Spinal Cord Injury SCI

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Spinal Cord Injury SCI
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Concept Map Selected Topics in Neurological
Nursing
PATHOPHYSIOLOGY Traumatic Brain Injury Spinal
Cord Injury Specific Disease Entities
Amyotropic Lateral Sclerosis Multiple
Sclerosis Huntingtons Disease
Alzheimers Disease Huntingtons Disease
Myasthenia Gravis Guillian-Barre Syndrome
Meningitis Parkinsons Disease
PHARMACOLOGY --Decrease ICP --Disease /
Condition Specific Meds
ASSESSMENT Physical Assessment Inspection
Palpation Percussion
Auscultation ICP Monitoring Neuro Checks Lab
Monitoring
Care Planning Plan for client adls, Monitoring,
med admin., Patient education, Discharge
Planning, morebased On Nursing Process A_D_P_I_E
Nursing Interventions Evaluation Execute the
care plan, evaluate for Efficacy, revise as
necessary
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Objectives

• Explain pathophysiology of various SCIs and
  related conditions
• Detail signs symptoms and functionality of
  different level SCIs
• Differentiate between Neurogenic Shock and Spinal
  Shock
• Explain Autonomic Dysreflexia / Hyperreflexia and
  list appropriate nursing interventions
• Discuss overall medical nursing management of
  SCIs

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SCI Goals of Care

• There's no way to reverse damage
• Treatment focuses on
• 1. Preventing further injury
• 2. Enabling people to return to an active and
  productive life within the limits of their
  disability

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Treatment

• Spinal Immobilization / Traction
• High doses of corticosteroid drug
  Methylprednisolone (Medrol) STAT !
• must be within eight hours of injury
• A few days after injury medical reassessment and
  repeat of diagnostic tests will help determine
  the severity of the injury and likely extent of
  recovery
• Surgery as indicated

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Tong Care to Prevent Infection
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Stryker Frame Traction Bed
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Log Rolling Technique
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SCI Meds

• Glucocorticoids (Decadron suppress immune
  response)
• Vasopressors (treat hypotension)
• Plasma extenders (treat shock)
• Atropine (treat bradycardia)
• Muscle relaxants
• Anti-Spasmodics (Dantrium)
• Analgesics
• Antidepressants
• Zantac, Ranitidine (prevent gastric ulcers)
• Stool Softeners
• Vasodilaters (Hydralazine, nitroglycerin to
  treat HTN such as AD)
• Anti-Seizure (gabapentin, phenytoin)

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Neurogenic Shock

• Occurs in acute stage of SCI (first hour per ATI)
  
• Usually in injuries ABOVE T6
• D/T interruption of the CNS
• causing disruption of sympathetic outflow
  from T1 to L2
• with unopposed vagal tone

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Neurogenic Shock S Ss

• Warm and DRY skin does not perspire on the
  paralyzed parts of body d/t blocked sympathetic
  activity
• Hypotension Bradycardia Hypothermia
• (d/t vascular dilation therefore blood
  pooling )

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Spinal Shock

• D/t concussive effect of the primary SCI on the
  nervous system
• Can last days or months
• Interferes with definitive diagnosis of permanent
  deficit
• Effect causes temporary (transient) depression of
  all reflexes
• - paralysis (flaccid)
• - loss of sensation
• - loss of autonomic function
• - loss of B B control (Sometimes priapism)
• Spasticity or hyperreflexia signals end of this
  shock

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Autonomic Dysreflexia ( Hyperreflexia )

• SCI acute syndrome of excessive uncontrolled
  sympathetic output
• Occurs ONLY after spinal shock has resolved
• SCI above T6
• Life-threatening HTN emergency

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A. D. (Hyperreflexia)

• Below T6 intact sensory nerves transmit noxious
  impulses up the spinal cord
• . BUT
• Sympathetic inhibitory impulses above T6
• are blocked
• THEREFORE

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• Sympathetic outflow continues
• causing release of norepinephhrine and dopamine

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Result

• Severe Vasoconstriction
• H/A Sudden HTN

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Result above the SCI

• Sweating Flushing

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Other Distinctive S S

• Bradycardia
• Blotching of the Skin
• Restlessness
• Goose bumps
• Stuffy nose (nasal congestion)

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A.D. / Hyperreflexia

• Clients with spinal cord injuries at Thoracic 6
  10
• (T6 -T10) may be susceptible
• Patients with Thoracic 10 (T-10) and below are
  usually not susceptible
• The older the injury the less likely the person
  will experience autonomic dysreflexia

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Common Causes

• The most common cause of noxious stimuli is
  distension of the hollow viscera (80), such as
  the urinary bladder or bowel
• 1. Urinary Retention
• 2. Constipation
• Simple kinks in the tubing or plugs in the
  urinary catheter can trigger autonomic dysreflexia

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Credes Method

• Credé's method is a manual suprapubic pressure
  exerted with a clenched fist or fingers, used to
  initiate micturition, in patients with spinal
  cord injury (SCI) who have neurovesical
  dysfunction.
• However, it is currently NOT recommended practice
  because of the risk of bladder rupture.
• Sources
• Hockenberry, M.J. (2003). Wongs Nursing Care of
  Infants and Children. (7th ed.). St. Louis
  Mosby, pp. 1326-1328.
• Reinberg Y., Fleming T., Gozalez, R. (1994).
  Renal Rupture After the Crede Maneuver. Journal

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Treatment

• Assist to sitting position to lower the BP
  through lower-extremity vascular pooling
• Loosen restrictive garments (shirts, belts,
  slacks, straps and even shoes)
• Monitor Vitals
• Look for Cause Eliminate!

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Treatment

• Ensure catheter patency (make sure catheter not
  kinked or pulled too tight, and is actually
  draining urine)
• Catheterize to decompress bladder
• Assess for signs of urinary tract infection, such
  as dark, cloudy urine or sediment in catheter
  tubing
• If bowel is distended, disimpact after inserting
  anesthetic jelly or ointment per rectum
• Hypertension should be treated medically if it
  persists

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Still Cant Find Cause ? !!!

• Cause may not be readily found
• Careful physical exam is imperative during this
  crisis
• Other causative agents usually not considered in
  medical emergencies include skin irritations,
  wounds, pressure sores, burns, broken bones,
  pregnancy, ingrown toenails, appendicitis, and
  other medical complications
• Still cannot find cause? .
• focus on decreasing the blood pressure!

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Antihypertensive Meds

• Nifedipine (Adalat) 10 mg orally - instruct the
  patient to bite the capsule, then swallow it
• Nitroglycerin sublingual or topical paste (1/2
  inch)
• Prazosin (Minipress)
• Clonidine (Catapres) 0.1- 0.2 mg PO
• Hydralazine (Apresoline) 10 - 20 mg IM/IV

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Client Teaching

• Provide education about early recognition and
  treatment of A.D.
• Encourage the client to carry some type of medic
  alert identification
• (It is estimated that approximately 85 of
  spinal cord injury patients at level T-6 will
• suffer at least one episode of
  autonomic dysreflexia)

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Client Teaching

• Prevention
• Frequent pressure relief in bed/chair
• Avoid sun burn/scalds (avoid overexposure, use of
  15 sunscreen, watch water temperatures)
• Faithful adherence to bowel program
• Keep catheters clean and remain faithful to
  catheterization schedule
• Well balanced diet and adequate fluid intake
• Compliance with medications

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SCI Recovery

• Recovery typically starts between a week and six
  months after injury, if it occurs, with the
  majority of recovery taking place within one year
• Doctors generally regard any impairment remaining
  after 12 to 24 months as likely to be permanent

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SCI Nursing Interventions

• Bowel retraining program
• ROM
• Sexual function adaptive strategies
• PT
• OT
• Assistive devices
• Q2H turns skin care
• Nutrition

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SCI Nursing Interventions

• Referrals
• Social Services
• Support Groups
• Appropriate specialists

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SCI Rehabilitation

• Initial rehabilitation emphasizes regaining leg
  and arm strength, redeveloping fine-motor skills
  and learning adaptive techniques to accomplish
  day-to-day tasks
• Then long-term rehab typically includes exercise
  and training with
• Modern wheelchairs - Improved, lighter weight
  wheelchairs are more mobile and more comfortable.
  The Food and Drug Administration has even
  approved a wheelchair that can climb stairs and
  elevate a seated passenger to eye level to reach
  high places without help
• Computer devices - Computer-driven tools and
  gadgets can help with daily routines.
  Voice-activated computer technologies to answer
  and dial a phone, or to use a computer and pay
  bills. Computer-controlled technologies can also
  help with bathing, dressing, grooming, cleaning
  and reading

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Complications

• Urinary tract problems - urinary incontinence
  increases risk of urinary tract infections,
  kidney infection, kidney or bladder stones. d/t
  ongoing catheterizations
• Bowel management difficulties Reduced
  peristalsis and fecal incontinence
• Pressure sores - particularly susceptible to
  pressure sores because the injury reduces or
  eliminates sensations, making it difficult to
  know when a sore is developing
• Deep vein thrombosis and pulmonary embolism
• Lung and breathing problems - Difficult to
  breathe and cough with weakened abdominal and
  chest muscles, so people with cervical and
  thoracic spinal cord injury may develop
  pneumonia, asthma or other lung problems

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Complications

• Spasticity some people develop muscle spasms
  and jumping of their arms and legs because some
  of the nerves in the lower spinal cord become
  more sensitive after injury and cause muscle
  contractions. However, because of the spinal cord
  injury, the brain can no longer send signals to
  the lower nerves to regulate the contractions
• Weight control issues - Weight loss and muscle
  atrophy are common. But the change in lifestyle
  and activities may eventually cause weight gain,
  which can make it difficult for the pt lift
  themselves or be lifted from place to place

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Concerns

• Pain
• - It's possible to feel pain in areas where
  there's little or no sensation
• - May also experience pain from overusing
  muscles in one part of the body. Many people
  develop shoulder tendinitis from manually
  operating a wheelchair for a long period of time
• - Any kind of pain can have a negative impact
  on daily living
• .
• New Injuries
• - Susceptible to injury of any part of the body
  that has impaired sensation
• - May even receive a burn or cut without
  realizing it

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Male Concerns

• Sexual Dysfunction
• Still have erections, even with little sensation
  in the genital area
• But erections may not be firm enough or last long
  enough for sexual activity
• Fertility also can be affected
• - 99 aren't able to ejaculate during
  intercourse
• - Low sperm counts
• - Poor sperm motility
• However, men can be sexually active and
  father a child

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Female Concerns

• Sexual Dysfunction
• Most have no physical change that inhibits sexual
  intercourse or pregnancy
• But may lose ability to produce vaginal
  lubrication or control vaginal muscles
• Many experience changes in body image that affect
  sexuality
• Any pregnancy will likely be considered high risk
• There may be amenorrhea for about 6 months after
  SCI

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Coping

• Grieving
• Healthy part of recovery. It's natural and
  important to grieve the loss of the way the
  person was before. Thennecessary to set new
  goals and find a way to move forward with life
• Depression and alcohol abuse
• Taking control
• Education about injury and options for
  reclaiming an independent life
• Because the costs can be overwhelming, find out
  about economic assistance or support services
  from the state or federal government or from
  charitable organizations
• Talking
• Friends and family may respond in different ways

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Continued

• Dealing with intimacy
• Self - Care
• Looking ahead