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Med Surg 2 > spinal cord injuries > Flashcards

spinal cord injuries Flashcards

1
Q

what does a spinal cord injury involve

A

loss of motor function, sensory function, reflexes, and control of elimination.

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2
Q

Injuries in the cervical region result in what

A

quadriplegia
- paralysis/paresis of all four extremities and trunk.

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3
Q

Injuries below T1 result in what

A

paraplegia
- paralysis/paresis of the lower extremities.
- Truncal instability also results if the lesion is in the upper thoracic region

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4
Q

spinal cold injruies risk factors

A
  • Male clients age 16 to 30
  • High-risk activities (extreme sports or high-speed driving)
  • Participation in impact sports (football or diving)
  • Acts of violence (gunshot and knife wounds)
  • Alcohol or drug use
  • Disease (metastatic cancer or arthritis of the spine)
  • Falls, especially in older adults
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5
Q

what causes hyperflexion

A

Hyperflexion injuries are caused by injuries that cause sharp forward flexion of the spine:
- Head-on collision
- Fall
- Diving

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6
Q

what causes hyperextension

A

injuries are caused by a backward snap of the spine:
Rear-end collision
Downward fall onto the chin

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7
Q

diagnostic studies

A
  • CT scan
  • Cervical x-rays
  • MRI
  • Comprehensive neurologic examination
  • CT angiogram
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8
Q

an injury at C4 or above poses a great risk for …..

A

impaired spontaneous ventilation due to the involvement of the phrenic nerve.

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9
Q

are all fractures of vertebrae

A

don’t cause sci

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10
Q

contusions and lesions

A
  • Range from contusions or incomplete lesions of the spinal cord to complete lesions caused by an actual transection of the spinal cord.
  • Complete lesions result in the loss of all voluntary movement and sensation below the level of the injury.
  • Incomplete lesions result in varying losses of voluntary movement and sensation below the level of the injury.
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11
Q

expected findings for sci

A
  • Report of lack of sensation of dermatomes below the level of the lesion
  • Report of neck or back pain
  • Inability to feel light touch
  • Inability to discriminate between sharp and dull when touched
  • Inability to discriminate between hot and cold
  • Absent deep tendon reflexes.
  • Flaccidity of muscles.
  • Hypotension that is more severe when the client is in sitting in an upright position.
  • Shallow respirations.
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12
Q

respiratory system

A

Monitoring respiratory status is the first priority!!!
- Involuntary respirations can be affected from a lesion immediately below C4.
- Lesions in the cervical or upper thoracic area will also impair voluntary movement of muscles used in respiration
- Provide oxygen and suction as needed.
- Assist with intubation and mechanical ventilation if necessary.
- Assist the client to cough by applying abdominal pressure when attempting to cough.
- Teach the client about incentive spirometer use, and coughing and deep breathing regularly.

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13
Q

Neurogenic Shock what causes it and what do you support

A
  • Associated with cervical or high thoracic injury: C1-T6
  • Injury to Autonomic Nervous System
  • after initial injury
  • support bp and not make fluid overload
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14
Q

Neurogenic Shock key symtoms

A

Characterized by
- Hypotension
- Bradycardia

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15
Q

Neurogenic Shock: injury to SNS

A

Injury to SNS
- Peripheral vasodilation
- Venous pooling
- ↓Cardiac output

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16
Q

neurogenic shock nursing care

A
  • Monitor for hypotension, dependent edema, and loss of temperature regulation
  • When in an upright position, clients who are in neurogenic shock will experience postural hypotension.
  • Transferring the client to a wheelchair should occur in stages.
  • Monitor for manifestations of thrombophlebitis (swelling of extremity, absent/decreased pulses, and areas of warmth and/or tenderness).
  • The client might be on anticoagulants to prevent development of lower extremity thrombi.
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17
Q

sci nursing care i&o

A
  • The client might be NPO for several days. Regulation of fluid balance and nutritional support is necessary.
  • Maintain an adequate fluid intake for the client.
  • Fluid will aid in preventing urinary calculi and bladder infections, and will maintain soft stools.
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18
Q

sci neurological staus

A

After determining the baseline, monitor for an increasing loss of neurological function.

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19
Q

Clients who have upper motor neuron injuries (above L1 and L2) will convert to

A
  • a spastic muscle tone after neurogenic shock.
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20
Q

Clients who have lower motor neuron injuries (below L1 and L2) will convert to

A
  • a flaccid type of paralysis.
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21
Q

muscle strength and tone

A
  • After determining the baseline, monitor for an increasing loss of muscle strength in the affected extremities.
  • Encourage active range-of-motion (ROM)
  • Assist with passive ROM if the client lacks all motor function.
22
Q

mobility

A
  • Clients who have complete injuries will not regain mobility.
  • Clients who have incomplete injuries can regain some function that will allow mobility with various types of braces.
23
Q

sensation

A
  • Varying degrees of loss of sensation will be experienced depending on whether the lesion is complete or incomplete.
  • Prevent skin breakdown in both the bed and wheelchair.
  • Various types of foam and air mattresses are available for beds and wheelchairs.
24
Q

Spastic neurogenic bladder

A

Clients who have upper motor neuron injuries develop spastic bladder after the neurogenic shock resolves`

25
Q

bladder management options for male

A

options for male clients include condom catheters and stimulation of the

26
Q

flaccid neurogenic bladder

A

Clients who have lower motor neuron injuries develop a flaccid bladder.

27
Q

credes method

A

downward pressure placed on the bladder to manually express the urine

28
Q

bowl and bladder

A
  • Neurogenic bowel functioning does not differ between upper and lower motor neuron injuries.
  • Daily use of stool softeners or bulk-forming laxatives is recommended.
  • Digital stimulation should be used cautiously to avoid provoking a vagal response, which can result in bradycardia and syncope.
  • Development of a schedule as part of bladder and bowel training is critical in preventing complications related to immobility and promoting adequate nutrition and fluid balance
29
Q

skin integrity

A
  • Changing the client’s position every 2 hr (every 1 hr when in a wheelchair) is critical. Clients who have a SCI can neither move nor feel pain from prolonged pressure.
  • Pressure-relief devices in both the bed and the wheelchair must be consistently used.
30
Q

glucocorticoids

A

Adrenocortical steroids, such as methylprednisolone, aid in decreasing edema of the spinal cord (spinal shock), which can cause spinal cord compression and areas of ischemia

31
Q

vasopressors

A

Norepinephrine and dopamine are administered to treat hypotension, particularly during neurogenic shock.

32
Q

antimuscarinic

A

Atropine may be used to treat bradycardia.

33
Q

plasma expanders

A
  • Dextran, a volume expander, is used to treat hypotension secondary to spinal shock.
  • Observe for manifestations of fluid overload
34
Q

muscle relaxants

A
  • Baclofen and dantrolene: Administered to clients who have severe muscle spasticity.
  • Monitor for drowsiness and muscle weakness.
  • Baclofen may be administered intrathecally to reduce the sedative effects.
35
Q

cholinergics

A
  • Bethanechol: Decreases spasticity of the bladder, allowing for easier bladder training and fewer accidents.
  • Observe for urinary retention. Measure residual periodically.
36
Q

analgesics

A
  • Opioids, nonopioids, and NSAIDs are administered for pain. Clients might not be able to feel pain from spinal cord injury. Clients who have muscle spasticity can report feeling discomfort from the muscle spasms
37
Q

Anticoagulants

A
  • Heparin or low-molecular-weight heparins are used for DVT prophylaxis.
  • Monitor INR, PT, and aPTT for therapeutic levels of anticoagulation.
  • Observe for manifestations of gastrointestinal bleeding or bleeding secondary to unrecognized injury.
38
Q

Stool softeners and bulk‑forming laxatives

A

Docusate sodium or polycarbophil prevent constipation and keep the stool soft.

39
Q

vasodilators

A
  • Hydralazine and nitroglycerin: Use PRN to treat episodes of hypertension during automatic dysreflexia.
  • Monitor blood pressure frequently.
40
Q

Application of immobilization devices and traction

A
  • Clients who have cervical fractures may be placed in a halo fixation device or cervical tongs. The purpose is to provide traction and/or immobilize the spinal column.
  • Maintain body alignment and ensure cervical tong weights hang freely.
  • Monitor skin integrity by providing pin care and assessing the skin under the halo fixation vest as appropriate.
  • Do not use the halo device to turn or move a client.
41
Q

decompressive laminectomy

A
  • performed by removing a section of lamina; accessing the spinal canal; and removing bone fragments, foreign bodies, or hematomas that can place pressure on the spinal cord.
  • Donor bone often is obtained from the iliac crest and used to fuse together the vertebrae that are unstable.
42
Q

spinal fusion

A
  • Application of paravertebral rods
  • In cervical fusion, monitor for possible airway compromise from swelling or hemorrhage. Observe for deviation of the trachea.
  • Assess neurological status and vital signs every hour for the first 4 hr following spinal fusion.
  • Inform the client that an area of decreased range of motion will always exist in the area of fusion or paravertebral rods.
  • Rods are usually not removed unless they cause pain. Removal can be done after the spine has restabilized.
43
Q

orthostatic hypoension

A
  • Occurs when clients change position due to the interruption in functioning of the automatic nervous system and pooling of blood in lower extremities when in an upright position.
  • Change the client’s positioning slowly and place the client in a wheelchair that reclines.
  • Use thigh-high elastic hose or elastic wraps to increase venous return.
44
Q

spinal shock

A
  • Spinal shock is the spinal cord’s response to the inflammation caused by the injury.
  • Manifestations include flaccid paralysis, loss of reflex activity below level of injury, and paralytic ileus due to the loss of autonomic function.
45
Q

autonomic dysreflexia

A
  • Occurs secondary to the stimulation of the sympathetic nervous system and inadequate compensatory response by the parasympathetic nervous system.
  • Sympathetic stimulation is usually caused by a triggering stimulus in the lower part of the body.
46
Q

Stimulation of the sympathetic nervous system causes

A

extreme hypertension, sudden severe headache, pallor below the level of the spinal cord’s lesion dermatome, blurred vision, diaphoresis, restlessness, nausea, and piloerection (goose bumps).

47
Q

Stimulation of the parasympathetic nervous system causes

A

bradycardia, flushing above the corresponding dermatome to the spinal cord lesion (flushed face and neck), and nasal stuffiness.

48
Q

autonomic dysreflexia cause

A
  • Distended bladder: most common cause (kinked or blocked urinary catheter, urinary retention, or urinary calculi)
  • Fecal impaction
  • Cold stress or drafts on lower part of the body
  • Tight clothing
  • Undiagnosed injury or illness (kidney infection or stone, lower extremity fracture)
49
Q

nursing actions for autonomic dysreflexia

A
  • Sit the client up to decrease blood pressure secondary to postural hypotension.
  • Notify the provider.
  • Determine the cause.
  • Relieve the kink in the catheter or irrigate to remove blockage.
  • Catheterize the client.
  • Remove the impaction.
  • Adjust the room temperature and block drafts.
  • Remove tight clothing.
  • Monitor vital signs for severe hypertension and bradycardia.
  • Administer antihypertensives (nitrates or hydralazine).
50
Q

goals of care

A
  • Optimal level of neurologic functioning
  • Minimal to no complications of immobility
  • Learn skills, gain knowledge, and acquire behaviors to care for self.
  • Return to home and community.
51
Q

evaluation

A
  • Adequate ventilation/oxygenation
  • Intact skin
  • No complications of immobility!
  • Bowel and bladder management based on neurologic function, caregiver status, and lifestyle choices.
  • No episodes of autonomic dysreflexia.

Med Surg 2 (35 decks)

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