Question

Please use complete sentences .

Christopher Allen, a 19-year-old college student, was rock climbing when he fell 30 feet to the ground. Paramedics arriving at the scene found him lying in the supine position, unable to move any extremities and complaining of neck pain. He was awake, alert, and oriented to his current location, the date and day of the week, and the details of his fall. His responses to questioning were appropriate. His pupils were equal and reactive to light. He showed no other signs of injury except for several scrapes on his arms. His vital signs revealed a blood pressure of 110/72, heart rate of 82 beats per minute, respirations of 18 per minute. The paramedics applied a cervical collar, placed him on a back board, immobilized his head, and transported him to the trauma center by helicopter.

Upon examination at the hospital, vital signs were taken again and were as follows: blood pressure = 94/55; heart rate = 64; respiratory rate = 24 (with shallow breathing). His oral temperature was 102.2 degrees F. His color was dusky and his skin was warm and dry to the touch. His perception of sensory stimuli ended bilaterally at an imaginary line drawn across his chest about 3 inches above the nipples (i.e., everything below felt numb). He had some sensation in his arms, but could not localize touch or describe texture with any consistency there. He was able to raise his shoulders and tighten his biceps brachii slightly in each arm, but could not raise either arm against gravity. His lower extremities were flaccid, despite attempts to move them.

X-rays taken upon arrival revealed a fractured vertebra at T3. A chest x-ray showed a decreased lung expansion upon inhalation. Blood tests were normal, with the exception of a respiratory acidosis (blood pH = 7.25). The neurosurgeons immobilized his neck by inserting tongs into the skull above the ears to hold his neck in a position so that no further injury could occur. Christopher was transferred to intensive care and his condition was stabilized. A physical examination 4 days later revealed normal vital signs and no change in his arm strength or sensation, but also marked spasms and exaggerated stretch reflexes of the lower extremities. He also had urinary incontinence which required the placement of a Foley catheter connected to a urine collection bag.

• Why did Christopher's heart rate and blood pressure fall in this time of emergency (i.e., at a time when you would expect just the opposite homeostatic responses)?
• Upon admission to the hospital, Christopher's breathing was rapid and shallow. He had dry skin and a fever. Can you explain why?
• What is the normal pH of the blood? Why was Christopher's blood pH below normal?
• Why did Christopher suffer from urinary incontinence?
• List one nursing diagnosis with three nursing interventions related to the psychosocial aspect of spinal cord injury.

Answer 1

1.Neurogenic shock is a haemodynamic phenomenon that can occur within 30 minutes of a spinal cord injury at the fifth thoracic vertebra or above and last upto 6 weeks.The injury results in a massive vasodilation without compensation due to the loss of SNS vasoconstrictor tone.This massive vasodilation leads to a pooling of blood in the blood vessels,tissue hypoperfusion and ultimately impaired cellular metabolism.The most important clinical manifestations in neurogenic shock are hypotension and bradycardia .

2The most important clinical manifestations in neurogenic shock are hypotension from the massive vasodilation and bradycardia ,from unopposed parasympathetic stimulation.The patient in neurogenic shock may have an inability to regulate temperature.The inability to regulate temperature ,combined with massive vasodilation ,promotes heat loss.Initially ,the patients skin will be warm due to the massive dilation without compensation .As the heat dissipates ,the patient is at risk for hypothermia.Later the patients skin may be cool or warm depending on the ambient temperature.In either case the skin will usually be dry .

3 Normal pH level of blood is 7.35 to 7.45,.Decreased tissue perfusion results in acidosis

4 In the post acute phase ,the bladder may become hyper irritable ,with a loss of inhibition from the brain resulting in reflex emptying.Chronic indwelling catheter increases the risk of infection.Once the patient is medically stable and large quantities of IV fluids are no longer required,the indwelling catheter should be removed and intermittant catheterization should begin as early as possible.

5 Ineffective coping related to loss of control over bodily functions and altered lifestyle secondary to paralysis as evidenced by verbalization of inability to cope ,expression of anger or other negative feelings ,refusal to discss changes in function and participate in social contacts.

Interventions

• Appraise patients judgement to changes in body image.
• Appraise impact of patients life situation on roles and relationships.
• Provide an atmosphere of acceptance.