Nurb test 2: spinal injury Flashcards
- Many patients remain independent
- 90% are discharged to their home-hospital stay 3-4 weeks, rehab 40 days
- 10% are discharged to nursing homes, chronic care facilities, or group homes
- Young adult men between ages 16 and 30 are at greatest risk: dare devils, risk takers
- Affects every system in the body, psychological aspect is devastating
spinal cord injury
Ongoing, progressive damage that occurs after initial injury=can spread from initial injury
- Secondary injury
A. area of injury
B. Inflammation
C. Vasoconstriction= clot formation to stop bleeding
D. migration = causes edema, presses on spinal cord, less oxygen to the area, potential for more death
Initial Injury
-50%, complete loss of all reflexes, sensation, completely flaccid below the injury, wait for it to run its course 1-6 weeks, may have a little movement
Spinal Shock
- gradually wears off may still have low bp may take 6 months
- the person loses sympathetic control to a degree, but maintains parasympathetic=lowers, dilates
- body can’t communicate
Manifestations: hypotension, orthostatic, bradycardia
Neurogenic Shock
- Try to predict the highest level of the function
1. Mechanism of Injury
2. Level of injury
3. Degree of injury
Classification of Spinal Cord Injury
mechanisms of injury
flexion hyperextension penetrating compression flexion-rotation
- pushing neck forward, hurt spinal cord posteriorly
Flexion
-injury or fall hit h=chin and neck is pushed backed, tearing in anterior location
Hyperextension
- from fall, pressure directly on head Ex: dive hit head, or hit bottom
Compression
- tearing on one side
Flexion-rotation
- gunshot or stab that goes into spinal cord
Penetrating
- Injury is the vertebral level where there is most damage to vertebral bones and ligaments
Skeletal level
-Lowest segment of spinal cord with normal sensory and motor function on both sides of the body, may not match skeletal level
Neurologic level
resp center not compatable with life, die initially
Cervical 1-3:
portable ventilator, affects intercostal and diaphragm breathing still effected
Cervical 4:
: a little shoulder movement, move elbow, no fine motor mov, better resp reserve
Cervical 5
care- work electric wheel chair- hand control, able to feed self, participate self care, some type of attended care 10 hours a day
cervical 5
Care- electric wheel chair with chin control, 24 hour care home or facility= bc vent
cervical 4
- better flexion with elbow and bicep control, have a thumb grasp
Cervical 6
Care- can drive a wheel chair van, can type on the computer, 6 hours a day of attended care= can be home health
cervical 6
finger control, ability flex and extend, ability to grasp
Cervical 7-8-
Care- transfer independently=slide board, roll self, maybe sit up some, care is 0-6 hours
cervical 7-8
paraplegic not quad.
Vertebra 6-12:
- Total loss of sensory and motor function below level injury
Complete cord involvement
Mixed loss of voluntary motor activity and sensation and leaves some tracts intact, may have pain but no temperature
Incomplete (partial) cord involvement-
central cord syndrome anterior cord syndrome bronw sequard syndrome posterior cord syndrome causda equina syndrome conus medullaris syndrome
6 syndromes with incomplete leisions
-area of the cord, central part
Sx: lose motor function, worse in upper extremities
Central cord syndrome
- lose motor function, pain and temperature sensation below injury all other are intact- touch, motor, position, vibration
Anterior cord syndrome
-effects on side of the spinal cord, but can have some symptoms on each side bc tracts
contralateral=crosses ipsilateral=same side
Brown-Séquard syndrome
SX: will lose pain, light touch, and temperature on the opposite side
-lose motor function, vibration, position, and deep touch sensation one the same side as cord damage
brown sequard syndrome
- affects posterior spinal artery
- lose position sense, everything else is intact
Posterior cord syndrome
-Number one reason for death, can dev pneumonia=no good cough, long term risk, careful monitoring
Initial stages- ventilator
Respiratory System
Loss of respiratory muscle function
Above level of c 4
respiratory system sx
-Diaphragmatic breathing if phrenic nerve is functioning
Respiratory insufficiency if phrenic nerve affected
Insufficient cough
Below level of c4
respiratory system sx
Above level T6 ↓ the influence of SNS Bradycardia Peripheral vasodilation Hypotension Orthostatic= careful with vagal stimulation, can’t counter act
Cardiovascular System
- low on spinal cord, almost all will have
Urinary retention common, lose the reflex
May loose bowl also
Bladder may be over distended
Bladder may become hyperirritable
Reflex emptying
Will regain through incontinence able to empty
Long term at risk for uti, bladder infection
Urinary System
- initial stage body is in stress and doesn’t do this
Above ___: hypomotility
Paralytic ileus – bowls in shock
Gastric distention- may need an ng to suction to keep decompressed
Stress ulcers common- can be hidden bc pain is different, watch for bleeding, labs hemoglobin drop gradually, abd begin to distend and hard , bp affected
Intraabdominal bleeding may occur
SX: hypotension despite treatment
decreased Hgb and Hct
Injury __ and below- loss of bowel control
Gastrointestinal System
t 5
t 12
- Consequence of lack of movement is skin breakdown , won’t be able to move self
- Pressure ulcers can occur quickly=can lengthen stay
- Can lead to major infection or sepsis
Integumentary System
poikilothermism
- Adjustment of body temperature to room temperature
- Decreased ability to sweat-unable to cool body off, can have heat stroke
- Decreased ability to shiver
Thermoregulation
-loose ability to adjust body temperature, more with cervical injury, lose communication to hypothalamus
Poikilothermism
- very high in the beginning
- Loss of body weight is common
- Increased nutritional needs – maintain, assess good swallowing, most time on tpn
- Needed to prevent skin breakdown and infection
- Decreases rate of muscle atrophy
- Depression and lack of taste can cause them to not eat
Metabolic Needs
Sustain life
- Prevent further cord damage-stabilize head=just for prevention because you don’t know
- in er will be put in collar till they rule out back injury
- At cervical level, all body systems must be maintained until full extent of damage is known
Collaborative Care Initial goals
-Stabilization of injured spinal segment and decompression
-Cervical traction for waiting for surgery
-After surgery will go into a halo for several months up to 3 months, keep flexion or extension from occurring, allows them to be up earlier , makes cpr difficult, always has wrench with them to undo if needed, generally go to rehab not usually going home
- do not pull on vest could dislodge the traction
Pin care- assess signs of infection, clean around, skin break down
Collaborative Care Nonoperative Stabilization
- Evidence of cord compression on mri
- Progressive neurologic deficit on assessments, had before and now is worsening
- Compound fracture
- Bony fragments
- Penetrating wounds of spinal cord or surrounding structures
Collaborative Care Surgical Therapy Criteria for early surgery
- Decompression laminectomy
- Insertion of stabilizing rods
- Clean out any bony fragments
Collaborative Care Surgical Therapy
used to try to prevent immune response, trying to prevent secondary damage
- initial bolus then iv for 24 hours Ex: Methylprednisolone (MP)
- Administered early and in large doses there is greater recovery of neurologic function
- Corticosteroid
Education Counseling Maintaining appointments Referral to programs Recreation and exercise programs Alcohol treatment programs Smoking cessation programs
Nursing Implementation Nursing Interventions
Correct alignment-once in vest it is easier, still need to be careful
Turn body as a unit- log roll
Maintain traction at all times
Maintain braces use as ordered
Immobilization
specially higher vertebra, but all
long term watch for signs of pneumonia- to hard to clear airways
-Monitor for respiratory distress
-Monitor ABG’s, breath sounds, sputum
-Injury at or above C3
-Mechanical ventilation
Trach care and suctioning- most often needed for a few months
Abdominal thrusts for coughing – pillow over abd, hemilick with cough make it more effective, can teach caregiver to do and time with the cough
- vest that squeezes = used to prevent or if having signs
Use incentive spirometer
Long term teach deep breathing – use abd and diaphragm to breath
Respiratory Dysfunction
care
Monitor VS=low bp and pulse, watch orthostatic bp: take time, work way up , esp bradycardia
Limit ↑ in vagal stimulation can result in cardiac arrest- body can’t correct, =bearing down with pooping= stool softner, coughing, suctioning out a trach= make passes quick 10 sec or less spread out care
Compression gradient stockings- prevent dvt
Prophylactic anticoagulants-prevent dvt, Coumadin, can be long term
Vasopressin- constrict to increase bp
Cardiovascular Instability
care
Nasogastric tube may be inserted initially to decompress the abd
Tpn, feeding tube maybe until able to swallow
Monitor fluid and electrolyte
Monitor bowel function
Assess swallowing
Oral food and liquids can be given once bowel sounds are present or flatus is passed
Fluid and Nutritional Maintenance care
Urine is retained early on, after awhile may be able to empty on own
Cath to start with
Intermittent catheterization program – to decrease infection, someone will have to learn, more freedom
Monitor for infection-urostomy at some point so don’t have to be constantly cathed decrease infection
Teach cath to pt/family- q 6-8 hours,
Bladder Management care
Most will regain
1. Timed defecation after meal
2. Rectal stimulant- give suppository
3. Digital stimulation- go around inside the rectum to start peristalsis
3. Left side-lying position until able to use BSC if going in bed, most will get up to bsc gravity helps
4. Usually takes 20-30 minutes, can digitally remove after
Care for spinal cord patient find out what program is, try to keep them on it
Bowel Management
care
Teach prevention of skin breakdown
Position every 2 hours
Pressure-relieving cushions in wheelchairs
Avoid thermal injury- heat=extra careful of temperature don’t want burn and cold, make sure they remember they used it
Carful with wrinkles in sheets, all tubing
Teach care giver at home- help with positioning, way shoes fit, us arm and elbow to change position in wheel chair
Integumentary
care
helps the lungs, moves side to side, tolerance can vary with patient, trouble with motion sickness won’t tolerate
Used only after spine stabilized
Temperature Control
Below level of injury, no Vasoconstriction
Piloerection
Heat loss through perspiration
Nurse must monitor environment and body temperature
Kinetic Therapy care
high risk first 2 weeks, prophylactic
Monitor for signs- bleeding= abd distention, watch hemoglobin, watch blood in emesis stool darker test for blood
Stress Ulcers
care
Injury level is T6 or ↑ normally happens to
Occurs in response to visceral stimulation and it irritates the body, massive vasoconstriction= increases bp to threatening levels 300 systolic
Life-threatening- not reverse quickly
Most common precipitating factor is distended bladder kink or rectum is full, could be something on the skin= something too tight, wrinkle in bed, ingrown toenail, extreme temp change, woman in labor
Complication: Autonomic Dysreflexia
Hypertension Blurred vision Throbbing headache—take BP Marked diaphoresis above lesion level Bradycardia- hr down Piloerection (erection of body hair) Flushing of skin above lesion Spots in visual field Anxiety Nausea
Autonomic Dysreflexia Manifestations
Elevate head of bed at 45 degrees or sit patient upright
Notify physician
Assess cause head to toe, cather emptying, recent bowl mov, loosen clothing
As soon as your reverse cause can reverse sx and progression
Teach patient and family causes and symptoms: must be reversed immediately = could cause stroke or mi/ learn to recognize and get help right away/ how to take bp
Autonomic Dysreflexia Nursing interventions
Important issue regardless of patient’s age or gender, usually occurs in younger and during child bearing years, hard to predict
Injury level and completeness of injury is needed to understand the male patient’s function
Effects of spinal cord injury on female sexual response are less clear
Woman of childbearing age remains fertile and has the ability to become pregnant or to deliver normally through birth canal-might be able to concieve usually plan a c section
Men- Sometimes impudent, unable to ejaculate, some can be able to have children
sexuality
May feel an overwhelming sense of loss- bc big lifestyle changes
May believe they are useless and burdens to their families
Working through grief is a lifelong process
Needs support and encouragement
Nurse’s role in grief work is to allow mourning
a lot are on antidepressant
usually have a need for control= very difficult for caregiver, ask how they want things: communicate to each shift
Anger can be frustrating to receive care from so many people
grief and family
paraplegia
t1-t12, L1-L4
lowest portion of the spinal cord
- paralysis of lower limbs, loss of bowel and bladder
conus medullaris syndrome
can use upper extremitie, back, and hand muscles
full strength n grasp
decreased trunk stability
t1-t6
full independence with wheelchair
able to drive care with hand control
independent standing in standing frame
t1-t6 care
full stable throacic muscles and upper back
functional intercostals
increase in resp reserve
t6-t12
independent with wheelchair
stand erect with long leg brace
ambulate with crutches with swing
can’t climb stairs
t6-t12 care
varying control of legs and pelvis
instability with lower back
L1-2
good sitting balance
use wheelchair
ambulate with long leg braces
care L1-2
quad and hip flexors
absence of hamstring function
flail ankles
L3-4
: ↓ Reflexes, Loss of sensation, Flaccid paralysis below level of injury
Manifestations spinal shock
