arterial blood gas values. Early and vigorous attention to clearing bronchial and
pharyngeal secretions can prevent retention of secretions and atelectasis. Suctioning
may be indicated, but caution must be used, because this procedure can stimulate the
vagus nerve, producing bradycardia, which can result in cardiac arrest.
If the patient cannot cough effectively because of decreased inspiratory volume and
inability to generate sufficient expiratory pressure, chest physical therapy and assisted
coughing may be indicated. Specific breathing exercises are supervised by the nurse to
increase the strength and endurance of the inspiratory muscles, particularly the
diaphragm. Assisted coughing promotes clearing of secretions from the upper
respiratory tract and is similar to the use of abdominal thrusts to clear an airway (see
Chapter 25). Ensuring proper humidification and hydration is important to prevent
secretions from becoming thick and difficult to remove even with coughing. The
patient is assessed for signs of respiratory infection (cough, fever, dyspnea). Smoking is
discouraged, because it increases bronchial and pulmonary secretions and impairs
ciliary action.
Ascending edema of the spinal cord in the acute phase may cause respiratory difficulty
that requires immediate intervention. Therefore, the patient's respiratory status must be
monitored frequently.
Improving Mobility
Proper body alignment is maintained at all times. The patient is repositioned frequently
and is assisted out of bed as soon as the spinal column is stabilized. The feet are prone
to footdrop; therefore, various types of splints are used to prevent footdrop. When used,
the splints are removed and reapplied every 2 hours. Trochanter rolls, applied from the
crest of the ilium to the midthigh of both legs, help prevent external rotation of the hip
joints.
Patients with lesions above the midthoracic level have loss of sympathetic control of
peripheral vasoconstrictor activity, leading to hypotension. These patients may tolerate
changes in position poorly and require monitoring of blood pressure when positions are
changed. Usually, the patient is turned every 2 hours. If not on a rotating bed, the
patient should not be turned unless the spine is stable and the physician has indicated
that it is safe to do so.
Contractures develop rapidly with immobility and muscle paralysis. A joint that is
immobilized too long becomes fixed as a result of contractures of the tendon and joint
capsule. Atrophy of the extremities results from disuse. Contractures and other
complications may be prevented by range-of-motion exercises that help preserve joint
motion and stimulate circulation. Passive range-of-motion exercises should be
implemented as soon as possible after injury. Toes, metatarsals, ankles, knees, and hips
should be put through a full range of motion at least four, and ideally five, times daily.
For most patients who have a cervical fracture without neurologic deficit, reduction in
traction followed by rigid immobilization for 6 to 8 weeks restores skeletal integrity.
These patients are allowed to move gradually to an erect position. A four-poster neck
brace or molded collar is applied when the patient is mobilized after traction is
removed (see Fig. 63-8).
Promoting Adaptation to Sensory and Perceptual Alterations
The nurse assists the patient to compensate for sensory and perceptual alterations that
occur with SCI. The intact senses above the level of the injury are stimulated through
touch, aromas, flavorful food and beverages, conversation, and music. Additional
strategies include the following: