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Peripheral Nerve and Spinal Cord Problems
Chapter 60
Spinal Cord Injury (SCI)
● Trauma or change to the spinal cord ● Tx strategies have improved life span of patient with SCI ● 17,000 Americans suffer SCI each year ● Young adult men 16-30 have highest risk Patho ● Initial injury ○ Cord compression by body displacement ○ Interruption of blood supply to the cord ○ Traction resulting from pulling on the cord ○ Tearing and transection-stab & gunshot wounds ● Primary injury (direct physical trauma to the cord) ● Secondary injury (hemorrhage, edema, hypoxia, ischemia) ○ Ongoing, progressive damage that occurs after the initial injury ○ Because secondary is ongoing, extent of injury & prognosis for recovery are determined at least 72 hours or more after injury ● Hemorrhagic areas in the center of the spinal cord appear within 1 hr and by 4 hrs there may be infarction in the gray matter. Immediate tx for SCI is important. ● The spinal cord has minimal ability to adapt to vasospasm ● Permanent damage can occur in 24 hours or less due to edema. No room for tissue expansion. Spinal Shock ● Occurs in about 50% of cases ● Temporary neurologic syndrome characterized by: ○ ↓reflexes ○ Loss of sensation ○ Flaccid paralysis below the level of injury ● Last days to months Neurogenic Shock ● Due to loss of vasomotor tone caused by injury ● Characterized by ○ Hypotension ○ Bradycardia
○ Decreased cardiac output ● Usually associated with cervical or high thoracic injury (T6 or higher) Classification of Spinal Cord Injury
- Mechanism of injury
- Level of injury
- Degree of injury
Mechanism of Injury
● Flexion ● Hyperextension ● Flexion-rotation ● Extension-rotation ● Compression
Level of Injury
● Skeletal level–vertebral level; damage to bones & ligaments ● Neurological level–lowest segment of the spinal cord with normal sensory & motor function on both sides of body. (cervical, thoracic, or lumbar) ○ Cervical & lumbar injuries most common ○ Cervical–tetraplegia (formally quad–all extremities) ○ Thoracic or lumbar–paraplegia (legs)
American Spinal Injury Association Impairment Scale ● Used to classify the severity of impairment resulting from SCI ● Combines assessments of motor and sensory function to determine neurologic level and completeness of injury
Clinical Manifestations of SCI
● Depends on the level and degree of injury ● Incomplete lesion demonstrate mixture of symptoms ● Higher the injury, the more serious the symptoms Table 60-2 Level of SCI and Rehab Potential pg 1408
Respiratory System Complications ● Cervical injury above C4–total loss of respiratory muscle function ● Below level of C4–results in diaphragmatic breathing if the phrenic nerve is functioning (hypoventilation) ○ Spinal cord edema and hemorrhage can affect the function of the phrenic nerve and
○ Pts with high cervical injuries have a greater loss of the ability to regulate temperature than do those with thoracic or lumbar injuries. Metabolic Needs ● NG suctioning–leads to metabolic alkalosis, electrolyte disturbances ● Decreased tissue perfusion–may lead to acidosis ● Wt loss of 10% or more ○ Nutritional needs–greater ○ High protein diet Peripheral Vascular Problems ● DVT–first 3 months ○ Usual S&S not present ● Pulmonary embolism–chest pain may not be felt! Pain Nocioceptive pain ● Develops from musculoskeletal, visceral, and/or other type of injury (skin ulceration, HA) ● Described as dull or aching ● Worsens with movement ● Visceral pain–dull, tender, or cramping Neuropathic pain ● Occurs from damaged cord or nerve roots ● Located at or below level of injury ● Hot, burning, tingling, pins and needles, cold or shooting ● Very sensitive to stimuli Diagnostic Studies/Interprofessional Care ● CT, cervical xrays if CT not available ● MRI ● Vertebral angiography ● ABGs, H&H, glucose, electrolytes, urinalysis ● AIRWAY–immediate post injury goal ● Emergency treatment Prehospital ● Immediate postinjury goals: airway, ventilation, breathing ● Second is immobilization to prevent further injury (backboard, cervical collar) ● Monitor for shock
Acute Care ● History of injury? ● Immobilization–traction ● Maintain heart rate–atropine > ● Maintain bp–phenylephrine (preferred), norepineprine, dopamine MAP >85 to maintain perfusion to spinal cord ● Steroids–24 hour high dose methylprednisolone within 8 hours (controversial), some do not use anymore because of side effects ● NG w/suction ● Intubate ● 02 ● Foley ● IVFs ● Stress ulcer prophylaxis ● VTE prophylaxis w/in 72 hours unless contraindicated (internal bleeding, abnormal kidney function, recent surgery)–enoxaparin, heparin
Nursing Management
Nursing Implementation Health Promotion ● Identify high risk populations ● Education–seat belt, helmets, child safety seats ● Teaching and counseling ● Referral to programs (stop smoking) ● Routine physical exams for SCI pt Acute Intervention ● Most complex–high cervical injury ● Immobilization ○ Proper immobilization of the neck–maintenance of neutral position ○ Skeletal traction–not used as much since improvement in surgeries ■ Crutchfield, Vinke, or Gardner-Wells tongs
● If pt cannot count to 20 aloud without taking a breath, they need immediate attention. ● Administer O2 until ABGs stabilize ● Chest physiotherapy & assisted coughing to clear secretions ○ Assisted (augmented) coughing simulates the action of the ineffective abdominal muscles during the expiratory phase of the cough. ○ Place the heels of both hands below the xiphoid process and exert firm upward pressure to the area timed with the patient’s efforts to cough. ○ Suction if crackles or rhonchi are present. ○ Incentive spirometry CARDIOVASCULAR INSTABILITY ● Heart rate is slowed <60 BPM (unopposed vagal response) ○ Atropine ○ Temp or permanent pacemaker ● Any increase in vagal stimulation (turning, suctioning) can result in cardiac arrest ● Chronic low BP ○ Dopamine, phenylephrine, norepineprine ○ Fluid replacement ● DVT/VTE ○ Compression devices or TED hose ■ Remove to provide skin care q 8 hours ○ Venous duplex studies ○ ROM–active or passive ○ Assess q shift for DVT ○ Prophylactic heparin/lovenox ● Assess vital signs frequently ● Consider previous cardiovascular disease, esp elderly ● Reduced cardiac output ● If blood loss involved–H&H and admin blood as needed ● Monitor for hypovolemic shock & hemorrhage FLUID AND NUTRITIONAL MAINTENANCE ● 1st 48-72 hours after injury–paralytic ileus ○ NG tube ○ NPO ○ Monitor fluids & elytes ● Once bowel sounds are present or flatus is passed–oral food & fluids gradually introduced ● Because of severe catabolism–high protein, high-cal diet (energy & tissue repair) ● High cervical injury– evaluate swallowing ○ Enteral or TPN may be necessary ● Anorexia (due to depression, boredom with institutional food, or discomfort at being fed (often
by a hurried nurse)--may be a control issue ● Calorie counts & daily weights ● Dietary supplements–esp. Fiber Bladder and Bowel Management ● Initially…Foley ○ Immediately after injury, urine is retained (loss of autonomic and reflex control of the bladder and sphincter). ○ Lack of sensation of fullness causes bladder overdistention and bladder may rupture. ○ Strict aseptic tech for cath care ○ During the period of indwelling cath, large fluid intake is required. ● After the pt is stabilized, pt started on intermittent cath program. ○ Cath Q 3 to 4 hrs to prevent bacterial overgrowth ○ Monitor for UTI ○ PREVENT CAUTI! ● Older adult is more likely to develop renal calculi ● Prostatic hyperplasia ● Constipation - problem during spinal shock (no vol or involuntary (reflex) evacuation of the bowels occurs. ○ Start bowel program during acute care. ■ Choosing a rectal stimulant (suppository or mini-enema) inserted daily at a regular time followed by gentle digital stimulation or manual evacuation until evacuation is complete. ■ Initially, program may be done in bed in the side-lying position, but as soon as the pt has resumed sitting, it should be done in the upright position on a padded bedside commode chair. Temperature Control ● Lack of vasoconstriction causes piloerection, or heat loss through perspiration below the level of injury. ● Temperature control is largely external to the pt. ○ Monitor the environment closely - maintain an appropriate temperature. ○ Monitor body temp regularly. ○ Do not overload pt with covers or unduly expose them ○ If infection with high fever develops, more extensive means of temperature control, such as a cooling blanket, may be necessary. Stress Ulcers ● Stress ulcers - physiologic response to severe trauma, psychologic stress, and high-dose
Autonomic Dysreflexia
● Developed by pt with injury at T6 or higher. ● Also known as autonomic hyperreflexia ● Life-threatening situation, requires immediate attention ● If resolution does not occur, this condition can lead to status epilepticus, stroke, myocardial infarction, and even death. ● Massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system. ● Occurs in response to visceral stimulation after spinal shock resolved. ● Most common precipitating cause a distended bladder or rectum, although any sensory stimulation may cause autonomic dysreflexia. ● Contraction of the bladder or rectum, stimulation of the skin, or stimulation of the pain receptors may also cause autonomic dysreflexia. ● Clinical Manifestations: ○ Hypertension (up to 300 mm Hg systolic) ○ Throbbing headache ○ Marked diaphoresis above the level of the lesion ○ Bradycardia (30 to 40 beats/minute) ○ Piloerection ○ Flushing of the skin above the level of the lesion ○ Blurred vision or spots in the visual fields ○ Nasal congestion ○ Anxiety ○ Nausea ● Important - measure BP when a pt w/ SCI complains of a headache. ● Nursing interventions ○ This is serious emergency ○ Elevate the head of the bed 45 degrees or sit the pt upright ○ Notify physician ○ Assessment to determine the cause. ■ Most common cause is bladder irritation ■ Immediate catheterization to relieve bladder distention may be necessary.
■ Lidocaine jelly should be instilled in the urethra before catheterization. ● If a catheter is already in place, it should be checked for kinks or folds. If plugged, irrigate or replace ● Stool impaction can also cause autonomic dysreflexia. ○ Digital rectal examination after anesthetic ointment to decrease rectal stimulation. ○ Remove all skin stimuli (constrictive clothing & tight shoes). ○ Monitor BP frequently during the episode. ○ If symptoms persist after the source has been relieved, α-adrenergic blocker or an arteriolar vasodilator (e.g., prazosin, nifedipine [Procardia]) is administered. ○ Careful monitoring must continue until the vital signs stabilize. ○ Teach pt & caregiver to recognize the causes and symptoms of autonomic dysreflexia (Table 60-7). ○ They must understand the life-threatening nature of this dysfunction and must know how to relieve the cause. Rehabilitation & Home Care ● Rehab is complex and involved. ● Pt can learn to func. At highest level of wellness ● A specialized rehab center is recommended for new SPI. (Cardinal Hill) ● Focus of rehab: ○ Retraining of physiologic processes & pt, caregiver, and family teaching on management of physiologic and life changes (how to cath self, how to move safely from wheelchair to bed) ● Multi team approach. (nurses, doctors, psychologist, Prosthetists, dietitians) ● Progress is usually slow, need a lot of encouragement ● Respiratory Rehabilitation ○ Pt w/ high cervical spinal cord injury may have greatly increased mobility with phrenic nerve stimulators or electronic diaphragmatic pacemakers. ○ Ventilators can also be reasonably portable ○ Ventilator-dependent tetraplegic pts can be mobile ○ Pt w/ cervical –level injury – taught assisted coughing and regularly use of incentive spirometry & deep breathing exercises Neurogenic Bladder ● bladder dysfunction related to abnormal or absent bladder innervation. ● After spinal cord shock resolves, pt usually have some degree of neurogenic bladder. (depends on completeness of SPI) ● Neurogenic bladder have no reflex (areflexic, flaccid) or hyperactive reflex (hyperreflexic,
● Anticholinergic drugs (oxybutynin [Ditropan], tolterodine [Detrol]) may be used to suppress bladder contraction. ● α-Adrenergic blockers (e.g., terazosin [Hytrin], doxazosin [Cardura]) may be used to decrease outflow resistance at the bladder neck ● Antispasmodic drugs (e.g., baclofen [Lioresal]) may be used to decrease spasticity of pelvic floor muscles. ● Reflexic usually tx with meds. ● Areflexic usually managed with intermittent cath or Foley. ● Long term increases risk of ○ CAUTI ○ Fistula ○ diverticula ● Change cath 1 wk – 1 month ● Intermittent cath (most commonly recommended method of bladder mgmt) ● Initially cath Q 4 hrs ● Assess bladder volume before cath w/ ultrasound. ● If <200 mL time interval extended ● If >500 mL time interval shortened ● # of caths per day is 5 or 6 ● Overdistended bladder can cause ischemia of the bladder wall. ● Urinary diversion ○ If pt has repeated UTIs ○ Repeated stones ● Surgeries ○ Bladder neck revision (sphincterotomy) ○ Bladder augmentation (augmentation cystoplasty) ○ Penile prosthesis, artificial sphincter, perineal ureterostomy, cystotomy, vesicotomy, and anterior urethral transplantation. Neurogenic Bowel ● Neurogenic bowel – Loss of voluntary bowel control ● Prevention of constipation ● High-fiber diet ● Adequate fluid intake ● Table 60-10 Pt & caregiver teaching guidelines related to bowel management. ● suppositories (bisacodyl [Dulcolax] or glycerin) or small-volume enemas and digital stimulation (performed 20 to 30 minutes after suppository insertion) by the nurse or pt may be necessary. ● In the patient with an upper motor neuron lesion, digital stimulation is necessary to relax the external sphincter to promote defecation. ● Stool softener (docusate sodium (Colace) ● Oral laxatives only if absolutely necessary for a day or two and not on a regular basis. (become
laxative dependent) ● Valsalva maneuver and manual stimulation are useful in pts with lower motor neuron lesions. ● VM requires intact abdominal muscles (pt with injuries below T12) ● BM every other day is considered adequate. ● Incontinence can result from too much stool softener or a fecal impaction. ● Record BM – amt, time, consistency Spasticity ● Spasticity improves circ. ● Decreases orthostatic hypotension ● Decreases risk of VTE ● Can cause pain and discomfort to pt ● Do good ROM Skin Care ● Prevent pressure ulcers & skin breakdown.
