SPINAL CORD INJURY

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SPINAL CORD INJURY

• through the
• Acute and the Rehabilitative Phases of Nursing
  Care

K. BROOKS, RN, MSNEd
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Risk Factors for SCI

• Each year, 11,000
• people experience a SCI.
• 200,000 more people are living with spinal cord
  injury results
• Statistics show that males are highest number.
  Ages 16 30 y.o. Why do you think that is so?

Motor Vehicle Accidents
Sports Injuries
Violent Acts
Falls / Accidents
Data taken from 126 patient admissions
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Examples of Injury

• Accidents (45)
• Car, van, coach 16.5
• Motorcycle 20
• Bicycle 5.5
• Pedestrian 1.5
• Helicopter 1.5
• Domestic / Industrial Accidents (34)
• Sport Injury 15
• Diving 4 vertical compressions
• Rugby 1
• Horse Riding 3
• Other 7
• Assault 6
• Self Harm 5
• Assaulted 1

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Profound Health Care Effects

• Average cost of care for a person with a cervical
  injury
• 572,178 first year
• 102,491 each year after
• Economic Hardship
• High cost of rehab and long term care effects
• 90 of discharged SCI patients go home
• 10 of dishcarged SCI patients go to nursing
  home, chronic care facility, group home

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Lifelong Needs of SCI

• Physical
• Psychosocial
• Financial
• Vocational
• Social Functioning

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CASE STUDY ONE

• T.W. is a 22 yo male patient fell 50ft from a
  chairlift while skiing and landed on hard snow.
  He was found to have a T10-11 fracture with
  paraplegia. He was admitted to the ICU and place
  on high doses of steroids for 24hrs. He was taken
  to surgery for external spinal stabilization. He
  spent two days back in the ICU, 5 days on Step
  Down, and is now ready to be transferred to your
  rehab unit. He continues to have no movement to
  the lower extremities.

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1 Goal of Treatment in Acute Phase

• Pathophysiology immediate mechanical disruption
  of axons as a result of a laceration, stretch,
  tear, or sever
• Primary Injury / Secondary Ongoing Injury
• Normal blood flow is disrupted to area
• Spinal cord deprived of O2 .ischemia and cell
  death Within four hours
• Free Radicals released
• Hemorrhage in area causes edema and compression
  further damage to axons bleeding appears within
  one hour this can spread the area of injury and
  damage
• The longer this process, the more permanent
  damage CNS does not regenerate!

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1 Critical Nursing Care / Goals

• Immediate Stabilization to prevent further
  injury, trauma, and cascade of secondary injury
• How do we do this?
• Survive the Injury
• Maintain physiological stability through spinal
  shock

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ACUTE SPINAL FACTS

• The extent of damage results from the primary and
  secondary injury and can be devastating if
  stabilization and early treatment were not
  started
• Prognosis / Recovery most accurately determined
  72hrs or more after injury

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2 Steroid Therapy Benefits

• High dose IV steroids (Solumedrol) given within
  frist 8hrs of injury
• Reduce damage to cell membranes and decrease
  inflammation.
• Found in the early 80s to be highly effective to
  reduce the length of time for spinal shock and to
  reduce degree of injury
• Side Effects decreased immune response, risk
  for infection, increase serum glucose, induce
  depression, psychosis, risk for GI bleed

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3 What is Spinal Shock?(AKA Neurogenic Shock)

• Temporary Condition / Acute Phase
• Sympathetic function / communication is impaired
  below the level of injury Sympathetic nerves
  leave the spine at thoracic and lumbar areas
• Parasympathetic function takes over
• Vasodilation , Venous Pooling, Decreased
  Cardiac Output
• VS Changes Hypotension, Bradycardia,
  Temperature fluctuations, Flushed extremities,
  Hypoxia
• Loss of Spinal Reflexes
• Loss of Sensation
• Flaccid Paralysis below injury
• Time Frame one week to six months
• Masks the extent of injury
• Spinal Shock Resolves Reflexes return

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3 Nursing Support

• Bradycardia
• Anticholinergic Atropine
• Temporary Pacemaker
• Hypotension
• Fluids
• Dopamine
• Careful monitor of ABCs. Any increase of vagal
  response can further increase bradycardia and
  cause cardiac arrest.

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4 Post Acute Phase

• Stabilizing the spine and resolving spinal shock
  will allow for early mobilization.
• Early mobilization prevents further
  complications.
• What system by system complications are we
  concerned with ?
• Cardiovascular
• Respiratory
• Gastrointestinal / Nutrition
• Elimination
• Musculoskeletal
• Integumentary

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Respiratory Complications

• Major cause of death in the acute phase!
• Pulmonary support
• Suctioning / Postural Drainage / Turning
• Coordinate with RT
• HHN
• O2 support
• Ventilator? Ambu at bedside
• Trach needed?
• Monitor ABGs gas exchange
• Breath sounds / breathing patterns / sputum
  production
• Poor cough effort
• Atelectasis / Pneumonia
• Higher the level injury, the higher the risk!
• Above C4 / Below C4 (Phrenic nerve at
  diaphragm. Intercostal muscle impaired)

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Cardiovascular Complications

• Hypotension
• Bradycardia
• Decreased Cardiac Output
• Venous Pooling
• Impaired Tissue Perfusion
• Risk for Deep Vein Thrombosis DVT Prophylaxis!

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Gastrointestinal / Nutrition Complications

• Paralytic Ileus
• Septic Bowel
• Necrotic Bowel
• Stress Ulcers
• GIB
• Malnourishment
• What does the nurse assess? What does the nurse
• monitor? Abdominal assessment? NGT to suction?

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Elimination Complications

• Loss of Bladder and Bowel control
• Neurogenic B/B
• Risk for Impaction / Retention / Incontinence /
  Urinary Tract Infections

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Musculoskeletal Complications

• Risk for Contractures
• Muscle spasticity
• Contractures .. Loss of function
• Bone loss
• Muscle Atrophy

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Skin Complications

• Patients who do not have an ulcer state
• that nurses in the ICU turned them every 2
• hours after injury
• Research shows that patients go to rehab with
• ulcers already formed DISGUSTING nursing
• care!
• Risk factors for skin breakdown?
• Interventions? Skin Inspections?

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5 Rehabilitative Needs
MASLOWS HIERARCHY

• Self Actualization
• (4) Community Integration
• (3) Adjustment to living at home
• (2) Accomplishment of ADLS
• (1) Stabilization of Physiological Systems

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6 Self Care Abilities of T10-11

• Level of T2 T12 should be independent with the
  wheelchair
• May even walk short distances with orthotics and
  crutches
• Manage their own ADLs
• Manage their B/ B routine

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LEVELS OF INJURY

• Symptoms, degree of paralysis, extent of injury,
  and disability depends on the level of cord that
  is injured
• Cervical / Thoracic / Lumbar
• Cervical (C1 T1)
• - Tetraplegia (arms are rarely completely
  paralyzed)
• Thoracic / Lumbar (T2 lumbar)
• Paraplegia (full us of arms)

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• Complete vs. Incomplete
• Complete Total loss of sensory and motor
  function below the level of injury
• Incomplete Mixed loss of voluntary and
  involuntary activity and sensation
• Cervical Injuries
• C1-2 limited head and trunk control , requires
  w/c with breath controls
• C3-4 Dependent with ADLs, may still need
  ventilator support
• C4 and above some sort of lifelong ventilatory
  support
• C5 elbow flexion
• C6 wrist extension
• C7 finger control
• Independence increases from C6 down

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7 Bladder Function

• SCI above T12 Spastic or Reflexic Bladder
• Characterized by involuntary bladder contractions
  with uncontrolled voiding and incontinence.
• SCI below L1 Areflexic or Flaccid Bladder
• Absent bladder contractions resulting in high
  volumes of residual urine and urinary retention
• Risks Renal Calculi , UTIs
• Goals Avoid bladder infections. Increase fluids.
  Bladder program

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• Pt Teaching
• s/ sx of infection
• Intermittent cath program
• Medications to help bladder with tone
• Stimulate urine flow
• Increase fluids
• Indwelling catheter irrigations
• Cranberry juice
• Meds
• Anticholinergics to suppress contraction
• Antispasmotics to decrease spasticity

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8 Bowel Training

• The bowel has its own neural control that
  responds to distention. This is what helps SCI
  patients regain control of emptying.
• Train the bowel a predictable pattern of emptying
• Meds
• Stool Softeners
• Stimulant Laxatives
• Diet
• Fiber, fluids
• Digital stimulation (avoid enemas)
• Positioning
• Abdominal Massage
• Valsalva

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CASE STUDY 2

• 43 yo male pt entered the hospital with a left
  ischial
• pressure sore stage IV. He is a Incomplete C5
  C6 level of
• injury for 20 years after suffering a SCI after a
  diving
• accident. He has a history of pressure ulcers.
• Vital Signs T 96.0, BP 88/42, P52, RR20
• He also has a history of Autonomic Dysreflexia
• Take a look at his medication regiman.

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1 INCOMPLETE? SELF CARE ABILITIES?

• Full head, neck, and shoulder control
• Diaphragm control
• Should not need respiratory support
• Elbow flexion with some wrist extension
• Assistive devices for fine motor skills
• Independent feeding, grooming, bathing,
  wheelchair on even surfaces, drive with hand
  controls
• Assistance Transfers, dressing

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2 VS Changes in SCI

• Autonomic Nervous System effected with injuries
  above the T6 level.
• There can be a loss of communication within the
  body with the ANS.
• Inability to autoregulate particularly VS
• Low BP, Low Pulse, Poiklothermia (taking on the
  temp of the room with periods of flushing and
  inability to sweat)

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4 Medication Regimen

• Muscle Spasticity
• Baclofen
• Flexeril
• Valium
• Vitamins
• Pain and Muscle Relaxation
• Neurontin
• Bladder Care
• Detrol
• Ditropan
• Bowel Care
• Colace
• Suppository

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5 Autonomic Dysreflexia

• Abnormal ANS response in SCI pts with a T6 or
  higher
• Patho ANS cannot decipher stimulus responses
  rapidly coming up the spinal tract causing an
  abnormal ANS response flight and flight
• Precipitated by noxious stimuli below the level
  of injury
• Congested communication in spinal tract
• Can be Life Threatening cause increased ICP,
  hemorrhage, Seizure, Stroke
• Medic Alert!

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• AD is usually brought on by B / B distention,
  UTI, spasms, pressure sores, infection, ingrown
  toenail, insect bite, dysmennorhea, surgery site,
  constrictive clothing
• Assess fast!
• Headache
• Flushing
• Sweating
• High BP
• Blurred vision
• Nausea
• Act fast!
• Elevate HOB, contact MD, monitor VS, identify
  noxious stimuli, treat cause

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6 Lets Talk About Sex Baby!

• Reflex erection is possible with upper motor
  neuron lesions
• Orgasm and ejaculation is not usually possible
• Drugs or surgery for erectile dyfunction option
• Poor sperm quality
• Usually remain fertile and can have children
• Uterine contraction not felt
• Allow venting of feelings, offer support, suggest
  counseling, educate

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PSYCHOSOCIAL CONCERNS??

• What can you come up with???

INTERDEPENDENCE MODE
SELF CONCEPT
ROLE FUNCTIONS
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Collaborative Goals with SCI

• Maintain optimal level of wellness
• Maintain optimal functioning
• Minimal or no complications of immobility
• Learn new skills, self care
• Return to home
• Integrate back into community