Spinal Cord Injuries (Final exam) Flashcards
Types of spinal cord injuries (2)
1) blunt trauma: d/t compression, flexion, extension, rotation of spinal column, diving, falls, motor vehicle crash, pedestrian accidents, sports injuries
2) penetrating trauma: d/t gunshot/stab wounds, stretched/torn/crushed/lacerated spinal cord
Primary vs secondary spinal cord injury
Primary: direct trauma to the spinal cord d/t blunt or penetrating trauma
Secondary: ongoing progressive damage that occurs AFTER the primary injury
In a primary injury, a spinal cord injury is caused by? (3)
bone displacement, traction from pulling on a cord, penetrating trauma (gunshot, stab)
Describe secondary injury (5)
- begins a few mins after injury and lasts for months
- results in EDEMA, ischemia, inflammation
- spinal cord injury = decreased O2
- edema is HARMFUL = limited space for tissue expansion = compression of the spinal cord occurs = INCREASING ISCHEMIC DAMAGE
- APOPTOSIS (cell death) occurs
Initial assessment in the ED for a neck injury (2)
- manage ABCs and vitals to maintain SaO2 >92% and MAP >85 mmHg
- avoid SBP <90 mmHg
Subjective data for patients with a neck injury
Past health hx (motor crash, sports injury, gunshot/stabbing, falls)
Objective data for patients with a neck injury
- poikilothermia, integ (2), cardio (3), GI (5), GU (4), reproductive, neuro (2), musculo (2), pain (3)
- poikilothermia: take on the temperature of their environment
- integ: warm, dry skin BELOW the level of injury (neurogenic shock)
- cardio: above T6 = bradycardic, hypotensive, s/s of internal bleeding (decreased BP and increased HR)
- GI: paralytic ileus in injuries above T5, ABD distension, constipation, fecal incontinence and impaction
- urinary: retention (T1-L2), flaccid bladder (acute), spasticity with reflex bladder emptying (later), hematuria indicates internal injuries
- reproductive: priapism
- neuro: tetra (above C8) or para (below C8), BILATERAL POSITIVE BABINSKI TEST (toes fan OUT)
- musculo: muscle atony, contractures
- pain: neuropathic pain, visceral = test with pinprick
What should be assumed for patients with a head injury?
“assume until proven otherwise” - patient with a head injury also has a spinal cord injury
What is spinal shock?
occurs shortly after an injury and lasts days to weeks, may mask post-injury neurologic function
characterized by: loss of deep tendon reflexes and sphincter reflexes (incontinence), loss of sensation, flaccid paralysis below the level of injury
What 2 medical interventions may the doctor order to reduce the chances of a secondary injury?
1) STABILIZATION: traction or realignment (early realignment by closed reduction through the craniocervical traction)
2) SURGICAL THERAPY: to manage instability and decompress the spinal cord
Objective data for respiratory in terms of the level of injury?
- C1 to C3
- C4
- C5 to T6
C1 to C3: apnea, inability to cough
C4: poor cough, diaphragmatic breathing, hypoventilation
C5-T6: decreased respiratory reserve
Breathing findings for patients with a spinal cord injury according to the location of the injury?
- above C3
- C3-C5
- Cervical and thoracic injuries (4)
Above C3: TOTAL LOSS of respiratory function = intubation
C3-C5: respiratory insufficiency; will arrest within mins if not intubated, decreased strength in chest and ABD wall
Cervical and thoracic injuries:
- paralysis of the ABD muscles and intercostal muscles causes INEFFECTIVE COUGH = aspiration, atelectasis, pneumonia
- hypoventilation = decreased vital capacity
- fluid overload = pulmonary edema
- increased SNS activity = neurogenic pulmonary edema
List general findings for a patient with spinal cord injury according to its location
- C4
- C6
- T6
- L1
C4: tetraplegic (complete paralysis below the neck
C6: partial paralysis of hands and arms as well as the lower body
T6: paraplegic (paralysis below the chest)
L1: paraplegic (paralysis below the WAIST)
What does a traumatic injury or lung contusion cause? Interventions? (6)
compromised airway function = respiratory acidosis
interventions:
- deliver oxygen (maintain PaO2 >92%)
- refractory hypoxemia = indicates when we need to intubate
- assess for respiratory distress: dyspnea, PaCO2 >20 mmHg
- maintain ventilation: admin oxygen, ventilation
- secretion management: chest physiotherapy, augment cough, IS, pain management, deep breathing exercises, suctioning
- positioning: elevate HOB at least 45 degrees
Intervention for patients with cervical and thoracic injury in terms of ineffective cough?
push up on epigastric to improve mobilization of secretions
Cervical fractures (4)
- cause paralysis of the ABD and intercostal musculature, leads to:
- ineffective coughing = aspiration, atelectasis, pneumonia
- neurogenic pulmonary edema = shunts blood to the lungs
- pulmonary edema (fluid overload)
Nursing management for patients with a cervical fracture? (5)
1) maintain proper immobilization with a traction or realignment
2) assess respiratory function if placed on ventilator
3) assess for vagal stimulation (ie: turning, suctioning) and its effect on cardio (possible cardiac arrest)
4) administer atropine for low HR, dopamine for low BP
5) lack of muscle tone to aid venous return = possible VTE (tx: heparin)
Goal of immobilization? (2)
restrict spinal motion, maintain neck in a neutral position
closed reduction with spinal traction: early realignment (reduction) for cervical injuries using a HALO RING
Management for patients with cervical traction for immobilization
Pin care:
- meticulous skin care
- cleanse with chlorhexidine BID and apply antibiotic ointment
Cardiovascular manifestations of a spinal cord injury (4)
- injury above T6 = dysfunction of the SNS
- leads to neurogenic shock = bradycardia, hypotension, peripheral vasodilation
- decreased CO = hypotension
- tachycardia may not occur with hemorrhage for patients who take beta-blockers or are young/healthy
Cardiovascular interventions for spinal cord injury (4)
- for bradycardia, admin atropine
- fluid replacement and vasopressor (ie: norepinephrine) for hypotension
- monitor for hypovolemic shock (possible blood transfusion)
- for orthostatic hypotension (occurs for injuries at T6 or above): use ABD binders and compression
socks, midodrine (promotes venous return), heparin with pneumatic compression devices
Urinary system manifestations and intervention for a spinal cord injury? (2)
NEUROGENIC BLADDER leads to bladder distension, leads to rupture, leads to renal failure
intervention: insert foley catheter then intermittent foley cath
GI system manifestations for patients with a SCI? (4)
1) paralytic ileus: peristalsis stops = severe nausea and cramping; increase in HCO
2) intra abdominal bleeding: difficult to diagnose, no pain or tenderness (monitor hemoglobin and hematocrit)
3) dysphagia: requires intubation
4) neurogenic bowel: loss of voluntary control; hyperreflexic bowel: increased rectal and sigmoid compliance = constipation and stool retention
Treatment for paralytic ileus (3) and neurogenic bowel (2) in patients with SCI
paralytic ileus:
- may require NG tube (first 48-72 hrs of paralytic ileus)
- prophylactic medication for stress ulcers: H2-receptor blockers, PPIs (famotidine)
- oral foods and fluids can be introduced if swallowing is intact and bowel sounds are present = high protein and caloric diet
neurogenic bowel:
- enema, suppository
- side lying position
Thermoregulatory s/s of patients with an SCI and management (3)
poikilothermia: inability to maintain a constant core temperature
decreased ability to sweat or shiver BELOW the level of injury = hypo/hyperthermia = deadly arrhythmias/pulseless activity
management: monitor the environment to maintain an appropriate temperature
Integumentary complications for patients with SCI and treatment? (2)
1) ulcers: painful, nociceptive visceral pain; dull or aching
- tx: opioids, ibuprofen (Motrin)
2) VTE: common d/t hypercoagulability, difficult to detect because no s/s of pain or tenderness
- tx: heparin
Metabolic needs for patients with an SCI and intervention
decreased muscle atrophy
intervention: start early enteral or parenteral nutrition
Pain in patients with an SCI
NEUROPATHIC pain d/t damage to spinal cord
BELOW THE LEVEL OF INJURY: hot, burning, pins/needles, shooting pain
Equipment for tetraplegic patient with a C1-C3 injury
electric wheelchair with portable ventilator, requires care 24 hr/day
Equipment for tetraplegic patient with C5 injury
electric wheelchair with mobile hand support, able to feed self with a setup
Equipment for tetraplegic patient with a C6 injury?
push wheelchair on smooth, flat surface, feed self with hand device
Equipment for tetraplegic patient with a C7-C8 injury
transfer self to wheelchair, independent use of wheelchair, performs most self-care
Equipment for paraplegic patient with T1-T6 injury
full independence in self-care (eating) and in wheelchair
Equipment for paraplegic patient with a T6-T12 injury
full independent use of wheelchair, can ambulate using crutches but not on stairs
Equipment for paraplegic patient with L1-L2 injury
full use of wheelchair, good sitting balance
Equipment for paraplegic patient with a L3-L4 injury
completely independent, unable to stand for long periods of time
What is autonomic dysreflexia? (2)
massive, uncompensated cardiovascular reaction mediated by the SNS in response to a SCI
medical emergency that occurs AT or ABOVE T6
3 main causes of autonomic dysreflexia (3 B’s)
Bladder: most common, overdistended bladder
Bowel: most common, hardened stool
Breakdown of skin: ingrown toe, broken skin
Prevention for the causes of autonomic dysreflexia?
bladder: don’t hold in pee
bowel: avoid caffeine, increase fiber and fluids, regulate bowel movements
breakdown of skin: avoid tight shoes/clothing, repositioning q2h
S/S of autonomic dysreflexia (3)
- throbbing headache (check BP immediately)
- hypertension (20-40 mmHg higher than baseline, eg: 106/78 to 146/92)
- sweating and flushing ABOVE the level of injury
Interventions for patients with autonomic dysreflexia (6)
1) measure BP q2-5 mins when a patient with SCI reports a headache
2) elevate HOB 45 degrees or sit upright (to lower BP)
3) report to HCP
4) assess for and remove cause (bowel impaction, urinary retention, UTI, tight shoes/clothing)
5) immediate catheterization to relieve bladder distension
6) if symptoms persist, give rapid-onset and short-duration agent (nitroglycerin, nitroprusside, hydralazine)
Psychosocial dx for patients with a SCI?
difficulty coping r/t depression
goal: express feelings of grief of CHRONIC, life-long disease
Intervention for cauda equina injury?
intermittent catheterization to empty the bladder 3-4 hrs
