Clinical Manifestations and Collaborative Care of SCI Flashcards
Clinical Manifestations (5)
- generally a direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection
- related to level and degree of injury
- clients with an incomplete lesion may demonstrate a mixture of symptoms
- the higher the injury, the more serious the sequelae: proximity of cervical cord to medulla and brain stem
- movement and functional goals are related to specific location of spinal cord injury
Immediate post-injury problems include: (4)
- maintaining an airway - if high C-spine they may not
- Make sure adequate ventilation - diaphragmatic movement, degree of chest expansion, resp rate, O2 level
- Adequate circulating blood volume. Internal injury. Are they going into neurogenic shock?
- Trying to prevent the extension of cord damage by secondary injury
Respiratory System
respiratory complications closely correspond to level of injury
Respiratory System: Cervical injury above C4
Above level of C4
- presents special problems because of total loss of respiratory muscle function
- Mechanical ventilation is required to keep client alive
Respiratory System: Cervical Injury Below C4 (3)
- 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
Respiratory System: Cervical and thoracic injuries cause paralysis of (3)
- abdominal muscles
- intercostal muscles
Client cannot cough effectively - leads to atelectasis or pneumonia
Respiratory System: Artificial airways
Artificial airway provides direct access for pathogens (trach)
Important to reduce infections
Respiratory System: Pulmonary Edema (2)
Neurogenic pulmonary edema may occur: a rare form of pulmonary edema caused by an increase in pulmonary, interstitial, and alveolar fluid that develops within a few hours
Pulmonary edema may occur in response to fluid overload: vasodilation from neurogenic shock causes fluid to move into interstitial space. careful with fluid resuscitation
Cardiovascular System: affected in what level of injury
Any cord injury above level T6 greatly reduces the influence of the sympathetic nervous system
Cardiovascular System: changes in VS and fluid balance
bradycardia occurs
peripheral vasodilation results in hypotension
relative hypovolemia exists due to increased venous capacitance
Cardiovascular System: peripheral vasodilation causes (3)
decreased venous return
decreased CO, low BP
IV fluids or vasopressor drugs may be required to support BP
Cardiac monitoring is necessary
Urinary System: Common problem
- urinary retention is common
- bladder is atonic and overdistended
Urinary System: Catheterization
In-dwelling catheter inserted during acute phase - increased risk of infection
Post-acute phase: indwelling catheter should be removed and intermittent catheterization should begin as early as possible to help maintain bladder tone and decrease the risk for infection
Urinary System: hyper-irritable bladder (2)
Bladder may become hyper-irritable (post-acute phase)
- loss of inhibition from brain
- results in reflex emptying
GI system: level of injury (2)
If cord injury is above T5, primary GI problems are related to hypomobility
Injury level of T12 or below, or in spinal shock:
- bowel is areflexic
- decreased sphincter tone
GI system: Decreased GI motor activity contributes to development of: (2)
Paralytic ileus
Gastric distension
- NG decompression. metoclopramide
GI system: Intra-abdominal bleeding (3)
- indications of it
Intra-abdominal bleeding may occur:
- difficult to diagnose
Indications of bleeding may be:
- continued hypotension despite treatment
- drop in hemoglobin and hematocrit
Additional GI manifestations (3)
Stress ulcers common
Expanding girth may also be noted
Less voluntary control over bowel results in a neurogenic bowel
GI system: As reflexes return (3)
Bowel becomes reflexic
Sphincter tone is enhanced
Reflex emptying occurs
Integumentary system (3)
Consequence of lack of movement is skin breakdown
Pressure ulcers can occur quickly
Can lead to major infection or sepsis
Thermoregulation: Poikilothermism (4)
- Def’n: Adjustment of body temperature to room temperature
- Occurs in spinal cord injuries because of sympathetic nervous system interruption preventing peripheral temperature sensations from reaching hypothalamus
- Ability to sweat or shiver is decreased below the level of injury
- Degree of poikilothermism depends on the LOI
Metabolic Needs: acid/base and electrolyte
- Nasogastric suctioning may lead to metabolic alkalosis
- reduced tissue perfusion may lead to acidosis
- monitor electrolyte levels until suctioning is discontinued and normal diet is resumed
Metabolic Needs: nutrition
high-protein diet (2)
loss of body weight is common
nutritional needs much greater than expected for immobilized person
High-protein diet
1. ward off skin breakdown and infection
2. reduces rate of muscle atrophy
Peripheral Vascular Problems (2)
Deep Vein thrombosis is a common problem
Pulmonary embolism is a leading cause of death
DVT assessments
Doppler examination
measurement of legs and thigh girth
Diagnostic Studies (3)
CT scan may be used to assess stability or injury, location, and degree of bone injury
MRI is gold standard for imaging
Comprehensive neurological examination
Collaborative Care: goals and ABCs
Immediate goals are to sustain life and prevent further cord damage
- patent airway
- adequate ventilation
- adequate circulating volume
Systemic and neurogenic shock must be treated to maintain BP and MAP>65. managing with fluids or vasopressors
Collaborative Care: thoracic and lumbar vertebrae injuries (4)
- systemic support less intense than cervical injury
- respiratory compromise not as severe
- bradycardia is not a problem
- specific problems treated symptomatically
Collaborative Care: After stabilization, history is obtained
- emphasis on how injury occurred
- extent of injury as perceived by client immediately after event
Collaborative Care: Assessment (6)
- test muscle groups with and against gravity, alone and against resistance, and on both sides of the body
- note spontaneous movement
- sensory examination
- position sense and vibration
- musculo-skeletal injuries
- trauma to internal organs
Collaborative Care: Assess for brain injury (3)
Brain injury may have occurred - assess history for:
1. unconsciousness
2. signs of concussion
3. increased ICP
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 - hard collar immediately
Collaborative Care: Criteria for early surgery (6)
- cord decompression may result in decreased secondary injury
- evidence of cord compression
- Progressive neurologic deficit
- compound fracture
- bony fragments
- penetrating wounds of the spinal cord or surrounding structures
Common Surgical procedures (3)
Include decompression, realignment, and stabilization with instrumentation
- if instability is considered severe enough, both anterior and posterior stabilization is considered
Collaborative Care: Drug Therapy - steroids
Methylprednisolone
- when administered early and in large doses, recovery of neurological function is greater
- may be used as a treatment option
- no benefit after 8 hours post-injury
Collaborative Care: Drug Therapy - Vasopressor agents
- used in acute phase to maintain BP or MAP
- contract blood vessels. Used to treat severely low BP. No impact if there is nothing to squeeze inside the vessels. Give fluid and then squeeze.
Collaborative Care: Drug Therapy - Pharmacological Agents
Drug interactions may occur
Used to treat specific autonomic dysfunctions (GI hypoactivity, bradycardia, orthostatic hypotension)
