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Nursing 272: Final Semester > Unit 1: Spinal Cord Injury (SCI) > Flashcards

Unit 1: Spinal Cord Injury (SCI) Flashcards

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1
Q

Spinal Cord

A

-18 inches long
-nerves within the cord carry messages from the brain to the spinal nerves (upper motor neurons) and back
-spinal nerves (lower motor neurons) branch out from the spinal cord to specific areas of the body
-lower motor neurons: have 2 parts
>sensory portion: carries messages from the body to the brain
>motor portion: carries messages back to body parts to initiate actions like muscle movements
-spinal cord does not have to be severed for loss of functioning to occur (ex: neuronal axonal injury)
-protected by vertebral column, spinal meninges, and CSF

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2
Q

Functions of the spinal cord

A 
>Somatic and autonomic reflexes
>Motor control centers:
-somatic nervous system
-autonomic nervous system (ANS); sympathetic and parasympathetic
>Sensory/motor modulation
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3
Q

Pathophysiology of SCI

A

damage to the spinal cord w/ results of functional loss of mobility and/or sensation

  • complete or incomplete
  • results from concussion, contusion, compression, tearing, laceration, transection, or ischemia of the spinal cord
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4
Q

Acute Spinal Cord Injury

A
  • unexpected, catastrophic event
  • loss of function; mobility or sensation
  • spinal cord trauma may result from direct injury to the cord
  • spinal cord trauma may result from indirect injury from damage to surrounding bones, tissue, and blood vessels; caused by hyperextension, hyperflexion, rotation and vertical compression (axial loading), or penetrating injuries
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5
Q

Risk Factors for SCI

A
  • occur in ages 16 and 18
  • high-risk physical activities; speeding and drinking while under the influence of alcohol
  • substance use
  • not using protective gear in sports or recreational activities
  • in older population, increased risk of spinal cord injuries r/t fall related injuries
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6
Q

Where are injuries most commonly located on the spinal cord?

A

C4, C5, C6 and T12

-half of injuries resulting in paraplegia and half in quadriplegia

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7
Q

Paraplegia

A

paralysis of the legs and lower body

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8
Q

Quadriplegia

A

paralysis of all four limbs

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9
Q

Causes of SCI

A
  • leading cause is automobile accidents then,
  • falls
  • acts of violence/guns
  • sports injuries
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10
Q

Secondary Injury

A

-occurs d/t edema at the site of injury
-leakage of blood w/ decreased flow to the injured area
-and inflammatory processes causing neuronal death and the formation of scar tissue
>this sequelae can result in further functional deficits in the patient

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11
Q

Complete Injury

A

-total loss of motor and sensory function below the level of injury

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12
Q

Incomplete Injury

A 
incomplete structural damage w/ some function preserved below the primary level of injury
>central cord syndrome
>anterior cord syndrome
>posterior cord syndrome
>Brown-Sequard syndrome
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13
Q

Incomplete Injury: Central Cord Syndrome

A
  • most common
  • hyperextension injury w/ central cord swelling
  • manifestations: functional motor loss greater in arms than legs
  • bladder dysfunction
  • variable loss of sensation
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14
Q

Incomplete Injury: Anterior Cord Syndrome

A

-acute anterior compression from bony fragments or acute disk herniation
>Manifestations:
-loss of motor function (paresis or paralysis), pain, temperature, crude touch and pressure below level of injury
-preserved sense of proprioception (position sense), fine touch and pressure, and vibration

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15
Q

Incomplete Injury: Posterior Cord Syndrome

A
  • acute compression
  • loss of proprioception (position sense), fine touch and pressure, and vibration
  • intact pain, temperature, and crude touch and pressure
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16
Q

Incomplete Injury: Brown-Sequard Syndrome

A

-hemisection of the spinal cord resulting from penetrating injury (i.e. gunshot, knife)
-also occur as a result of primary ischemia, infection, or hemorrhagic event
-ipsilateral (same side) loss of motor function, proprioception (position sense) and vibration
-contralateral loss of pain and temperature
>you can still have sensation of the affected side, no motor function; have no sensation on opposite side of injury

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17
Q

Clinical Manifestations of SPI

A 
>depends on the level of injury
>spinal cord trauma results in motor and sensory loss below the level of injury
>clinical manifestations vary depending on the location and severity of the cord damage and are caused by loss of innervation at the affected spinal cord levels
-inability to breathe
-paraplegia
-loss of bowel, bladder, sexual function
-chronic pain
-hypotension
-impaired temperature control
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18
Q

Clinical Manifestations of Cervical Cord Injuries

A

> cervical cord injuries that occur in the neck result in manifestations that affect the arms, legs, and middle of the body

  • difficulty breathing; can result in inability to breathe (above C4) as the phrenic nerve innervates the diaphragm in this area
  • quadriplegia
  • requires ventilator
  • loss of bowel and bladder control
  • numbness
  • weakness or paralysis
  • pain
  • sensory changes
  • spasticity
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19
Q

Clinical Manifestations of Thoracic Cord Injuries

A

> occur at chest level

  • paraplegia
  • loss of normal bowel and bladder control (constipation, incontinence, and bladder spasms)
  • numbness
  • sensory changes
  • spasticity (increased muscle tone)
  • pain
  • weakness, paralysis
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20
Q

Clinical Manifestations of Lumbar and Sacral Cord Injuries

A

> occur at lower back level

  • decreasing control of legs
  • altered bowel/bladder function
  • sexual dysfunction
  • numbness
  • pain
  • sensory changes
  • spasticity
  • weakness and paralysis
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21
Q

C1-C4

A
  • quadriplegic (paralysis of all 4 limbs)

- requires ventilator

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22
Q

C5-C6

A
  • quadriplegic (paralysis of all 4 limbs)
  • phrenic nerve intact
  • gross arm movements, shoulder strength
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23
Q

C7-C8

A
  • quadriplegic (paralysis of all 4 limbs)
  • diaphragmatic breathing
  • biceps, triceps, wrist extension
  • no core strength
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24
Q

T1-T5

A
  • Paraplegic (paralysis of legs and lower body) w/ trunk involvement
  • Normal arm/hand movement
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25
Q

T6-T12

A
  • Paraplegic (paralysis of legs and lower body)
  • ability to control balance and trunk
  • no voluntary bowel/bladder control
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26
Q

Below T12

A
  • variable motor/sensory loss of lower extremities

- reflexive bowel/bladder

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27
Q

How we Diagnose SCI

A
  • time between SCI and tx affects outcome
  • if admitted w/ suspected SCI associated w/ trauma to head or neck the spine is immobilized (cervical collar, spine backboard) until exam is performed to identify level of injury b/c any significant movement of the spine can = further damage
  • physical and neurological examination; include reflexes
  • X-ray to look for damage to the vertebrae
  • If patient has clinical manifestations of a SCI (inability to move/feel) a CT scan or MRI to show the location nd extent of damage; to reveal problems like a hematoma
  • the level of injury refers to the vertebra closest to the site of injury
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28
Q

Medical Management for SCI

A 
>no way to reverse spinal cord damage
>acute stage: focus on
-maintain airway patency
-adequate breathing and oxygenation
-preventing spinal shock
-restoring and maintaining BP
-preventing further cord damage
-spinal immobilization
-avoiding possible complications
>monitored for vital sign changes that may indicate spinal shock
>maintain airway patency, maintain BP, and spinal immbolization
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29
Q

Surgical Management

A
  • w/ no evidence of external pressure on spinal cord transferred to ICU in traction
  • evidence of spinal cord compression, progressive deficits, compound vertebral fractures, penetrating spinal cord wounds, or bony fragments in the spinal canal; early surgery for decompression and fusion to stabilize spinal column
  • w/ neurological evidence of spinal instability patients are admitted to the ICU for a diagnostic work-up and neurological monitoring
  • types of surgery: Decompression Laminectomy, and Posterior Laminectomy
30
Q

Decompression Laminectomy

A

using anterior cervical and thoracic approaches with fusion in which one or more laminae are removed to allow for cord expansion b/c of edema

31
Q

Posterior Laminectomy

A

and fusion with bone graft to immobilize the neck and prevent further damage to the spinal column
-posterior approach using a bone graft or the insertion of rods or other instruments to correct and stabilize the deformities

32
Q

Immobilization an Stability

A
  • fracture/dislocation must be reduced early
  • spinal immobilization obtained to prevent further loss of function, ischemia, pain, and necrosis
  • realignment of the spine w/ traction, a halo device, or surgery to achieve optimal function
33
Q

Halo Traction Device

A

used to maintain cervical immobilization

  • made up of a ring around head attached to a special vest by 4 rods
  • titanium screws are screwed into the skull bone and attached to device; weights connect to the halo at the head of the bed over a pulley system; weights slowly added, with x-rays taken between each additional weight until spinal alignment achieved
34
Q

Gardner-Wells Tongs

A

u-shaped tongs used for spinal traction

  • pressure-controlled pins are inserted into the skull at opposite ends to permit a longitudinal force to be applied to the axis of the spinal column
  • tongs are attached to weights using a pulley system at the HOB
35
Q

Halo Brace/Traction Complications

A
  • pin infections
  • skin breakdown
  • loosening or movement of pins
  • swallowing problems
  • dural tears
36
Q

Halo Brace/ Traction Care

A
  • sites must be frequently assessed for infection
  • site care once a shift and PRN
  • kept clean using a clean cotton-tipped applicator or gauze soaked in normal saline
  • new clean applicator or gauze used for each pin site
  • if crusting; wrap a gauze soaked w/ normal saline around pin site for 15 minutes; after removing gauze, use a clean cotton-tipped applicator to gently remove crust from pin site
  • ointments and solutions like hydrogen peroxide should not be used b/c they can irritate the skin and cause breakdown at the pin site
37
Q

Safety Alert: Halo Brace Pin Site Loosening

A

leads to cervical instability and infection
>manifestations = pins are loose:
-redness
-swelling
-drainage
-site pain
-areas where the skin has pulled away from the site
-pt complains of neck pain and that “the vest does not fit correctly/feel the same”
-some pts may notice ability to move their neck; notify provider immediately; place pt in a hard cervical collar; prepare for radiological imaging to assess for change in spinal alignment
>if no infection, provider may tighten pins
>if pins remain loose = halo ring may migrate = loss of immobilization
>perform a neurological exam to determine if new or worsening deficits
>halo will be reapplied using new pin sites

38
Q

Halo Brace/Traction Complications: Skin Breakdown

A

> Pressure injuries from vest portion of halo brace result from improper vest size, poor application, or insufficient padding

  • meticulous skin care
  • assessment for early signs of skin irritation
  • turn and position q 2 hours and PRN
  • vest fits properly; padded sufficiently
39
Q

Halo Brace/Traction Complications: Swallowing Difficulties

A

dysphagia may occur w/ brace

  • the head and neck are placed in an exaggerated extension position
  • notify provider if complaints of swallowing difficulty
  • adjust halo
  • speech or language pathologist can be consulted
40
Q

Spinal Cord Injury Complications

A
  • Spinal Shock
  • Neurogenic Shock
  • Autonomic Dysrelfexia
41
Q

Complications: Spinal Shock

A

-occurs immediately after injury; temporary
-temporary suppression of all reflexes below the level of cord injury
-complete but temporary loss or depression of sensory, motor, and autonomic activity below injury level
-hypotension possible
-brain is unable to transmit signals to muscles and organs = loss of sensation, movement, and other body function
-manifestation can start within 30 minutes and last days/months
-reappearance reflex activity signals the end of spinal shock (“anal wink”); contraction of anal sphincter
-Clinical Manifestations:
>flaccid paralysis of all skeletal muscles
>absence of deep tendon reflexes
>impaired proprioception (position sense)
>decreased visceral and somatic sensations
>penile reflex
>urinary and fecal retention
>anhidrosis (absence of sweating)
>paralytic ileus

42
Q

Complications: Neurogenic Shock

A
  • distributive shock
  • causes vasodilation and relative hypovolemia
  • threatens underlying acute conditions d/t hypoperfusion if not recognized and treated
  • disruption in sympathetic nervous system stimulation causes an inability of vascular smooth muscle to constrict, resulting in decreased blood return to the heart and decreased cardiac output
  • sympathetic nervous system interruption w/ unopposed parasympathetic action, may result in transient profound bradycardia

-Clinical Presentation:
>bradycardia (give atropine)
>Hypotension (fluids/vasoactive drugs)
>Change in LOC

>Metabolic acidosis
-Manifestations:
>vasodilation
>bradycardia
>body temperature instability
>hypotension
>can lead to organ dysfunction or organ death if not tx
>tx = increase fluids, vasopressors
43
Q

Complications: Autonomic Dysreflexia

A

massive imbalanced reflex sympathetic discharge occurring above T5-T6 level
-occurs up to 1 year after injury
-BP 20-40 mmHg above patients baseline
-triggered by noxious stimulus
>a strong sensory input (pain, distended bladder, rapid temperature changes, infection, or full rectum) is carried into the spinal cord via intact peripheral nerves
>input travels up the spinal cord and evokes a massive sympathetic surge from the intact thoracolumbar sympathetic nerves which = widespread vasoconstriction = peripheral arterial hypertension
>brain detects this hypertensive crisis through intact baroreceptors; uses 2 methods to stop its progression
1. Brain attempts to shut down the sympathetic surge by sending descending inhibitory impulses; these impulses are blocked in the injured spinal cord
2. Brain attempts to lower BP by slowing the HR via vagus nerve (parasympathetic); bradycardia is inadequate; hypertension continues
>once stimulus has been removed, reflex hypertension resolves
>Clinical Manifestations:
-severe headache
-hypertension
-bradycardia
-tachycardia
-flushing above the injury level
-pallor below injury level

44
Q

Nursing Care for Autonomic Dysreflexia

A

-observing for a rapid rise in BP (20 to 40 mmHg above baseline)
>observe for:
-bradycardia
-diaphoresis
-flushing of the skin above level of lesion
-chills
-pallor below level of lesion
-severe headache w/ nasal congestion, anxiety, blurred vision, chest pain, or a sense of impending doom
-if episode of autonomic dysreflexia is not treated = seizures, pulmonary edema, MI, cerebral hemorrhage, and death

45
Q

Nursing Interventions for Treatment of Autonomic Dysreflexia

A

> Monitor BP closely; q 5 minutes
-to evaluate treatments; see if source of the episode has been found + removed

> Antihypertensive meds as ordered

> HOB at 45 degrees; sit patient up
-reduces BP by allowing blood to pool in lower extremities

> Loosen restrictive clothing

  • remove braces, antiembolism stocking, shoes; look for sources of pain from these items
  • allows for pooling of blood in lower extremities to decrease BP

> Check Bladder

  • indwelling catheter- check patency + adequate drainage
  • no catheter- intermittent catheterization or place indwelling catheter per order; collect sample for UA
  • urinalysis sent to assess for a UTI or kidney infection

> Check bowel for impaction

  • assess for possible source and remove to terminate episode
  • digital rectal exam delayed until cardiovascular condition stabilized b/c this can exacerbate hypertension

> Check patients body for other sources of noxious stimuli

  • assess for possible source
  • remove to terminate autonomic dysreflexia episode
46
Q

Nursing Management: Assessment and Analysis

A
  • spinal cord trauma = motor and sensory loss below level of injury
  • manifestations vary on location and severity of cord damage
  • manifestations are caused by loss of innervation at affected spinal cord levels
47
Q

Assessment and Analysis: Cervical Cord Injuries

A

-occur in the neck
-manifestations that affect arms, legs, and middle of body
>difficulty breathing
>loss of bowel and bladder control
>numbness
>weakness or paralysis
>pain
>sensory changes
>spasticity

48
Q

Assessment and Analysis: Thoracic Cord Injuries

A 
-occur at chest level
>loss of normal bowel and bladder control (constipation, incontinence, and bladder spasm)
>numbness
>sensory changes
>spasticity (increased muscle tone)
>pain
>weakness, paralysis
49
Q

Assessment and Analysis: Lumbar, Sacral Injuries

A 
-occur at lower back level
>loss of normal bowel and bladder control
>numbness
>pain
>sensory changes
>spasticity (increased muscle tone)
>weakness and paralysis
50
Q

Nursing Diagnoses For SCI

A
  • alterations in respiratory function r/t paralyzed muscles, hypoventilation secondary to loss of diaphragm function d/t denervation of phrenic nerve
  • decreased cardiac output r/t loss of vasomotor tone secondary to spinal/neurogenic shock
  • impaired physical mobility r/t neuromuscular impairment secondary to loss of nerve cells at injured level
  • fear/anxiety secondary to loss of motor function and potential for permanent damage
51
Q

Nursing Assessments for Spinal Cord Injury

A
  • Respiratory Function
  • Vital Signs
  • Motor function/Sensory Level
  • Pain
  • Intake + Output
  • Surgical and/or Pin Sites
  • Bowel Sounds
52
Q

Assessments: Respiratory Function

A
  • loss of intercostal muscle function = decreased tidal volume and may lead to hypoventilation
  • C4 and higher injuries may result in complete loss of diaphragmatic effort
53
Q

Assessment: Vital signs

A
  • depending on level of injury, b/c loss of sympathetic input, may experience spinal shock, neurogenic shock, respiratory or cardiac arrest, or autonomic dysreflexia
  • unable to regulate temperature
  • hypothermia may result b/c of loss of control of blood vessels
54
Q

Assessments: Motor Function/Sensory Level

A
  • locate specific injury level used to choose and evaluate treatment
  • used to see if deficits increase or decrease over time
55
Q

Assessments: Pain

A

-there may be increased pain above the level of injury as a result of damage to spinal cord or nerve roots

56
Q

Assessments: Intake + Output

A
  • fluid volume status in evaluating effectiveness of therapies
  • w/ decreased renal perfusion = decreased urine output
57
Q

Assessment: Surgical and/or Pin Sites

A

sites frequently assessed for infection, bleeding, and CSF leak

58
Q

Assessments: Bowel Sounds

A

decreased perfusion to the GI tract = decreased motility and paralytic ileus

59
Q

Nursing Actions for Spinal Cord Injury (SCI)

A
  • Suction Equipment
  • Facilitate cough effectiveness
  • Maintain spinal immobilization
  • Passive ROM
  • Reposition and maintain good alignment
  • Perform Routine Pin Site Care
  • Intermittent Catheterization/ Bowel Regimen
60
Q

Nursing Actions: Maintain suction equipment at bedside

A

w/ decreased cough effectiveness, may require suctioning to clear airway

61
Q

Nursing Actions: Facilitate Cough Effectiveness

A

b/c of muscle weakness or lack of diaphragmatic innervation, assistance is needed to remove secretions

62
Q

Nursing Actions: Maintain Spinal Immobilization

A

prevents further injury from an unstable spinal column

63
Q

Nursing Actions: Passive ROM

A
  • prevents contractures and loss of muscle tone
  • strengthens unaffected muscles
  • minimizes risk of developing DVT
64
Q

Nursing Actions: Reposition and maintain good alignment

A
  • prevents pressure injuries

- decreases risk of DVT d/t immobility

65
Q

Nursing Actions: Perform routine pin site care

A
  • pin sites kept clean using a clean cotton-tipped applicator or gauze soaked w/ normal saline
  • new clean applicator/ gauze used for each pin site
  • if crusting, wrap a gauze soaked w/ normal saline around pin site for 15 minutes; after removing gauze, use a clean cotton-tipped applicator to gently remove the crust
66
Q

Nursing Actions: Intermittent Catheterization/ Bowel Regimen

A
  • patients may not have innervation to the bladder or bowel

- urinary retention and constipation not only present problems but can trigger autonomic dysreflexia

67
Q

Nursing Teachings

A
  • Clinical manifestations of Respiratory Distress; b/c pts w/ high cervical injuries are at risk of ineffective breathing and coughing
  • Clinical manifestations of Autonomic Dysreflexia; life-threatening emergency
  • Skin care/management; help identify causes of and prevent breakdown; w/ wheelchair, taught to refrain from sitting in one position too long b/c it can lead to decreased perfusion
  • Management of bowel and bladder elimination
  • Monitor for signs of infection
68
Q

Nursing Interventions for Neurogenic Shock

A

> Raise HOB slowly:

  • 10-15 degrees/ hour in a systematic manner
  • b/c of loss of systemic vasomotor tone, raising HOB may cause orthostatic hypotension b/c of an inability of the peripheral blood vessels to constrict upon change
  • orthostatic hypotension may cause hemodynamic instability (lowered BP and cardiac output)

> Assist w/ insertion of hemodynamic monitoring devices:

  • an arterial line for continuous BP monitoring
  • arterial line enables continuous monitoring of BP and the ability to set alarm parameters so that hypotension is identified
  • frequent blood sampling for ABGs and other lab tests facilitated by presence of arterial line

> Assist w/ insertion of pulmonary artery catheter in situations where cardiovascular dysfunction severe
-allows for frequent monitoring of preload (CVP and PAOP), afterload (SVR), and contractility in order to optimize medical therapies

> Administer IV fluids as ordered
-fluid resuscitation is undertaken in order to increase vascular volume, which is inadequate compared to the increase in the size of vascular space d/t vasodilation

> Administer Medications as ordered; (sympathomimetic agents (phenylephrine [NeoSynephrine], norepinephrine [Levophed])
-aids in increasing vasomotor tone, which is reflected as an increase in systemic vascular resistance

> Administer Atropine
-inhibit the action of the vagal nerve, causing the HR to increase and treat bradycardia

> Prepare for Pacing

  • a temporary pacemaker may be required to manage bradycardia in patients w/ neurogenic shock b/c of sympathetic nervous system dysfunction
  • if sympathetic nervous system dysfunction is irreversible, a permanent pacemaker may be required

> VTE prophylaxis

  • w/ neurogenic shock at high risk for VTE, especially when etiology is spinal cord injury
  • pharmacological methods or mechanical devices
69
Q

Evaluating Care Outcomes

A
  • support through acute phase of spinal cord trauma and prevent complications
  • prevent muscle wasting and contractures
  • emotional support
  • airway management
  • cardiopulmonary support
  • maximizing spinal cord perfusion and oxygen delivery
  • pain relief
  • pulmonary care (suctioning/ assisting w/ cough)
  • turning to prevent pressure injuries
  • DVT prophylaxis
  • Bowel/Bladder training
  • Management of nutrition
  • Management of limb edema
  • Management of orthostatic hypotension
  • once stable = rehabilitation phase and optimal recovery of neurological function
  • physical therapy to minimize muscle wasting and prevent contractures
70
Q

Pharmacological and Fluid Management

A

-loss of autoregulation and reduced sympathetic stimulation = cardiac dysrhythmias, hypotension, decreased blood vessel tone, and reduced cardiac output
-interruptions to the cardiac accelerator nerves from a cervical SCI = heart to beat dangerously slow or pound rapidly and irregularly; medications or pacemaker used to control irregular heart beat
-loss of vasomotor tone = blood to pool in vessels = low BP; IV fluids, vasopressors and inotropes to provide fluid resuscitation, increase tone, and increase cardiac output
>high doses of vasopressors can cause decreased perfusion in GI tract, kidneys, and extremities = decreased GI motility, impaired renal function, and ineffective peripheral perfusion; monitor

Nursing 272: Final Semester (79 decks)

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