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Spinal Cord Injuries

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cdunbar4's version from 2017-03-06 16:56

SCIs

Question Answer
Four types of spinal cord injuriesconcussion w/o direct trauma; penetrating wound or fracture dislocation; hemorrhage; compression of blood supply
Complete neurological deficitno voluntary motor activity or sensation BELOW level of injury
Incomplete neuro deficitsome voluntary motor activity or sensation BELOW level of injury
Paraplegiathoracic vertebral injury or lower; lower extremities affected
Tetraplegia (quadriplegia)Cervical vertebral injury; all four extremities involved
Spinal shock symptomsflaccid paralysis of skeletal muscles, complete loss of all sensation, suppression of somatic (pain, touch, temp) & visceral reflexes (e.g. peristalsis)
Other assessment findingspostural hypotension, bradycardia; circulatory problems such as edema; alterations in normal thermoregulation
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Functional level of spinal cord injury & rehab potential

Question Answer
C1-C3 level of injuryoften fatal; vagus nerve domination of heart, respiration, blood vessels and all organs below injury
C1-C3 movement remainingneck and above can move. Loss of innervation of diaphragm, cannot respirate independently
C1-C3 and C4 rehab potentialelectric wheelchair with portable ventilator by using chin or mouth stick, need a headrest to stabilize head; 24-hour care, can instruct others
C4-C8 level of injuryvagus nerve domination of heart, respirations, & all vessels & organs below injury
C4 movement remaining traps/sternocleidomastoid muscles can move. No UE muscle function, minimal ventilatory capacity
C5 movement remainingfull neck, possible partial strength of shoulder & biceps; decreased respiratory reserve; cannot roll over or use hands
C5 rehab potentialelectric wheelchair with mobile hand supports; indoor mobility in manual wheelchair; feeds self with adaptive equipment; 10/day of care needed.
C6 movement remainingpartial strength in pec major; shoulder & upper back abduction & rotation of shoulder; full biceps to elbow flexion, wrist extension, weak thumb grasp, ↓ respiratory reserve
C6 rehab potentialcan assist with transfer & perform some self-care; feeds self with hand devices; pushes wheelchair on smooth surface; drives adapted van; independent computer use with adaptive equipment; care for 6hr/day
C7-8 movement remainingall triceps to elbow extension, finger extensors & flexors; good grasp with some decreased strength, decreased respiratory reserve
C7-8 rehab potentialcan transfer self to wheelchair; rolls over & sits up in bed; pushes self on most surfaces; performs most self-care; independent use of wheelchair; can drive car with powered hand controls; care 0-6 hrs/day
T1-T4 functional abilitygood upper extremity muscle strength
T1-T4 self-care capabilitysome independence from wheelchair; long-leg braces for standing exercises
T5-L2 functional abilitybalance difficulties
T5-L2 self-care capabilitystill needs wheelchair, limited ambulation with long-leg braces & crutches
L3-L5 functional abilitytrunk-pelvis muscle function intact
L3-L5 self-care capabilitymay use crutches or canes for ambulation
L5-S3 functional abilitywaddling gait
L5-S3 self-care abilityambulation
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Emergency Management & Nursing Assessment Findings

Question Answer
Etiologies of blunt injuriescompression, flexion, extension, or rotational; motor vehicle collisions; pedestrian injuries; falls; diving
Penetrating injuries etiologiesstretched, torn, crushed or lacerated spinal cord; gunshot wounds; stab wounds
General potential assessment findingspain; muscle spasms; numbness; alterations in sensations; spinal shock; neurogenic shock; dyspnea; urinary retention
Initial interventionsENSURE AIRWAY; stabilize C spine; O2 NC or mask; IV access with 2 large bore catheters; assess for other injuries; control external bleeding; get x-rays, CT, MRI; prep for stabilization with cranial tongs; administer dose methylprendinsolone if ordered.
Ongoing monitoringVS, LOC, O2 Sat, cardiac rhythm, UO; keep warm; monitor for urinary retention; HTN; anticipate need for intubation if gag reflex is absent
Health-perception-health mgmtuse of alcohol or rec drugs; risk-taking behaviors
Activity-exercise patternloss of strength, movement & sensation below level of injury; dyspnea; inability to breathe adequately (air hunger)
Cognitive-perceptualtenderness, pain at or above level of injury; numbness, tingling, burning, twitching of extremities
Coping-stress tolerancefear, denial, anger, depression
Poikilothermisminability to regulate body heat
Integumentary (neurogenic shock)warm, dry skin below level of injury
Respiratory assessment with lesions at C1-3apnea, inability to cough
Respiratory assessment with lesions at C4poor cough, diaphragmatic breathing, hypoventilation
Respiratory assessment with lesions at C5-T6↓ respiratory reserve
CV assessment with lesions above T5bradycardia, hypoTN, postural hypoTN, absence of vasomotor tone
GI assessment↓ or absent bowel sounds (paryalytic ileus in lesions above T5); abd distention, constipation, fecal incontinence, fecal impaction
Urinaryretention for lesions b/t T1-L2; flaccid bladder (acute stages); spasticity w/ reflex bladder emptying (later stages)
Reproductivepriaprism, loss of sexual function
Neurologic (complete)flaccid paralysis & anesthesia below level of injury resulting in tetraplegia (above C8) or paraplegia (lesions below C8); hyperactive DTRs; bilaterally + Babinski test
Neurologic (incomplete)mixed loss of voluntary motor activity & sensation
Musculoskeletalmuscle atony (in flaccid state); contractures (in spastic state)
Possible diagnostic findingslocation of level & type of bony involvement on spinal xray: lesion, edema, compression on CT scan & MRI; positive finding on myelogram
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Autonomic Dysreflexia

Question Answer
AKAautonomic hyperreflexia. It is a clinical ER! If not resolved, could lead to status epilepticus, stroke, MI & even death.
Definitionmassive uncompensated CV reaction mediated by the SNS.
Injury to ____ and aboveT6 It is a loss of CNS control of symptathetic reflexes below level of injury
Patho flownoxious/visceral stimuli (over-distended bladder)→ uncontrolled activation of local sympathetic reflexes below level of injury→ vasoconstriction below level of injury→ ↑ BP→ hits baroreceptors in heart (vagal slowing of heart) => vasodilation/sweating/flushed skin/h/a ABOVE injury
Manis below level of injurypiloerection, pale, cool, moist skin
When does it occur?after spinal shock has resolved. Usually within 1st 6 months after injury
Most common precipitating causedistended bladder or rectum
Teach s/ssudden onset of h/a, ↑BP and/or reduced HR, flushed face & upper chest with pale extremities, sweating above injury, nasal congestion, feeling of apprehension
Immediate interventionsraise person to sitting, REMOVE NOXIOUS STIMULI (kinked urinary cath, tight clothing, fecal impaction); call provider if sx do not get alleviated
Measures to ↓ incidencemaintain reg bowel function; monitor UO; wear Medic Alert bracelet indicating hx of autonomic dysreflexia
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Collaborative Care

Question Answer
Diagnostich&p, neuro exam; ABGs; PFTs; elytes, glucose, coagulation profile, HH; urinalysis; spinal xray studies; CT/MRI; myelography
Acute careimmobilze vertebral column via skeletal traction; maintain HR (atropine) & BP (dopamine); NG tube with suction; O2 by high humidity mask; Foley; IV fluids; Stress ulcer & DVT prevention; bowel/bladder training
Rehab/Home CarePT (ROM, mobility training, muscle strengthening); OT (splints, ADL training); bowel/bladder training; RT; pressure ulcer prevention; autonomic dysreflexia prevention; pt./caregiver teaching
Intentions for nonoperative stabilization of injured spinal segmentto prevent secondary spinal cord damage
Surgical Therapy criteriaevidence of cord compression; progressive neuro deficit; compound fx of vertebrae; bony fragments; penetrating wounds
Drug Therapycorticosteroids are used usually in first 8 hours by most physicians in order to gain as much motor function & sensation possible. Use of methylpredinsolone should be used in caution with geriatric pop.
MOA of methylpredinsoloneblocks lipid peroxidation by-products. It is thought to improve blood flow & ↓ edema in spinal cord.
SE methylpredinsoloneimmunosuppression, ↑ freq. of upper GI bleeding & ↑ RF infection
Figure 61-9 cervical tractiontongs attached to head & traction is extended with a pulley & ropes. Infection precautions.
Figure 61-11 Halo Vestimmobilizes C-spine to allow pt. to ambulate & participate in self-care
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Neurogenic Bladder Types

Question Answer
Reflexic bladder (spastic, uninhibited, upper motor neuron) characteristicsno inhibitions influence time/place of voiding; bladder empties in response to stretching of bladder wall
Causes of reflexiccorticospinal tract lesion; observed in SCI, stroke, MS, brain tumor, brain trauma
Reflexic Manisincontinence, frequency, urgency, voiding is unpredictable & incomplete
Areflexic bladder (autonomous, flaccid, lower motor neuron) characteristicsbladder acts as if there were paralysis of all motor functions, fills w/o emptying
Areflexic causeslower motor neuron lesion caused by trauma involving S2-S4; lesions of cauda equina, pelvic nerves
Areflexic manisif sensory function is intact feels bladder distention & hesitation; no control of micturition (ejection of urine out of urthera) which results in overdistention
Sensory bladder characteristicslack of sensation of need to urinate
Sensory bladder causesdamage to sensory limb of bladder spinal reflex arc; seen in MS & DM
Sensory bladder clinical manispoor bladder sensation, infrequent voiding of large residual volume
Nursing managementintermittent cath initially Q4h, then assess bladder before cath. If <200mL time interval can be extended, if >500mL, interval can be shortened.
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Neurogenic bowel management

Question Answer
General measures to prevent constipationhigh-fiber diet, adequate fluids, may need suppositories, laxatives are last resort
Optimal nutritional intake includes3 well balanced meals/day; 2 servings from milk group; 2+ servings from meat group (poultry, beef, pork, eggs & fish); 4+ servings from fruit/veggie group; 4+ serving from bread/cereal group
Fiber intake in g/day20-30. Fiber amount should be ↑ gradually over 1-2 wks.
Fluids2-3 qts, unless CI. Limit caffeine & cola (caffeine simulates fluid loss which is needed to soften stools.
Timingest. regular bowel schedule, usually about 30 min after bfast
Position If possible, upright position with feet flat on floor or on stepstool; do not stay on toilet longer than 20-30 min as it can cause skin brkdwn
Activityexercise is important for bowel function, improves muscle tone & ↑ GI transit time/appetite.
Drug txsuppositories can help with stimulation, stool softeners used PRN, only use oral laxatives if absolutely necessary
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Skin Care Teachings

Question Answer
Change position frequentlylift self up & shift wt. Q 15-30 minutes; if in bed, regular turning schedule; use cushions to reduce pressure; pillows to protect bony prominences
Monitor skin conditionfor areas of redness, swelling and breakdown
Fingernailskeep trimmed to avoid scratches & abrasions
If wound developsfollow standard wound protocol mgmt
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