Spinal Cord Injuries Flashcards
(48 cards)
1
Q
Spinal Cord Injury (SCI)
A
- A major health problem
- 276,000 persons in the U.S. live with disability from SCI
- 17,000 new cases per year
- Trauma is leading cause which include MVAs (35%), violence (24%), falls (22%), and sports injuries (8%)
- Males account for 80%
- Ages 16 to 30 account for more than half of all new SCIs
- Risk factors include alcohol and drug use
2
Q
Primary
A
- The result of concussion, contusion, laceration or compression of spinal cord
- Primary injury is the result of the initial trauma and usually permanent
- Treatment is needed to prevent partial injury from developing into more extensive, permanent damage
3
Q
Secondary
A
- Secondary injury is usually the result of hemorrhage, ischemia, hypovolemia, hypoxia, local edema and which destroys the nerve tissues
- Secondary injuries are thought to be reversible/ preventable during the first 4 to 6 hours after injury
- Treatment is needed to prevent partial injury from developing into more extensive, permanent damage
4
Q
Complete vs Incomplete Injury Spinal Cord Injuries
A
5
Q
Effect of spinal cord injuries:
Central Cord Syndrome
A
6
Q
Effect of spinal cord injuries:
Anterior Cord Syndrome
A
7
Q
Effect of spinal cord injuries:
Lateral Cord Syndrome
(Brown-Sequard Syndrome)
A
8
Q
Types of Spinal Cord Injuries
A
Tetraplegia/ Quadriplegia
- neck down
Paraplegia
- cant walk
9
Q
Mechanism of Injury
A
- Hyperflexion
- Hyperextension
- Axial loading or vertical compression (caused by jumping, for example)
- Excessive head rotation beyond its range
- Penetration (caused by bullet or knife, for example)
10
Q
Hyperflexion
A
11
Q
Hyperextension
A
12
Q
axial loading (vertical compression)
A
13
Q
A
14
Q
Emergency Management Assessment
A
- First priority: assessment of patient’s ABC status
- Assessment for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around fracture sites
- Assessment of level of consciousness using Glasgow Coma Scale
- Establishment of level of injury: tetraplegia, quadriplegia, quadriparesis, paraplegia, and paraparesis
- Assess for Spinal Shock
- Assess for Neurogenic Shock
— Assessment of Sensory and Motor Ability (ASIA Scale) Figure 68-5
— Hypoesthesia
— Hyperesthesia
— Monitor for bladder retention or distention, gastric dilation, and ileus
— Temperature; potential hyperthermia
15
Q
A
16
Q
Emergency Management
A
- Proper handing of patient
- Consider head/neck trauma
- Rapid assessment Immobilization
- Extrication Control of life-threatening injuries
- Transport to the appropriate facility
- Pharmacologic Therapy IV Corticosteroids (methylprednisolone sodium succinate [Solu-Medrol]) (Controversial)
- Respiratory Therapy
- Fractures
- Surgical Management
- The patient’s vital organ functions and body defenses must be supported and maintained until spinal and neurogenic shock abates and the neurologic system have recovered from the traumatic insult; this can take up to 4 months.
17
Q
Respiratory Management
A
- Monitor carefully to detect potential respiratory failure
- Pulse oximetry and ABGs
- Lung sounds
- Early and vigorous pulmonary care to prevent and remove secretions
- Suctioning with caution
- Breathing exercises
- Assisted coughing
- Humidification and hydration
18
Q
Ineffective Airway Clearance and Breathing Pattern
A
- Airway management is the priority.
- Patients with injuries at or above the 6th thoracic vertebra are especially at risk for respiratory complications.
- Provide measures to maintain airway.
— Assisted coughing, quad cough, cough assist
— Use of incentive Spirometer - https://www.youtube.com/watch?v=cmzZkdACei4
19
Q
Cardiovascular Assessment
A
- Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous system especially if the injury is above the 6th thoracic vertebra.
- Cardiac dysrhythmias may result.
- Systolic BP below 90 requires treatment because lack of perfusion to the spinal cord could worsen the patient’s condition.
- Hypothermia.
- Assess for Venous Thromboembolism
- Never massage an immobile patient due to danger of dislodging a clot
20
Q
Lab and Imaging Assessment
A
- ABG’s
- CBC
- Hemoglobin
- CT Scan
- MRI
21
Q
Sensory and Motor Assessment
A
- Motor ability is tested by asking the patient to spread the fingers, squeeze the examiner’s hand, and move the toes or turn the feet.
- -Sensation is evaluated by gently pinching the skin or touching it lightly with an object such as a tongue blade, starting at shoulder level and working down both sides of the extremities. The patient should have both eyes closed so that the examination reveals true findings, not what the patient hopes to feel. The patient is asked where the sensation is felt.
- Any decrease in neurologic function is reported immediately.
22
Q
Planning and Goals
A
- Breathing
- Mobility
- Injury
- Skin
- GU
- GI
- Comfort
- Recognizing Emergency situations
23
Q
Impaired Urinary Elimination; Constipation
A
Interventions include:
- A bladder retraining program
- Spastic bladder—manipulating external area
- Flaccid bladder—Valsalva maneuver
- Encouraging consumption of 2000 to 2500 mL of fluid daily to prevent urinary tract infection Long-term renal complication
- Signs and symptoms of urinary tract infection not perceived by the patient
24
Q
Gastrointestinal and Genitourinary Assessment
A
- Assess abdomen for indications of internal bleeding, distention, or paralytic ileus.
- Assess for paralytic ileus.
- Assess for areflexic bladder, which later leads to urinary retention.
- Assess for neurogenic bladder
- Dietician Consult
- Swallow evaluation
25
Impaired Physical Mobility; Self-Care Deficit
Interventions include:
- In patients with spinal cord injury, monitor for risk of pressure ulcers, contractures, and deep vein thrombosis or pulmonary emboli.
- Proper positioning, skin inspection, ROM exercises, heparin, and graduated compression stockings.
- Prevent orthostatic hypotension.
- Promote self-care.
26
Management of SCI
- Nonsurgical management
— Immobilization
— Ensure Proper Body Alignment
- Drug therapy
- Surgical management
- Community resources
27
Review Chart 68-8 The Patient With A Halo Vest
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Surgical Management
Surgery is indicated in any of the following situations:
- Compression of the cord is evident.
- Injury results in a fragmented or unstable vertebral body.
- The injury involves a wound that penetrates the cord.
- Bony fragments are in the spinal canal.
- The patient’s neurologic status is deteriorating.
- The patient’s vital organ functions and body defenses must be supported and maintained until spinal and neurogenic shock abates and the neurologic system have recovered from the traumatic insult; this can take up to 4 months.
29
Immobilization for Cervical Injuries
- Fixed skeletal traction to realign the vertebrae, facilitate bone healing, and prevent further injury
- Stryker frame, rotational bed, kinetic treatment table
30
*Spinal Shock
Spinal shock – occurs immediately after injury
- A sudden depression of reflex activity below the level of spinal injury
- Flaccid paralysis of skeletal muscles, complete loss of sensation, Pulse, BP suppression of somatic (pain, touch, temp,) and visceral reflexes
- Bowel and bladder function affected.
- *Need to maintain MAP at 85 or higher
- cause by the swelling of the spine
- shock of spinal cord itself
31
* Neurogenic shock
- Due to the loss of function of the autonomic nervous system below the lesion.
- Vital organs affected causing a decrease in Blood pressure, heart rate and cardiac output
- Venous pooling occurs due to peripheral vasodilation
- Paralyzed portions of the body do not perspire
- shock of nervous system
- distributive
32
33
Spinal shock s/s
Definition:
- Immediate temporary loss of total power, sensation, and reflexes below the level of injury
- BP: hypotension
- Pulse: bradycardia
- Bulbocaverosus reflex: absent
- Motor: flaccid paralysis
- Time: 48–72 hours immediate after SCI
- Mechanism: peripheral neurons become temporarily unresponsive
34
*Neurogenic shock
Definition:
- sudden loss of sympathetic nervous system signals
BP: hypertension
Pulse: bradycardia
Bulbocarvernosus reflex: variable
Motor: variable
Time: 48 - 72 hours immediate after SCI
Mechanism: disruption of autonomic pathways
35
Treatment for Shock
- Maintain adequate hydration via IV and oral if possible
- Vasopressors, supportive care.
- Observe for manifestations of neurogenic shock
- *May occur within 24 hours after injury most commonly in patients with injuries above T6.
- Monitor hourly V/S including pulse ox and symptoms of aspiration, decreased LOC, decreased urine output
- Notify MD immediately as this is an emergency.
— neurogenic shock
36
Drug Therapy
- Dextran – plasma expander
- Anticholinergic - Atropine sulfate
- Vasopressors
- Adrenergic Drugs - Epinephrine and nor epinephrine
- Muscle Relaxants
37
Autonomic Dysreflexia
- Acute emergency
- Occurs after spinal shock has resolved and may occur years after the injury
- Occurs in persons with a SC lesion above T6
- Autonomic nervous system responses are exaggerated
- Triggering stimuli include distended bladder (most common cause), distention or contraction of visceral organs (such as constipation), or stimulation of the skin
— too tight of a shirt/ belt, socks/ shoes
— laying on a syringe
— full bladder/ bowel
— blankets on top that are too heavy
- teach them s/s to look out for
38
Autonomic Dysreflexia
Spinal cord injury at T-6 or higher:
- Triggered by sustained stimuli at T-6 or below from:
— restrictive clothing
— pressure areas
— full bladder, or UTI
— fecal impaction
S/S:
- Increased BP (severe and rapid)
- Flushed face
- Headache
- Distended neck veins
- Decreased HR
- Sweating
- Vasodilation above injury
- Vasoconstriction below injury
— pale, cool, no sweating
39
Autonomic Dysreflexia 2
- Sudden, significant rise in systolic and diastolic blood pressure, accompanied by bradycardia
- Profuse sweating above the level of lesion—especially in the face, neck, and shoulders; rarely occurs below the level of the lesion because of sympathetic cholinergic activity
- Goose bumps above or possibly below the level of the lesion
- Flushing of the skin above the level of the lesion—especially in the face, neck, and shoulders
- Blurred vision
40
Autonomic Dysreflexia
- Place patient in seated position to lower BP
- Notify MD
- Assess for and treat cause
- Empty the bladder using a urinary catheter and irrigate/change indwelling catheter
- Examine rectum for fecal mass
- Examine skin
- Examine for any other stimulus
- Monitor BP every 10-15 mins
- Give Nifedipine or nitrate
- May give alpha blocker prophylactically
- Label chart or medical record that patient is at risk for autonomic dysreflexia
- Instruct patient in prevention and management
41
An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first?
a. Assess level of consciousness.
b. Obtain vital signs.
c. Administer oxygen therapy.
d. Evaluate respiratory status.
D
42
Priority Problems for Long-Term Management DX
- Difficulty breathing
- Impaired physical mobility (safety)
- Spastic or flaccid bladder and bowel
- Skin Integrity
- Impaired adjustment
43
A client was admitted this morning with an incomplete cervical spinal cord injury and is placed in a halo fixator. Halo fixation is used to reduce motion of the cervical spine. Which assessment finding will the nurse report immediately to the health care provider?
A A new-onset heart rate of 48 beats/min
B Mean arterial pressure of 90 mm Hg
C Pain level of 2 on a 0-to-10 pain scale
D Oxygen saturation of 95% on room air
A
44
A nurse assesses a client with a spinal cord injury at level T5. The client’s blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first?
a. Initiate oxygen via a nasal cannula.
b. Place the client in a supine position.
c. Palpate the bladder for distention.
d. Administer a prescribed beta blocker.
C
45
A nurse cares for a client with a lower motor neuron injury who is experiencing a flaccid bowel elimination pattern. Which actions should the nurse take to assist in relieving this client’s constipation? (Select all that apply.)
a. Pour warm water over the perineum.
b. Provide a diet high in fluids and fiber.
c. Administer daily tap water enemas.
d. Implement a consistent daily time for elimination.
e .Massage the abdomen from left to right.
f. Perform manual dis-impaction.
B,D,F
46
Adjusting to Life Change, Promoting Resilience
- Help patient set realistic goals
- Help patient verbalize feelings
- Help patient understand diagnosis and potential for recovery
- Collaborate with heath care team including discharge planner, social worker home care nurse.
- Help family find community resources.
- Help patients understand their sexuality
47
After teaching a male client with a spinal cord injury at the T4 level, the nurse assesses the client’s understanding. Which client statements indicate a correct understanding of the teaching related to sexual effects of this injury? (Select all that apply.)
a. “I will explore other ways besides intercourse to please my partner.”
b. “I will not be able to have an erection because of my injury.”
c. “Ejaculation may not be as predictable as before.”
d. “I may urinate with ejaculation but this will not cause infection.”
e. “I should be able to have an erection with stimulation.”
C,D,E
48
A nurse assesses a client who recently experienced a traumatic spinal cord injury. Which assessment data should the nurse obtain to assess the client’s coping strategies? (Select all that apply.)
a. Spiritual beliefs
b. Level of pain
c. Family support
d. Level of independence
e. Annual income
f. Previous coping strategies
A, C, D, F
