Exam 3: Spinal Cord Injury Flashcards
1
Q
What can cause a spinal cord injury?
A
38% motor vehicle collisions 30% falls 14% violence 9% sports injuries 9% other miscellaneous cases
2
Q
SCI Etiology and Pathophysiology: Primary Injury
A
- SCI due to cord compression by:
- Bone displacement
-Interruption of blood supply - Traction from pulling on cord
- Bone displacement
- Penetrating trauma → tearing and transection
3
Q
SCI Etiology and Pathophysiology: Secondary Injury
A
- Ongoing, progressive damage that occurs after initial injury
- Several theories exist on what causes ongoing damage
4
Q
Secondary Injury: Several Theories exist on what can cause ongoing damage to the spinal cord
A
- Vascular changes (d/t hemorrhage, vasospasm, thrombosis, loss of autoregulation, breakdown of blood brain barrier and infiltration of inflammatory cells that cause ischemia, edema and cellular necrosis)
- Free radical formation, Lipid peroxidation, Release of glutamate and Uncontrolled calcium influx (can lead to neuronal cell death and reduced spinal cord flow)
- Apoptosis (can contribute to post-injury demyelination)
5
Q
Events leading to secondary injury
A
- The resulting hypoxia reduces the oxygen levels below the metabolic needs of the spinal cord.
- Lactate metabolites and an increase in vasoactive substances, including norepinephrine, serotonin, and dopamine, occur.
- High levels of these vasoactive substances cause vasospasms and hypoxia with subsequent necrosis.
- Unfortunately, the spinal cord has minimal ability to adapt to vasospasm.
- Look at photo on slide!
6
Q
Secondary SCI: Extent of damage and prognosis
A
- Within 24 hours, permanent damage may occur because of edema
- Extent of damage and prognosis for recovery most accurately determined 72 hours or more after injury
- Greatest improvement occurs in first 3 to 6 months following injury
*Read notes!!
7
Q
What is spinal shock?
A
- May occur following acute SCI.
- Lasts days to weeks and may mask post-injury neurologic function.
8
Q
Spinal Shock is characterized by
A
- ↓ Reflexes
- Loss of sensation
- Absent thermoregulation
- Flaccid paralysis below level of injury
9
Q
Neurogenic Shock
A
- Results from loss of vasomotor tone due to injury.
- Associated with cervical or high thoracic injury (T6 or higher)
10
Q
Neurogenic shock is characterized by
A
Hypotension and bradycardia
11
Q
Neurogenic Shock: Loss of SNS innervation leads to
A
- Peripheral vasodilation
- Venous pooling
-↓Cardiac output
12
Q
How is SCI classified?
A
- Mechanism of injury
- Level of injury
- Degree of injury
13
Q
Major Mechanisms of SCI
A
- Flexion
- Hyperextension
- Flexion-rotation (most unstable because ligaments that stabilize the spine are torn; most often contributes to severe neurologic deficits)
- Extension-rotation
- Compression
*Look at image on slide 12
14
Q
Level of Injury
A
- Skeletal versus neurologic level
- Level of injury may be: cervical, thoracic, lumbar or sacral.
15
Q
Skeletal level injury
A
the vertebral level with the most damage to vertebral bones and ligaments
16
Q
Neurologic Level Injury
A
- Is the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body.
- The level of injury may be cervical, thoracic, lumbar, or sacral
17
Q
Level of Injury: If cervical cord is involved,
A
- Paralysis of all four extremities occurs, resulting in tetraplegia (formerly quadriplegia).
- The degree of impairment in the arms following cervical injury depends on the level of injury.
- The lower the level, the more function is retained in the arms.
18
Q
Level of Injury: If the thoracic, lumbar or sacral spinal cord is damaged, the result is
A
paraplegia (paralysis and loss of sensation in the legs)
19
Q
Degrees of Injury include
A
Complete or Incomplete (Partial)
20
Q
Degree of Injury: Complete
A
Total loss of sensory and motor function below level of injury
21
Q
Degree of Injury: Incomplete (Partial)
A
- Mixed loss of voluntary motor activity and sensation
- Some tracts intact
22
Q
C4 injury and above requires
A
Mechanical ventilation
23
Q
What are five syndromes associated with incomplete injuries?
A
- Central cord syndrome
- Anterior cord syndrome
- Brown-Séquard syndrome
-Cauda equina syndrome - Conus medullaris syndrome
24
Q
Incomplete SCI Central Cord Syndrome
A
- Damage to central spinal cord
- Most commonly cervical region and more common in older adults
25
Incomplete SCI: Anterior Cord Syndrome
- Damage to anterior spinal artery → compromised blood flow
| - Typically results from flexion injury
26
Incomplete SCI: Brown-Séquard Syndrome** Biggest one on test!!
- Damage to one-half of cord
| - Typically results from penetrating injury
27
Degree of Injury: Conus Medullaris Syndrome results from
Damage to conus medullaris (lowest portion of spinal cord)
28
Conus Medullaris Syndrome: Clinical Findings
- Motor function in legs may be preserved, weak, or flaccid
- Decrease in or loss of sensation in perianal area
- Areflexic bladder and bowel
- Impotence
- Pain is uncommon
29
Brown-Séquard Syndrome: Clinical Findings
- Ipsilateral loss of motor function and pressure, position, and vibration sense
- Contralateral loss of light touch, pain, and temperature sensation
30
Incomplete SCI Anterior Cord Syndrome: Clinical Findings
- Motor paralysis
| - Loss of pain and temperature sensation below level of injury
31
Incomplete SCI Central Cord Syndrome: Clinical Findings
- Motor weakness and sensory loss
- Lower extremities are not usually affected
- Dysesthetic burning pain in upper extremities
32
Cauda Equina Syndrome results from
Damage to cauda equine (lumbar and sacral nerve roots)
33
Cauda Equina Syndrome: Clinical Findings include
- Asymmetrical distal weakness
- Flaccid paralysis of lower extremities
- Complete loss of sensation in saddle area
- Areflexic (flaccid) bladder and bowel
- Severe, radicular, asymmetric pain
34
Clinical Manifestations of SCI
- Related to level and degree of injury
- Incomplete → variable
- Sequelae more serious with higher injury
35
Manifestations of C4 Injury
- Tetraplegia
| - Results in complete paralysis below the neck
36
Manifestations of C6 Injury
-Results in partial paralysis of hands and arms as well as lower body
37
Clinical Manifestations of T6 Injury
- Paraplegia
| - Results in paralysis below the chest
38
Clinical Manifestations of L1 Injury
- Paraplegia
| - Results in paralysis below the waist
39
ASIA Impairment Scale
- Classifies the severity of impairment resulting from SCI.
- It combines assessment of motor and sensory function to determine neurologic level and completeness of injury.
*Don’t need to do for test!!
40
SCI Clinical Manifestations: Respiratory System
- Closely correspond to level of injury
- Above level of C4 = Total loss of respiratory muscle function
- Below level of C4 = Diaphragmatic breathing → respiratory insufficiency
- Cervical and thoracic injuries
- Risk for neurogenic pulmonary edema
41
SCI Clinical Manifestations of the Respiratory System: Cervical and Thoracic Injuries can cause
Paralysis of abdominal and intercostal muscles → ineffective cough → risk for aspiration, atelectasis, pneumonia
*Read notes!
42
SCI Clinical Manifestations: Cardiovascular System
- Injury above T6 leads to dysfunction of sympathetic nervous system
- Leads to neurogenic shock:
- bradycardia
- peripheral vasodilation
- hypotension: Relative hypovolemia (because of increase in capacity of dilated veins) and reduced venous return = decreased CO.
43
SCI Clinical Manifestations: Urinary System
- Neurogenic Bladder
- Acute phase symptoms
- Postacute phase symptoms
44
SCI Clinical Manifestations of Urinary System: Neurogenic Bladder
Bladder dysfunction related to abnormal or absent bladder innervation:
- No reflex detrusor contractions (flaccid, hypotonic)
- Hyperactive reflex detrusor contractions (spastic)
- Lack of coordination between detrusor contraction and urethral relaxation (dyssynergia)
*Read notes!
45
SCI Clinical Manifestations of Urinary System: Acute Phase symptoms include
- Urinary retention
- Bladder atonic, overdistended, fails to empty
- Indwelling catheter (inserted to drain catheter)
46
SCI Clinical Manifestations of Urinary System: Postacute phase symptoms include
- Bladder may become hyperirritable
- Loss of inhibition from brain
- Reflex emptying and failure to store urine
47
SCI Clinical Manifestations: GI System
1. Decreased GI motor activity:
- Gastric distention
- Development of paralytic ileus
- Gastric emptying may be delayed
- Excessive release of HCl may cause stress ulcers
- Dysphagia may be present
2. Intraabdominal bleeding may be difficult to diagnose
*Read notes
48
SCI Clinical Manifestations: Integumentary System
- Potential for skin breakdown
- Poikilothermism
*Read notes
49
What is poikilothermism?
- Interruption of SNS
- ↓Ability to sweat or shiver below the level of injury
- More common with high cervical injury
50
SCI: NG suctioning
- May lead to metabolic alkalosis.
- Need to monitor electrolytes, especially sodium and potassium
- Limit suctioning
51
SCI: Increased nutritional needs
- Nutritional support to focus on caloric and nitrogen needs
| - Helps to prevent skin breakdown, reduce infection, decrease muscle atrophy
52
SCI Clinical Manifestations: Peripheral Vascular Problems
- Venous thromboembolism (VTE): Deep vein thrombosis (DVT) may be difficult to detect
- Pulmonary embolism: Leading cause of death
53
SCI Clinical Manifestations: Pain
- Nociceptive Pain
| - Neuropathic Pain
54
Nociceptive Pain
- Musculoskeletal pain dull or aching, worsens with movement
- Visceral pain in thorax, abdomen, pelvis - dull, tender, or cramping
- Give morphine, dilaudid
55
Neuropathic Pain
- Located at or below level of injury
- Hot, burning, tingling, pins and needles, cold, shooting
- May be extremely sensitive to stimuli
- Give neurotin
56
SCI: Diagnostic Studies include
- CT scan (preferred imaging study to diagnose the location and degree of injury as well as degree of spinal canal compromise)
- Cervical x-rays
- MRI (assess soft tissue injury, neurologic changes, unexplained neurologic deficits or worsening of neurologic condition)
- Comprehensive neurologic examination
- CT angiogram
57
SCI: Initial care includes
- Cervical injury requires more intense support
- Obtain history, emphasizing incident
- Assess extent of injury
- Initial assessment: Managing ABCs and vital signs
- Medical interventions and diagnostics
- Complete neurologic assessment using ASIA tool
*Read notes
58
Intraprofessional Care: Additional Assessment
- Brain injury and/or vertebral artery injury:
- History of unconsciousness
- Signs of concussion
- Increased intracranial pressure
- Musculoskeletal injuries
- Trauma to internal organs
*Read notes
59
Intraprofessional Care: Acute Care of SCI’s include
- Move the patient in alignment as a unit (logroll)
| - Monitor respiratory, cardiac, urinary, GI functions
60
Intraprofessional Care of SCI’s: Nonoperative Stabilization includes
- Stabilization of injured spinal segment: Eliminates damaging motion and prevents secondary damage
- Decompression: Traction or realignment
- Early realignment: Closed reduction and craniocervical traction
*Read notes
61
Intraprofessional Care of SCI’s: Surgical Therapy
- Used following acute SCI to fix instability and decompress the spinal cord
- Surgery within first 24 hours associated with improved neurologic outcome
- Can be performed from the back of the spine (posterior approach) or from the front of the spine (anterior approach)
- Fusion
62
SCI Surgery: Fusion
- Involves attaching metal screws, plates, or other devices to the bones of the spine to help keep them aligned.
- This procedure is usually done when two or more vertebrae have been injured.
- Small pieces of bone may also be attached to the injured bones to help them fuse into one solid piece.
- The bone used for this procedure can be obtained from the patient’s spinal bone harvested during surgery, from another bone in the patient’s body (autologous), or from donor bone (allograft).
63
SCI’s: Drug Therapy include
- Low-molecular weight heparin: prevent VTE
- Vasopressor agents (phenylephrine or norepinephrine)
*Altered drug metabolism = increases risk for interactions
64
SCI Drug Therapy: Vasopressor Agents
- Maintain mean arterial pressure >85-90 mm Hg to improve perfusion to spinal cord.
- Significant risk of complications
65
SCI: Subjective Data includes
- Health history
- Use of alcohol or recreational drugs; risk-taking behaviors
- Loss of strength, movement, and sensation below level of injury; dyspnea, inability to breathe adequately (“air hunger”)
- Presence of tenderness, pain at or above level of injury; numbness, tingling, burning, twitching of extremities
- Fear, denial, anger, depression
66
SCI: General Objective Data includes
Poikilothermism (unable to regulate body heat)
67
SCI: Integumentary Objective Data includes
Warm, dry skin (neurogenic shock)
68
SCI: Respiratory Objective Data includes
- Injury at C1-3: apnea, inability to cough
- Injury at C4: poor cough, diaphragmatic breathing, hypoventilation
- Injury at C5-T6: decreased respiratory reserve
69
SCI: Cardiovascular Objective DAta includes
Injury above T5: bradycardia, hypotension, postural hypotension, absence of vasomotor tone
70
SCI: GI Objective Data includes
- Decreased or absent bowel sounds
- Abdominal distention
- Constipation, incontinence, impaction
71
SCI: Urinary System Objective Data includes
- Urinary retention
| - Flaccid or spastic bladder
72
SCI: Reproductive Objective Data includes
- Priapism
| - Loss of sexual function
73
SCI: Musculoskeletal Objective Data includes
- Paralysis
- Hyperactive deep tendon reflexes
- Muscle atony, contractures
74
Overall Goals of Care for SCI’s
- Optimal level of neurologic functioning
- Minimal to no complications of immobility
- Learn skills, gain new knowledge, and acquire new behaviors to care for self
- Return to home at optimum level of functioning
75
Acute Care of SCI: Immobilization
- Maintain neutral position
- Stabilize to prevent lateral rotation (Hard cervical collar or backboard)
- Keep body in correct alignment
- Turn as a unit (logrolling)
76
Immobilization: Skeletal Traction
- Realignment or reduction of injury (includes Crutchfield, Gardner-Wells, or halo; Rope, pulley, and weights)
- Traction must be maintained at all times
- If displacement occurs, hold head in neutral position and get help
*Read notes
77
Pin Site Care: Common Protocol involves
- Cleansing with ½ strength peroxide and normal saline twice a day
- Applying antibiotic ointment
78
Immobilization: Kinetic Therapy
- Continual side-to-side rotation
| - Need to prevent pulmonary complications and pressure ulcers
79
Halo Vest
- When a patient can begin to mobilize after a stable injury (for which surgery is not needed), the halo frame can be attached to a special vest (Halo vest).
- This allows the patient to mobilize and ambulate while cervical bones fuse.
- However, the halo is not indicated if the patient has ligament instability from the injury. That patient will require surgery.
80
Immobilization of patients with stable thoracic or lumbar spine injury includes
- Custom thoracolumbar orthosis (TLSO or body jacket)
- Jewett brace
*Read notes
81
Care related to profound effects of immobility
- Meticulous skin care critical (more susceptible to skin breakdown)
- Fit immobilizers properly
82
SCI: Respiratory Complications
- Spinal cord edema may increase during first 48 hours
- May need intubation and mechanical ventilation
- ↑ Risk for pneumonia and atelectasis
*Read notes!
83
SCI Nursing Care for Respiratory Complications
- Regular assessment
- Intervene to maintain ventilation:
- Administer oxygen
- Provide ventilator support
- Chest physiotherapy
- Assisted (augmented) coughing
- Tracheal suctioning
- Incentive spirometry
- Appropriate pain management
84
SCI Complications: Cardiovascular Instability
- Risk for bradycardia and cardiac arrest
- Chronic low blood pressure with postural hypotension
- ↑ Risk for DVT
- Dysrhythmias may occur
85
SCI Nursing Care for Cardiovascular Complications
- Frequently assess vital signs:
- Anticholinergic drug/pacemaker
- Fluid replacement, vasopressor agent
- If blood loss occurred:
- Monitor hemoglobin and hematocrit
- Possible blood administration
- Assess orthostatic BP
- Abdominal binders/compression stockings
- Drug therapy
*Read notes
86
Treatment of DVT
- Prophylactic low-molecular-weight heparin or low-dose heparin
- Sequential compression devices and/or gradient stockings
- Assess thighs and calves every shift
- Range-of-motion exercises and stretching
87
Fluid and Nutritional Maintenance
- Paralytic ileus may occur, requiring NG tube
- Monitor fluid and electrolytes
- Nutrition should be started within 72 hours:
- Individualized solutions/additives
- High-protein, high-calorie diet
- Possible parenteral nutrition
88
SCI’s: Nursing interventions for inadequate nutritional intake
- Assess for cause
- Contract with patient
- General measures:
- Pleasant eating environment
- Adequate time
- Calorie count
- Dietary supplements
- Increased dietary fiber
*Read notes!
89
SCI: Bladder Management
- Neurogenic bladder initially:
- Indwelling urinary catheter (strict aseptic technique and ↑fluid intake)
- Intermittent catheterization program: Every 4-6 times daily; monitor for signs and symptoms of urinary tract infections
*Read notes
90
SCI: Bowel Management
Neurogenic bowel initially
- Bowel program started during acute care: Daily rectal stimulant (Suppository or small-volume enema) and/or digital stimulation/manual evacuation
- Adequate fluid and fiber intake
- Increased activity and exercise
91
SCI: Temperature Control
- No vasoconstriction, piloerection, or heat loss through perspiration below level of injury
- Temperature control is external
- Monitor environment and body temperature
- Do not use excessive covers or unduly expose patient
*Read notes
92
SCI: Stress Ulcer Care
- ↑Risk secondary to severe trauma and physiologic stress
- Monitor stool, gastric contents, and hematocrit
- Prophylactic medications
93
SCI Care: Sensory Deprivation
Secondary to absent sensations
-Stimulate patient above level of injury
- Conversation, music, and interesting foods
- Prism glasses to read and watch TV
- Help patient avoid withdrawing from the environment
*Read notes
94
SCI: Pain Management
- Musculoskeletal nociceptive pain: Antiinflammatory drugs and opioids
- Visceral nociceptive pain: Diagnostic imaging to evaluate cause
-Neuropathic pain: Gabapentin (Neurontin) or pregabalin (Lyrica)
- Teach about pain triggers and relaxation therapy
*Read notes
95
SCI: Skin Care includes
- Comprehensive visual and tactile examination
- Careful positioning and repositioning every 2 hours
- Specialty mattresses, pressure-relieving cushions
- Assess nutritional status
*Read notes!
96
Return of Reflexes may complicate rehabilitation including
- Hyperactive
- Exaggerated responses
- Penile erections
- Spasms (i.e cant do ROM with spasms)
*Read notes!
97
SCI Nursing Care: Reflexes
- Patient teaching
-Antispasmodic drugs
| * Read notes
98
What is autonomic dysreflexia?
- Massive uncompensated cardiovascular reaction mediated by sympathetic nervous system
- SNS responds to stimulation of sensory receptors – parasympathetic nervous system unable to counteract these responses.
*READ NOTES!!
99
What is the most common precipitating factor for autonomic dysreflexia?
Distended bladder or rectum *
100
Clinical Manifestations of Autonomic Dysreflexia
- Hypertension (up to 300 mm Hg systolic)**
- Throbbing headache
- Marked diaphoresis above level of injury
- Bradycardia (30 to 40 beats/minute)**
- Piloerection
- Flushing of skin above level of injury
- Blurred vision or spots in visual field
- Nasal congestion
- Anxiety
- Nausea
101
Autonomic Dysreflexia: Nursing Interventions include
1st. Elevate head, sit upright (because it will drop their BP)
- Notify HCP
- Assess for and remove cause:
- Immediate catheterization
- Remove stool impaction if cause
- Remove constrictive clothing/tight shoes
- Monitor and treat BP (beta blocker)
- Patient and caregiver teaching
*Read notes!!
102
Neurogenic Bladder can be
- Areflexic (flaccid)
- Hyperreflexic (spastic)
- Dyssynergia
103
Common Problems of Neurogenic Bladder include
- Urgency
- Frequency
- Incontinence
- Inability to void
- High Bladder pressures resulting in reflux of urine into kidneys
104
Neurogenic Bladder: Drug therapy include
- Anticholinergic drugs
- α-Adrenergic blockers
- Antispasmodic drugs
105
Neurogenic Bladder: Drainage Methods include
- Bladder reflex training
- Indwelling, intermittent, external catheterization
- Urinary diversion surgery
106
Neurogenic Bowel Treatment includes
- Voluntary control may be lost
- High-fiber diet
- Adequate fluid intake
- Suppositories
- Small-volume enemas
- Digital stimulation
- Mandatory for upper motor neuron injury
- Stool softener
- Oral stimulant laxatives
- Valsalva maneuver with manual stimulation
- Use of gastrocolic reflex
- Timing to not interrupt therapy
107
Spasticity
- Can be both beneficial and undesirable
| - Ashworth and modified Ashworth scales
108
Treatment for Spasticity include
- ROM exercises
- Antispasmodic drugs
- Botulinum toxin injections
109
Neurogenic Skin Care include
- Prevention essential
- Patient teaching
- Comprehensive daily exam
- Teach to reposition: At least every 2 hours while in bed; Every 15 to 20 minutes when in a chair
- Pressure-relieving cushion or mattress
- Adequate nutrition
- Protect from thermal injury
110
Acute Pain Management includes
- Assess, evaluate, and treat routinely
- Analgesics
- Massage and repositioning
111
Chronic Pain Management includes
- May be result of overuse of muscles
- Sleep may be disrupted
- May refer to pain management specialist
112
Sexuality: The nurse must
- Have an awareness and an acceptance of personal sexuality
- Have knowledge of human sexual responses
- Use medical terminology
113
Treatments for erectile dysfunction include
- Drugs
- Vacuum devices
- Surgical procedures
114
Sexuality problems RT SCI include
- Fertility issues
| - Psychogenic versus reflex erection
115
SCI: Fertility
-Not usually affected: pregnancy complicated; risk for precipitous delivery
116
Female Sexual Activity
- Urinary catheterization
- Planning for bowel evacuation prior
- Incontinence
- Lubrication
*Read notes to understand!!
117
SCI: Grief And Depression
- Depression is common
- Overwhelming sense of loss
- Loss of control
- Adjustment more than acceptance
- Wide fluctuation in emotions
- Allow mourning while encouraging hope
118
Grief and Depression Nursing Care includes
- Sympathy not helpful
- Encourage patient participation
- Consistency of care
- Psychiatric consult if needed
- Caregiver and family counseling
- Support group
119
SCI Care: Expected Outcomes include
- Adequate ventilation
- Adequate circulation and BP
- Intact skin
- Adequate nutrition
- Bowel management
- Bladder management
- No autonomic hyperreflexia
