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Complex care > SCI > Flashcards

SCI Flashcards

1
Q

layout of spine

A
  • 8 cervical spinal nerve pairs (C1-C8)
  • 12 thoracic pairs (T1-T12)
  • 5 lumbar pairs (L1-L5)
  • 5 sacral pairs (S1-S5)
  • 1 coccygeal pair.
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2
Q

function of the spinal cord

A

Conduction
Locomotion
Reflexes

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3
Q

function of vertebral column or spinal column

A

Support/protect spinal cord

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4
Q

reflexes

A

-Stereotypical response with enough stimulus
-have issues with this
-Spinal shock with SCI
-Micturition (voiding)
External sphincter normally contracted
Mediated by S2, 3, 4
-Digestion to defecation (bowl)
Gastrocolic and duodenocolic reflexes=peristalsis
Intrinsic defecation reflex and parasympathetic defecation reflex

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5
Q

SCI classification

A
  • Mechanism of injury
    1. Flexion
    2. Hyperextension
    3. Flexion-rotation
    4. Extension-rotation
  • Skeletal and Neurologic level of injury
    1. Skeletal = vertebra, ligaments
    2. Neurologic = lowest segment of spinal cord with sensory/motor function
  • Degree of injury
    1. Complete = total sensory/motor loss
    2. Incomplete = mix sensory/motor loss
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6
Q

SCI dx

A
  • CT-gold standard for degree of bone injury
  • MRI-soft tissue and neural changes gold standard for degree of injury
  • ASIA-will be determined by mapping the dermatomes. a physician will be determining where the specific level of injury is by assessing the sensory and motor levels which were affected by the spinal cord injury..
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7
Q

patho of sci

A

Primary: occurs at the time of impact
Result of injury concussion, contusion etc…
Secondary: occurs after impact minutes hours days due to complicated systemic response

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8
Q

secondary injury can lead to

A
  • tissue hypoxia or further damage to the spinal cord
  • variety of ways damage can happen such as vasospasms of the arteries which will decrease blood supply to tissue, increased inflammation which can lead to ischemia or cellular necrosis or disruption in the movement of potassium, sodium, and calcium within the cells.
  • edema above and below injury can take at least 72 hours or more to develop. We cannot determine extent of injury until the edema process has ended! We want to limit further destruction and control the secondary injury because permanent damage can occur within 24 hours.
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9
Q

c3, 4, 5

A
  • keep the fella alive

- breathing

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10
Q

c1-c4

A

-ventilator and 24hr/day care

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11
Q

c4

A

requires a mouth stick to drive an electric wheelchair

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12
Q

c5

A

10hr/day care

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13
Q

c6

A

may be able to use hand controls and close of thumb and forefinger to move wheelchair and require 6hr/day care

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14
Q

t6

A

can use a non motorized chair and has full independence

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15
Q

L1

A

may not need a chair all the time can ambulate with long leg braces

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16
Q

L3-4

A

completely independent with ambulation but unable to stand for long periods

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17
Q

c8 and above

A

C8 and above is a tetraplegic (formerly known as quadraplegic) cannot move legs and arms

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18
Q

T1

A

paraplegic so cannot move legs.

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19
Q

what does the phrenic nerve help with

A
  • helps with breathing a C3-5
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20
Q

spinal shock

A
  • Syndrome
  • from swelling in the SC
  • Temporary loss of reflexes, sensation
  • Paralysis below level of injury that turns into contracture later
  • Lasts days to weeks
  • can mask post injury neurological function
  • On assessment you know spinal shock is resolving when you start to see reflexes return and patients can even be hyperreflexive
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21
Q

neurogenic shock

A
  • Loss of vasomotor tone- actually a form of distributive shock with T6 or above injury
  • Hypotension
  • Bradycardia
  • Warm or cold, dry extremities- they are not thermoregulating below the level of injury so they cannot sweat or shiver so it will depend on the room temperature on how they feel.
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22
Q

Anterior cord syndrome

A

-Not common
r/t flexion injury
-back is not injured so Sensation of touch, position vibration, motion
-Loss of motor, pain, and temperature below level of injury

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23
Q

central cord syndrome

A 
-More common cervical 
	injury
-Seen in the elderly
-Motor and sensory loss in 
	both upper and lower 
	extremities
-Upper extremities are MORE weak than lower
24
Q

brown-sequard syndrome

A
  • usually from penetrating injuries- knives/ GSW or disc rupture
  • Ipsilateral (same side of injury) Loss of motor function, light touch, pressure position, and vibration sense
  • Contralateral (opposite side of injury) loss of pain and temp sensation below level of lesion
25
Q

cons medullaris complete injury

A

Result from damage to conus medullaris (lowest portion of spinal cord)
Motor function in legs may be preserved, weak, or flaccid
Decrease in or loss of sensation in perianal area
Areflexic bladder and bowel
Impotence

26
Q

cauda equina complete injury

A

Result from damage to cauda equine (lumbar and sacral nerve roots)
Asymmetrical distal weakness
Flaccid paralysis of lower extremities
Complete loss of sensation in saddle area
Areflexic (flaccid) bladder and bowel
Severe, radicular, asymmetric pain

27
Q

how to stabilize spine

A
  • first thing have to do
    -The use of surgery or traction
    -Decompression laminectomy, fusion, insertion of stabilizing rods: to releive pressure and stabalize spine
    -
28
Q

respiratory care

A

-Above C 4: total loss of respiratory function
-Below C 4: diaphragmatic breathing if phrenic nerve
is functioning
-Cervical/thoracic: paralysis of abdominal muscles and intercostal muscles = not able to cough
-Complete: increased severity of ventilator
difficulties

  • Take home:
    1st 48 hours edema may increase the level of
    dysfunction
    -This matters because someone with an injury at C5 could look more like an injury at C3 and require ventilation
29
Q

respiratory complications

A

Hypoventilation
Atelectasis
Pneumonia

30
Q

cardiovascular

A
  1. T6 and above
    -Decrease in SNS
    -Neurogenic shock
    -Bradycardia d/t vagal response HR <60 (atropine)
    Vagal stim., turning, suction lead to cardiac arrest
    -Peripheral vasodilation=hypotension

-patients with SCI may always have a SBP in the 80’s or 90’s

  • ortho hypo: abdominal binder, stockings
  • DVT: compression stockings, ROM, heparin
31
Q

urinary

A
  1. Acute
    - Spinal shock-bladder is atonic → distended (neurogenic bladder) = not allowing for elimination so place cath
    - Urine can reflex to kidneys
    - CAUTI
  2. Chronic
    - loss of autonomic and reflex control of bladder and sphincter.
    - No sensation of fullness or distention so urine can reflux into kidney leads to renal failure
    - wont empty all the way on its own
    - Kidney stones from increased CA
    - UTI from stasis of urin
32
Q

GI: acute phase/spinal shock

A

Acute: Decreased GI motility leads to gastric distention and paralytic ileus but have high metabolic demand so nutrition is important
Acute: Excess HCl acid in stomach
Chronic: Dysphagia
Chronic: Neurogenic bowel
Chronic: hemorrhoids, abdominal distention INC

33
Q

mitrofanoff

A
  • The channel is constructed between the bladder and the skin utilizing appendix or bowel with the stoma placed at the level of the umbilicus or on the lower abdomen.
  • The most common complication is stenosis or leaking of the stoma at the skin which may require dilation or surgical revision.
  • procedure for stable patients with SCI who are at least 1 year out past their injury
  • part of the appendix is removed and used to create a sphincter for straight catheterization. The reason patients have to wait at least 1 year for this procedure is because the complications are high. The main post operative complication is infection.
34
Q

GU: reflex (spastic) neurogenic

A
  • Injury above T12 (UMN)
  • uncontrolled voiding
  • Spinal reflex arc takes over
  • Inability for distal sphincter to relax so leads to increased bladder pressure with emptying and larges amounts of residual urine (cant completely empty the bladder)
  • Intermittent catheterization
35
Q

GU: Areflexic (Flaccid)

A

-Injury at or below T12 (LMN)
-Decreased sensation of bladder fullness
-Loss of voluntary voiding except with straining
-Overflow and INC is common
Intermittent catheterization

36
Q

neuroginic bowl: Reflex bowel (spastic bowel)

A
  • above T12 the anal
  • sphincter remains closed, reflex BM can occur anytime when stools fill rectum (bowel regimen daily, every other day, or 3 times a week),
  • Keep stool soft since have tight sphincter
37
Q

neurogenic bowl:Areflexic (Flaccid) bowel

A

-below T12 loss of anal
sphincter
-tightness and reduced peristalsis however bowel not empty itself (1-2 times a day),
-Keep stool firm

38
Q

bowl regimen for T12 and above

A
  • (spastic): Above T12 sphincter is tightly closed = keep stool soft
  • commode (no bed pans)
  • mannual removal of stool with finger
  • stimulants (enema)
  • digital rectal stimulation
  • over if: no stool after 2 consecutive stims or mucus coming out wihtout stool
39
Q

bowl regimine for t12 and below

A

-(Flaccid) Below T12: loss of anal sphincter tightness and reduced peristalsis = keep stool firm

  • toilet/commode
  • manual removal of stool with finger
  • stimulants not effective
  • promote stool movement
  • BM over if: no stool after 2 manual removes or 10 minutes without results
40
Q

GI care

A
  1. distension: NG tube
  2. Ulcers: H2 recpetors, PPI
  3. intra abdominal bleeding: guaiac stool for heme positive and watch H/H maybe expanding abdominal girth
  4. constipation: bowl regimen, meds
  5. severe catabolism: high protien calories orally, feeding tube, parental feeding
  6. disphagia: speech and swallow consult
  7. poor po intake: assess signs of depression
41
Q

integumentary

A 
PRESSURE ULCERS!!
Infection → sepsis
Interventions
Change position Q 2 hours
Check for all equipment such as tubes
Take weight off of pressure points
Hot/cold packs-watch out
Special cushions/pads
42
Q

thermoregulation

A

-Poikilothermism= adjustment of body temperature to room temperature
-Degree depends on level of injury
-higher cervical greater loss of ability to regulate
-T6 and above
Interruption of SNS
-Decreased ability to sweat (anhidrosis) or shiver

43
Q

peripheral vascular problems

A

DVT or pulmonary embolism (PE)
Intervention
Doppler
Measurement of leg/thigh

44
Q

reflexes coming back after spinal shock resolves

A

Hyperactive/exaggerated
Spasms below level of lesion (uncomfortable) peak spasticity occurs after 2 years
Tx: muscle relaxants ex. Baclofen, botulinum toxin injections, cordotomy
Spasms can cause contractures
Tx: May need splints to keep limbs aligned
worn most of the day
ROM

45
Q

autonomic dysreflexia

A
  • Life threatening emergency
  • exaggerated reflex response by SNS
  • vasoconstriction below the injury= HTN (increased BP)
  • vasodilation above the injury = decreased HR (bradycardia)
  • Occurs AFTER spinal shock
    1. irritating stimulus (full bladder)
    2. Eggagerated SNS reflex response
    3. vasoconstriction below inj = increase in BP
    4. baroreceptors sense increase in BP so para response kicks in above the injury and causes vasodilation = decrease HR
46
Q

patho of AD

A

Stimulation below level of injury
SNS is intact below injury→ vasoconstriction
PNS-cannot respond
Baroreceptors in heart leads to decreased HR
peripheral vessels not dilate

47
Q

signs of AD

A
  • HTN (240-300/150 mmHG)
  • bradycardia
  • HA
  • blurred vision and dilated pupils
  • stuffy nose
  • goosebumps
  • flushing (red) and diaphoresis of skin above level of injury
  • Cold pale skin below the level of injury
48
Q

AD leads to

A

Status epilepticus
Stroke
MI
Death

49
Q

common precipitating factors of AD

A

-3 big B’s (bladder, bowel, breakdown of skin
Distended bladder or rectum (kinked Foley/impaction)
Tight clothing
Wrinkle in bed sheet
wounds

50
Q

interventions for AD

A 
Elevated HEAD >45 degrees
Monitor BP frequently Q 3-5 minutes
Notify MD or health care provider
Assess for a cause
Check bladder drainage
If AD is during bowel program, stop bowel program
Check skin
Loosen Tight clothing or shoes
Monitor BP frequently Q 3-5 minutes
May require medication
2% nitroglycerin, nifedipine (bitten or chewed), atropine for significant bradycardia
***teach the patient
51
Q

spine on one slide: C5

A

Tetraplegia, can control head, loss of sensation below the clavicle, phrenic nerve intact, no intercostal respiratory muscles, diaphragmatic breathing

52
Q

spine on one slide: T3

A

Phrenic nerve intact, some intercostal muscles, paraplegia below midchest (around the nipple line), intact shoulders upper chest, arms and hands

53
Q

SPINE ON one slide: T6

A

this and above at risk for Autonomic dysreflexia and neurogenic shock

54
Q

spine on one slide: t9

A

Minor respiratory deficits, decreased vital capacity, loss of everything below the waist (sensation T10 supplies the umbilicus/T12 supplies the groin) immobility

55
Q

spine on one slide: t12

A

above keep stool soft, below keep stools firm

56
Q

spine on one slide: L1

A

No respiratory issues inability to move from about hips and below but can use hip flexors and quadriceps absence of hamstring

Complex care (9 decks)

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