Focus on Spinal Cord Injury Relates to Chapter

Focus on Spinal Cord Injury (Relates to Chapter 61, “Nursing Management: Peripheral Nerve & Spinal Cord Problems, ” in the textbook) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc.

Spinal Cord Injuries • Even young patients with spinal cord injuries can anticipate a long life. § § Prognosis for life is about 5 years less than persons without spinal cord injuries. Cause of premature death is usually related to compromised respiratory function. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 2

Spinal Cord Injuries • Spinal cord injuries can cause major problems. § § § Potential disruption of individual growth and development Economic loss High cost of rehabilitation and long-term health care Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 3

Spinal Cord Injuries • Estimates from CDC § § 12, 000 Americans suffer spinal cord injuries each year. Approximately 259, 000 Americans live with spinal cord injuries. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 4

Spinal Cord Injuries • Cost of spinal cord injury care is high. • For patient with high cervical injury, § § First year: $682, 957 Subsequent years: $122, 334 Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 5

Spinal Cord Injuries • Many spinal cord patients remain independent. § § 90% are discharged to their home or to another noninstitutional residence. 10% are discharged to nursing homes, chronic care facilities, or group homes. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 6

Etiology and Pathophysiology • Young adult men between ages 16 and 30 are at greatest risk. • 81% of spinal cord injury patients are 19 -year-old males. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 7

Etiology and Pathophysiology • Causes § § § 42% Motor vehicle crashes 27% Falls 15% Violence • § § In large urban areas, gunshot wounds may surpass falls. 7% Sports injuries 8% Other miscellaneous Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 8

Etiology and Pathophysiology Initial Injury • Spinal cord is wrapped in tough layers of dura. • Rarely torn or transected by direct trauma Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 9

Etiology and Pathophysiology Initial Injury • Spinal cord injury due to cord compression by § § § Bone displacement Interruption of blood supply to cord Traction resulting from pulling on cord • Penetrating trauma (gunshot wound or stab wounds) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 10

Etiology and Pathophysiology Initial Injury • Primary injury § Initial mechanical disruption of axons as a result of stretch or laceration • Secondary injury § Ongoing, progressive damage that occurs after initial injury Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 11

Etiology and Pathophysiology Initial Injury • Several theories on what causes ongoing damage at molecular and cellular levels § § Free radical formation Uncontrolled calcium influx Ischemia Lipid peroxidation Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 12

Etiology and Pathophysiology Initial Injury • Apoptosis occurs and may continue for weeks or months after initial injury. • Complete cord damage in severe trauma related to autodestruction of cord § Petechial hemorrhages are in central gray matter of cord shortly after injury. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 13

Events Leading to Spinal Cord Ischemia and Hypoxia of Second Injury Fig. 61 -4. Cascade of metabolic and cellular events that leads to spinal cord ischemia and hypoxia of secondary injury. RBCs, red blood cells; SCBF, spinal cord blood flow. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 14

Etiology and Pathophysiology Initial Injury • Resulting hypoxia, ↓ oxygen tension below level that meets metabolic needs of spinal cord • Lactate metabolites • ↑ vasoactive substances § § § Norepinephrine Serotonin Dopamine Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 15

Etiology and Pathophysiology Initial Injury • By ≤ 24 hours, permanent damage may occur because of edema. • Edema secondary to inflammatory response is harmful because of lack of space for tissue expansion. • Resultant compression of cord and extension of edema above and below injury increase ischemic damage. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 16

Etiology and Pathophysiology Initial Injury • Extent of neurologic damage caused by spinal cord injury results from § Primary injury damage • § Actual physical disruption of axons Secondary damage • Ischemia, hypoxia, microhemorrhage, and edema Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 17

Spinal and Neurogenic Shock • Spinal shock § § Temporary neurologic syndrome Characterized by ↓ reflexes • Loss of sensation • Flaccid paralysis below level of injury • § Experienced by about 50% of people with acute spinal cord injury Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 18

Spinal and Neurogenic Shock • Neurogenic shock § § Loss of vasomotor tone caused by injury Characterized by hypotension and bradycardia (important clinical cues) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 19

Spinal and Neurogenic Shock • Neurogenic shock (cont’d) § Loss of sympathetic nervous system innervation causes Peripheral vasodilation • Venous pooling • ↓ cardiac output • Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 20

Spinal and Neurogenic Shock Classification of Spinal Cord Injury • Classified by mechanism of § § Injury Skeletal level of injury Neurologic level of injury Completeness or degree of injury Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 21

Mechanisms of Injury • Major mechanisms of injury are § § § Flexion Hyperextension Flexion-rotation Extension-rotation Compression Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 22

Mechanisms of Injury Fig. 61 -5. Mechanisms of spinal cord injury. Many situations may produce these injuries. This only shows some examples. A, Flexion injury of the cervical spine ruptures the posterior ligaments. B, Hyperextension injury of the cervical spine ruptures the anterior ligaments. C, Compression fractures crush the vertebrae and force bony fragments into the spinal canal. D, Flexion-rotation injury of the cervical spine often results in tearing of ligamentous structures that normally stabilize the spine. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 23

Level of Injury • Skeletal level § Injury is at the vertebral level, where there is most damage to vertebral bones and ligaments. • Neurologic level § Lowest segment of spinal cord with normal sensory and motor function on both sides of the body Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 24

Level of Injury • Level of injury may be § § § Cervical Thoracic Lumbar Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 25

Level of Injury • Paralysis of all four extremities occurs (tetraplegia [quadriplegia]) if cervical cord is involved. • Paraplegia results if thoracic or lumbar cord is damaged. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 26

Level of Injury Fig. 61 -6. Symptoms, degree of paralysis, and potential for rehabilitation depend on the level of the lesion. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 27

Degree of Injury • Degree of spinal cord involvement may be § Complete cord involvement • § Results in total loss of sensory and motor function below level of lesion (injury) Incomplete (partial) cord involvement • Results in mixed loss of voluntary motor activity and sensation and leaves some tracts intact Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 28

Degree of Injury • Degree of sensory and motor loss varies depending on § § Level of lesion Specific nerve tracts damaged and those spared Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 29

Syndromes Associated With Incomplete Cord Lesions Fig. 61 -7. Syndromes associated with incomplete cord lesions. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 30

Degree of Injury Central Cord Syndrome • Damage to central spinal cord • Occurs most commonly in cervical cord region • More common in older adults • Motor weakness and sensory loss are present in both upper and lower extremities. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 31

Degree of Injury Anterior Cord Syndrome • Caused by damage to anterior spinal artery • Results in compromised blood flow to anterior spinal cord • Typically results from injury causing acute compression of anterior portion of spinal cord § Often a flexion injury Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 32

Degree of Injury Brown-Séquard Syndrome • Result of damage to one half of spinal cord • Characterized by loss of motor function and position and vibration sense • Vasomotor paralysis on the same side as lesion Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 33

Degree of Injury Posterior Cord Syndrome • Results from compression or damage to posterior spinal artery • Very rare condition • Usually dorsal columns are damaged. § Results in loss of proprioception • Pain, temperature sensation, and motor function below level of lesion remain intact. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 34

Degree of Injury Conus Medullaris Syndrome and Cauda Equina Syndrome • Result from damage to very lowest portion of spinal cord (conus) and lumbar and sacral nerve roots (cauda equina) • Injury to these areas produces flaccid paralysis of lower limbs and areflexic (flaccid) bladder and bowel. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 35

Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 36

ASIA Impairment Scale • American Spinal Injury Association (ASIA) impairment scale • Commonly used for classifying severity of impairment resulting from spinal cord injury Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 37

ASIA Impairment Scale • Combines assessment of motor and sensory function • Determines neurologic level and completeness of injury • Useful for § § Recording changes in neurologic status Identifying appropriate functional goals for rehabilitation Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 38

ASIA Impairment Scale Fig. 61 -8. The American Spinal Injury Association Impairment Scale. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 39

Clinical Manifestations • Generally direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection • Related to level and degree of injury • Patient with an incomplete lesion may demonstrate a mixture of symptoms. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 40

Clinical Manifestations • Higher the injury, the more serious the sequelae § Proximity of cervical cord to medulla and brainstem • Movement and rehabilitation potential are related to specific location of spinal cord injury. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 41

Clinical Manifestations • Immediate postinjury problems include § § Maintaining a patent airway Adequate ventilation Adequate circulating blood volume Preventing extension of cord damage (secondary damage) Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 42

Clinical Manifestations Respiratory System • Respiratory complications closely correspond to level of injury. • Cervical injury § Above level of C 4 Presents special problems because of total loss of respiratory muscle function • Mechanical ventilation is required to keep patient alive. • Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 43

Clinical Manifestations Respiratory System • Cervical injury (cont’d) § Below level of C 4 Diaphragmatic breathing if phrenic nerve is functioning • Spinal cord edema and hemorrhage can affect function of phrenic nerve and cause respiratory insufficiency. • Hypoventilation almost always occurs with diaphragmatic breathing. • Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 44

Clinical Manifestations Respiratory System • Cervical and thoracic injuries cause paralysis of § § Abdominal muscles Intercostal muscles • Patient cannot cough effectively. § Leads to atelectasis or pneumonia Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 45

Clinical Manifestations Respiratory System • Artificial airway provides direct access for pathogens. • Important to ↓ infections • Neurogenic pulmonary edema may occur. • Pulmonary edema may occur in response to fluid overload. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 46

Clinical Manifestations Cardiovascular System • Any cord injury above level T 6 greatly ↓ the influence of the sympathetic nervous system • Bradycardia occurs. • Peripheral vasodilation results in hypotension. • Relative hypovolemia exists because of ↑ in venous capacitance Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 47

Clinical Manifestations Cardiovascular System • Cardiac monitoring is necessary. • Peripheral vasodilation § § ↓ venous return of blood to heart ↓ cardiac output • IV fluids or vasopressor drugs may be required to support BP. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 48

Clinical Manifestations Urinary System • Urinary retention common • Bladder is atonic and overdistended. • Indwelling catheter inserted § Increased risk of infection • Bladder may become hyperirritable. § § Loss of inhibition from brain Reflex emptying Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 49

Clinical Manifestations Gastrointestinal System • If cord injury is above T 5, primary GI problems related to hypomotility • Decreased GI motor activity contributes to development of § § Paralytic ileus Gastric distention • Nasogastric tube may relieve gastric distention. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 50

Clinical Manifestations Gastrointestinal System • Stress ulcers common • Intraabdominal bleeding may occur. § § Difficult to diagnose Indications of bleeding Continued hypotension despite treatment • Decreased hemoglobin and hematocrit • • Expanding girth may also be noted. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 51

Clinical Manifestations Gastrointestinal System • Less voluntary neurogenic control over bowel results in a neurogenic bowel. • Injury level of T 12 or below § § Bowel is areflexic. ↓ sphincter tone Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 52

Clinical Manifestations Gastrointestinal System • As reflexes return, § § § Bowel becomes reflexic Sphincter tone is enhanced Reflex emptying occurs Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 53

Clinical Manifestations Integumentary System • Consequence of lack of movement is skin breakdown. • Pressure ulcers can occur quickly. • Can lead to major infection or sepsis Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 54

Clinical Manifestations Thermoregulation • Poikilothermism § § Adjustment of body temperature to room temperature Occurs in spinal cord injuries because sympathetic nervous system interruption prevents peripheral temperature sensations from reaching hypothalamus Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 55

Clinical Manifestations Thermoregulation • With spinal cord disruption, there is also § § Decreased ability to sweat Decreased ability to shiver • Degree of poikilothermism depends on level of injury. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 56

Clinical Manifestations Metabolic Needs • Nasogastric suctioning may lead to metabolic alkalosis • ↓ tissue perfusion may lead to acidosis • Monitor electrolyte levels until suctioning is discontinued and normal diet is resumed Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 57

Clinical Manifestations Metabolic Needs • Loss of body weight is common • Nutritional needs much greater than expected for immobilized person • Positive nitrogen and high-protein diet § § Prevents skin breakdown and infection Decreases rate of muscle atrophy Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 58

Clinical Manifestations Peripheral Vascular Problems • Deep vein thrombosis (DVT) problem • Pulmonary embolism a leading cause of death • DVT assessments § § § Doppler examination Impedance plethysmograph Measurement of legs and thigh girth Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 59

Diagnostic Studies • CT scan may be used to assess stability of injury, location, and degree of bone injury. • MRI is used where there is unexplained neurologic deficit. • Comprehensive neurologic examination Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 60

Collaborative Care • Immediate goals are to maintain § § § Patent airway Adequate ventilation Adequate circulating blood volume • Systemic and neurogenic shock must be treated to maintain BP. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 61

Collaborative Care • Thoracic and lumbar vertebrae injuries § § Systemic support less intense than cervical injury Respiratory compromise not as severe Bradycardia is not a problem. Specific problems treated symptomatically Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 62

Collaborative Care • After stabilization, history is obtained. § § Emphasis on how injury occurred Extent of injury as perceived by patient immediately after event Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 63

Collaborative Care • Assessment § § Test muscle groups with and against gravity. Note spontaneous movement. Sensory examination Position sense and vibration Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 64

Collaborative Care • Assessment (cont’d) § Brain injury may have occurred—assess history for Unconsciousness • Signs of concussion • Increased intracranial pressure • § § Musculoskeletal injuries Trauma to internal organs Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 65

Collaborative Care Nonoperative Stabilization • Focused on stabilization of injured spinal segment and decompression • Through traction or realignment • Eliminates damaging motion at injury site • Intended to prevent secondary damage Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 66

Collaborative Care Surgical Therapy • Criteria for early surgery § § § Cord decompression may result in ↓ secondary injury Evidence of cord compression Progressive neurologic deficit Compound fracture Bony fragments Penetrating wounds of spinal cord or surrounding structures Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 67

Collaborative Care Surgical Therapy • Common surgical procedures § § § Decompression laminectomy by anterior cervical and thoracic approaches with fusion Posterior laminectomy with use of acrylic wire mesh and fusion Insertion of stabilizing rods Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 68

Collaborative Care Drug Therapy • Methylprednisolone (MP) § § § When administered early and in large doses, recovery of neurologic function is greater. Commonly used treatment option No benefit after 8 hours post injury Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 69

Collaborative Care Drug Therapy • Vasopressor agents § § Used in acute phase Maintain mean arterial pressure • Drug interactions may occur. • Pharmacologic agents § Used to treat specific autonomic dysfunctions Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 70

Nursing Assessment • Subjective data § § § Past health history Health perception–health management Activity-exercise Cognitive-perceptual Coping–stress tolerance Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 71

Nursing Assessment • Objective data § § § General: poikilothermism Integumentary: neurogenic shock Respiratory: lesions at C 1 -3 Cardiovascular: lesions above T 5 GI: decreased or absent bowel sounds Urinary: retention, flaccid bladder Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 72

Nursing Diagnoses • Impaired gas exchange • Decreased cardiac output • Impaired skin integrity • Constipation • Impaired urinary elimination Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 73

Nursing Diagnoses • Impaired physical mobility • Risk for autonomic dysreflexia • Ineffective coping • Interrupted family process Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 74

Planning • Overall goals § § Maintain an optimal level of neurologic functioning. Have minimal to no complications of immobility. Learn skills, gain knowledge, and acquire behaviors to care for self. Return to home and community. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 75

Nursing Implementation • Health promotion § Identify High-risk populations • Counseling • Education • § Support legislation on seat belt use, helmets for motorcyclists/bicyclists, and child safety seats. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 76

Nursing Implementation • Nursing interventions § § Education Counseling Maintaining appointments Referral to programs Recreation and exercise programs • Alcohol treatment programs • Smoking cessation programs • Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 77

Immobilization • Proper immobilization involves maintenance of a neutral position. • Stabilize neck to prevent lateral rotation of cervical spine. § § § A blanket or towel Hard cervical collar Backboard Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 78

Immobilization • Body should always be correctly aligned. • Turn patient so that he or she is moved as a unit to prevent movement of spine. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 79

Immobilization • Skeletal traction § § Realignment or reduction of injury Provided by rope from center of tongs over a pulley that has weights attached at end Traction must be maintained at all times. Stabilize head if dislodged, and then call for help. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 80

Immobilization Fig. 61 -9. Cervical traction is attached to tongs inserted in the skull. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 81

Immobilization • Skeletal traction (cont’d) § § Sites of tong insertion can become infected. Clean twice daily. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 82

Immobilization • Kinetic therapy § § § Uses a continual side-to-side slow rotation laterally with patient in constant motion Can be manual or automatic Decreases pressure ulcers and cardiopulmonary complications Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 83

Immobilization • After cervical fusion, a hard cervical collar or a sternal–occipital– mandibular immobilizer brace can be worn. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 84

SOMI Brace Fig. 61 -10. Sternal-occipital-mandibular immobilizer (SOMI) brace. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 85

Immobilization • Halo fixation is the most commonly used method of stabilizing cervical injuries. § § Hanging weights may be incorporated. May be attached to a body vest that allows ambulation Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 86

Halo Vest Fig. 61 -11. Halo vest. The halo traction brace immobilizes the cervical spine, which allows the patient to ambulate and participate in self-care. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 87

Immobilization • Thoracic or lumbar spine injuries § § Custom thoracolumbar orthosis (“body jacket”) Meticulous skin care is critical. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 88

Respiratory Dysfunction • During first 48 hours, spinal cord edema increases level of dysfunction. • Respiratory distress may occur. • Injury at or above C 3 § § Patient is exhausted. Labored breathing/ABGs deteriorate. Endotracheal intubation/tracheostomy Mechanical ventilation Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 89

Respiratory Dysfunction • Respiratory arrest a possibility • Other potential problems § § Pneumonia and atelectasis Nasal stuffiness and bronchospasms • Aggressive chest physiotherapy • Adequate oxygenation • Proper pain management Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 90

Respiratory Dysfunction • Regularly assess § § § § Breath sounds and breathing patterns ABGs Tidal volume Vital capacity Skin color Subjective comments Amount and color of sputum Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 91

Cardiovascular Instability • Heart rate is slow (<60 beats per minute) because of unopposed vagal response. • Any ↑ in vagal stimulation can result in cardiac arrest § § Turning Suctioning Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 92

Cardiovascular Instability • Frequently assess vital signs. • Anticholinergic for bradycardia • Temporary/permanent pacemaker • Compression gradient stockings § Remove every 8 hours for skin care. • Prophylactic heparin or low-molecular-weight heparin Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 93

Fluid and Nutritional Maintenance • During first 48 to 72 hours, GI tract may stop functioning. • Nasogastric tube may be inserted. • Fluid and electrolyte needs must be carefully monitored. • Oral foods and liquids can be given once bowel sounds are present or flatus has passed. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 94

Fluid and Nutritional Maintenance • High-protein, high-calorie diet • Evaluate swallowing in high cervical cord injuries before starting oral feedings. • If patient is not eating, cause should be thoroughly assessed. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 95

Bladder and Bowel Management • Immediately after injury § § Urine is retained. Loss of autonomic and reflex control of bladder and sphincter Bladder overdistention can result in reflux into kidney with eventual renal failure. Intermittent catheterization program • Urinary tract infections Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 96

Bladder and Bowel Management • Constipation § § § Problem during spinal shock No voluntary or involuntary evacuation of bowels occurs. Rectal stimulant (suppository or mini-enema) inserted daily Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 97

Temperature Control • Below level of injury § § § Vasoconstriction Piloerection Heat loss through perspiration • Temperature is largely external to patient. • Nurse must monitor environment and body temperature. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 98

Stress Ulcers • Physiologic response to severe trauma or physiologic stress • High-dose corticosteroids • Peak incidence occurs 6 to 14 days after injury. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 99

Sensory Deprivation • Stimulate patient above level of injury. • Conversation, music, strong aromas, and interesting flavors • Prism glasses to read and watch TV • Every effort should be made to prevent patient from withdrawing. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 100

Reflexes • Return of reflexes may complicate rehabilitation. § § Hyperactive Exaggerated responses Penile erections Spasms • Patient or family may see this as return of function. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 101

Autonomic Dysreflexia • Massive uncompensated cardiovascular reaction mediated by sympathetic nervous system • Occurs in response to visceral stimulation • Life-threatening Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 102

Autonomic Dysreflexia • Most common precipitating factor is distended bladder or rectum. • Manifestations § § § Hypertension Blurred vision Throbbing headache—take BP Marked diaphoresis above lesion level Bradycardia Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 103

Autonomic Dysreflexia • Manifestations (cont’d) § § § Piloerection (erection of body hair) resulting from pilomotor spasm Flushing of skin above lesion Spots in visual field Nasal congestion Anxiety Nausea Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 104

Autonomic Dysreflexia • Nursing interventions § § Elevate head of bed at 45 degrees, or sit patient upright. Notify physician. Assess cause. Provide immediate catheterization. • Teach patient and family causes and symptoms. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 105

Rehabilitation and Home Care • Organized around individual patient’s goals and needs • Patient expected § § To be involved in therapies To learn self-care • Can be very stressful • Frequent encouragement Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 106

Rehabilitation and Home Care Fig. 61 -12. Patient participating in occupational therapy. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 107

Respiratory Rehabilitation • Phrenic nerve stimulators or electronic diaphragmatic pacemakers increase mobility. • Teach cervical level injury patients who are not ventilator dependent. § § Assisted coughing Regular use of spirometry or deep breathing exercises Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 108

Neurogenic Bladder • Any type of bladder dysfunction related to abnormal or absent bladder innervation • Common problems § Urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux of urine into kidneys Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 109

Neurogenic Bowel • Voluntary control may be lost. • High-fiber diet and adequate fluid intake • Suppositories, small-volume enemas, or digital stimulation by patient or nurse • Carefully record bowel movements. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 110

Neurogenic Skin • Prevention of pressure ulcers and other types of injury to insensitive skin is essential. • Teach these skills and provide information about daily skin care. • Careful positioning and repositioning should be done every 2 hours with gradual ↑ in time Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 111

Neurogenic Skin • Pressure-relieving cushions must be used in wheelchairs. • Protect skin by avoiding thermal injury. • Teach family members skin care as well. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 112

Sexuality • Important issue regardless of patient’s age or gender • Nurse must § § § Have an awareness and an acceptance of personal sexuality Have knowledge of human sexual responses Use medical terminology Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 113

Sexuality • Injury level and completeness of injury are needed to understand the male patient’s potential for orgasm, erection, and fertility, and the patient’s capacity for sexual satisfaction. • Treatments for erectile dysfunction include drugs, vacuum devices, and surgical procedures. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 114

Sexuality • Effects of spinal cord injury on female sexual response are less clear. • Woman of child-bearing age remains fertile and has the ability to become pregnant or to deliver normally through birth canal. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 115

Grief and Depression • May feel an overwhelming sense of loss • May believe they are useless and burdens to their families • Response and recovery differ from those experiencing loss from amputation or terminal illness. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 116

Grief and Depression • Working through grief is a difficult, lifelong process. • Needs support and encouragement • Nurse’s role in grief work is to allow mourning as a component of rehabilitation process. • Patient’s family may also require counseling. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 117

Grief and Depression • Support groups can help family members’ knowledge and grieving process. • During the stage of depression, the nurse must be patient and persistent, and must maintain a sense of humor. • Clinically depressed patients require drug treatment or psychotherapy. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 118

Grief and Depression • Sympathy is not helpful. • Patient should be § § Treated in an adult manner Involved in decision-making process Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 119

Evaluation • Maintains adequate gas exchange • No signs of respiratory distress • Maintains adequate cardiac output with stable BP and pulse • No signs of infection at skull tong sites • Maintains intact skin over bony prominences Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 120

Evaluation • Establishes a bowel management program based on neurologic function and personal preference • Maintains a bowel movement every other day Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 121

Evaluation • Establishes a bladder management program based on neurologic function, caregiver status, and lifestyle choices • Develops no complications of immobility • Experiences no episodes of dysreflexia Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 122

Evaluation • Describes causes, prevention, symptoms, and management of dysreflexia • Reports ability to cope with effects of spinal cord injury • Expresses feelings of grief in adapting to losses related to chronic condition Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 123

Evaluation • Family members demonstrate effective communication patterns. • Family members establish a mutually satisfactory program of care for the family member with a spinal cord injury. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 124

Gerontologic Considerations • Spinal cord injury patients are living much longer life spans. • Aging has serious impact on the older adult with a spinal cord injury. • Health promotion and screening are important. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 125

Audience Response Question A patient is just admitted to the hospital following a spinal cord injury at the level of T 4. A priority of nursing care for the patient is monitoring for: 1. Return of reflexes. 2. Bradycardia with hypoxemia. 3. Effects of sensory deprivation. 4. Fluctuations in body temperature. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 126

Audience Response Question A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C 7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to: 1. Breathe with respiratory support. 2. Drive a vehicle with hand controls. 3. Ambulate with long-leg braces and crutches. 4. Use a powered device to handle eating utensils. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 127

Audience Response Question During assessment of a patient with a spinal cord injury at the level of T 2 at the rehabilitation center, which of the following findings would concern the nurse the most? 1. A heart rate of 92 2. A reddened area over the patient’s coccyx 3. Marked perspiration on the patient’s face and arms 4. A light inspiratory wheeze on auscultation of the lungs Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 128

CASE STUDY Spinal Cord Injury Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 129

Case Study • 36 -yr-old woman was brought to the ED after being thrown from her car following a motor vehicle accident. • She was not wearing a seat belt. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 130

Case Study • Her cervical spine is stabilized. • She cannot move her legs. • She is complaining of pain and is crying. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 131

Case Study • Cervical spine x-rays and CT reveal fractured C 7 -8 vertebrae. • She is taken to surgery to stabilize her cervical vertebrae. Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 132

Discussion Questions 1. What are the priority nursing interventions for her? 2. What problems could indicate respiratory distress? Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 133

Discussion Questions 3. What are realistic long-term goals considering the level of her injury? 4. How can you help her adjust to her situation? Copyright © 2011, 2007 by Mosby, Inc. , an affiliate of Elsevier Inc. 134