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Norma McNair, RN, clinical nurse specialist, tends to a patient at UCLA Medical Center.

When asked to share those heart-stopping stories about experiences with patients on their units, nurses who care for spinal cord injured patients say all their patients fit the bill.

Nurses are usually the ones charged with attempting to reassure these patients, “who are absolutely terrified,” says Mimi Sutherland, RN, MS, BSN, CNRN, nurse surgical coordinator, Jackson Health System, Miami.

“We’ve had patients range from [expressing] total denial, to ‘let me die.’” Sutherland says. “The nurses have to have a considerable amount of expertise in managing that range of emotion of both the patient and the family, once they realize they’re paralyzed.”

It’s one thing to feel like you can’t move, Sutherland says. It’s another to ask a nurse when she’s going to perform a procedure, only to find out that she’s already done it.

The first 48 hours of care after an spinal cord injury is a tough time, nurses admit. But good nursing care is critical in the acute phase of injury, when these patients are so physiologically vulnerable to complications.

“The first 48 hours is critical to prevent further injury and complications and to monitor for changes in neurologic level. Rehabilitation begins at the time of injury to prevent complications such as pressure ulcers, infections, and pulmonary compromise,” says Kelly Johnson, RN, MSN, CFNP, CRRN, CNAA, vice president of patient care services at Craig Hospital in Englewood, Colo., one of the major spinal cord injury centers in the United States.

These cases often are complicated, according to Daniel Lammertse, MD, medical director of Craig Hospital.

“Although spinal cord patients are commonly young and previously healthy, they are rendered extremely vulnerable to medical complications. They have lost not only sensation and movement, but they have also lost a lot of autonomic function,” he says.

The good news in what is a devastating injury is that myriad advances in health care have contributed to positive outcomes for people with traumatic SCI. Johnson says that in the early stages of care, these include improvements in prehospital care, trauma and acute care, neurodiagnostic, and improved diagnosis and treatment in the acute management of SCI.

The advances, which nurses should know about, have been instrumental in improving morbidity and mortality rates, she says. “Pharmacologic advances have improved health outcomes for individuals with SCI on many levels: prehospital and trauma management; prevention of complications such as infection and deep vein thrombosis; and acute and long-term management issues such as pain and spasticity.”

“There is a lot of special attention that these folks need from skilled nursing staff in the critical care units, intensive care units, neurointensive care units — wherever nurses may be seeing these patients. Since these patients are quite vulnerable to medical complications, there is a lot of nursing care planning and intervention that can go a long way to reduce the risk of those problems,” Lammertse says.

SCI is a low-incidence disability, according to Lammertse, which happens to about 10,000 people in the United States a year. So, unless nurses are in big-city trauma centers, they might not see many of these patients.

On the lookout

“It’s important for nurses — especially if they don’t see many of these patients — to go through a mental checklist of all the things that they need to be thinking about,” he says.

That mental checklist encompasses the cascade of events that happen along with many spinal cord injuries, such as respiratory issues, the need for spinal immobilization, blood pressure and heart rate issues, elevated risks of deep vein thrombosis and pressure ulcers, pain management, and more.

Cynthia Bautista, RN, PhD, CNRN, neuroscience clinical nurse specialist, Yale-New Haven Hospital, New Haven, Conn., says that patients with around a C-4 and above injury have probably eradicated the phrenic nerve and will no longer be able to move their diaphragms.

Lammertse says that respiratory therapists and nurses need to closely monitor vital capacity and inspiratory force of especially those patients who are high-level paraplegics and all tetraplegics.