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A comprehensive overview of spinal cord injury (sci), covering its pathophysiology, classification, clinical manifestations, and nursing management. It delves into the mechanisms of injury, the different types of sci, and the associated complications, including respiratory, cardiovascular, urinary, gastrointestinal, and integumentary system problems. The document also outlines diagnostic studies, interprofessional care, and nursing interventions for managing sci patients.
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● 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
● Flexion ● Hyperextension ● Flexion-rotation ● Extension-rotation ● Compression
● 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
● 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
● 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.