Test 3 Spinal Cord Injury (CNS, Spinal Cord) Flashcards
What is the pathophysiology of Spinal Cord Injury (SCI)?
Spinal Cord Injury Patho:
- Hemorrhage
- Metabolic (Inflammatory Processes)
- Cellular changes
- Vasoconstriction/Thrombosis
- Vasospasms/Edema
- Decreased spinal cord blood flow
- Spinal cord ischemia and hypoxia
What is a complete injury?
Total loss of sensory and motor function below level of injury
What are the 2 types of Complete injuries?
2 Types of Complete Injuries:
- **Tetraplegia (Quadriplegia)
- Cervical area down
- All 4 extremities
- **Paraplegia
- From waist down
Complete Injury
What are the characteristics of tetraplegia?
Tetraplegia:
Characteristics:
-Paralysis of both arms and legs
Injuries in the cervical region result in quadriplegia –paralysis/paresis of all 4 extremities and trunk.
Complete Injury
With a tetraplegic, where did the injury occur on the spine?
Complete Injury: Tetraplegia
*** Injury to cervical region C1-C8 **
What is the goal with a tetraplegic patient (Complete Injury)?
Why is this goal important?
Goal: Airway Management
- Paralysis of the diaphragm if injury above C3.
- An injury at C4 or above poses a great risk for impaired spontaneous ventilation because of the the involvement of the phrenic nerve (originates in the neck and passed down between the lung and heart to reach the diaphragm).
Complete Injury
What are the characteristics of paraplegia?
Paraplegia:
Characteristics: Paralysis of both LEGS
Waist down
Complete Injury
With a paraplegic, where did the injury occur on the spine?
Complete Injury: Paraplegic
Injury to the thoracolumbar region T2-L1
Complete Injury: Paraplegia
How are arms affects?
What is required?
Is respiratory compromised?
Complete Injury: Paraplegia
- May have full use of arms
- May require wheelchair or have some limited use lower extremities
- May have some respiratory compromise (varying degrees of intercostals and abdominal muscle paralysis
If a person has COPD or a respiratory problem, can respiratory be compromised?
Yes. If person all ready CODP or respiratory problem, can still have respiratory compromise b/c don’t have as much abdominal muscle use.
What is an Incomplete Injury?
Incomplete Injury:
Mixed loss of voluntary motor activity and sensation below level of injury.
What are the 4 Types of Incomplete Injury?
4 Types of Incomplete Injury:
- Brown-Sequard Syndrome
- Central Cord Syndrome
- Anterior Cord Syndrome
- Posterior Cord Syndrome
Incomplete Injury:
What is Brown-Sequard Syndrome?
Brown–Sequard Syndrome
-Transection/Damage of one side of spinal cord
Incomplete Injury:
Brown-Sequard Syndrome
What type of injury can cause this?
Incomplete Injury:
Brown-Sequard Syndrome
Patient stabbed in the back with an icepick or small knife. The smallness of the object is the cause of this injury.
What clinical manifestations occur with Brown-Sequard Syndrome below the injured site cord:
- Motor? Which side?
- Sensation? Which side?
Below injured site cord…
-Loss voluntary motor function
SAME SIDE AS INJURY
-Loss of pain, temperature, & sensation
opposite side of injury
Incomplete Injury:
What is Central Cord Syndrome?
What is it associated with?
Incomplete Injury:
Central Cord Syndrome
- Hematoma formation in center of cervical cord
- Associated with cervical flexion/extension injury
Incomplete Injury:
What are the clinical manifestations of Central Cord Syndrome?
Motor? Side effected?
Sensory?
What else is effected?
Incomplete Injury:
Central Cord Syndrome
Motor weakness
-Upper extremities weaker than lower
- Sensory function varies
- Varying degrees bowel and bladder dysfunction
B/c edema is in the middle of the Central cord, it has effect on the ascending and descending tracts.
Incomplete Injury:
What is Anterior Cord Syndrome?
What is it associated with?
Incomplete Injury:
Anterior Cord Syndrome
- Acute compression of anterior portion of spinal cord
- Associated with flexion injuries or acute herniation of an intervertebral disc
What are the clinical manifestations of Anterior Cord Syndrome?
Motor?
Sensation?
Incomplete Injury:
Anterior Cord Syndrome
- Loss motor function below site of injury
- Loss pain, temperature & CRUDE sensation
Incomplete Injury:
What is Posterior Cord Syndrome?
What is it associated with?
Incomplete Injury:
Posterior Cord Syndrome
-Damage to the posterior column
Not as common, but unique to look at!
-Associated with cervical hyperextension injury
Incomplete Injury:
What are the clinical manifestations of Posterior Cord Syndrome?
Motor?
Sensation?
Incomplete Injury:
Posterior Cord Syndrome
- Loss position sense, vibration, and pressure (May not have ability to walk)
- Motor function, pain and temperature sensation intact.
What will be part of the assessment with a spinal cord injury?
What is an important unique assessment to pay attention to and why?
- Pain at level of injury
- Numbness/weakness, loss of sensation below level of injury
- Complete/incomplete
- Address Respiratory distress
- Alterations in bowel and bladder function
-Alterations in temperature control
They tend to take on the temp of the room b/c cannot vasodilate like normal.
What is spinal shock?
How long does it last? (Think about football player)
- Spinal shock is Initial period of flaccid paralysis and loss of sensation and reflexes.
- Lasts between 48 hours to several weeks
What assessment findings occur with spinal shock?
When does this occur?
What else happens?
When does this occur?
Spinal Shock:
- Complete loss of all reflex activity below level of injury:
- **Loss of sensation
- **Flaccid paralysis
- **Absent reflexes
- Occur shortly after injury
- **Muscle spasms
- Hyper-reflexic and spastic
- Occurs within days to weeks
What are Nursing Diagnosis to include with a Spinal Cord Injury?
- **Respiratory
- Know how breathing
- Patient may need to be intubated and on ventilator. May need tracheotomy when off.
- Teach coughing
- **Circulation
- CO, Tissue Perfusion, Dysrhythmias, -Emboli (DVTs)
- May be on anticoagulant for rest of life
- **Skin Integrity
- Q2h is NOT enough, more frequently
- Check bed and wheelchair
- Can die from infection
Management Goals:
Goal: Maintain patent airway
What to do if unresponsive? What position is the neck? What method is used to open airway? What should be provided? If injury is above \_\_\_, need \_\_\_\_ \_\_\_\_. What should be monitored? What should be done PRN?
Airway management
Goal: Maintain patent airway
- If unresponsive insert oral airway
- Keeping neck in neutral position
- Jaw thrust method to open airway
- Provide oxygen/ventilator
- If injury above C3 need mechanical ventilation
- Monitor ABG’s
- Suction prn
Management Goals:
What is included with managing circulation?
***___ ___
What is interrupted?
What response is lost?
What can blood vessels not do and Side effects?
*** ___ ___
____ ____
Prophylaxis?
What is there a loss of?
- **Cardiac output
- Sympathetic nervous system interrupted
- Loss of vasomotor response
- Blood vessels cannot constrict
- –Hypotension, venous pooling, decreased CO
- **Tissue perfusion
- Orthostatic hypotension
- DVT prophylaxis
- Loss of thermoregulation
Management Goals:
Cervical Immobilization What position? What may be used? How is the body correctly aligned? What may be required? Give examples?
Cervical Immobilization
- Immobilize and stabilize in neutral position
- Sandbags, cervical collars, and backboards
- Body should be correctly aligned, log roll. Always log roll with another person!
-May require surgical stabilization: -Laminectomy, Spinal fusion, Rods
Management Goals:
Cervical Immobilization:
____ ____ using skull tongs
____ provided by ___ system and ___
How often should pin sites be cleansed?
What else can be used?
- Cervical traction using skull tongs
- Traction provided by pulley system and weights
- Cleanse pin sites twice a day
- Halo traction
Management Goals:
Cervical Immobilization:
What should be inspected?
What should be taped to the jacket? Why is this needed?
What are body shells used for?
Management Goals:
Cervical Immobilization:
- Inspect skin under jacket for breakdown
- Keep Allen wrench taped to jacket
- Used to open up traction to do CPR, chest compression
- Body shells for stable thoracolumbar injuries
When caring for spinal cord edema, what medications can be used?
How should this be administered?
Why is this medication used?
Spinal cord edema: Drug Therapy
- Corticosteroids
- High dose “Methylprednisolone” IV
- Administer within 8 hours of injury
- Start bolus, then, continuous drip for 24-48 hours
-Edema of the spinal cord could cause spinal compression and areas of ischemia.
What is Neurogenic shock?
When does it occur?
What are the symptoms?
Blood vessels?
HR?
Temp?
Skin? Why?
Neurogenic Shock:
- Loss of vasomotor tone & sympathetic innervation of heart
- Neurogenic shock occurs after spinal cord injury and can cause total loss of voluntary and autonomic function for several days to weeks.
- HYPOTENSION (Low BP); dependent edema
- Hypovolemia, vasodilatation, ↓SVR (systemic vascular resistance), ↓Venous Return, ↓Stroke Volume, ↓CO, ↓Preload, Inhibited Baroreceptor response
- Blood vessels unable to constrict
- End up with a Low HR
- Poikilothermic (Take on temp of the room)
- SKIN WARM & DRY
- Why? Vasodilation. Blood is in the wrong places.
How do you fix Neurogenic Shock?
Resusitation?
Drug? Why?
Temp?
Avoid? Why? Never in ____!
Management to fix this:
Careful fluid resuscitation
-May give a little fluids
- **VASOPRESSORS
- Need to constrict
- **Keep ATROPINE by the bedside
Maintain normothermia
-Need to warm this patient up b/c taking temp of room.
Position to AVOID ORTHOSTATIC HYPOTENSION (AKA orthostasis)
-Bed at 10-15 degree level (Won’t sit straight up)
If sitting up, go SLOWLY
NEVER IN TREDELENBURG
Clients who have upper neuron injuries (above ___ and ___) will convert to a ____ ____ ____ after neurogenic shock.
Clients who have upper neuron injuries (above L1and L2) will convert to a spastic muscle tone after neurogenic shock.
Paraplegics who have lower neuron injuries (below ___ and ___) will convert to a ___ ___ ___ ___.
Paraplegics who have lower neuron injuries (below L1 and L2) will convert to a flaccid type of paralysis.
SCI Nursing Goal: Altered Elimination Pattern
Bladder problem?
Why? What Results?
Altered elimination pattern: Bladder
- Retention urine due to loss of autonomic and reflex control of bladder and sphincter.
- Results in over-distention and may reflux into kidney
- Ppl with spinal cord injuries have UTI for this reason b/c cannot sense when bladder is full.
SCI Nursing Goal: Altered Elimination Pattern
What to do during:
Initial injury?
Long term care?
Prevent UTIs with?
SCI Nursing Goal: Altered Elimination Pattern
Initial injury?
-indwelling catheter
Long term care?
-intermittent catheterization
-Prevent UTI’s with cranberry, apple, and grape juice (Drink these)
SCI Nursing Goals: Bladder
After the neurogenic shock resolves, patients with upper motor neuron injuries will develop what kind of bladder?
Clients with lower motor neuron injuries will develop what kind of bladder?
SCI Nursing Goals: Bladder
- After the neurogenic shock resolves, patients with upper motor neuron injuries will develop “Spastic Neurogenic Bladder”
- Clients with lower motor neuron injuries will develop flaccid neurogenic bladder.
SCI: Nursing Goals: Bowel
Upper motor neuron (Has what?)
_____ bowel
Lower motor neuron \_\_\_\_\_ bowel (Has what?)
May need what?
SCI: Nursing Goals: Bowel
Upper motor neuron (Has spasticity)
-Reflexive bowel
Lower motor neuron
-Areflexic bowel (No reflexes in bowel)
May need enema to clear themselves completely.
SCI: Bowel Management
How do you prevent constipation?
Drugs?
SCI: Bowel Management
- Knowing Scheduled bowel program
- Encouraging food high in fiber
- Increase fluid intake
-Suppository and stool softeners: biscodyl (Dulcolax), docusate sodium (Colace) or polycarbophil (Fibercon)
- Digital stimulation for Upper Motor -Neuron (UMN) injuries when putting enema in
- Enemas
SCI Nursing Goals:
What do the spasms look like?
How do you prevent spasms?
Drugs?
SCI Nursing Spasm:
Inappropriate reflexes:
- -> Hyper-reflexia
- -> Mild twitches, convulsion, erections
Relieve spasms with:
-Warm baths
-Muscle relaxants
Baclofen (Lioresal) & dantrolene socium (Dantrium)
-Antispasmodics
Bethanechol (Urecholine)
Name of muscle relaxants?
Given for? What could results if not given?
Monitor for?
Muscle relaxants:
-Baclofen (Lioresal) & dantrolene socium (Dantrium)
- Given to patients with severe spasticity. Spasticity can be so severe that clients develop pressure ulcers, which makes sitting in wheelchair difficult.
- Monitor for drowsiness, muscle weakness
What drug is used to decrease spasticity of the bladder, allowing for easier bladder training and fewer accidents?
Classification?
Nursing consideration?
Bethanechol (Urecholine)
Classification: Cholinergic
Nursing Consideration:
-Observe client for urinary retention. Measure residual periodically.
What drug is used during neurogenic shock?
What does it treat?
- Vasopressors
- Norepinephrine and dopamine are given to treat hypotension, particularly during neurogenic shock.
What drug is used to treat bradycardia?
Classification?
- Atropine sulfate is used to treat bradycardia.
- Classification: Antimuscarinic
What drug is a plasma volume expander?
What does it treat?
Nursing consideration?
Dextran
Dextran, a volume expander, is used to treat hypotension secondary to shock to spinal cord.
Nursing Consideration:
Observe client for fluid overload
What drugs are used to treat pain from spinal cord injury (discomfort from muscle spasms)?
Classification?
Opiods, non-opiods, and NSAIDs
Classification: Analgesic
What anticoagulant drug is used with SCI?
Used for?
Nursing considerations?
Heparin
Used for DVT prophylaxis
Nursing considerations:
- Monitor INR, PT, aPTT for therapeutic levels of anticoagulantion
- Observe for signs of GI bleeding or bleeding secondary to unrecognized injury.
What drug is used PRN to treat episodes of hypertension during automatic dysreflexia?
Classification?
Nursing Consideration?
Hydralazine (Apresoline) & Nitroglycerine (Nitrostat)
Classification: Vasodilators
Nursing Considerations:
-Monitor blood pressure frequently
SCI Nursing Goals:
What is a contracture?
What is a decubiti?
How are contractures (mostly ____) and decubiti prevented?
- Contracture: Shortening and hardening of muscles, tendons, and other tissues leading to deformity.
- Decubiti: Skin ulcer over bony part of body from immobility
Preventing contractures (mostly UMN) and decubiti:
- Turn Q2h
- Out Of Bed to Chair ASAP
- Specialty beds that provide side-to-side lateral rotation
What is a complication of SCI that is considered an emergency?
What is another name for this?
What is the definition of the?
Who does this mostly occur in?
what is it caused by?
- Autonomic Dysreflexia
- Also known as Hyper-reflexia
- Exaggerated autonomic response to stimuli in a person with a SCI ABOVE T6 resulting in profound hypertension.
- Mostly occurs in tetraplegics
Caused by:
- Distended bladder or rectum
- Stimulation of skin, pain
What is the Cause of Autonomic dysreflexia in detail ?
Where is the triggering stimulus?
- Autonomic dysreflexia occurs secondary to the stimulation of the sympathetic nervous system and inadequate compensatory response by the parasympathetic nervous system.
- Sympathetic stimulation is caused by a triggering stimulus in the lower part of the body.
Autonomic dysreflexia:
Review Symptoms of PNS and SNS
Stimulation of the sympathetic nervous system causes what?
-Stimulation of the Sympathetic Nervous System causes (fight-or-flight response) dilation of the pupils, increased HR, vasoconstriction, decreased peristalis and tone of the gut, hypertension, sudden severe headache, pallor below the level of the spinal cord’s lesion dermatome, blurry vision, diaphoresis, restlessness, nausea, and piloerection (goose bumps), releases epinephrine and norepinephrine
-
Autonomic dysreflexia:
Review Symptoms of PNS and SNS
Stimulation of the parasympathetic nervous system causes what?
Stimulation of the parasympathetic nervous system causes bradycardia, flushing above the corresponding dermatome tot he spinal cord lesion (flushed face and neck), nasal stuffiness, constriction of the pupils, decreased HR, increased peristalsis and tone of the gut.
Autonomic dysreflexia:
What are the assessment finding for autonomic dysreflexia/Hyperreflexia?
What is a significant symptoms? Why?
- Severe HTN (SBP may be 300)
- Bradycardia
- Severe Head Ache –> Blurred vision
- Nausea, Restlessness
***Skin Flushed above injury, Pale below b/c so constricted below, warm above b/c flushed
-Distended bladder, bowel
Autonomic dysreflexia:
What is the FIRST intervention?
Autonomic dysreflexia: #1 immediately sit the patient up b/c want orthostatic hypotension to happen to lower the severe hypertension!!!
What are the Priority problems for Long-term Management?
- Difficulty breathing
- Impaired physical mobility (safety)
- Spastic or flaccid bladder and bowel
- Impaired adjustment
Mechanism of injury: HYPERFLEXION
What are Hyperflexion injuries caused by?
Examples of Hyperflexion injuries?
Where is this frequently seen at the spine?
What results from this?
Mechanism of Injury: HYPERFLEXION
- Caused by acceleration injuries that cause shard FORWARD flexion of the spine
- Head-on-collision, Fall, or Diving
- Frequently seen at C5 and C6
Resulting in….
- Compression of cord from fractures
- Rupture or tearing of muscles or ligaments
Mechanism of Injury: HYPEREXTENSION
What are Hyperextension injuries caused by?
Examples of Hyperextension injuries?
What results from this?
Mechanism of Injury: HYPEREXTENSION
- Caused by a BACKWARD snap of the spine
- Rear-end collision (Whiplash), Diving accidents, a downward fall onto the chin
Resulting in…
-Spinal cord is stretched and distorted resulting in contusion or ischemia
Mechanism of Injury:
What are Axial Loading or Vertical Compression injuries caused by?
Examples of this injury?
What results from this?
Mechanism of Injury:
AXIAL LOADING/ VERTICAL COMPRESSION
- Caused by vertical force on spine
- Long fall landing on feet or buttocks, Diving
Resulting in…
-“Burst” fractures (small, bony fragments that occur from the injury in the spinal canal).
Mechanism of Injury:
What are excessive head rotation injuries caused by?
Examples of this injury?
What does this injury occur along with?
What results from this?
Mechanism of Injury:
EXCESSIVE HEAD ROTATION
- Displacement of the spinal column & Tearing of the posterior ligaments
- Boxing Injury, Falling
- Occurs along with BOTH extension, flexion injuries
Resulting in…
-May disrupt ligaments, vessels, tissue, bone, and related organs
