Beth - Week 8 - Exam 3 Flashcards
what are the 3 phases of SCI?
Acute Phase, Rehab Phase, Chronic Phase
what population of people are most likely to have an SCI?
males ages 15 - 35 account for >50%
> 10% of patient over 60 years of age get SCI, what contributes to this?
falls, osteoporosis, less likely to be active → less strong
what are the risk factors (associated cause) of SCI?
- motor vehicle crashes (40-50%)
- falls (30%)
- violence (15%) → in large urban areas, gunshot wounds may surpass falls
- sports injuries (10%)
what are the three classifications of spinal cord injuries?
- mechanism of injury
- level of injury - skeletal and neurologic
- completeness or degree of injury test
what are the 5 different mechanisms of injury?
- hyperextension
- hyperflexion
- compression
- flexion
- rotation: most unstable d/t torn ligaments
which mechanism of injury can be added to another?
rotation
what is the main characteristic of an initial spinal cord injury?
AXONS disrupted
what are the two ways that an initial SCI can occur?
- cord compression
- penetrating injury causing tearing or transection
what are the different ways that the cord can be compressed?
- by bone displacement
- interruption of blood supply (d/t hematoma)
- pulling or stretching on the cord
what are the different types of penetrating injuries?
- gunshot → all tissue around GSW is injured/exploded
- stab wound
what is a secondary injury?
ongoing, progressive damage; extent and prognosis for recovery are determined at least 72 hrs or more after an injury
T/F extent and prognosis for recovery are determined at least 72 hrs or more after an injury
TRUE
what are the 5 secondary injuries of a SCI that can occur? *test
- hemorrhage
- edema (bad in spine → end up w/ ischemia/death
- free radical formation
- calcium influx
- ischemia → death
what are the three different levels of injury?
cervical
thoracic
lumbar
what are the common sites of a SCI?
C5-6 and T12-L1
what is a skeletal level injury?
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
what is a neurologic level injury?
lowest segment of spinal cord with normal sensory and motor function on both sides of the body
C4/C5 ____ is _____
diaphragm is alive
what does the phrenic nerve do?
innervates C3-C5 → diaphragm
how is the classification of injury decided? (degree of injury) test
according to the degree of loss of motor and sensory function BELOW the level of inury
the degree of sensory and motor loss varies depending on what two things?
- level of lesion or injury
- specific nerve tracts damaged and those spared
what are the two categories for degree of injury?
complete and incomplete
what is a complete SCI consist of?
- loss of voluntary movement/sensation below the injury
- reflex activity below level of lesion may return after spinal shock resolves
- worse prognosis for recovery
what does an incomplete SCI consist of?
- varying degrees of motor/sensory loss below the level of injury
- central, lateral, posterior injury
what are the 5 types of incomplete SCIs?
- central cord
- brown-sequard
- anterior cord
- cauda equina
- conus medullaris
what are the characteristics of a C4 injury?
quadriplegia/tetraplegia, results in complete paralysis below the neck
what are the characteristics of a C6 injury?
results in partial paralysis of hands and arms as well lower body
what are the characteristics of a T6 injury?
paraplegia, results in paralysis below the chest
what are the characteristics of a L1 injury?
paraplegia, results in paralysis below the waist; bladder and bowel problem; pressure ulcer risk
what is central cord syndrome?
caused by forced hyperextension; sensory and motor deficits; upper > lower extremities; average prognosis `
what are the sxs of an incomplete anterior SCI?
loss of motor, pain/temp
mixed sensory loss
touch, proprioception, vibration remains intact
what are the causes of an incomplete anterior SCI?
trauma, hyperflexion with fracture or spinal artery injury; injury to blood supply → trauma/stabbing/tumor/clot
what are the sxs of an incomplete central SCI?
weak motor and sensation varies
worse in arms
“can walk to the door, but can’t open it”
what are the causes of an incomplete central SCI?
trauma, usually hyperextension
what are the sxs of an incomplete brown-sequard SCI? (cord hemi-section)
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
what is the cause of an incomplete brown-sequard SCI?
penetrating injury
what are the sxs of an incomplete cauda equina/conus medullaris SCI?
- 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
what is sacral sparing in an incomplete SCI?
- 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
what are the dermatomes for C4, C6, C7, C8, T4, T10, T12, L4, and S1
- 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
when does neurogenic shock occur?
- spinal cord injuries above thoracic nerves (specifically above T6)
what is neurogenic shock?
disruptions in the autonomic system
what does the autonomic system control?
automatic functions like HR, BP, and untreated neurogenic shock can cause organ failure, proving fatal
T/F spinal shock and neurogenic shock often co-occur
TRUE
____ shock resolves on its own while _____ shock is a medical emergency
spinal; neurogenic
what are the sxs of spinal neurogenic shock?
- 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
what are the characteristics of spinal shock lasting 1-2 days after injury?
Nerve cells become less responsive to sensory input,
resulting in full or partial loss of spinal cord reflexes
what are the characteristics of spinal shock lasting 1 - 3 days after injury?
- 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
what are the characteristics of spinal shock lasting 1 - 4 weeks after injury?
Hyperreflexia, a pattern of unusually strong reflexes,
occurs. This is the result of new nerve synapse growth,
and is normally temporary.
what are the characteristics of spinal shock lasting 1 - 12 months after injury?
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.
spinal shock is d/t what?
d/t an acute spinal cord injury
what is spinal shock?
absence all voluntary and reflex neurologic activity below level of injury
- loss of sensation
what does the return of anal wink signify?
that spinal shock is near end → deficits don’t change
what are the characteristics of neurogenic shock?
(Transient) - Can last days or months - Resolving - when return of reflexes: → Spastic movement and spastic bladder
when does neurogenic shock occur? what is the pathophysiology of it?
- 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
what are the three assessment findings of neurogenic shock?
- Hypotension d/t massive vasodilation
- Bradycardia- d/t unopposed parasympathetic stimulation
- Poikilothermic d/t inability to regulate temperature
what is the management for neurogenic shock?
determine the underlying cause
- airway support
- fluids???
- atropine (HR)
- vasopressors
- temperature control
what are the characteristics of spinal shock recovery?
- spinal neurons become excitable
- bradycardia and hypotension persist even after resolution of spinal shock
what are the 4 sxs of the recovery of spinal shock?-
return of
- anal wink or anal reflex
- spasticity
- spastic bladder
- mild tingling to intractable pain
what is the SCI protocol for drug therapy?
methylprednisolone (solumedrol)
- large doses during the 1st 24 hrs of injury - initiated within the first 8 hrs of injury
what is the purpose of methylprednisolone?
- Improves perfusion
- Prevents cell membrane breakdown
- Improves energy metabolism
- Better odds of moving to a higher sensory/motor category
test what is autonomic dysreflexia (hyperreflexia)?
Syndrome in which there is a sudden onset of
excessively high blood pressure.
- Medical Emergency if untreated can lead to Seizure,
Stroke and death
what area is affected in autonomic dysreflexia?
Spinal cord injuries that involve the thoracic nerves of
the spine or above (T6 or above).
what are the two main sxs of autonomic dysreflexia?
HTN and bradycardia
what are the sxs of autonomic dysreflexia below the injury?
(sympathetic)
vasoconstriction, skin cool–goosebumps (piloerection)
what are the sxs of autonomic dysreflexia above the injury?
(parasympathetic)
vasodilatation, flushed face, warm skin, H/A, nasal congestion
what are the nursing assessment findings for someone with autonomic dysreflexia?
- 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”
what are the nursing priorities for someone with autonomic dysreflexia?
- 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
what are the possible triggers for autonomic dysreflexia?
bladder full, infection, pain, damage to butt
which of the following are sxs of autonomic dysreflexia?
BP of 180/90, flushing above the level of
injury, cool below the level of injury and a
pounding HA
what are the basic nursing priorities for a SCI?
- 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)
what are the nursing assessment circulation priorities
for SCI?
- 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
what are the nursing assessment respiratory priorities?
- 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
what are nursing interventions to help breathing for SCI?
- 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
what are nursing interventions for mobility and prevention of further injury?
- 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
what is the nursing patient and family teaching for rehab potential/motor function for a patient with a C1-C3 injury?
absence of resp function Drive electric w/c; portable vent; mouthpiece
what is the nursing patient and family teaching for rehab potential/motor function for a patient with a C5-C6
raise & extend arms (no hands) electric or manual w/c; feed self w/adaptive equipment
what is the nursing patient and family teaching for rehab potential/motor function for a patient with a C7-C8
open & close hands + arms most of Self care; transfer self to w/c; roll/sit up in bed; drive car w/ hand controls
what is the nursing patient and family teaching for rehab potential/motor function for a patient with a T1-T6
arms/hands + decreased trunk + decreased resp reserve Ind. self care; drive w/ hand controls; stand in standing frame
what is the nursing patient and family teaching for rehab potential/motor function for a patient with a T7-12
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
what is the nursing patient and family teaching for rehab potential/motor function for a patient with a L1-2
varying control of legs/pelvis Good sitting/balance; Ind. In w/c; amb w/ long leg braces
what is the nursing patient and family teaching for rehab potential/motor function for a patient with a L3-L4?
quads/hip flexors; no hamstring/poor ankles Ind w/ amb w/ short leg braces/canes; can’t stand for long periods.
what are nursing interventions r/t bowel function (neurogenic)?
- 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
T/F almost every SCI loses voluntary control of bladder function
TRUE
what are the NIs of a neurogenic bladder?
- prevent over distention
- empty bladder completely
- maintain urine sterility - minimize UTI
what are the complications of a neurogenic bladder?
- hypertrophy of bladder (fvesicoureteral reflux, hydronephrosis)
- urolithiasis
- UTI
what are the characteristics of a spastic bladder?
´Upper motor neuron (above L3)
´reflex voiding center is intact
´reflex incontinence and incomplete emptying
what are the characteristics of a flaccid/atonic bladder?
´ Lower motor neuron damage (below L3)
´ Resulting in Urinary retention
´Overflow distention
what are the NIs for a bladder retraining flaccid bladder?
´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
what are the NIs for bladder retraining spastic bladder?
´Stroke inner thigh (trigger) ´Warm water over perineum ´Anal stimulation (NOT on cardiac patient) ´ Post void residual ´(PVR)--<100cc
what are the nursing priority for skin integrity?
´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)
what are the nursing understanding of the psychological effects of a SCI pt?
´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
what are the nursing understanding of the psychological effects of a SCI pt family?
´Stages of Grieving ´Coping ´Realistic Expectations ´Teaching!!! ´care of the client
what are the nursing education for a male pt sexuality?
- upper motor lesion: reflex erection ´most patients cannot ejaculate ´Complete SCI (most) no ejaculation ´10% can father child
what are the nursing education for a female pt sexuality?
´Loss of sensation during intercourse regardless of complete or incomplete ´Can become pregnant ´Birth control counseling ´(No birth control pills high risk PE
what is the education regarding nutrition?
´ 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
what is the education regarding self care?
´Maintain Independence ´Maintain Dignity ´Occupational Therapy ´Eating devices ´Mobility devices ´Prizm glasses
what is the education regarding safety?
´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
