Week 7 - Spinal Cord Injury Flashcards
1
Q
what is a spinal cord injury
A
- an injury to the vertebra that affects the spinal cord
2
Q
who do SCIs commonly affect
A
- most freq in young people between ages 15-25
- male to female ratio = 4:1
3
Q
what is tetraplegia
A
- paralysis of both arms, leg, and the trunk
4
Q
an injury to ___ causes tetraplegia
A
- above C8
5
Q
what are the most common causes of premature death in an individual w tetraplegia related to (3)
A
- compromised resp function (penumonia)
- impaired renal function (UTI)
- impaired skin integrity (ulcers)
6
Q
what are common causes of SCI (6)
A
- motor vehicle accidents
- sports injuries
- trauma
- medical conditions
- violence
- falls
7
Q
SCI occurs d/t (2)
A
- cord compression by bone displacement, tumour, or abscesses
- interruption of blood flow to the cord
8
Q
what is paraplegia
A
- paralysis of the legs
9
Q
an injury to which part of the spinal cord causes paraplefia
A
- below T1
10
Q
an injury to L1 and lower causez?
A
- paraplegia
- better trunk control
11
Q
the pathophys of SCIs is best describe as ??
A
- biphasic
= the initial mechanical injury (primary injury) is followed by a second phase (secondary injury)
12
Q
the primary injury includes
A
- initial mechanical injury w failure of the spinal column (fracture or dislocation) imparts force to the spinal cord
= disrupted axons, blood vessels, and cell membranes
13
Q
the secondary injury involves (8)
A
- ongoing, progressive damage that occurs after the initial injury
- vascular dysfunction
- edema
- ischemia
- electrolyte shifts
- inflammation
- free radical production
- apoptic cell death
14
Q
what is the goal in care for SCIs? how is this done (2)?
A
- limit further cord damage/extension of injury
1. immobilize
2. methylprednisone
15
Q
how is methylprednisone given for an acute SCI? why is it given?
A
- bolus followed by infusion
- purpose: minimizes secondary injury by reducing inflammation
16
Q
what is immobilization
A
- involves the maintenance of a neutral position
17
Q
how can pts experiencing SCI by immobilized? (4)
A
- blanket or rolled towel
- aspen collar
- backboard
- cervical traction –> halo traction
18
Q
describe how a pt with an SCI should be aligned and turned
A
- correctly aligned
- moved as a unit to prevent movement of spine
ex. log rolling
19
Q
when is cervical traction used (2)
A
- for cervical injuries
- only when the pt can communicate changes in clinical status during application and subsequent assessment
20
Q
what is the goal of cervical traction
A
- realignment or reduction of the injury
21
Q
what does halo traction involve
A
- placement of a halo ring or crown that is secured into the skull with four pins
- includes subsequent additions of weight to aid in spinal realignment
22
Q
how is traction provided w halo traction
A
- by a rope that is extended from the center of the halo crown over a pulley and has weights attached to the end
- must be maintained at all times!
23
Q
once proper alignment has occur w halo traction, what happens
A
- a halo vest is applied to provide ongoing immbolization of the cervical spine
24
Q
what is the benefit of halo vest
A
- stabilizes the injured area
- allows ambulation of the pt if they are neurologically intact
25
why is special care imp for the halo vest and halo traction (2)
- prevent skin breakdown
| - prevent infection
26
what is included in nursing care to prveet infection at the pin sites of halo traction (2)
- clean the sites twice a day w NS
| - assess for development of redness or crusting
27
what is included in nursing care to prevent skin breakdown r/t the halo vest and halo traction (5)
- use of special beds to provide kinetic therapy
- meticulous skin care
- remove from backboards asap to prevent coccygeal and occipital area skin breakdown
- properly fit and replace cervical collars
- assess areas under the halo vest, braces, and orthoses regularly
28
decsribe how the use of special beds can provide kinetic therapy
- involves continual side-to-side slow rotation, with the pt in constant motion
- turns more than 200 times per day
29
what is a con to kinetic therapy (2)
- can cause motion sickness
| - risk of pt falling out of bed
30
what should be done if crusting is present on pin sites (3)
- increase freq of cleaning pin sites to 3x/day
- wrap the pin site w NS soaked gauze for 15-20 min and then remove
- using a gentle rolling motion, the crust can then be removed w a cotton-tipped applicator that has been soaked in NS
31
describe how to provide skin care to a pt with halo vest (6)
- have pt lie down on a bed on their side
- loosen one side of vest, place towel against the sheepskin to protect it from getting wet
- assess skin for redness and signs of skin breakdown
- dry skin thoroughly, and resecure buckle straps
- do not use lotions or powders under vest
- turn pt to opposite side and repeat the steps
32
in case of emergency, what should be done r/t halo vest
- keep a wrench taped to the halo vest at all times
33
what is the difference between a complete and incomplete spinal cord lesions
- complete = no motor or sensory function below the lvl of injury
- incomplete = some motor and sensory function preserved below lvl of injury
34
manifestations of SCIs are r/t?
- lvl (where on the spinal cord?) and degree of injury (complete or incomplete?
35
what does immediate post injury care for SCIs include (5)
- maintain patency of airway
- adequate ventilation
- adequate circulating blood vol & blood pressure to minimize extension of spinal cord damage
- immobilization
- methylprednisone
36
describe resp complications r/t SCIs
- closely relate to lvl of injury
37
describe the impact of an SCI to C1-C3 (above C4) on the resp system (3)
= total loss of resp muscle function
- often fatal
- mechanical ventilation required to keep pt alive
38
describe the impact of an SCI from C4-T6 on resp function (6)
- may breathe spontaneously
- may have resp insufficiency
- may have poor cough
- take small breaths
- hypoventilation w diaphragmatic breathing
- decreased vital capacity and tidal volume
39
SCI to what part of the spinal cord impacts the pt's ability to cough? how? what does this increase the risk of
- cervical and thoracic injuries
- cause paralysis of abdominal muscles and often intercosta muscles = cannot cough effectively
= risk of atelectasis and pneumonia
40
what impact does a SCI to below T6 have on the resp system
- no resp effects
41
describe the impact of SCIs on resp function during the first 48 hrs
- spinal cord edema increases = resp distress may occur
42
describe what is included in nursing care & mngmt of resp effects of SCIs (14)
- ensure airway
- chest physio
- adequate oxygenation
- pain mngmt
- regular assessments
- assess ABGs
- DB&C
- assistive coughing
- tracheal suctioning if crackles or wheezing
- incentive spirometry
- intubation & mechanical ventilation
- assess tidal volume, vital capacity
- assess breathing patterns (esp use of accessory muscles)
- assess color and amt of sputum
43
describe assisted coughing
- stimulates action of the ineffective abdominal muscles during the expiratory phase of a cough
- nurse places heels of both hands below pts xiphoid process and exerts firm upwards pressure to the area
- should be timed w pts efforts to cough
44
what may indicate need for intubation or mechnical ventilation (3)
- if injury at or above C3
- if pt is exhuasted from labored breathing
- if ABG lvls deteriorate
45
what may indicate that a pt w an SCI requires immediate attention r/t the resp system
- if they cannot count to 10 out loud without taking a breathing
46
what are resp risks associated w SCIs(3)
- resp arrest
- pneumonia
- atelectasis
47
what type of SCI has a signif impact on the CVS
- any cord injury above lvl of T6
48
describe the impact of an SCI above T6 on CVS (5)
- decreases the influence of the SNS
| = bradycardia, hypotension (d/t peripheral vasodilation), hypovolemia, decreased CO
49
d/t its impact on CVS, a SCI to above T6 requires? (3)
- cardiac monitoring
- if bradycardia <40 beats/min, atropine used to increase HR
- may require IV fluids or vasopressor drugs to support BP
50
what is included in nursing care/mngmt of a pt with SCI r/t the CVS (6)
- anticipate shock r/t decreased CO & possible hemorrhage from other injuries
- assess VS frequently
- anticholinergic (ex. atropine) for symptomatic bradycardia
- vasopressors for hypotension (ex. dopamine, NE)
- fluid replacement
- temp pacemaker
51
what are risks associated w the CVS impact of SCIs (3)
- postural hypotension (d/t loss of sympathetic tone)
- risk of DVT (d/t lack of muscle tone to aid venous return = sluggish blood flow)
- cardiac arrest
52
what can increase the risk of cardiac arrest r/t SCIs
- any increase in vagal stimulation
| ex. turning and suctioning
53
what is included in nursing care r/t to the risk of DVTs w SCIs (4)
- DVT prophylaxis
- sequential compression devices
- admin of LMWH within 72 hrs of injury
- ROM and stretching
54
describe nursing care r/t SCD
- stockings should be remoevd q8h for skin care and assessment
55
at what point should LMWH be withheld
- morning of surgery
| - continue within 24 hr postop
56
what can cause urinary retention r/t SCIs? (3)
- SCI to T1-L2
- acute SCI --> immediately after injury
- spinal shock
57
after the acute phase, what impact do SCIs have on the bladder
- becomes hyperirritable with a loss of inhibition from the bain = reflex emptying
58
what is included in nursing care for urinary retention (6)
- encourage toilet routines
- indwelling urinary cath asap during acute phase
- once pt hemodynamically and medically stable & large quantities of IV fluids not required, intermittent cath
- fluid restriction of 1800-2000 mL/day
- monitor urine output
- bladder training program
59
what is included in nursing care r/t insertion of an indwelling cath (2)
- ensure patency thru inspection and irrigation
| - strict aspectic technique for insertion
60
describe nursing care to prevent UTIs in pts with SCI (4)
- best method = complete and regular bladder drainage
- cath to prevent bladder vol from exceeding 500 mL
- cranberry juice and cranberry extract tablets
- urine specimen is signs of UTI
61
what are risks associated w urinary retention (2)
- overdistension = reflux into kidneys = renal failure
| - rupture of bladder
62
what is neurogenic bladder? when does it occur?
- any type of bladder dysfunction r/t abnormal or absent bladder innervation
- occurs after spinal shock
- includes both urgency, frequency, inability to void, high bladder pressure
63
what are the types of neurogenic bladder (3)
- reflexic = incont, freq, urgency, unpredictable
- areflexic = bladder distension, hesitancy, overflow incont
- sensory = lack of sensation to urinate = poor bladder sensation, infreq voiding of large residual vol
64
what meds can be used to treat reflexic bladder (3)
- anticholinergics (suppress bladder contractions, for reflexic)
- alpha adrenergic blockers (decrease outflow resistance, relax urethral sphincter)
- antispasmodics (suppress pelvic floor spasticity)
65
an SCI to what lvl of the spinal cord impacts the GI system
- above T5
66
describe an SCI to above T5's impact on the GI system (3)
= hypomotility, paralytic ileus, gastric distension, constipation
67
when and why is constipation generally a problem
- during spinal shock bc no voluntary or involuntary exacuation of the bowel
68
what is included in nursing care for the risk of constipation w SCIs (8)
- NG tube for intermittent suctioning
- metoclopramide or maxoran (encourage gastric emptying)
- H2RB, PPIs in the intial phase
- suppositories
- disimpaction
- stool softeners
- bowel program
- monitor for abdominal distension, LBM
- high fibre & fluids
69
why are H2RBs and PPIs administered during the initial phase of SCIs
- the development of stress ulcers is common d/t excessive release of HCl in the stomach in response to severe trauma, stress, and high-dose corticosteroids
= prevention
70
loss of nuerological control over the bowel results in..
- neurogenic bowel
71
when does neurogenic bowel occur
- occurs in the early period after injury when spinal shock is present
- injury lvl of T12 or below
72
describe neurogenic bowel
- in the early period, bowel is areflexic & sphincter tone decreased
- as reflexes return, bowel becomes reflexic & bowel tone is enhance = reflex emptying
* includes both constipation & incont.*
73
how can neurogenic bowel be managed
- regular bowel program coordinated w gastrocolic reflex to minimize incontinence
74
what impact do SCIs have on the integ system
- lack of movement = potential for skin breadown over bony prominences, esp. in area w no or decreased sensation
- r/o pressure ulcers which can lead to major infection or sepsis
75
what impact do SCIs have on thermoregulation (3)
= poikilothermism, the adjustment of the body temp to room temp
- decreased ability to sweat or shiver below lvl of injury = impacts the ability to regulate body temp
- temp control is largely external to the pt
76
why does poikilothermism occur w SCIs
- occur d/t the interruption of the SNS = prevents peripheral temp sensations from reaching the hypothalamus
77
the degree of poikilothermism depends on? how?
- the lvl of injury
| ex. pts w cervical injuries have a greater loss of ability to regulate temp than those w thoracic or lumbar
78
what is included in nursing care r/t the temp control impact SCIs have (4)
- monitor the enviro closely to maintain an approp temp
- regularly monitor body temp
- do not overload the pt with covers or duly exposured (such as during bathing)
- if pt gets an infection & fever, may have to use cooling blankets
79
how can SCIs impact metabolic needs (2)
- NG suctioning can lead to metabolic alkalosis, impact electrolytes
- decreased tissue perfusion can lead to acidosis
80
describe the nursing care for the metabolic impacts of SCIs
- monitor electrolytes until suctioning is d/c
81
what impact do SCIs have on peripheral vascular problems
- r/o DVT & PE during first 3 months
82
what are diagnostic studies used for SCIs (5)
- xray --> assess vertebral fracture
- mri --> image neurological issues
- CT --> extent of bone injury & degree of spinal cord compromise
- comprehensive neuro exam
- assess head, chest, abdomen
83
what are the initial goals for a pt with an SCI (3)
- sustain life
- prevent further cord damage
- treat systemic and neurogenic shock to maintain BP
84
for an SCI at the cervical lvl, what is included in treatment/care?
- all body systems must be maintained until full extent of damage is evaluated
85
what interventions are included in initial management of SCIs (7)
- ensure patent airway
- stabilize cervical spine w hard collar / sand bags
- admin O2 via nasal cannula or nonrebreathing mask
- establish IV access w 2 large bore catheters to admin NS or LR
- assess for other injuries
- control external bleeding
- insert foley
86
what is included in ongoing monitoring of SCIs (7)
- VS
- LOC
- O2 sat
- cardiac rhythm
- urine output
- keep pt warm
- anticipate need for intubation if gag reflex absent or resp function declines
87
what is included in acute care for a cervical cord injury (10)
- maintenance of heart rate & BP (aropine, doapmine)
- high dose methylprednisone
- NG tube & suction
- intubation if indicated
- admin of O2
- insert indwelling cath
- placement of halo traction if necessary
- prophylaxis for DVTs
- bowel and bladder training
- pressure/relieving surface
88
to prevent further injury, how should pts w an SCI be moved and aligned
- should be correctly aligned
| - turned and moved as a unit --> thru log rolling
89
describe the diet of a pt with SCI (3)
- high protein
- high cal
- high fibre
90
what should be assessed before oral feedings are started
- swallowing
| * oral route is optimal for pts with SCI*
91
describe the impact of SCIs on nutrition (2)
- during first 48-72 hr, get paralytic ileus = NG tube
| - once bowel sounds are present or flatus has passed, oral food and fluids can be gradually introduced
92
why is a high protein & cal diet imp for a pt with SCI (3)
- have increased metabolic rate during acute phase
- imp for energy and tissue repear
- prevent skin breakdown and muscle wasting
93
what should be monitored r/t nutrition for a pt w SCI (2)
- fluid and electrolytes
| - metabolic demands to avoid overfeeding
94
what should be done to prevent sensory deprivation in a pt w an SCI
- compensate for absence of sensations by stimulating the pt above the lvl of injury
95
what are some examples of ways to avoid sensory deprivation (5)
- conversation
- music
- strong aromas
- interesting flavours
- prism glasses for reading & TV
96
describe the impact of SCIs on reflexes
- once spinal shock has resolves, reflexes are hyperactive and responses may be exaggerated
97
what are some examples of how reflexes are hyperactive (3)
- penile erections may result from a variety of stimuli
- mild twitches or convulsive movements below lvl of lesion
- neurogenic bladder & bowel
98
how can hyperactive reflexes be mnged
- antispasmodic drugs
99
what are 4 examples of antispasmodic drugs
- baclofen
- dantrolene
- tizanidine
- botulism toxin injections
100
what is included in nursing care r/t the skin for a pt with an SCI (8)
- inspection 2x/day (esp over bony prominences)
- keep clean and dry
- skin care
- turn q2h
- use of special mattresses or roho cushion
- assess nutritional status (adequate protein imp.)
- avoid friction, shear, and abrasion
- avoid thermal injury
101
describe the impact of SCIs on sexuality (3)
- dysfunction depends on lvl of injury
- may impact sensation (esp males)
- may impact fertility (males) --> may be able to retrive sperm for later or may not
102
describe the impact of SCIs on emotional and mental health
- may experience grief, loss, and depression
103
what is included in nursing care r/t the emotional and mental impacts of SCIs (5)
- goal is adjustment
- support pt & family
- identify friends and forms of support
- community resources
- help them transition thru stages of grief
104
what should you discuss w the pt & family regarding the rehab process
- expectations regarding recovery
- can be a long or short process
- can be in or out patient
105
what is the focus of the rehab process for SCIs (2)
- retrain body systems
| - long term mngmt of any permanent changes
106
what is spinal shock
- a temporary neurological condition that occurs at the time of injury
- can lasts days to months, resolves spontaneously
107
what is spinal shock characterized by (4)
- decreased reflexes
- loss of sensation
- flaccid paralysis
- NO changes to VS
*all neural activity below or at the lvl of injury ceases*
108
what is a con to spinal shock
- may mask secondary signs
109
what is neurogenic shock
- medical emergency
| - caused by loss of vasomotor tone as a result of SCI at T5 or above (slides say T5 but I think it's also for above T6)
110
when does neurogenic shock occur
- can occur up to 6 weeks post-injury
111
why does neurogenic shock occur
- d/t impairment in SNS
= peripheral vasodilation
= venous pooling
= decreased CO
112
what are signs of neurogenic shock (3)
- hypotension (massive dilation)
- bradycardia (d/t unopposed SNS)
- warm & dry extremities (venous pooling d/t decreased CO)
113
what is included in treatment of neurogenic shoick (3)
- fluid resus (hypotension)
- vasopressors (hypotension)
- atropine (bradycardia)
114
what is autonomic dysreflexia (AD)
- massive, uncompensated CVS reaction mediated by the SNS
- return of reflexes after the resolution of spinal shock
- medical emergency that required immediate resolution
115
with what lvl of injury does AD occur
- SCI at T6 or higher
116
what can cause AD
- occurs d/t an irritating simuli below the lvl of injury = exaggerated SNS response
117
what 4 main causes of AD
- bladder distension
- bowel /rectum distension
- breakdown of skin
- stimulation of pain receptors
118
the SNS in response to stimuli in AD causes (3)
- reflex vasoconstriction below the injury (the impulse cant pass thru)
- bradycardia (in response to vasoconstriction)
- vasodilation above injury (impulse from the brain blocked to stop vasoconstriction)
119
what are symptoms of AD (9)
- HTN
- throbbing headache
- diaphoresis or flushing of skin above injury
- bradycardia
- piloerection (raising of body hair)
- blurred vision or spots in visual field
- nasal congestion
- nausea
- anxiety
- , pale, cool, clammy below injury
120
what are nursing interventions for AD (5)
- raise HOB to 45 degrees or sit pt upright (cause blood to pool in lower extremities)
- notify physician
- determine and remove cause (ex. if it is pain, treat the pain)
- VS
- nifodipine (ca channel blocker for HTN)
121
if the cause of AD is bladder distension, what should be done
- immediate cath
122
what should be instilled in the urethra before cath for treatment of AD? why?
- lidocaine gel
| - prevent further stimulation
123
if the cause of AD is fecal impaction, what should be done (4)
- digital rectal exam
- disimpaction
- stool softener
- enema
124
a digital rectal exam for AD should only be done after..
- application of an anaesthetic ointment to decrease rectal stimulation and prevent increase in symptoms
125
if neither bladder or bowel is the cause of AD, what should be done
- removal of all skin stimuli
| ex. constrictive clothing, tight shoes, splints
126
if symptoms persist after the cause of AD has been removed, what should be done
- admin of alpha adrenergic blockers
| - or arterial vasodilator
127
what is an example of an arteriolar vasodilator
- nifedipine
128
if a pt with SCI is complaining of a HA, what is the priority
- check BP
129
prevention of AD is key. what measures can be taken to prevent it (5)
- bowel regime
- local anasthetics for invasive procedures (ex. manual rectal stimulation)
- close monitoring of ins and outs (for signs of urinary rention)
- maintain regular bowel and bladder function
- wear a medical bracelet indicating history of AD
130
if resolution of AD does not occur, what could happen (4)
can lead to
- status epilectusus
- stroke
- MI
- death
131
what are some meds used for SCI mngmt (3)
- methylprednisone (reduce inflam, aggressive in first 8 hrs of injury)
- dopamine (increase perfusion)
- atropine (increase perfusion)
132
what is the goal of surgery for SCI
- stabilize and realign the spinal column
133
what is an examples of surgeries done for SCIs
- laminectomy w fusion
134
what is included in nonsurgical mngmt of SCIs (5)
- alignment
- stabilization
- traction
- physio (strengthening, stretching, balance)
- mobility aids (braces, canes, wheelchairs)
135
what is a laminectomy
- removal of lamina (back part of vertebra) to increase intervertebral space = decomp. surgery
- enlarges spinal canal w intention of relieving P on spinal cord or nerves
136
what is a lami & fusion
- use of metal implants (rods, hooks, wires, plates, and screws) secured to vertebra to hold them together until new bone can grow between them
- may be there forever or revised over time
137
what impact does a lami & fusion have on the vertebra
- the vertebra wont turn the same way anymore
| ex. cervical fusion = effect mobility & ROM of neck
138
a nursing diagnosis rt SCIs is ineffective breathing pattern. what nursing interventions can be done for this (7)
- resp monitoring
- monitor for diaphragmatic muscle fatigue
- auscultate
- note changes in SaO2, ABGs
- monitor ability to cough
- identify and assess if pt needs actual or potential airway insertion
- perform endotracheal or nasotracheal suctioning
139
a nursing diagnosis r/t SCIs is impaired skin integirty. what are nursing interventions for this (7)
- monitor for sources of pressure & friction
- monitor for infection at pin sites, open tong sites
- ensure approp wound care techniques
- monitor skin for signs of breakdown
- use of an approp therapeutic mattress & deviced to relieve pressure
- turn q2h
- monitor pts nutritional status
140
a nursing diagnosis r.t SCI is constipation. what nursing interventions can be done for this (4)
- monitor BM
- monitor BS
- instruct pt on high fibre and fluid intake
- initiate bowel training program
141
a nursing diagnosis r/t SCIs is impaired urinary elimination. what nursing interventions can be done for this (5)
- monitor I&O
- monitor degree of bladder distension w palpation, percussion, bladder scanner
- insert cath
- implement intermittent cath in postacute phase
- refer to urinary continence specialist
142
a nursing diagnosis r.t SCI is risk of AD. what nursing interventions can be done for this (7)
- identify and minimize stimuli that may cause
- monitor for S&S
- investigate and remove cause
- place of HOB in upright position (to reduce BP and promote cerebral venous return)
- stay w pt and monitor q3-5 min
- admin antihypertensives IV
- educate pt & fam on causes, symptoms, treatment, prevention
