SCI Flashcards
Risk factors SCI (3)
- males
- adolescent
- drug/alcohol abuse
Complete transection
- complete severing of spinal cord
- patient paralyzed below point of injury
What is a primary injury SCI?
caused by the initial event
what is a secondary injury SCI?
cascade of events in the body after the initial trauma –> body’s attempt to deal with the injury
s/s complete spinal cord injury
- loss of sensation/motor function
- paraplegia or tetraplegia
s/s incomplete spinal cord injury
- spinal cord still able to relay some messages to and from brain
- partial motor/sensory dysfunction below level of injury
Assessment and dx SCI (7)
- Xray
- CT
- MRI (shows soft tissue injury)
- assess for additional injuries
- monitor VS
- continuous tele monitoring
- assess CSM to determine level of injury
Emergency management SCI- 5
- patient is immobilized
- head and neck maintained in neutral position
- no flexion, extension, rotation of spine
- stabilize any other life threatening injuries
- one member of the team must assume control of the patients head
medical management goals for SCI-3
-prevent secondary injury, observe s/s of progressive neuro defeats, and prevent complications
situations when surgery is indicated for SCI (4)
- compression of spinal cord is evident
- injury results in a fragmented or unstable vertebral body
- involves a wound that penetrates the cord
- neuro status is deteriorating
Nursing Management for SCI (9)
- assess respiratory function
- maintain body alignment/spinal precaution
- prevention of DVT/PE
- prevent skin breakdown
- maintain bowel-bladder function
- promote effective coping mechanisms
- monitor for potential complications
- comfort measures for patient with traction with tongs or halo brace
Preventing skin breakdown SCI -3
- reposition q 2 hours
- should be kept clean with mild soap, rinsing well, and blotting dry
- lubricate pressure sensitive areas with lotion or oil
maintain bowel/ bladder function SCI- 3
- bladder –> foley usually inserted initially then discontinued ASAp
- Bowel –> paralytic ileus usually develops (NG tube needed to decompress, normal bowel activity usually comes back within a week)
comfort measures for patient with traction with tongs or spinal halo-4
- areas around the four pin sites of halo devicese are cleaned at least once a day and observed for s/s infection
- observe for loosening (torque screwdriver should be nearby for tightening)
- skin under the halves should be inspected for excessive perspiration, redness, and skin blistering
- vest can be opened ,for the skin to be washed (worn 23 hours/day)
potential complications of SCI- 6
- spinal shock
- neurogenic shock
- VTE
- pressure ulcers
- respiratory complications
- autonomic dysreflexia
What is spinal shock?
sudden loss of reflex activity below the level of injury
phases of spinal shock-4
- areflexia (0-1 days)
- initial return of reflex activity (1-3 days)
- initial hyper-reflexia (1-4 weeks)
- final hyper-reflexia (1-12 months)
Sign that means a patient is coming out of spinal shock
return of reflex activity
What is neurogenic shock?
loss of autonomic nervous system function below level of injury
s/s neurogenic shock and how long it lasts
- hypotension
- bradycardia
- decreased CO
- peripheral vasodilation
- respiratory dysfunction
- organ dysfunction or failure
- inability to perspire in paralyzed areas
lasts 1-3 weeks
What is autonomic dysreflexia?
exaggerated autonomic response to stimuli
When can autonomic dysreflexia occur?
only after spinal shock has resolved
autonomic dysreflexia is a _________
life threatening emergency
At what spinal nerve and above does autonomic dysreflexia occur
T6 or above
s/s autonomic dysreflexia-6
- severe HA
- hypertension
- bradycardia
- diaphoresis above injury
- nasal congestion
- nausea
What triggers autonomic dysreflexia?
- bladder distention (most common)
- bowel distention
- stimulation of the skin
Nursing interventions for autonomic dysreflexia-5
- sit patient up to lower BP
- empty bladder via urinary cath
- inspect rectum for stool/impaction
- identify areas of pressure on the skin
- identify temp stimuli
