakdown due to the loss of sensation and immobility. Pressure injuries can develop rapidly and progress to severe stages, leading to sepsis and drastically delaying rehabilitation.

Nursing Interventions:

• Meticulous daily skin inspections, particularly over bony prominences (sacrum, heels, ischium, occiput).
• Strict turning schedule every 2 hours while in bed. When sitting in a wheelchair, patients must perform pressure relief weight shifts (e.g., leaning forward or side-to-side) for at least 1-2 minutes every 15-30 minutes.
• Use of pressure-relieving mattresses and specialized wheelchair cushions.