Spinal cord injury Flashcards
upper motor neurons
descend through brainstem and spinal cord to control LMNs
lower motor neurons
extend from CNS to PNS to voluntary movements
afferent
away
efferent
descending
paralysis
loss of movement
plegia
suffix for paralysis
paresis
motor weakness
hypotonia
decrease on muscle tone
flaccidity
absent muscle tone, end result of lower motor neuron disorders
hypertonia, rigidity, spasticity, tetany
increase muscle tone
muscle continuously or repeatedly contracted
end result of upper motor neuron disorders
fasciculation
involuntary tiny muscle movements
what is the most common cause of spinal cord injuries
motor vehicle accidents
other causes of spinal cord injury
-falls
-violence
-sports injuries
non-traumatic disorders that cause SCI
congenital, tumors, bone disease
what ages do SCIs typically occur?
16-30, typically male
mortality causes of SCI
-pneumonia
-PE
-sepsis
-acute respiratory failure in high cervical spine injuries
complete SCI
-severed
-total loss of sensation and voluntary muscle control below the level of injury in the spinal cord
incomplete or partial SCI
-damaged
-some sensory or motor fiber connections are preserved
Horner’s syndrome
-can happen after SCI
-pupilar changes
-facial droop in one eye
-facial sweating, can’t sweat
primary injury
-result in initial trauma, -irreversible
-manifestaions related to cord level and degree of injury
secondary injury
-results of ischemia, edema, hypoxia, &/or hemorrhage that destroys surrounding nerve issue
-may be reversible or preventable during first 4-6 hours of primary injury
-STABILIZING SPINE IS IMPORTANT
-happens after primary injury
-usually going to be an OR patient
SCI C4 & above
need ventilation for the rest of life
SCI C5-C8
limited arm, hand, and finger control, paraplegia
swelling can go up and affect C4, worry about airway
T1-T12
full UE control, limited full intercostal control & paraplegia
L1-L5
full intercostal and and muscle control, limited LE control
S1-S5
limited to full foot control, limited full bowel/bladder/sexual function
ASIA assessment
used to assess neurological function in SCI patients
why should you be very diligent about vital signs?
patients are very liable
why should SCI patients have continuous telemetry monitoring?
risk of dysrhythmias with higher level injuries
do you get an MRI right away with SCI patients?
no, CT then OR. Not enough time for MRI
when should neuro/SCI assessments be done?
as prescribed & at change of shift with both nurses
how do acute SCI patients have to be positioned at all times?
flat and straight
no pillows unless between legs
person cannot twist
what should you do if you believe a patient has a SCI?
c-collar, log rolls, use backboard
what should you always be prepared for with an SCI patient?
intubation
log rolling
turn a patient as a single unit to prevent the movement of spine
person at head is director
if a person comes into the ED with a suspected SCI what are your concerns?
-airway/breathing
-vomiting aspiration
-skin integrity
-elimination (urine)
-patient fear and anxiety
leading cause of death in patient with C4 and above SCI
acute respiratory failure
can T12 and above impact respiratory function?
yes
what part of respiration does T1-T6 affect
intercostals
what part of respiration does T6-T12 affect
abdominals
why is hypotension so bad in SCI patients
cord needs perfusion, want 95% and above
what are prevention techniques of early SCI complications
-keep MAP above 85
-spinal stabilization and realignment
-ongoing neurological and spinal assessments
spinal shock
-SUDDEN, complete loss of motor, sensory, reflex, and ANS function below injury
-flaccid paralysis, no sensation, no DTSs (areflexia)
-loss of bowel/bladder function
-spinal shock can last hours, days, or weeks after initial injury
-KEEP MAP ABOVE 85 TO PREVENT FURTHER DAMAGE TO SPINAL CORD
does spinal shock involve vital signs?
no, just motor
neurogenic shock
-cardiovascular collapse can develop as a result of loss of sympathetic nervous system (SNS) tone
-injury at T6 & above is at greatest risk
does neurogenic shock have tachycardia or Bradycardia?
only shock with bradycardia
what does neurogenic shock look like in a person?
-bradycardia
-hypotensive
-pass out right away
-drowsy/confused
how do you help neurogenic shock?
bunch of fluids
stabilization and realignment SCI
-early interventions are crucial to decrease secondary injuries
-surgeries: reduce (set/realign) fractures, decrease spinal cord compression, and increase overall vertebrae stability
how long does traction stay on for SCI
24/7 for six weeks
what happens if traction is dislodged?
stabilize the head in a neutral position and call for help
can nurses do pin care for traction?
yes
Halo vest
-used with or without traction to stabilize C-spine injuries
-pin care: clean daily, prevent infections
-skin care under and around vest
-change liner periodically
-patient/ family teaching and demonstrations
ongoing neuro/spinal assessments
-LOC
-establish baseline of motor, sensation, and circulation
-motor: ROM & strength
-do not attempt to assess head ROM in acute cervical injury
-tactile sensation: test with patients eye closed
-report any new decrease in neurologic function immediately
can you do chest PT in acute phase of SCI?
no, but you can in chronic phase
why do you want to suction with caution in people with SCI?
creates a vagal nerve response and decreases heart rate
fix it by stopping
why will SCI patients be at a higher risk of DVT and PE?
immobility, decrease in vasomotor tone, hyper coagulability (esp, in acute phase, and stasis of blood in LE
what interventions do you anticipate to prevent DVTs?
-pneumatic compression boots/stocking
-elevate LE for venous return
-herparin or warfarin
-adequate hydration
-passive ROM if possible
-neuromuscular electrical stimulation
-almost impossible to diagnose in this patient
how will you assess DVT?
-cannot assess pain in legs, redness may be absent
-check edema (esp. unilateral, calf/thigh measurements
-edema may be absent; US can confirm/deny
a patient is diagnosed with an acute large right femoral DVT, what priority interventions do you anticipate?
-place limb alert, remove compression boot to right leg (confirm with provider)
-initiate therapeutic anticoagulant
-surgery to place IVC filter
how will you assess for PE?
-pleuritic chest pain (ripping pain)
-anxiety
-SOB
-abnormal blood gases (increased CO2 and decreased O2)
gastric dilation
-enlargement of the stomach due to a lack of blood flow/obstruction
-need to decompress stomach with NGT
temp regulation below level of injury
loss of vasoconstriction, piloerection (“goose bumps”), sweating, shivering
can’t regulate body temp cause cannot feel
poikilothermy
temperature control is largely external to the patient
do patients with SCI have a high risk for heatstroke and hypothermia?
yes, nurse needs to ensure body temperature and environment is okay
teach family about this
skin integrity
-can begin within hours of acute SCI
-exacerbated by decrease in peripheral circulation
-move patient from spinal backboard as soon as possible
-braces and collar also pose risk for skin breakdown
-can progress to osteomyelitis, sepsis, death
interventions for pressure injuries
-turn/reposition at least every 2 hours in bed, 30 minutes in chair
-clean and dry skin
-very carefully inspect skin
-utilize cushion/foam dressing to bony prominences
-put patients on a high protein diet
neurogenic bladder
-loss of bladder sensation, reflex contraction, and urination control –> urinary retention
-can have a spastic bladder where it’s overactive (associated with urgency and frequency)
-happens with most SCI above sacrum
-flaccid bladder is underachieve & happens with SCI starting at sacrum (infection risk & hyronephroesis (bakcking up of urine), associated with over filling of bladder)
what interventions should you do for a patient with w neurogenic bladder?
get good routine, give 2.5L of fluid a day, straight Cath every 6 hours
monitor for UTI cause huge risk
what complications can occur from urinary retention
-hydronephritis (urine reflux to kidney) –> kidney failure
-high UTI risk –> pylenephritis –> bloodstream
-severe overdistension –> bladder rupture
what interventions do you anticipate with a neurogenic bladder?
-indwelling Cath in acute phase then intermittent
-timed bladder training
-urostomy
-teaching and recording I/O & voiding pattern, teaching for smell of urine
-bladder scan cause even someone with a wet pad can retain
nutrition/elimination
-decrease in Gi motility (esp in 1st 72 hours and injuries at T5 or above), can lead to paralytic ileus and gastric distention
-NG tube to decompress stomach, prevent vomit/aspiration
-IV fluids and nutrition (e.g., TPN) until GI motility returns
-advance to high calorie, high protein, high fiber diet (as tolerated) with food amounts gradually increased
neurogenic bowel
-loss of bowel sensation, defecation reflex, tone, and/or voluntary control, can lead to Gi constipation
-may have both incontience and constipation
-both internal and external anal sphincters control the anal canal
-can do anal sphincter massage once daily to stimulation pooping
elimination
-usually develop bowel program routine
if you’re assisting a provider with fecal disimpaction, what concerns do you have?
worry abut nasal response
autonomic dysreflexia (AD)
-a massive sympathetic (SNS) over-stimulation that can occur in injuries at T6 or above
-cannot occur until after spinal shock has resolved
-most unpredictable during first year of injury, but can occur throughout lifetime
-can occur after recovery from neurogenic shock
-acute life-threatening emergency; can lead to status epileptics (ongoing seizures), MI, stroke
most common cause of AD
full bladder
causes of AD
full bladder, distended rectum, stimulation of skin or pain receptors, erection, uterine contractions
pretty much any stimulation below injury
signs and symptoms of AD
-HTN
-POUNDING HEADACHE
-flushed skin above injury
-piloerection (goosebumps) below injury
-anxiety
-bradycardia
-profuse sweating above injury
-pale, cool skin below injury
-nasal congestion
AD interventions
-immediately sit patient up with legs dependent to decrease BP
-remove constricting clothing or support stockings/boots to increase venous pooling in legs
-rapid assessment to identify cause (bladder >bowel>skin)
-immediate urinary Cath if indicated
-notify provider
-treat persistent HTN
-teach family
concerns with SCI patient on sildenafil?
vasoconstriction, leads to hypotension
AD prolonged erection
concerns of females with SCI
-decrease in vaginal lubrication
-menses return 3-5 months post injury
-can carry baby (usually c-section delivery)
-concerned about DVT if on birth control
baclofen
-can be given orally or intrathecal pump
-adverse effects of CNS depression, fatigue, dizziness, confusion, headache, insomnia
-inrathecal: seizures and life-threatening CNS depression possible
-never drink with them
-never withdrawal abruptly or let pump go dry
