Clinical Manifestations and Collaborative Care of SCI

Question 1

Clinical Manifestations (5)

Answer 1

• 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

Question 2

Immediate post-injury problems include: (4)

Answer 2

1. maintaining an airway - if high C-spine they may not
2. Make sure adequate ventilation - diaphragmatic movement, degree of chest expansion, resp rate, O2 level
3. Adequate circulating blood volume. Internal injury. Are they going into neurogenic shock?
4. Trying to prevent the extension of cord damage by secondary injury

Question 3

Respiratory System

Answer 3

respiratory complications closely correspond to level of injury

Question 4

Respiratory System: Cervical injury above C4

Answer 4

Above level of C4
- presents special problems because of total loss of respiratory muscle function
- Mechanical ventilation is required to keep client alive

Question 5

Respiratory System: Cervical Injury Below C4 (3)

Answer 5

• 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

Question 6

Respiratory System: Cervical and thoracic injuries cause paralysis of (3)

Answer 6

• abdominal muscles
• intercostal muscles
  Client cannot cough effectively - leads to atelectasis or pneumonia

Question 7

Respiratory System: Artificial airways

Answer 7

Artificial airway provides direct access for pathogens (trach)
Important to reduce infections

Question 8

Respiratory System: Pulmonary Edema (2)

Answer 8

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

Question 9

Cardiovascular System: affected in what level of injury

Answer 9

Any cord injury above level T6 greatly reduces the influence of the sympathetic nervous system

Question 10

Cardiovascular System: changes in VS and fluid balance

Answer 10

bradycardia occurs
peripheral vasodilation results in hypotension
relative hypovolemia exists due to increased venous capacitance

Question 11

Cardiovascular System: peripheral vasodilation causes (3)

Answer 11

decreased venous return
decreased CO, low BP
IV fluids or vasopressor drugs may be required to support BP
Cardiac monitoring is necessary

Question 12

Urinary System: Common problem

Answer 12

• urinary retention is common
• bladder is atonic and overdistended

Question 13

Urinary System: Catheterization

Answer 13

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

Question 14

Urinary System: hyper-irritable bladder (2)

Answer 14

Bladder may become hyper-irritable (post-acute phase)
- loss of inhibition from brain
- results in reflex emptying

Question 15

GI system: level of injury (2)

Answer 15

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

Question 16

GI system: Decreased GI motor activity contributes to development of: (2)

Answer 16

Paralytic ileus
Gastric distension
- NG decompression. metoclopramide

Question 17

GI system: Intra-abdominal bleeding (3)
- indications of it

Answer 17

Intra-abdominal bleeding may occur:
- difficult to diagnose
Indications of bleeding may be:
- continued hypotension despite treatment
- drop in hemoglobin and hematocrit

Question 18

Additional GI manifestations (3)

Answer 18

Stress ulcers common
Expanding girth may also be noted
Less voluntary control over bowel results in a neurogenic bowel

Question 19

GI system: As reflexes return (3)

Answer 19

Bowel becomes reflexic
Sphincter tone is enhanced
Reflex emptying occurs

Question 20

Integumentary system (3)

Answer 20

Consequence of lack of movement is skin breakdown
Pressure ulcers can occur quickly
Can lead to major infection or sepsis

Question 21

Thermoregulation: Poikilothermism (4)

Answer 21

• 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

Question 22

Metabolic Needs: acid/base and electrolyte

Answer 22

• 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

Question 23

Metabolic Needs: nutrition
high-protein diet (2)

Answer 23

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

Question 24

Peripheral Vascular Problems (2)

Answer 24

Deep Vein thrombosis is a common problem
Pulmonary embolism is a leading cause of death

Question 25

DVT assessments

Answer 25

Doppler examination
measurement of legs and thigh girth

Question 26

Diagnostic Studies (3)

Answer 26

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

Question 27

Collaborative Care: goals and ABCs

Answer 27

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

Question 28

Collaborative Care: thoracic and lumbar vertebrae injuries (4)

Answer 28

• systemic support less intense than cervical injury
• respiratory compromise not as severe
• bradycardia is not a problem
• specific problems treated symptomatically

Question 29

Collaborative Care: After stabilization, history is obtained

Answer 29

• emphasis on how injury occurred
• extent of injury as perceived by client immediately after event

Question 30

Collaborative Care: Assessment (6)

Answer 30

• 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

Question 31

Collaborative Care: Assess for brain injury (3)

Answer 31

Brain injury may have occurred - assess history for:
1. unconsciousness
2. signs of concussion
3. increased ICP

Question 32

Collaborative Care: Nonoperative Stabilization

Answer 32

• 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

Question 33

Collaborative Care: Criteria for early surgery (6)

Answer 33

1. cord decompression may result in decreased secondary injury
2. evidence of cord compression
3. Progressive neurologic deficit
4. compound fracture
5. bony fragments
6. penetrating wounds of the spinal cord or surrounding structures

Question 34

Common Surgical procedures (3)

Answer 34

Include decompression, realignment, and stabilization with instrumentation
- if instability is considered severe enough, both anterior and posterior stabilization is considered

Question 35

Collaborative Care: Drug Therapy - steroids

Answer 35

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

Question 36

Collaborative Care: Drug Therapy - Vasopressor agents

Answer 36

• 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.

Question 37

Collaborative Care: Drug Therapy - Pharmacological Agents

Answer 37

Drug interactions may occur
Used to treat specific autonomic dysfunctions (GI hypoactivity, bradycardia, orthostatic hypotension)