NLE Neurosensory Nursing — Spinal Cord and Peripheral Nerve DisordersRevision Notes

Exam Tips

• NLE questions often begin with a trauma scenario (vehicular crash, diving) — your FIRST action is ALWAYS immobilization, then ABC assessment.
• Memorize: 'C3, 4, 5 keep the diaphragm alive' — if the injury is at C4 or above, anticipate the need for mechanical ventilation.
• Know the three incomplete syndromes by their DISTINCT patterns: Central Cord = upper limbs weaker; Anterior Cord = pain/temp lost but vibration/proprioception intact; Brown-Séquard = crossed deficits.
• The jaw-thrust is the safe airway maneuver for SCI — this appears frequently in NLE airway management questions.
• Log-rolling details matter: the person at the HEAD is in charge/gives the command, the spine stays in neutral, and a minimum of 3 people is preferred.

Key Points

• SCI results from trauma — vehicular crashes (most common in the Philippines), falls, diving accidents, and violence — causing compression, contusion, laceration, or transection of the cord.
• The LEVEL of injury determines the deficit: CERVICAL injury = TETRAPLEGIA (quadriplegia, all four limbs affected); THORACIC or LUMBAR injury = PARAPLEGIA (lower limbs affected).
• CRITICAL MEMORY AID: 'C3, 4, 5 keep the diaphragm alive' — injuries AT or ABOVE C4 impair the phrenic nerve, paralyze the diaphragm, and require IMMEDIATE ventilatory support.
• A COMPLETE injury = total loss of all motor AND sensory function below the level of injury.
• An INCOMPLETE injury = some motor or sensory function is preserved below the level.
• Secondary injury compounds the initial trauma through cord edema, hemorrhage, and ischemia — this is why rapid, careful management in the first hours is critical.
• The FIRST nursing priority at the scene and on arrival in the Emergency Room is SPINAL IMMOBILIZATION — cervical collar and backboard — to prevent extending the injury.
• LOG-ROLLING is the correct technique for moving SCI patients: spine kept in neutral alignment, one person stabilizes the head, the team rolls the patient as a single unit.
• Airway management must NEVER involve hyperextending the neck — use JAW-THRUST maneuver instead of head-tilt-chin-lift.
• Surgical decompression and stabilization may be required; high-dose corticosteroids are no longer routinely recommended.

Definitions

Section Title

Spinal Cord Injury (SCI): Overview, Classification, and Emergency Management

Common Mistakes

• Performing head-tilt-chin-lift on a suspected SCI patient — always use jaw-thrust instead to avoid neck hyperextension.
• Confusing the level of injury with the level of paralysis — the level of injury IS the HIGHEST functional level, and deficits are BELOW that level.
• Assuming that because the patient can move their legs, spinal injury is ruled out — incomplete injuries can present with partial movement.
• Forgetting respiratory assessment in cervical injuries — C4 and above ALWAYS means evaluate the airway and breathing immediately.
• Moving an SCI patient without log-rolling technique — any twisting or bending of the spine can convert an incomplete injury to a complete one.

Exam Tips

• The NLE's favorite question: 'A patient with T4 SCI develops hypotension and bradycardia with warm, dry skin — what type of shock is this?' Answer: NEUROGENIC SHOCK.
• The key word differentiator: WARM, DRY skin = neurogenic shock (vasodilation). COLD, CLAMMY skin = hypovolemic/hemorrhagic shock.
• Vasopressors (not just fluids) are the priority in neurogenic shock — a common wrong answer is to give large volumes of IV fluid as first management.
• Atropine is for BRADYCARDIA in neurogenic shock — remember this drug connection.
• Spinal shock is TEMPORARY (neurologic); neurogenic shock is a hemodynamic EMERGENCY — both occur after SCI but are managed differently.

Key Points

• Spinal shock and neurogenic shock are TWO DIFFERENT phenomena that can occur simultaneously after SCI — the NLE tests whether you can distinguish them.
• SPINAL SHOCK is a NEUROLOGIC phenomenon — temporary loss of ALL reflex activity, motor function, sensation, and autonomic function below the injury level immediately after SCI.
• During spinal shock, the patient has FLACCID paralysis and ABSENT reflexes (areflexia), including absent bowel and bladder reflexes — this is temporary.
• Spinal shock RESOLVES over days to weeks as spinal reflexes return — the return of the bulbocavernosus reflex is the classic sign that spinal shock has ended.
• NEUROGENIC SHOCK is a HEMODYNAMIC/CARDIOVASCULAR phenomenon seen with injuries at or ABOVE T6.
• In neurogenic shock, loss of sympathetic tone leads to VASODILATION — the classic triad is: HYPOTENSION + BRADYCARDIA + WARM, DRY SKIN.
• CRITICAL COMPARISON: Hypovolemic shock = hypotension + TACHYCARDIA + cold, clammy skin. Neurogenic shock = hypotension + BRADYCARDIA + warm, dry skin.
• Management of neurogenic shock: IV fluids (cautiously, to avoid fluid overload), VASOPRESSORS (dopamine, norepinephrine) to restore vascular tone, ATROPINE for symptomatic bradycardia.
• Always rule out CONCURRENT hypovolemic shock in trauma patients — a patient with SCI can also have internal bleeding.

Definitions

Section Title

Spinal Shock vs. Neurogenic Shock — Critical Distinction

Common Mistakes

• Confusing spinal shock (neurologic — flaccidity, areflexia) with neurogenic shock (hemodynamic — hypotension, bradycardia). These are completely different things.
• Treating neurogenic shock like hypovolemic shock with aggressive fluid resuscitation — this can lead to pulmonary edema. Vasopressors are the key intervention.
• Expecting tachycardia in neurogenic shock — BRADYCARDIA is the hallmark. Tachycardia in an SCI patient means look for blood loss (hemorrhagic/hypovolemic shock).
• Thinking spinal shock is permanent — it is TEMPORARY and resolves. Do not counsel the patient that total reflex loss is permanent during this phase.

Exam Tips

• If the NLE question shows a SCI patient (T6 or above) with sudden severe headache and high BP — think AUTONOMIC DYSREFLEXIA immediately.
• The FIRST action is always: RAISE THE HEAD OF THE BED / SIT UPRIGHT — this single step uses orthostatic pressure drop to help lower the BP while you search for the cause.
• Check order: Catheter/Bladder FIRST (most common cause) → Fecal impaction SECOND → Other skin stimuli THIRD.
• The drug of choice for persistent AD hypertension: NIFEDIPINE (calcium channel blocker, rapid-acting oral/sublingual) or NITRATES (nitroglycerin).
• Prevention strategy for the NLE: consistent BOWEL program + free BLADDER drainage + skin care = prevention of AD triggers.
• Key distinguishing feature: AD causes FLUSHING and SWEATING above the injury, PALLOR and COOLNESS below — the opposite pattern from the level of injury.

Key Points

• Autonomic dysreflexia (AD), also called autonomic hyperreflexia, is a TRUE MEDICAL EMERGENCY unique to SCI patients with injuries AT or ABOVE T6.
• It occurs AFTER spinal shock has resolved and reflexes have returned — typically in the rehabilitation or chronic phase of SCI, NOT immediately after injury.
• Pathophysiology: A noxious stimulus BELOW the level of injury triggers an exaggerated, uncontrolled sympathetic discharge. The normal inhibitory signals from the brain CANNOT pass the level of injury to dampen the response — leading to massive, unregulated sympathetic activation.
• CLASSIC MANIFESTATIONS: Sudden, severe, POUNDING HEADACHE (most prominent symptom); dangerous HYPERTENSION (systolic often >200 mmHg); BRADYCARDIA (reflex from baroreceptors detecting the high BP); PROFUSE SWEATING and FLUSHING above the injury level; PALLOR and COOLNESS below the injury level; nasal congestion; blurred vision; anxiety.
• The MOST COMMON TRIGGER is a DISTENDED BLADDER — from a blocked/kinked catheter or urinary retention. This must be checked FIRST.
• Second most common trigger: FECAL IMPACTION or constipation.
• Other triggers: pressure injuries, tight clothing, ingrown toenails, urinary tract infection, skin burns, even cold drafts.
• PRIORITY INTERVENTIONS IN ORDER: (1) SIT THE PATIENT UPRIGHT / RAISE HOB immediately to use gravity to lower BP. (2) Loosen tight clothing and devices. (3) Find and remove the trigger — CHECK BLADDER/CATHETER FIRST, then check for fecal impaction. (4) Give rapid-acting antihypertensive (nifedipine, nitrates) if BP remains dangerously high.
• When manually disimpacting, use ANESTHETIC LUBRICANT (lidocaine jelly) because digital rectal stimulation can worsen the autonomic response.
• If untreated, AD can lead to HYPERTENSIVE STROKE, seizures, myocardial infarction, pulmonary edema, and DEATH.
• PREVENTION is key: consistent bowel program, free bladder drainage, prevention of pressure injuries, and education of patient and caregivers.

Definitions

Section Title

Autonomic Dysreflexia — Life-Threatening Emergency

Common Mistakes

• Laying the patient FLAT in autonomic dysreflexia — this is WRONG and worsens hypertension by increasing venous return and BP. Always SIT THE PATIENT UPRIGHT first.
• Checking for fecal impaction BEFORE checking the catheter/bladder — the bladder is the MOST COMMON cause and must be checked first.
• Giving antihypertensives as the FIRST action without sitting the patient up and removing the trigger — removing the cause is the priority intervention.
• Confusing autonomic dysreflexia with neurogenic shock — AD causes HYPERTENSION, not hypotension. The 'hyper' in 'hyperreflexia' helps recall the hypertension.
• Forgetting that AD occurs in injuries AT or ABOVE T6, not below — a T10 SCI patient will NOT develop AD.
• Not using anesthetic lubricant before disimpaction — this is a critical safety step to prevent worsening the autonomic response.

Exam Tips

• NLE scenario: patient with back pain, leg radiation, and positive SLR = lumbar HNP. Conservative treatment is tried FIRST before surgery.
• The CAUDA EQUINA TRIAD (bowel/bladder + saddle anesthesia + bilateral leg weakness) = EMERGENCY — escalate immediately, prepare for surgery.
• Postoperative spinal surgery care priority: LOG-ROLL for repositioning, check neurovascular status, monitor for CSF leak.
• Sciatica comes from LUMBAR herniation; arm/hand pain/weakness comes from CERVICAL herniation — know which level produces which symptoms.
• Conservative management components to remember: Rest (limited) + PT + NSAIDS + Muscle relaxants + Body mechanics education = RPMBE.

Key Points

• A herniated disc (herniated nucleus pulposus, HNP) occurs when the soft inner nucleus pulposus ruptures through the tough outer annulus fibrosus and compresses a spinal nerve root.
• Most common levels: LUMBAR spine at L4–L5 and L5–S1 (most frequent overall); CERVICAL spine is second most common.
• LUMBAR herniation symptoms: low back pain, SCIATICA (pain radiating down the leg in the distribution of the sciatic nerve), numbness, tingling, and leg weakness. A POSITIVE STRAIGHT-LEG RAISE (SLR) TEST reproduces the radicular pain — this is a key clinical finding.
• CERVICAL herniation symptoms: neck pain, pain radiating down the arm, hand numbness/tingling, and arm weakness.
• Diagnosis is confirmed by MRI (gold standard for soft tissue visualization).
• CONSERVATIVE management first: limited bed rest (not prolonged), physical therapy, heat/cold therapy, NSAIDs, muscle relaxants, analgesics, and PROPER BODY MECHANICS education.
• Surgical indications: failure of conservative management after 6 weeks, progressive neurologic deficits, or CAUDA EQUINA SYNDROME.
• CAUDA EQUINA SYNDROME is a SURGICAL EMERGENCY: compression of the cauda equina nerve roots causing bowel AND bladder dysfunction (incontinence or retention), SADDLE ANESTHESIA (numbness in the perineum, inner thighs, buttocks — the area that contacts a saddle), and bilateral leg weakness. Requires EMERGENT surgical decompression.
• Surgical options: discectomy (removing the herniated material), laminectomy (removing part of the vertebral arch to decompress), spinal fusion (stabilizing vertebrae).
• POST-OPERATIVE NURSING CARE: LOG-ROLLING technique for repositioning, maintaining SPINAL ALIGNMENT, regular neurovascular checks, monitoring for CSF LEAK (clear fluid from wound, headache — report immediately), and for spinal fusion: no twisting and no heavy lifting during recovery.

Definitions

Section Title

Herniated Intervertebral Disc

Common Mistakes

• Recommending strict, prolonged bed rest for disc herniation — current evidence supports LIMITED rest and early, gradual mobilization with physical therapy.
• Missing the cauda equina syndrome triad — bowel/bladder dysfunction + saddle anesthesia + bilateral leg weakness is a SURGICAL EMERGENCY, not just 'worsening back pain.'
• Twisting or bending the spine when repositioning a post-op spinal surgery patient — always LOG-ROLL.
• Forgetting CSF leak monitoring post-operatively — clear drainage from the wound must be tested and reported.
• Applying heat immediately after acute disc injury — in the acute phase, COLD therapy (first 24–48 hours) reduces inflammation; heat is used for chronic pain and muscle spasm.

Exam Tips

• INTERMITTENT CATHETERIZATION every 4–6 hours = preferred long-term bladder management for SCI. This is a high-yield NLE answer.
• BOWEL program = scheduled time, fiber, fluids, stool softeners, digital stimulation = prevents impaction = prevents AD.
• For respiratory care in high SCI, remember: incentive spirometry + quad/assisted cough + chest PT = prevent pneumonia.
• Pressure injury prevention: reposition every 2 hours + inspect skin at EVERY turn + pressure-relieving surfaces.
• Rehabilitation is INTERDISCIPLINARY: nurse, physiatrist, PT, OT, speech therapist, social worker, psychologist, and the PATIENT as an active participant.

Key Points

• SCI patients are at HIGH RISK for complications of immobility — preventing these is a major nursing responsibility under the rehabilitation phase.
• RESPIRATORY: High cervical injuries (C4 and above) require mechanical ventilation. All SCI patients need incentive spirometry, regular chest physiotherapy, and ASSISTED COUGHING (quad cough) for cervical/upper thoracic injuries where abdominal muscles are paralyzed.
• SKIN INTEGRITY: Pressure injuries are a leading complication. Reposition every 2 hours, use pressure-relieving mattresses, perform meticulous skin inspection, and educate the patient to perform weight shifts when in a wheelchair.
• DEEP VEIN THROMBOSIS (DVT): High risk due to immobility and loss of muscle pump. Prophylaxis includes sequential compression devices, anticoagulation (low molecular weight heparin), and active/passive range-of-motion exercises.
• NEUROGENIC BLADDER: SCI disrupts voluntary bladder control. INTERMITTENT CATHETERIZATION on a schedule (every 4–6 hours) is the PREFERRED long-term management — prevents overdistension, reduces infection risk, and reduces autonomic dysreflexia triggers. An indwelling catheter is used short-term only.
• SPASTIC (REFLEX) BLADDER: Injuries ABOVE the conus medullaris (upper motor neuron) — bladder contracts automatically/involuntarily when filled. The bladder empties reflexively but not under voluntary control.
• FLACCID BLADDER: Injuries AT or BELOW the conus medullaris (lower motor neuron) — bladder is atonic, overfills, and cannot contract. Requires intermittent catheterization.
• NEUROGENIC BOWEL: A consistent BOWEL PROGRAM is essential — scheduled defecation, adequate dietary fiber, adequate fluid intake (2–3 liters/day), stool softeners, and digital stimulation. Prevents impaction (a major AD trigger).
• CONTRACTURES: Prevent through regular RANGE-OF-MOTION (ROM) exercises, proper positioning, and splints. Start early in rehabilitation.
• ORTHOSTATIC HYPOTENSION: Common when mobilizing SCI patients, especially those with cervical/upper thoracic injuries. Gradual position changes, compression stockings, abdominal binders, and adequate hydration help manage this.
• PSYCHOSOCIAL ADJUSTMENT: SCI is a life-altering event. Provide therapeutic communication, refer to psychiatric/psychological services, involve the family, and support the grief process (denial, anger, bargaining, depression, acceptance). Rehabilitation is INTERDISCIPLINARY and LONG-TERM.

Definitions

Section Title

Ongoing Nursing Care in SCI: Preventing Immobility Complications

Common Mistakes

• Using an indwelling (Foley) catheter long-term for neurogenic bladder — intermittent catheterization is PREFERRED to reduce infection and AD risk.
• Skipping the bowel program — fecal impaction is the second most common trigger of autonomic dysreflexia.
• Neglecting psychological care — SCI profoundly affects identity, sexuality, relationships, and independence. Psychosocial support is a nursing priority, not an afterthought.
• Starting mobilization too quickly without orthostatic hypotension precautions — use a tilt table, compression stockings, and abdominal binders during gradual upright progression.
• Not repositioning wheelchair-bound patients — pressure injuries on the ischium and sacrum are common; teach the patient to perform push-ups or weight shifts every 15–30 minutes.

Exam Tips

• STOCKING-GLOVE sensory loss = peripheral neuropathy. Unilateral or dermatomal = spinal/nerve root lesion.
• Drug of choice for NEUROPATHIC PAIN = GABAPENTIN or PREGABALIN (1st line), then amitriptyline or duloxetine. NOT paracetamol or NSAIDs.
• The most important nursing teaching for peripheral neuropathy: DAILY FOOT INSPECTION + PROTECTIVE FOOTWEAR + blood glucose control.
• Monofilament test: used to check PROTECTIVE SENSATION — if the patient cannot feel the 10g monofilament, they are at HIGH RISK for foot ulcers.
• In the Philippine context: link diabetes to peripheral neuropathy frequently — DM is among the top 10 causes of death in the Philippines and a highly prevalent condition managed by Filipino nurses at all levels of care.
• TIGHT GLYCEMIC CONTROL is the MOST IMPORTANT intervention to PREVENT and SLOW PROGRESSION of diabetic neuropathy — HbA1c target generally <7% (per ADA guidelines).

Key Points

• Peripheral neuropathy is damage to peripheral nerves (outside the brain and spinal cord) causing sensory, motor, and/or autonomic dysfunction.
• MOST COMMON CAUSE: Diabetes mellitus (diabetic peripheral neuropathy) — a major concern in the Philippines given the high prevalence of DM in the Filipino population.
• Other causes: chronic alcohol use, vitamin B12 deficiency (vegans, elderly, those on metformin long-term), chemotherapy (vincristine, cisplatin), autoimmune diseases (Guillain-Barré syndrome), infections (HIV, leprosy), and hypothyroidism.
• CLASSIC PRESENTATION: 'STOCKING-GLOVE' distribution — symmetrical numbness, tingling, burning pain, and loss of sensation starting in the FEET and HANDS (like wearing stockings and gloves), spreading proximally.
• Motor involvement: muscle weakness, diminished or absent deep tendon reflexes (especially ankle jerk), and foot drop in severe cases.
• Autonomic involvement: orthostatic hypotension, gastroparesis (delayed gastric emptying), erectile dysfunction, and bladder dysfunction.
• CENTRAL DANGER: LOSS OF PROTECTIVE SENSATION — patients cannot feel injuries, burns, pressure, or pain. This leads to UNNOTICED WOUNDS that can progress to infected ulcers, osteomyelitis, and AMPUTATION (especially in diabetic patients).
• Diagnosis: clinical assessment, MONOFILAMENT TESTING (Semmes-Weinstein 10-g monofilament) for protective sensation, vibration testing, ankle reflex testing, NERVE CONDUCTION STUDIES (NCS), and ELECTROMYOGRAPHY (EMG). Blood tests: fasting glucose, HbA1c, vitamin B12, TSH.
• MANAGEMENT: Treat the UNDERLYING CAUSE first — tight GLYCEMIC CONTROL is the most important intervention in diabetic neuropathy. Vitamin B12 supplementation for deficiency. Alcohol cessation.
• PHARMACOLOGIC MANAGEMENT OF NEUROPATHIC PAIN: GABAPENTIN or PREGABALIN (anticonvulsants — first-line), TRICYCLIC ANTIDEPRESSANTS (amitriptyline), and DULOXETINE (SNRI). Ordinary analgesics (paracetamol, NSAIDs) are generally INEFFECTIVE for neuropathic pain.
• KEY NURSING DIAGNOSIS: Risk for Impaired Skin Integrity / Risk for Injury related to loss of protective sensation.
• PATIENT TEACHING — DAILY FOOT CARE is the most important intervention to prevent ulcers and amputation: inspect feet daily (use a mirror for soles), wash with warm (not hot) water, dry between toes, wear WELL-FITTING PROTECTIVE FOOTWEAR (never go barefoot), test water temperature with elbow or thermometer, report any wound or redness immediately.

Definitions

Section Title

Peripheral Neuropathy

Common Mistakes

• Using ordinary analgesics (paracetamol, mefenamic acid, NSAIDs) for neuropathic pain and wondering why they don't work — neuropathic pain requires GABAPENTIN, PREGABALIN, AMITRIPTYLINE, or DULOXETINE.
• Neglecting foot inspection in diabetic patients — the 'I can't feel anything wrong' statement from the patient is actually the DANGER sign, not reassurance.
• Using hot water soaks for diabetic patients — they cannot feel excessive heat and will sustain burns. Always test water temperature with elbow or thermometer.
• Focusing only on sensory symptoms and missing AUTONOMIC features — orthostatic hypotension, gastroparesis, and bladder dysfunction are also part of diabetic autonomic neuropathy.
• Forgetting to check B12 in patients on long-term metformin — metformin reduces B12 absorption and can cause neuropathy.