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Nursing Semester 3 > Beth - Week 8 - Exam 3 > Flashcards

Beth - Week 8 - Exam 3 Flashcards

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1
Q

what are the 3 phases of SCI?

A

Acute Phase, Rehab Phase, Chronic Phase

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2
Q

what population of people are most likely to have an SCI?

A

males ages 15 - 35 account for >50%

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3
Q

> 10% of patient over 60 years of age get SCI, what contributes to this?

A

falls, osteoporosis, less likely to be active → less strong

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4
Q

what are the risk factors (associated cause) of SCI?

A
  • motor vehicle crashes (40-50%)
  • falls (30%)
  • violence (15%) → in large urban areas, gunshot wounds may surpass falls
  • sports injuries (10%)
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5
Q

what are the three classifications of spinal cord injuries?

A
  • mechanism of injury
  • level of injury - skeletal and neurologic
  • completeness or degree of injury test
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6
Q

what are the 5 different mechanisms of injury?

A
  • hyperextension
  • hyperflexion
  • compression
  • flexion
  • rotation: most unstable d/t torn ligaments
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7
Q

which mechanism of injury can be added to another?

A

rotation

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8
Q

what is the main characteristic of an initial spinal cord injury?

A

AXONS disrupted

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9
Q

what are the two ways that an initial SCI can occur?

A
  • cord compression

- penetrating injury causing tearing or transection

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10
Q

what are the different ways that the cord can be compressed?

A
  • by bone displacement
  • interruption of blood supply (d/t hematoma)
  • pulling or stretching on the cord
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11
Q

what are the different types of penetrating injuries?

A
  • gunshot → all tissue around GSW is injured/exploded

- stab wound

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12
Q

what is a secondary injury?

A

ongoing, progressive damage; extent and prognosis for recovery are determined at least 72 hrs or more after an injury

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13
Q

T/F extent and prognosis for recovery are determined at least 72 hrs or more after an injury

A

TRUE

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14
Q

what are the 5 secondary injuries of a SCI that can occur? *test

A
  • hemorrhage
  • edema (bad in spine → end up w/ ischemia/death
  • free radical formation
  • calcium influx
  • ischemia → death
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15
Q

what are the three different levels of injury?

A

cervical
thoracic
lumbar

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16
Q

what are the common sites of a SCI?

A

C5-6 and T12-L1

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17
Q

what is a skeletal level injury?

A

injury is at the vertebral level, where there is most damage to vertebral bones and ligaments
ex. C6 SCI = injury at the 6th vertebral level

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18
Q

what is a neurologic level injury?

A

lowest segment of spinal cord with normal sensory and motor function on both sides of the body

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19
Q

C4/C5 ____ is _____

A

diaphragm is alive

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20
Q

what does the phrenic nerve do?

A

innervates C3-C5 → diaphragm

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21
Q

how is the classification of injury decided? (degree of injury) test

A

according to the degree of loss of motor and sensory function BELOW the level of inury

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22
Q

the degree of sensory and motor loss varies depending on what two things?

A
  • level of lesion or injury

- specific nerve tracts damaged and those spared

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23
Q

what are the two categories for degree of injury?

A

complete and incomplete

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24
Q

what is a complete SCI consist of?

A
  • loss of voluntary movement/sensation below the injury
  • reflex activity below level of lesion may return after spinal shock resolves
  • worse prognosis for recovery
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25
Q

what does an incomplete SCI consist of?

A
  • varying degrees of motor/sensory loss below the level of injury
  • central, lateral, posterior injury
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26
Q

what are the 5 types of incomplete SCIs?

A
  • central cord
  • brown-sequard
  • anterior cord
  • cauda equina
  • conus medullaris
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27
Q

what are the characteristics of a C4 injury?

A

quadriplegia/tetraplegia, results in complete paralysis below the neck

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28
Q

what are the characteristics of a C6 injury?

A

results in partial paralysis of hands and arms as well lower body

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29
Q

what are the characteristics of a T6 injury?

A

paraplegia, results in paralysis below the chest

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30
Q

what are the characteristics of a L1 injury?

A

paraplegia, results in paralysis below the waist; bladder and bowel problem; pressure ulcer risk

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31
Q

what is central cord syndrome?

A

caused by forced hyperextension; sensory and motor deficits; upper > lower extremities; average prognosis `

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32
Q

what are the sxs of an incomplete anterior SCI?

A

loss of motor, pain/temp
mixed sensory loss
touch, proprioception, vibration remains intact

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33
Q

what are the causes of an incomplete anterior SCI?

A

trauma, hyperflexion with fracture or spinal artery injury; injury to blood supply → trauma/stabbing/tumor/clot

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34
Q

what are the sxs of an incomplete central SCI?

A

weak motor and sensation varies
worse in arms
“can walk to the door, but can’t open it”

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35
Q

what are the causes of an incomplete central SCI?

A

trauma, usually hyperextension

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36
Q

what are the sxs of an incomplete brown-sequard SCI? (cord hemi-section)

A

on same side as injury → loss of motor, touch, pressure, vibration, BUT pain/temp intact

on opposite side of injury → loss of pain/temp BUT motor, touch, sensory vibration intact

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37
Q

what is the cause of an incomplete brown-sequard SCI?

A

penetrating injury

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38
Q

what are the sxs of an incomplete cauda equina/conus medullaris SCI?

A
  • compression of lumbar-sacral area (conus T11 - L1; cauda L2 - sacral)
  • better prognosis b/c injury in horse tail area
  • loss of motor
  • sensory unimpaired
  • flaccid (atonic) bowel and bladder
  • impaired sexual function
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39
Q

what is sacral sparing in an incomplete SCI?

A
  • these sacral nerves are located on the periphery of the spinal → this is why they can be spared
  • when sacral nerves are spared, it is evidence of an incomplete injury (YAY)
  • FYI: best indicator of the possibility of return of cord function is MOTOR AND B/B
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40
Q

what are the dermatomes for C4, C6, C7, C8, T4, T10, T12, L4, and S1

A 
- Assessment of Pain and Sensation
• C4—top of shoulders
• C6—thumb
• C7—middle and ring finger
• C8—little finger
• T4—below nipple line
• T10—below umbilicus
• T12—loss in groin
• L4— variable great toe, buttock, genitalia
• S1—top of toe and small toe; perineal/anal numbness
41
Q

when does neurogenic shock occur?

A
  • spinal cord injuries above thoracic nerves (specifically above T6)
42
Q

what is neurogenic shock?

A

disruptions in the autonomic system

43
Q

what does the autonomic system control?

A

automatic functions like HR, BP, and untreated neurogenic shock can cause organ failure, proving fatal

44
Q

T/F spinal shock and neurogenic shock often co-occur

A

TRUE

45
Q

____ shock resolves on its own while _____ shock is a medical emergency

A

spinal; neurogenic

46
Q

what are the sxs of spinal neurogenic shock?

A
  • Hypotension—loss of vasomotor tone
  • Bradycardia—loss of vasomotor tone
  • hypothermia-poikilothermic
  • absence of sweating ↓ the injury
  • atonic bowel and bladder
  • flaccid paralysis ↓ the injury
  • loss sensation
47
Q

what are the characteristics of spinal shock lasting 1-2 days after injury?

A

Nerve cells become less responsive to sensory input,

resulting in full or partial loss of spinal cord reflexes

48
Q

what are the characteristics of spinal shock lasting 1 - 3 days after injury?

A
  • initial return of some reflexes Polysynaptic reflexes (For example, stimulation of pain receptors in the skin initiates a withdrawal reflex)
  • Next is the bulbocavernosus reflex - foley cath → pull → response in anus → spinal cord shock → no wink
49
Q

what are the characteristics of spinal shock lasting 1 - 4 weeks after injury?

A

Hyperreflexia, a pattern of unusually strong reflexes,
occurs. This is the result of new nerve synapse growth,
and is normally temporary.

50
Q

what are the characteristics of spinal shock lasting 1 - 12 months after injury?

A

Hyperreflexia continues, and spasticity may develop. This process is d/t changes in the neuronal cell bodies,
and takes much longer than the other stages.

51
Q

spinal shock is d/t what?

A

d/t an acute spinal cord injury

52
Q

what is spinal shock?

A

absence all voluntary and reflex neurologic activity below level of injury
- loss of sensation

53
Q

what does the return of anal wink signify?

A

that spinal shock is near end → deficits don’t change

54
Q

what are the characteristics of neurogenic shock?

A 
(Transient)
- Can last days or months
- Resolving
- when return of reflexes:
→ Spastic movement and spastic bladder
55
Q

when does neurogenic shock occur? what is the pathophysiology of it?

A
  • Occurs within 30 min cord injury level T 5-6 or above; last up to 6 weeks
  • Loss of sympathetic tone in peripheral vessels results in vasodilatation
56
Q

what are the three assessment findings of neurogenic shock?

A
  • Hypotension d/t massive vasodilation
  • Bradycardia- d/t unopposed parasympathetic stimulation
  • Poikilothermic d/t inability to regulate temperature
57
Q

what is the management for neurogenic shock?

A

determine the underlying cause

  • airway support
  • fluids???
  • atropine (HR)
  • vasopressors
  • temperature control
58
Q

what are the characteristics of spinal shock recovery?

A
  • spinal neurons become excitable

- bradycardia and hypotension persist even after resolution of spinal shock

59
Q

what are the 4 sxs of the recovery of spinal shock?-

A

return of

  • anal wink or anal reflex
  • spasticity
  • spastic bladder
  • mild tingling to intractable pain
60
Q

what is the SCI protocol for drug therapy?

A

methylprednisolone (solumedrol)

- large doses during the 1st 24 hrs of injury - initiated within the first 8 hrs of injury

61
Q

what is the purpose of methylprednisolone?

A
  • Improves perfusion
  • Prevents cell membrane breakdown
  • Improves energy metabolism
  • Better odds of moving to a higher sensory/motor category
62
Q

test what is autonomic dysreflexia (hyperreflexia)?

A

Syndrome in which there is a sudden onset of
excessively high blood pressure.
- Medical Emergency if untreated can lead to Seizure,
Stroke and death

63
Q

what area is affected in autonomic dysreflexia?

A

Spinal cord injuries that involve the thoracic nerves of

the spine or above (T6 or above).

64
Q

what are the two main sxs of autonomic dysreflexia?

A

HTN and bradycardia

65
Q

what are the sxs of autonomic dysreflexia below the injury?

A

(sympathetic)

vasoconstriction, skin cool–goosebumps (piloerection)

66
Q

what are the sxs of autonomic dysreflexia above the injury?

A

(parasympathetic)

vasodilatation, flushed face, warm skin, H/A, nasal congestion

67
Q

what are the nursing assessment findings for someone with autonomic dysreflexia?

A
  • Chest tightness, fluttering of the heart, trouble breathing
  • Pounding headache
  • Flushing or sweating of the above the level of
    cord injury
  • Increased BP (250/150)
  • Bradycardia
  • Anxiety
  • Nasal Congestion
  • Visual Changes
  • “Goose Bumps”
68
Q

what are the nursing priorities for someone with autonomic dysreflexia?

A
  • Elevate the HOB 45 degree
  • Check Bladder and drain if needed
  • Take off any tight clothing/covers
  • Empty bowel NO digital stimulation
  • Monitor BP q5min
  • Find the negative stimuli and remove it
69
Q

what are the possible triggers for autonomic dysreflexia?

A

bladder full, infection, pain, damage to butt

70
Q

which of the following are sxs of autonomic dysreflexia?

A

BP of 180/90, flushing above the level of
injury, cool below the level of injury and a
pounding HA

71
Q

what are the basic nursing priorities for a SCI?

A
  • ABCs
  • Stabilize the Spine (backboard in place until order to remove)
  • Do Not Move patient without MD order
  • Spinal precautions (Log roll, Hard collar in place (if ordered), TLSO on unless you have orders to remove, Tongs in alignment)
  • Maintain normal vital signs
  • IVF
  • OG/Ng tube
  • Maintain normal body temperature
  • GU-Foley
  • Pain control
  • Skin breakdown
  • Education (Safety)
72
Q

what are the nursing assessment circulation priorities

for SCI?

A
  • Maintain BP (High risk for hypotension due to loss of vagal tone0
  • Pulse (High risk for bradycardia cardiac arrhythmia and Vagus nerve stimulation is lost)
  • Body Temperature control d/t Loss of vagal tone
  • High risk for PE due to poor circulation/lack of
    movement
73
Q

what are the nursing assessment respiratory priorities?

A
  • Potential for pneumonia
  • Caution: Lesions ↑ T 12 may
  • Watch for breathing and effective coughing (Nerves controlling intercostal/abdominal emerge
    from thoracic vertebrae and nerves controlling diaphragm emerge from C 3-5)
    ´- HIGH RISK Patient
  • C 4 = ventilator dependent
  • watch out for bowel tones → potential ileus
74
Q

what are nursing interventions to help breathing for SCI?

A
  • Caution with injury’s affecting the function of breathing:
  • Watch for fatigue
  • Quad cough (syllabus)
  • Glossopharyngeal breathing
  • Do not preform after eating
  • Stomach is full of food and you may
    induce vomiting
75
Q

what are nursing interventions for mobility and prevention of further injury?

A
  • Restricting mobility
  • Stryker frame
  • Roto-Kinetic bed
  • Halo and Tongs (Pin care, Alignment, Check weights)
  • TLSO brace (Check for correct fit, Alignment/log roll)
  • Reduction of skin breakdown
  • ROM
  • Splinting
  • Prevention of PE
  • PAS stockings
76
Q

what is the nursing patient and family teaching for rehab potential/motor function for a patient with a C1-C3 injury?

A

absence of resp function Drive electric w/c; portable vent; mouthpiece

77
Q

what is the nursing patient and family teaching for rehab potential/motor function for a patient with a C5-C6

A

raise & extend arms (no hands) electric or manual w/c; feed self w/adaptive equipment

78
Q

what is the nursing patient and family teaching for rehab potential/motor function for a patient with a C7-C8

A

open & close hands + arms most of Self care; transfer self to w/c; roll/sit up in bed; drive car w/ hand controls

79
Q

what is the nursing patient and family teaching for rehab potential/motor function for a patient with a T1-T6

A

arms/hands + decreased trunk + decreased resp reserve Ind. self care; drive w/ hand controls; stand in standing frame

80
Q

what is the nursing patient and family teaching for rehab potential/motor function for a patient with a T7-12

A

leg paralysis + functional intercostals + arms/hands Ind. w/ w/c; stand erect w/ full leg brace, amb on crutches w/ swing—can’t do stairs; poor cough but better

81
Q

what is the nursing patient and family teaching for rehab potential/motor function for a patient with a L1-2

A

varying control of legs/pelvis Good sitting/balance; Ind. In w/c; amb w/ long leg braces

82
Q

what is the nursing patient and family teaching for rehab potential/motor function for a patient with a L3-L4?

A

quads/hip flexors; no hamstring/poor ankles Ind w/ amb w/ short leg braces/canes; can’t stand for long periods.

83
Q

what are nursing interventions r/t bowel function (neurogenic)?

A
  • Bowel Program
  • QD, QOD, 3x/wk
  • choose a convenient time
  • warm liquids
  • suppository/stool softeners
  • increase fluids and fiber
  • use BSC if possible &Val Salva if able
  • digital stimulation w/ or w/o suppository to
    stimulate bowel
84
Q

T/F almost every SCI loses voluntary control of bladder function

A

TRUE

85
Q

what are the NIs of a neurogenic bladder?

A
  • prevent over distention
  • empty bladder completely
  • maintain urine sterility - minimize UTI
86
Q

what are the complications of a neurogenic bladder?

A
  • hypertrophy of bladder (fvesicoureteral reflux, hydronephrosis)
  • urolithiasis
  • UTI
87
Q

what are the characteristics of a spastic bladder?

A

´Upper motor neuron (above L3)
´reflex voiding center is intact
´reflex incontinence and incomplete emptying

88
Q

what are the characteristics of a flaccid/atonic bladder?

A

´ Lower motor neuron damage (below L3)
´ Resulting in Urinary retention
´Overflow distention

89
Q

what are the NIs for a bladder retraining flaccid bladder?

A

´Help Patient to void (every 2-4 hours)
´Check post void residual (bladder scan)
´(PVR)–<100cc indicates training is working
´Intermittent cath. program every 2-4 hours
´Encourage fluids (prevent UTI/renal calculi)
´Bladder scan
´Do NOT >500cc in bladder between voids or
caths

90
Q

what are the NIs for bladder retraining spastic bladder?

A 
´Stroke inner thigh (trigger)
´Warm water over perineum
´Anal stimulation (NOT on cardiac patient)
´ Post void residual
´(PVR)--<100cc
91
Q

what are the nursing priority for skin integrity?

A 
´Special Beds to reduce pressure
injury
´Turn every 2 hours (inspect skin)
´Complications
´Pressure ulcers can spasticity
and autonomic dysreflexia
´Maintain normal body
temperature (Poikilothermic)
92
Q

what are the nursing understanding of the psychological effects of a SCI pt?

A 
´May see things differently in the
upright position
´Show them small steps of
improvement
´Talk to the patient-􀀁􀀁I am turning you
onto your left side􀀂􀀂
´Maintain a sense of person/dignity
´Assess: feelings of dependency,
sexuality, stages of grieving,
tolerance vs. acceptance
93
Q

what are the nursing understanding of the psychological effects of a SCI pt family?

A 
´Stages of Grieving
´Coping
´Realistic Expectations
´Teaching!!!
´care of the client
94
Q

what are the nursing education for a male pt sexuality?

A 
- upper motor lesion: reflex erection
´most patients
cannot ejaculate
´Complete SCI
(most) no
ejaculation
´10% can father
child
95
Q

what are the nursing education for a female pt sexuality?

A 
´Loss of sensation
during intercourse
regardless of
complete or
incomplete
´Can become
pregnant
´Birth control
counseling
´(No birth control
pills high risk PE
96
Q

what is the education regarding nutrition?

A

´ Increase fiber and fluids
´Concerns of osteoporosis for elderly SCI
´Concerns about paralytic ileus/gastric
distention
´Concerns about stress ulcers
´ increased production of hydrochloric acid from
loss of vagus nerve
´check gastric pH and start antacids or H2 blockers
´ start feeding as early as possible from injury

97
Q

what is the education regarding self care?

A 
´Maintain Independence
´Maintain Dignity
´Occupational Therapy
´Eating devices
´Mobility devices
´Prizm glasses
98
Q

what is the education regarding safety?

A 
´Watch for heat/cold
´use of heating/cooling pads
´Watch for pressure
´Extremity caught in the siderail
´ Specialized Call light
´Bulb or blow/breath into
´ Place near the nurses station

Nursing Semester 3 (29 decks)

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