SPINAL CORD INJURY

Agianto, S.Kep., Ns., MNS

Anatomy
Vertebrae circular like ring
Joint multiple
Trauma;
Bone
Muscle
Ligament

Mechanisme of injury
Trauma hyperfleksi
Trauma hyperextensi
Trauma compression
Trauma rotation



Epidemiology
80% Male
60% Age 15 25 years
48% accident
20% Fall
15% Gun and sharp
14% sports
Pathophysiologi
TRAUMA SPINAL CORD
Primary Trauma
spinal cord damage
Gray matter bleeding
EDEMA
Low blood flow
Hipoxia
Stimuly
vasoactive
vasospasm
NECROTIC
Enzyme
protiolitic
&lipolytic
Motoric
nerve
otonom
nerve
paralysis
Hypotension
Spinal Shock
vasodilatation
SecondaryTrauma
Cervical colar
paraplegia
SPINAL SHOCK
Severe; transient (30 min)
Loss of motor function
Loss reflexs
Automatic losses
The severity depend on area of primer
trauma

Clinical manifestation of spinal
shock:
1. Flaccid paralysis
2. Loss of spinal reflex acitivty
3. Loss of sensation below the trauma area
4. Bradicardia
5. Hypotention
6. Loss of thermo regulation
paralisis
Complication
Vascular
Respiratory
Musculus

ASSESSMENT
NURSING DIAGNOSES (NANDA)
EXPECTED PATIENT OUTCOMES
(NOC)
INTERVENTION IMPLEMENTATION
(NIC)
EVALUATION
NURSING MANAGEMENT
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Trauma area hemotoma, injury, wound
Airway - breathing
Level of consciousness
Movements of the extremities (muscle, posture, position)
Stiffness or flaccidity of the neck
Eye opening (size of pupils, ocular position)
Color of the face & extremities (Temp, moisture of the
skin)
Cranial nerve deficits
Quality & rates of pulse & resp (ABG)
Fluid (ingested excreted / 24 hours)
Presence of bleeding
Maintenance of BP
ASSESSMENT
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Autonomic dysreflexia
Risk for autonomic dysreflexia
Ineffective breathing pattern r/t
neuromuscular dysfunction
Acute pain
Impaired physical mobility
Self care deficits: (bathing, dressing, feeding,
toileting)
Readiness for enhanced self care

NURSING DIAGNOSES
(NANDA)
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Incontinence (functional urinary; overflow
urinary; reflex urinary; stress urinary; urge
urinary; risk for urge urinary)
Impaired urinary elimination
Urinay retention
Constipation
Diarrhea
Bowel incontinence
Risk for impaired skin integrity
Sexual dysfunction r/t altered body function
Interrupted family process r/t family roles shift
Risk for infection

Cont ...
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Optimizing cerebral tissue perfusion
Achieving an adequate breathing pattern
Preventing shoulder pain
Pain management
Improving mobility & preventing joint
deformities
Preventing shoulder adduction
Positioning the hand & fingers



NURSING INTERVENTION
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Changing positions
Establishing an exarcise program
Preparing for ambulation
Enhancing self care (eating, bathing,
grooming, toileting, dressing, mobility)
Managing dysphagia
Managing tube feedings
Attaining bowel & bladder control
Cont ...
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Improving communication
Maintaining skin integrity
Helping the patient cope with sexual
dysfunction
Improving thought processes (reality
orientation)
Improving family coping
Preventing infection
Managing sensory perceptual difficulties




Cont ...
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Demonstrates intact neurologic status &
normal vital signs & respiratory
Attains optimal airway and breathing
pattern
Achieves improved mobility
Achieves self care
Risk control

EVALUATION
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Achieves normal bowel & bladder
elimination
Maintains intact skin without breakdown
Has positive attitude regarding alternative
approaches to sexual expression
Participates in cognitive improvement
program
Family members demonstrate a positive
attitude & coping mechanism
Cont ...
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NOC :
- Mobility level (ability to move purposefully)
Indicators :
- Balance performance
- Body positioning performance
- Muscle movement
- Joint movement

Impaired physical mobility r/t
neuromuscular impairment
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Activities :
- Determine limitations of joint movement and effect on
function
- Collaborate with physical therapy
- Explain to patient/family the purpose and plan for joint
exercise
- Monitor location and discomfort during exercise
- Assist patient to optimal body position for passive/active
ROM
- Encourage active ROM
- Instruct patient/family how to systematically perform
passive-active ROM
- Provide written discharge instruction for exercise
- Encourage ambulation if appropiate
- Provide positive reinforcement

NIC :
Exercise therapy: joint mobility (use of active and passive
body movement to maintain or restore joint flexibility
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