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Adult Health IISpinal Cord Injury Part 2Jerry Carley RN, MA, MSN, CNESummer, 2010Spinal Cord Injury (SCI)1Concept Map: Selected Topics in Neurological NursingPATHOPHYSIOLOGY

Traumatic Brain InjurySpinal Cord Injury

Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntingtons Disease Alzheimers Disease Huntingtons Disease Myasthenia Gravis Guillian-Barre Syndrome Meningitis Parkinsons DiseasePHARMACOLOGY

--Decrease ICP--Disease / Condition Specific MedsASSESSMENTPhysical Assessment Inspection Palpation Percussion Auscultation ICP MonitoringNeuro Checks Lab MonitoringCare PlanningPlan for client adls, Monitoring, med admin.,Patient education, Discharge Planning, morebasedOn Nursing Process: A_D_P_I_ENursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary2ObjectivesExplain pathophysiology of various SCIs and related conditions

Detail signs & symptoms and functionality of different level SCIs

Differentiate between Neurogenic Shock and Spinal Shock

Explain Autonomic Dysreflexia / Hyperreflexia and list appropriate nursing interventions

Discuss overall medical & nursing management of SCIs 3SCI PART 23SCI Goals of CareThere's no way to reverse damage

Treatment focuses on:

1. Preventing further injury

2. Enabling people to return to an active and productive life within the limits of their disability44TreatmentSpinal Immobilization / Traction

High doses of corticosteroid drug Methylprednisolone (Medrol) STAT !must be within eight hours of injury

A few days after injury medical reassessment and repeat of diagnostic tests will help determine the severity of the injury and likely extent of recovery

Surgery as indicated

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Tong Care to Prevent Infection67

Stryker Frame Traction Bed7Log Rolling Technique8

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99SCI MedsGlucocorticoids (Decadron suppress immune response)Vasopressors (treat hypotension)Plasma extenders (treat shock)Atropine (treat bradycardia)Muscle relaxantsAnti-Spasmodics (Dantrium)AnalgesicsAntidepressantsZantac, Ranitidine (prevent gastric ulcers)Stool SoftenersVasodilaters (Hydralazine, nitroglycerin to treat HTN such as AD)Anti-Seizure (gabapentin, phenytoin)

1010Neurogenic ShockOccurs in acute stage of SCI (first hour per ATI)

Usually in injuries ABOVE T6

D/T interruption of the CNS

causing disruption of sympathetic outflow from T1 to L2

with unopposed vagal tone

1111Neurogenic Shock: S & SsWarm and DRY skin does not perspire on the paralyzed parts of body d/t blocked sympathetic activity

Hypotension + Bradycardia + Hypothermia (d/t vascular dilation therefore blood pooling )

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12Spinal ShockD/t concussive effect of the primary SCI on the nervous system

Can last days or months

Interferes with definitive diagnosis of permanent deficit

Effect causes temporary (transient) depression of all reflexes =- paralysis (flaccid)- loss of sensation- loss of autonomic function- loss of B & B control (Sometimes priapism)

Spasticity or hyperreflexia signals end of this shock

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Autonomic Dysreflexia ( Hyperreflexia )SCI acute syndrome of excessive uncontrolled sympathetic output

Occurs ONLY after spinal shock has resolved

SCI above T6

Life-threatening HTN emergency1414A. D. (Hyperreflexia)Below T6 intact sensory nerves transmit noxious impulses up the spinal cord

. BUT

Sympathetic inhibitory impulses above T6 are blocked

THEREFORE

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15Sympathetic outflow continues causing release of norepinephhrine and dopamine16

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1717ResultSevere Vasoconstriction H/A + Sudden HTN 18

18Result above the SCISweating + Flushing

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19Other Distinctive S & SBradycardia

Blotching of the Skin

Restlessness

Goose bumps

Stuffy nose (nasal congestion)20

20Autonomic Dysreflexia / Autonomic HyperreflexiaClients with spinal cord injuries at Thoracic 6 10 (T6 -T10) may be susceptible

Patients with Thoracic 10 (T-10) and below are usually not susceptible

The older the injury the less likely the person will experience autonomic dysreflexia 2121Common CausesThe most common cause of noxious stimuli is distension of the hollow viscera (80%), such as the urinary bladder or bowel

1. Urinary Retention2. Constipation

Simple kinks in the tubing or plugs in the urinary catheter can trigger autonomic dysreflexia2222Credes MethodCred's method is a manual suprapubic pressure exerted with a clenched fist or fingers, used to initiate micturition, in patients with spinal cord injury (SCI) who have neurovesical dysfunction.

However, it is currently NOT recommended practice because of the risk of bladder rupture. Sources:

Hockenberry, M.J. (2003). Wongs Nursing Care of Infants and Children. (7th ed.). St. Louis: Mosby, pp. 1326-1328. Reinberg Y., Fleming T., & Gozalez, R. (1994). Renal Rupture After the Crede Maneuver. Journal 2323TreatmentAssist to sitting position to lower the BP through lower-extremity vascular pooling

Loosen restrictive garments (shirts, belts, slacks, straps and even shoes)

Monitor Vitals

Look for Cause & Eliminate!

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24TreatmentEnsure catheter patency (make sure catheter not kinked or pulled too tight, and is actually draining urine)

Catheterize to decompress bladder

Assess for signs of urinary tract infection, such as dark, cloudy urine or sediment in catheter tubing

If bowel is distended, disimpact after inserting anesthetic jelly or ointment per rectum

Hypertension should be treated medically if it persists

2525Still Cant Find Cause ? !!!Cause may not be readily found

Careful physical exam is imperative during this crisis

Other causative agents usually not considered in medical emergencies include skin irritations, wounds, pressure sores, burns, broken bones, pregnancy, ingrown toenails, appendicitis, and other medical complications

Still cannot find cause? . focus on decreasing the blood pressure!

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26Antihypertensive MedsNifedipine (Adalat) 10 mg orally - instruct the patient to bite the capsule, then swallow it

Nitroglycerin sublingual or topical paste (1/2 inch)

Prazosin (Minipress)

Clonidine (Catapres) 0.1- 0.2 mg PO

Hydralazine (Apresoline) 10 - 20 mg IM/IV

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27Client TeachingProvide education about early recognition and treatment of A.D.

Encourage the client to carry some type of medic alert identification

(It is estimated that approximately 85% of spinal cord injury patients at level T-6 will suffer at least one episode of autonomic dysreflexia)

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28Client TeachingPrevention:

Frequent pressure relief in bed/chair

Avoid sun burn/scalds (avoid overexposure, use of #15 sunscreen, watch water temperatures)

Faithful adherence to bowel program

Keep catheters clean and remain faithful to catheterization schedule

Well balanced diet and adequate fluid intake

Compliance with medications2929SCI RecoveryRecovery typically starts between a week and six months after injury, if it occurs, with the majority of recovery taking place within one year

Doctors generally regard any impairment remaining after 12 to 24 months as likely to be permanent 30

30SCI Nursing InterventionsBowel retraining programROMSexual function adaptive strategiesPTOTAssistive devicesQ2H turns skin careNutrition3131SCI Nursing InterventionsReferrals:

Social ServicesSupport GroupsAppropriate specialists3232SCI RehabilitationInitial rehabilitation emphasizes regaining leg and arm strength, redeveloping fine-motor skills and learning adaptive techniques to accomplish day-to-day tasks

Then long-term rehab typically includes exercise and training with:

Modern wheelchairs - Improved, lighter weight wheelchairs are more mobile and more comfortable. The Food and Drug Administration has even approved a wheelchair that can climb stairs and elevate a seated passenger to eye level to reach high places without help

Computer devices - Computer-driven tools and gadgets can help with daily routines. Voice-activated computer technologies to answer and dial a phone, or to use a computer and pay bills. Computer-controlled technologies can also help with bathing, dressing, grooming, cleaning and reading333334

34Complications

Urinary tract problems - urinary incontinence increases risk of urinary tract infections, kidney infection, kidney or bladder stones. d/t ongoing catheterizations

Bowel management difficulties Reduced peristalsis and fecal incontinence

Pressure sores - particularly susceptible to pressure sores because the injury reduces or eliminates sensations, making it difficult to know when a sore is developing Deep vein thrombosis and pulmonary embolism

Lung and breathing problems - Difficult to breathe and cough with weakened abdominal and chest muscles, so people with cervical and thoracic spinal cord injury may develop pneumonia, asthma or other lung problems3535ComplicationsSpasticity some people develop muscle spasms and jumping of their arms and legs because some of the nerves in the lower spinal cord become more sensitive after injury and cause muscle contractions. However, because of the spinal cord injury, the brain can no longer send signals to the lower nerves to regulate the contractions

Weight control issues - Weight loss and muscle atrophy are common. But the change in lifestyle and activities may eventually cause weight gain, which can make it difficult for the pt lift themselves or be lifted from place to place

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36ConcernsPain

- It's possible to feel pain in areas where there's little or no sensation- May also experience pain from overusing muscles in one part of the body. Many people develop shoulder tendinitis from manually operating a wheelchair for a long period of time- Any kind of pain can have a negative impact on daily living. New Injuries

- Susceptible to injury of any part of the body that has impaired sensation- May even receive a burn or cut without realizing it

3737Male ConcernsSexual Dysfunction

Still have erections, even with little sensation in the genital area

But erections may not be firm enough or last long enough for sexual activity

Fertility also can be affected:

- 99% aren't able to ejaculate during intercourse- Low sperm counts- Poor sperm motility

***** However, men can be sexually active and father a child

3838Female ConcernsSexual Dysfunction

Most have no physical change that inhibits sexual intercourse or pregnancy

But may lose ability to produce vaginal lubrication or control vaginal muscles

Many experience changes in body image that affect sexuality

Any pregnancy will likely be considered high risk

There may be amenorrhea for about 6 months after SCI

3939CopingGrieving

Healthy part of recovery. It's natural and important to grieve the loss of the way the person was before. Thennecessary to set new goals and find a way to move forward with life

*** Depression and alcohol abuse***

Taking control

Education about injury and options for reclaiming an independent life

Because the costs can be overwhelming, find out about economic assistance or support services from the state or federal government or from charitable organizations

Talking

Friends and family may respond in different ways 4040COPING.ContinuedDealing with intimacy

Self - Care

Looking ahead

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