Spinal cord injury Flashcards
This following flashcard deck is going to discuss about spinal cord injury and will follow the recording that was taken in lecture class
When a patient has a spinal cord injury, one of the biggest thing to know is that a patient clinical manifestation will depend on what?
where in the spinal cord the injury occurred
She has this spinal cord injury and body system powerpoint, so the following flashcards are going to address those concerns
spinal cord injury
respiratory system
anything above c3
what happens to your respiratory
anything between c3-c5
what happens to your respiratory
below c5
what happens to your respiratory
total loss of function, need immediate intubation
severe insufficiency, needs intubation
- risk for aspiration, atelectatsis, pneumonia due to paralysis of abdominal muscles
- hypoventilation and impaired intercostal muscles lead to decreased vital capacity and till volume
- traumatic injury (lung contusion) causing comprised function
- fluid overload or increase SNS activity at the time of injury can cause pulmonary edema
what is our main goal in helping patients with the respiratory system with spinal cord injury?
maintain oxygen higher than 92% in order to reduce hypoxemia that causes bradycardia that can worsen secondary injury
what is going to happen in cardiovascular? (2)
neurogenic shock
hemorrhagic shock
how does neurogenic shock and hemorrhagic shock occur ?
neurogenic shock at t6 or above injury
other injuries and further decreased blood pressure
remember neurogenic shock will cause the blood pressure to go what?
so what do we want to assess ?
down
any and all causes of hypotension
in hemorrhagic shock tachycardia may not be present in patients who take beta blockers, are young and healthy and are older adults
however in neurogenic shock, its more than likely we are going to see
bradycardia !
what is going to happen to our patients with spinal cord injuries with their peripheral vascular ?
they have an increase risk of venous thromboembolism (vte)
why is VTE a common thing to occur with patients with spinal cord injury?
due to hypercoagualbility,venous status, and venous endothelia injury.
immobilization leading to venous statuses and thrombi in lower extremities
DVT can be very hard to detect and no pain or tenderness are usually present since remember, they end up getting paralysis
what is happening in the urinary system with a patient with a spinal cord injury?
urinary dysfunction occurs to patients due to the loss of autonomic and reflex control of bladder and sphincter
patients with spinal cord injuries end up getting a neurogenic bladder, which is ?
bladder dysfunction related to abnormal or absent bladder innervation
( impaired transmission between bladder muscles and micturition center in the brain )
in GU you can two types of bladder conditions with spinal cord injuries patients, which are?
and describe the two
flaccid
- hypotonic muscles causing bladder distention - can lead to bladder rupture
( meaning you can fill up bladder and not feel it, then pee all over yourself (rupture))
spastic muscles causing incontincene
- meaning you can not control when you pee, like your bladder thinks you need to pee all the time
at what spinal cord number can you get a spastic bladder?
above t12
spastic bladder can cause lack of coordination between muscles (dyssynerga) leading to what ?
reflux into the kidneys
what is happening in the GI system with patients with spinal cord injuries ?
delayed gastric emptying
constipation/impaction/
incontinence
intraabdominal bleeding
within the first 24-48 hours, what is our main concern when GI system ?
paralytic ileus
so within the first 24-48 hours in the GI system our main concern is a paralytic ileus, what should we do as nurses ?
NG tube for decompression and NPO
what is our main concern when it comes to talking about the skin system for patients with spinal cord injuries ?
pressure injury
- skin breakdown due to inability to move
what does pressure injury make patients at risk for when talking about skin for the spinal cord injury patients?
(2, they go hand and hand with each other )
infection - open wound
sepsis - infection enters the open wound and causes an systemic inflammation
what is our main concern with patients who have spinal cord injuries when we are talking about thermoregulation system ?
poikilothermia : the inability to maintain a constant core temperature due to malfunction of SNS
its important to note that patient who develop poikilothermia are usually those with a higher cervical injury number, but this also puts the ability for patients to not be able to do what to two things ?
sweat or shiver below the injury level
what is our concern for patient who have spinal cord injuries when we are talking about metabolic system for them?
increase metabolism and increased protein breakdown
with an increase in metabolism and increase protein breakdown, what does that put our patient at risk for ?
lean body mass, muscle atrophy, weight loss, and stress
how can we prevent metabolic increases in our patients with spinal cord injuries ?
start early feeding to prevent skin breakdown, reduce infection and decrease muscle atrophy
its important to note that a patient pain is also apart of the system. Reason why is because pain can vary due to the type and severity.
patient can have nociceptive pain which is ?
patient can have neuropathic pain which is ?
this can continue for years even after recovery from the injury by the way!
musculoskeletal pain ; dull or aching, starts or worsens with movement
damaged to cord or nerves, located at or below level of injury, hot burning, sensitive to stimuli and pain from light touch
now onto back of the video recording flashcards, just remember the other flashcards were things we still need to know but gives a great overview on each system and how a spinal cord injury can affect the body
what is the most common cause of spinal cord injuries?
trauma
( 38% cars and 30.5% falls)
there are two types of injuries when it comes to talking about spinal cord injury.
what is primary mean?
what is secondary mean ?
the direct cause
swelling, symptoms, complications leading to spinal cord injury
direct physical trauma to the spinal cord can be what ?
blunt, penetrating
spinal cord compression can be by what 3 things ?
bone displacement
interruption of blood supply
traction from pulling on cord
its important to note that with spinal cord injury, it can cause progressive damage, which we as nurses will try to do what to prevent it?
stabilize the spine, neck and head
what are 3 examples of secondary injury ?
edema
ishecmia
inflammation
how does edema cause a secondary injury to the spine ?
within 24 hours the edema will increase and put pressure on the spine and cause permanent damage
how does ischemia cause a secondary injury to the spine ?
lack of blood supply can lead to vasospasm in the spine causing damage
how does inflammation cause a secondary injury to the spine ?
leads to glial scar formation which restricts regeneration of the cord leading to permanent nerve and neural deficit damage
when it comes to spinal cord we are going to talk about two important types of shock, which are ?
spinal shock
neurogenic shock
when does spinal shock occur?
shortly after injury and last days to weeks
what is spinal shock characterized by ? (3)
loss of deep tendon reflexes
loss of sensation
flaccid paralysis below the level of injury(no tone)
how does spinal shock occur?
spinal cord is responding to the injury and it stops working because of the edema, damage, inflammation, ischemia
is spinal shock a protective mechanism ?
why is it and what is it protecting us from?
can this be resolved, if yes, how?
yes
protect nervous system from further injury
it can be with recovery
Remember, spinal shock happens directly after the injury and our body shuts down. no deep tendon reflexes, loss of sensation, flaccid paralysis ( no muscle tone ) as a protective mechanism for us.
and usually this will end up going away with recovery, however what is the issue behind this ?
right off the bat, we can not tell what neuro deficts they have because of the spinal shock
so we have to wait for it resolve before we know exactly what’s going on
where does neurogenic shock occur in? (cervical number)
how long can it last?
in cervical or high thoracic
(at or above t6) injury
1-3 weeks
neurogenic shock is characterized by what 3 things?
hypotension (less than 90)
bradycardia
temperature dysregulation
neurogenic shock is a loss of sis innervation causing what?
that answer meaning^
unopposed paraysmpathic response
- venous pooling
- decreased cardiac output
- peripheral vasodilation
t6 or above we can see what type of shock?
t12 or lumbar injury are they are going have neurogenic shock?
neurogenic shock
we are not going to see that there
since patients with neurogenic shock can not regulate their temperature, what temperature do you think they will end up being at?
room temp
how do we classify a spinal cord injury ? (3)
mechanism of injury (how)
level of injury (where)
degree of injury ( how bad )
what are some examples of mechanisms of injury patients can do to get an injury ?
flexion ( strong forward crash )
hyperextension ( banging head on table)
compression fracture
( diving into shallow pool )
flexion rotation
- most unstable due to ligament tearing like falling from a horse
when talking about the level of injury, we talk about two things, which are?
skeletal level
neurologic level
what is skeletal level?
what is neurologic level?
which vertebra is around the spinal cord is injured
(physical damage occur)
( broken )
these are the neurologic symptoms they exhibit
( nerve damage occurred )
C1-T1 is called what?
below t2 is what?
tetraplegia ( quadriplegia )
( all 4 extremities )
paraplegia
( can’t use legs )
she said to look at the picture in the powerpoint, this is the skeletal picture talking about the levels of paralysis a patient with a spinal cord injury will exhibit, so your job is to talk about what is happening at each level.
c4 injury
c6 injury
t6 injury
l1 injury
tetraplegia, complete paralysis below the neck
results in partial paralysis of the hands and arms and lower body
paraplegia, results in paralysis below the chest
paraplegia, results in paralysis below the waist
when we are talking about the degree of injury we are talking about 2 things which are?
complete
incomplete ( partial )
what is a complete degree of injury ?
total loss of sensory and motor function below level of injury
what is incomplete (partial) degree of injury ?
mixed loss of voluntary motor activity and sensation
what is the scale we use to assess the clinical manifestation for a patient with spinal cord injury ?
which helps us to?
American spinal injury association impairment scale
(ASIA)
- classifies severity of impairment
- combines assessment of motor and sensory function to determine neurologic level and completeness of injury
clinical manifestations are a direct results of trauma that causes what 4 things ?
cord compression
ischemia
edama
possible cord transection
what is a dermatome?
provide example
sensory region of skin corresponding to each spinal cord segment
spinal cord injury, move fingers
thumb issues - higher c6 injury
what are some diagnostic studies for spinal cord injuries?
cervical x-rays
ct scan
mri
ct angiogram
what is the emergency management for patients with spinal cord injuries ?
patent airway, adequate respiration
adminiser oxygen
maintain systolic blood pressure
iv access - 2 bore ivs
monitor for neurogenic shock
stablize cervcial spine
assess for other injuries
control external bleeding
obtain appropriate imaging
secure airways
keep warm
obtain brief history
we are going to need to roll the patient, how are we going to move them ?
log roll them
when you are concern with a patient for motor function, make sure you are doing what?
bilateral !!!
not one arm first then the other arm,
do it both!
how are we going to assess for sensory for patients with spinal cord injuries?
pinprick
position sense and vibration
inter professional care
acute care notes
brain injury and vertebral artery injury
- history of unconsciousness
- signs of concussion
musculoskeletal injuries
trauma to internal organs
- hemorrhage : decreased blood pressure, increased pulse
- hematuria
move the patient in alignment as a unit (logroll)
monitor respiratory, cardiac, urinary, gi functions
prepare for transfer to surgery or icu
Stabilization of injured spinal segment and decompression
- Traction or realignment
- Eliminates damaging motion
- Prevent secondary damage
Early realignment of unstable fracture-dislocation
- Closed reduction through craniocervical traction
Used following acute SCI to manage instability and decompress the spinal cord
- Reduces secondary injury and improves outcomes
Surgery within 24 hours of injury is recommended for central cord syndrome and adults with any SCI
we use to treat patients with high dose of what _____but we dont use it anymore
corticosteroids
examples like
methylprednisolone
remember patients with spinal cord injuries can not move their legs, so they are at risk for?
and we need to treat with what ?
VTE, DVT, blood clot
heparin
remember what type of motion are we going to do for patients with spinal cord injuries?
and why?
passive range of motion because remember they are paralysis!!
why night we need to use vasopressors agents to maintain the mean arterial pressure 85-90?
neurogenic shock
- they are hypotensive !
we may need to give vasopressor
what are some examples of vasopressors ?
phenylephrine, norepinephrine
nursing assessment notes
Subjective data
Health history, functional health patterns, coping
Objective data
- Poikilothermism
- Warm, dry skin below level of injury intially (neurogenic shock)
- Respiratory-Consider level of injury, Bradycardia, hypotension
Decreased or absent bowel sounds
Abdominal distention
Constipation, incontinence, impaction
Urinary retention, flaccid, spasticity
Priapism, altered sexual function
Neurologic
Complete: areflexic, paralysis, hyperactive deep tendon reflexes, positive Babinski
Incomplete: mixed loss of motor and sensory functions
Muscle atony, contractures
Pain
Possible diagnostic findings
nursing diagnoses notes
- Impaired breathing
- Impaired nutritional status
-Ineffective tissue perfusion - Impaired tissue integrity
- Impaired urinary system function
- Constipation
- Difficulty coping
nursing planning notes
Overall goals
- Maintain optimal level of neurologic functioning
- Have minimal to no complications of immobility
- Learn new skills, gain new knowledge, and acquire new behaviors to care for self or direct others to do so
- Return to home at optimum level of functioning
nursing implementation
health promotion notes
Identify high-risk populations and provide teaching
Support legislation to:
- Prohibit texting while driving
- Mandate use of seat belts in cars
- Mandate helmets for motorcyclists/ bicyclists
- Mandate child safety seats
- Promote programs for older adults to prevent accidental death and injury
- Recommend tougher penalties for impaired driving
Health promoting behaviors after SCI impact general health and well-being
- Teaching and counseling
- Referring to programs
- Performing routine physical exams
- Facilitate wheelchair-accessible exam rooms, adjustable height tables, and extra time for appointments
the higher you have a spinal cord injury, the more severe complications are going to be for patients.
so we always want to maintain a neutral neck position
- keep the body in correct alignment
- logroll to prevent movement of spine
closed reduction with skeletal traction for realignemt
- maintain traction at all times
surgical : cervical fusion or other stabilization procedure
typically when patients have a high spinal cord injury we are going to put them in this what ?
halo vest
what is the function of the halo vest?
main concern with
stabilize the neck
pins in the skull it attaches to
infection
how do we take care of the pins ?
clean with cholrhexidine twice a day
apply antibiotic ointment
if a patient has a lower spinal injury, we can put them in braces as well, only down side of this compared to the vest is that movement, like flexion, extension and rotation is very limited.
there are beds, that can move you to help prevent pressure injuries and aid with circulation , fluid mobilize so we can prevent respiratory issues
remember when a patient is having spinal shock, they are going to have no reflexes, however after the resolution of spinal shock, what will they have?
hyper active, exaggerated responses with no control
- muscle spams
(men will have penile erections)
its very sad to think and tell a patent, after your spinal shock reflexes, having none, has gone away and now your spinal shock has resolved, to where you have so much movement, you think youre doing better, you have to tell them what?
it does not mean mobility is returning back
how can we help a patient with hyper-reflexes? like what drug and injection ? (2)
antispasmodic drugs
botuslim toxin injection
autonomic dysreflexia is a what?
life threatening situation in where your t6 or below has a hyper stimulation of your nervous system
what is the biggest cause of autonomic dysreflexia ? (4)
restrictive clothing
full bladder/urinary tract infection
pressure areas
fecal impaction
what are clinical manifestations of autonomic dysreflexia ?(6)
vasodilation above the level of injury
high blood pressure
flushed face
headache
distended neck veins
decrease heart rate
increase sweating
what are clinical manifestations of vasoconstriction below level of injury for patient with autonomic dysreflexia? (3)
pale
Cool
no sweating
if autonomic dysreflexia is not resolved, it can lead to what?
status epilepticus
stroke
myocardial infarction
death
what is the first thing we are going to do if we suspect a patient to be having autonomic dysreflexia?
elevate the head of the bed 45, sit them up!!
after we sit them up, what are we going to assess or how are we going remove the cause for autonomic dysreflexia? (3)
think of the causes of autonomic dysreflexia In the first place
immediate catheriation - for the full blader
remove stool impaction
remove constrictive clothing/tight shoes
after someone is discharged from the hospital, we are can send them home or rehab.
Complex rehabilitation
Physical and psychological care and intensive and specialized rehabilitation lead to function at highest level of wellness
Interprofessional team effort
Problems from acute injury become chronic and last throughout life
Rehabilitation focuses on retraining physiologic processes and management of changes
Organized around patient’s goals and needs
Patient expected to be involved in therapies and learn self-care
Progress can be slow
Can be very stressful
Nurses provide frequent encouragement, specialized care, patient and caregiver education; and help coordinate efforts of team
respiratory rehabilitation
notes
Patients with mechanical ventilation need:
Round-the-clock caregiver
Respiratory hygiene
Tracheostomy care
Education (include caregiver)
Improved function possible with nerve stimulator
If removed from the ventilator, tracheostomy downsizing will take place in rehab
Teach:
- Assisted coughing, Incentive spirometry
- Breathing exercises, Limit exposure to sick people
- Swallowing precautions ad diet recommendations to reduce aspiration
notes
neurogenic bladder
Comprehensive program needed to manage bladder function
Goal is to improve quality of life and safety by:
- Preserving renal function
- Minimizing UTIs and bladder stones
- Developing a plan for incontinence
Management
Patient and caregiver teaching for successful self-management
- Where to obtain supplies for selected management technique
- When to seek health care
- Bladder retraining
- Fluid schedule
- Indwelling urinary catheter-needs 3-4 L of fluid daily
Factors to consider
- Patient preference, upper extremity function, and caregiver availability
what are some drainage methods for neurogenic bladder?
bladder reflex retraining
catherters
urinary diversion surgery
what type of diet for bowel moment for spinal cord injuries ?
high fiber to help with constipation
Voluntary control may be lost
Patient and Caregiver Teaching
High-fiber diet
Adequate fluid intake
Timing, position, activity
Drug treatment
Suppositories
Small-volume enemas
Digital stimulation
Valsalva maneuver
International Spinal Cord Injury Bowel Function Data Set
spasticity
can be both beneficial and undesirable
Aids with mobility
Improves circulation
Difficult positioning and mobility from spasms
Treatment
ROM exercises
Antispasmodic drugs
Botulinum toxin injections
skin care notes
Prevention of PI essential for life-long treatment plan
Patient and caregiver teaching
Comprehensive daily exam to monitor skin condition
Teach to reposition
At least every 2 hours while in bed
Every 15 to 20 minutes when in a chair
Pressure-relieving cushion, mattress, pillows
Adequate nutrition
Standard wound care procedures
pain management notes
Acute pain
- Initial injury pain persists for few weeks of rehabilitation
Chronic pain
-May be result of overuse of muscles
-Sleep may be disrupted
Assess, evaluate, and treat routinely
Analgesics
Massage and repositioning
Refer to pain management specialist
sexuality notes
Important issue regardless of patient’s age or gender
Nurse or rehabilitation specialist must:
Provide support for patient and partner
Discuss alternatives for sexual satisfaction
grief and depression
Depression common and disabling
Overwhelming sense of loss
Loss of control
Grief Response
Shock and denial
Anger
Depression
Adjustment and acceptance
Provide Support
Allow mourning while encouraging hope
Goal of recovery: adjustment more than acceptance
Sympathy not helpful
Encourage patient participation
Consistency of care
Psychiatric consult if needed
Drugs and therapy
Caregiver and family counseling
Support group
Expected outcomes
Adequate ventilation with no signs of respiratory distress
Adequate circulation and BP
Intact skin
Adequate nutrition
Bowel management
Bladder management
No autonomic dysreflexia
gerontologic considerations
Increased incidence
Falls are leading cause of SCI at age 65 and older
Increased complications
Hospitalized linger
Increased mortality rates
Health promotion and screening
Rehabilitation lengthened
