Week 7: Spinal Cord Trauma Flashcards
How to know if pt is coroners case
- less than 24 hours
- pt who just came out of surgery
Ideal time frame for doing post mortem care
-1 hour
Spinal cord begins and ends?
Spinal cord begins at the foramen magnum in the cranium and ends at the L1-L2 vertebra level
Spinal nerves continue until?
continue to the last sacral vertebra
Grey matter
voluntary and autonomic motor neurons
white matter
ascending and descending motor fibers
Posterios column dorsal
touch, proprioception and vibration sense
lateral spinothalamic tract
pain, temp sensation
lateral pyramidal
voluntary movement
- originate in cerebral cortex
- project downward
- result in skeletal muscle movement
- injury: spastic paralysis
upper motor neurons
- originates at each vertebral level
- project to specific parts of the body
- results in movement/sensation
- injury=flaccid paralysis
lower motor neurons
-skin innervated by sensory spinal nerves
Dermatones
Reflex arc
involuntary response to a stimulus without direct input from the brain
myotome
muscle group innervated by motor neurons
sympathetic response
- fight or flight
- everything centralized into core system of the body
- tachycardia
- dilated bronchi and pupils
- middle portion of spinal column
parasympathetic
- constriction of the pupils
- constriction of lungs
- hr slows down
- both at the top and bottom (brainstem and s2-4)
etioloy of traumatic SCI
- MVA (motor vehicle accident)most common cause
- falls, violence, sport injury
- SCI typically occurs from indirect injury from vertebral bones compressing cord
- SCI frequently occur with head injuries
- Cord injury may be caused by direct trauma from knives, bullets, etc
primary & secondary spinal cord injury
- right when the injury happens, immediate injury to spinal cord
- secondary is physiological response to the trauma: ischemia, hypoxia, hemorrhaging, edema
- due to loss of vasomotor tone
- SNS loss results in arasympathetic dominance with vasomotor failure
- loss of SNS innervation causes peripheral pooling and decreased cardiac output
- hypotention and bradycardia
- orthostatic hypotension and poor temperature control (poikilothermic)
neurogenic shock
- decreased reflexes and loss of sensation below the level of injury
- motor loss: flaccid paralysis below level injury
- sensory loss: touch, pressure, temperature pain, and proprioception perception below injury
- lasts days to months
spinal shock
how do you know spinal shock resolving
Clonus: one of the first signs
- hyperflexia of foot
- test by flexing leg at knee and quickly dorsiflex the foot
- rhythmic oscillations of foot agains hand
classification of SCI
mechanism of injury
skeletal neurologic level
completeness (degree) of injury
Mechanism of injury: felxion, hyperextension, compression, felxion/rotation
flexion (hyperflexion)
- most common because of natural protection position
- generally cause neck to be unstable because of stretching of the ligaments
hyperextention
caused by chin hitting a surface area, such as dashboard or bathtub
-usually causes central cord syndrome symptoms
compression
- caused by force from above, as hit on head
- or from below as landing on butt
- usually affects the lumbar region
flexion/rotation
- most unstable
- results in tearing of ligamentous structures that normally stabilize the spine
- usually results in serious neurologic deficits
skeletal level vs neurologic level
skeletal level: vertebral level where the most damage to the bones
neurologic level: the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body
after spinal shock:
- motor deficits:spastic paralysis below level of injury
- sensory: loss of all sensation perception
- autonomic deficits: vasomotor failure and spastic bladder
complete (transection) degree of SCI injury
- injury to the center of the cordd by edema and hemorrhage
- motor weakness and sensory loss in all extremities
- upper extremities affected more
incomplete degree of SCI, central cord syndrome
- hemisection of cord
- ipsilateral paralysis
- ipsilateral superficial sensation, vibration and proprioception loss
- contralateral loss of pain and temp perception
incomplete classification of SCI, brown-sequard syndrome
- injury to anterior cord
- loss of voluntary motor, pain, and temp perception below injury
- retains posterior column funtion (sensations of touch, position, vibration)
incomplete classification of SCI, anterior cord syndrome
- least frequent syndrome
- injury to the posterior (dorsal) columns
- loss of proprioception
- pain, temp, sensation, and motor function below the level of the lesion remain intact
incomplete SCI, posterior cord syndrome
- clonus medullaris: injury to the sacral cord (conus) and lumbar nerve roots
- cauda equina: injury to the lumbosacral nerve roots
- result: are flexic (flaccid) bladder and bowel, flaccid lower limbs
incomplete SCIs
upper motor deficits result in?
spastic paralysis
lower motor deficits result in?
flaccid paralysis and muscle atrophy
paresis
weakness
plegia
paralysis
c1-c3 are?
usually fatal
- ventilator dependent
- no bowel/bladder control
- electric wheelchair with chin/mouth
loss of phrenic innervation causes?
dependent on ventilator
C6 injury
weak grasp
- has shoulder/biceps to transfer/push wheelchair
- considered level of independence
T1-6
- full use of upper extremity
- transfer
- drive car with hand controls and do ADL’s
- no bowel/bladder control
immediate care of spinal injury at scene
-transport with c-collar
-assess abc’s
iv for life line
ng to suction
foley
solumedrol
- pt started within 4, treated for 24 hours of solumedrol
- within 8 hours, treated for 48 hours
- to decrease edema around spinal cord
medications for SCI
- vasopressors to maintain perfusion
- histamine H2 blockers to prevent stress ulcers
- anticoagulants
- stool softeners
- antispasmodics
gardner-wells tongs
on weights, versus halo which is put onto the patient with a brace
physical exam of spinal injury pt.
- LOC and pupils, may have indirect SCI from head injury
- respiratory status-phrenic nerve (diaphragm) and intercostals, lung sounds
- vital signs
- motor
- sensory
- bowel and bladder function
c6, t4, t10
c6: thumb
t4: nipple
t10: naval
Nursing problems/interventions
- impaired mobility
- impaired gas exchange
- impaired skin integrity
- constipation
- impaired urinary elimination
- risk for autonomic dysreflexia
- ineffective coping
ROM is done?
every 2 hours
how to deal with constipation in SCI
- bowels rely on more bulk than nerve
- stimulate bowels at the same time each day. Best after a meal when normal peristalsis occurs
- individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation
- assess bowel sounds prior to giving food for the first time-paralytic ileus!
goal for residual in bladder scan?
residual <100ml/20% of the bladder capacity
urecholine
stimulates bladder contraction
risk for autonomic dysreflexia description
- SCI above T6
- Results in loss of normal compensatory mechanisms when sympathetic nervous system is stimulated
- Life threatening-if goes unchecked BP an result in cerebral hemorrhage
- Vasodilation symptoms above SCI
- Vasoconstriction symptoms below SCI
- the cause of SNS stimulation
What one lab would you check with regards to skin integrity
-pre-albumin
autonomic dysreflexia nursing interventions
- elevate HOB-causes orthostatic hypotention
- indentify cause/alleviate if full bladder/cath, if skin/ remove pressure, if full bowel/ empty, etc
- remove support hose/abdominal binder
- monitor BP- can get >300 S
- Give PRN medication to lower BP
- If above not effective-call physician
What is the max amount of urine you can safely empty out the bladder at one time?
800mL
ineffective coping/sexuality nursing interventions
- assess readiness/knowledge/their ability
- use proper terminology
- suggestions: empty bladder before sex, withhold fluids and antispasmodics, certain positions may increase spasms, explore new erogenous zones, penile implants
- refer to specially trained counselor
