Spinal cord injury

Question 1

What are the two categories of spinal cord injuries?

Answer 1

traumatic (result of external physical impact)
non-traumatic (result of disease, infection, or tumour)

Question 2

Initial injury

Answer 2

Spinal cord is wrapped in tough layers of dura.
Rarely torn or transected by direct trauma

Compression (bone displacement, interruption of blood supply to cord, tumor)
Penetrating trauma (gunshot wound or stab wounds)

Primary injury (Initial mechanical disruption of axons as a result of stretch or laceration)
Secondary injury (Ongoing, progressive damage that occurs after initial injury (swelling))

Resulting hypoxia reduces oxygen tension below level that meets metabolic needs of spinal cord (needs o2)
Lactate metabolites (anaerobic metabolism)
Increase vasoactive substances (from stress)
- Norepinephrine
- Serotonin
- Dopamine

By ≤24 hours, permanent damage may occur because of edema.
Edema secondary to inflammatory response is harmful because of lack of space for tissue expansion.
Results in compression of cord and extension of edema above and below injury which increases ischemic damage.

Question 3

What is apoptosis

Answer 3

happens in initial injury
death of cells, after 24 hours development of edema above and below the level of injury results due to ischemic damage and can cause permanent cord damage

may continue for weeks or months after initial injury

identified by petechial hemorrhages are in central grey matter of cord shortly after injury

Question 4

Extent of neurological damage caused by spinal cord injury results from

Answer 4

primary injury damage.
- Actual physical disruption of axons
secondary damage due to:
1 ischemia
2 hypoxia
3 microhemorrhage
4 edema

Question 5

Spinal shock

Answer 5

Temporary neurological syndrome
Characterized by:
1 decreased reflexes
2 loss of sensation
3 flaccid paralysis below level of injury
may last days - mos
may masks pts ability to return to normal functioning

Question 6

Neurogenic shock

Answer 6

Caused by SCI at T5 or above
Loss of vasomotor tone by injury
Characterized by hypotension, hypothermia and loss of sympathetic innervation (important clinical cues)
Characterized by
1. hypotension
2. hypothermia
3. loss of sympathetic innervation

causes…
1 peripheral vasodilation (edema)
2 venous pooling
3 decreased CO

Question 7

How are spinal cord injuries classified?

Answer 7

Classified by Mechanism of Injury (MOI):

Skeletal level of injury
Neurological level of injury
Completeness or degree of injury

Question 8

Major MOIs

Answer 8

flexion.
hyperextension.
flexion–rotation. (most unstable b/c ligamented structures of the spine are torn, severe neurologic deficits occur)
extension–rotation.
compression.

Question 9

Skeletal level of injury

Answer 9

Injury is at the vertebral level, where there is most damage to vertebral bones and ligaments.

Question 10

Neurological level of injury

Answer 10

Lowest segment of spinal cord with normal sensory and motor function on both sides of the body

Question 11

Level of injury may be..

Answer 11

1. cervical - paralysis of all 4 extremities (tetraplegia) occurs
2. thoracic - paraplegia
3. lumbar - paraplegia

Why not sacral - spinal cord ends b/w L1/L2

Question 12

Degree of Injury

Answer 12

Degree of spinal cord involvement may be

Complete cord involvement
- Results in total loss of sensory and motor function below level of injury (equal on both sides)

Incomplete (partial) cord involvement
- Results in mixed loss of voluntary motor activity and sensation and leaves some tracts intact
- More complicated to assess as S+S are different between L and R sides

Question 13

ASIA impairment Scale

Answer 13

American Spinal Injury Association (ASIA) impairment scale
Commonly used for classifying severity of impairment resulting from spinal cord injury
used for (recording changes in neurologic status, identifying appropriate functional goals for rehab)

Question 14

Clinical manifestations for spinal cord injury

Answer 14

Generally a direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection
Related to level and degree of injury
Clients with an incomplete lesion may demonstrate a mixture of symptoms.
The higher the injury, the more serious the sequelae.
- Proximity of cervical cord to medulla and brain stem
Movement and functional goals are related to specific location of spinal cord injury.

Question 15

What are immediate post-injury problems of a spinal cord injury include

Answer 15

1 A – airway, patency
2 B – adequate ventilation, diaphregmatic movement, degree of chest expansion, respirate, o2 level
3 C – adequate circulating blood volume, is peripheral vasodilation occuring
4 D – prevent extension of cord damage by secondary injury, decrease disability

Question 16

Respiratory system manifestations

Answer 16

Above level of C4
- Presents special problems because of total loss of respiratory muscle function = Mechanical ventilation is required to keep client alive.
Below level of C4
- Diaphragmatic breathing if phrenic nerve is functioning (resulting in hypoventilation)
- Spinal cord edema and hemorrhage can affect function of phrenic nerve and cause respiratory insufficiency.
Cervical and thoracic injuries cause paralysis of:
- abdominal muscles.
- intercostal muscles.
= client cannot cough effectively (leads to atelectasis or pneumonia)

Artificial airway provides direct access for pathogens (ie trach)
Important to reduce infections
Neurogenic pulmonary edema may occur.
Pulmonary edema (increase in pulmonary and alveolar fluid) may occur in response to fluid overload.

Question 17

Cardiovascular system manifestations

Answer 17

Any cord injury above level T6 greatly reduces the influence of the sympathetic nervous system
bradycardia occurs.
Peripheral vasodilation results in hypotension.
Relative hypovolemia exists due to increased venous capacitance.

Cardiac monitoring is necessary, IV fluids, vasopressors to support BP

Question 18

What does peripheral vasodilation cause?

Answer 18

1 decreased venous return
2 decreased cardiac output

Question 19

Urinary system manifestations

Answer 19

Urinary retention is common.
Bladder is atonic and overdistended.
In-dwelling catheter inserted (acute)
- Increased risk of infection
Bladder may become hyper-irritable (post-acute phase)
- Loss of inhibition from brain
- Results in reflex emptying
Indwelling catheter should be removed, and intermittent catheterization should begin as early as possible (once med stable) – maintains bladder decreases risk of infection

Question 20

Gastrointestinal system manifestations

Answer 20

If cord injury is above T5, primary GI problems are related to hypomotility.
Stress ulcers common
Intra-abdominal bleeding may occur.
Expanding girth may also be noted.
Less voluntary control over bowel results in a neurogenic bowel.
Injury level of T12 or below, or in spinal shock:
- Bowel is areflexic
- Decreased sphincter tone
As reflexes return,
- bowel becomes reflexic.
- sphincter tone is enhanced.
- reflex emptying occurs.

Question 21

What does decreased GI motor activity contribute to?

Answer 21

1 deceased motor activity paralytic ileus
2 gastric distension

Question 22

Intra-abdo bleeding indications

Answer 22

Difficult to diagnose
1 continued hypotension despite treatment
2 drop in hemoglobin and hematocrit

Question 23

Integumentary system manifestations

Answer 23

Consequence of lack of movement is skin breakdown.
Pressure ulcers can occur quickly.
Can lead to major infection or sepsis.

Question 24

Thermoregulation manifestations

Answer 24

Poikilothermism
Def’n: Adjustment of body temperature to room temperature
Occurs d/t SNS interruption preventing peripheral temperature sensations from reaching hypothalamus
Ability to sweat or shiver is decreased below the level of injury

Question 25

Metabolic manifestations

Answer 25

Nasogastric suctioning may lead to metabolic alkalosis. Reduced tissue perfusion may lead to acidosis. Monitor electrolyte levels until suctioning is discontinued and normal diet is resumed. Loss of body weight is common. Nutritional needs much greater than expected for immobilized person High-protein diet: 1 helps ward off skin breakdown and infection 2 reduces rate of muscle atrophy

Question 26

Peripheral Vascular manifestations

Answer 26

Deep vein thrombosis (DVT) a common problem Pulmonary embolism is a leading cause of death. DVT assessments - Doppler examination - Measurement of legs and thigh girth Patients will not be able to notice pain in the lower legs so they wont know they have a DVT

Question 27

Diagnostic studies for spinal cord injuries

Answer 27

CT scan may be used to assess stability of injury, location, and degree of bone injury. MRI is gold standard for imaging neurological tissues. Comprehensive neurological examination (CT with contrast)

Question 28

Care for spinal cord injuries

Answer 28

Immediate goals are to sustain life and prevent further cord damage. 1 A patent airway 2 B adequate ventilation 3 C adequate circulating volume Systemic and neurogenic shock must be treated to maintain BP. (MAP > 65) – fluids and vasopressives

Question 29

Care for thoracic and lumbar injuries

Answer 29

Systemic support less intense than cervicle injury Respiratory compromise not as severe Bradycardia is not a problem. Specific problems treated symptomatically

Question 30

What happens with care after stabilization has happened?

Answer 30

history is obtained - Emphasis on how injury occurred - Extent of injury as perceived by client immediately after event

Question 31

Assessment of SCIs

Answer 31

Test muscle groups with and against gravity, alone and against resistance, and on both sides of the body. Note spontaneous movement. Sensory examination Position sense and vibration Brain injury may have occurred—assess history for: 1 unconsciousness 2 Signs of concussion 3 increased ICP Musculo-skeletal injuries Trauma to internal organs

Question 32

Non-operative stabilization

Answer 32

Focused on stabilization of injured spinal segment and decompression Through traction or realignment Eliminates damaging motion at injury site Intended to prevent secondary damage

Question 33

Surgical therapy

Answer 33

Criteria for early surgery 1 cord decompression may result in decreased secondary injury 2 evidence of cord compression 3 progressive neurologic deficit 4 compound fracture 5 bony fragments 6 penetrating wounds of the spinal cord or surrounding structures

Question 34

Common surgical procedures

Answer 34

Include decompression (reducing pressure), realignment (stabilizing spinal cord and structures surrounding), and stabilization with instrumentation. If instability is considered severe enough, both anterior and posterior stabilization may be considered.

Question 35

Drug therapy

Answer 35

Methylprednisolone (MP) is a steroid - When administered early and in large doses, recovery of neurological function is greater. - May be used as a treatment option - No benefit after 8 hours post injury Vasopressor agents - Used in acute phase to maintain blood pressure - Maintain MAP Drug interactions may occur. Pharmacological agents - Used to treat specific autonomic dysfunctions

Question 36

Subjective data with assessment

Answer 36

Past health history Current medication history Symptoms - Loss of strength, movement and sensation below level of injury - Dyspnea, “air hunger” - Pain - Fear, denial, anger, depression

Question 37

Objective data with assessment

Answer 37

General: poikilothermism Integumentary: neurogenic shock Respiratory: lesions at C1-C3, C4 and C5-T6 Cardiovascular: lesions above T5 GI: decreased or absent bowel sounds Urinary: retention, flaccid bladder Reproductive: priapism, loss of sexual function Neurological: Complete, incomplete Musculo-skeletal: atony, contractures Possible findings

Question 38

Nursing dx

Answer 38

Ineffective breathing pattern Imbalanced nutrition: less than body requirements Ineffective peripheral tissue perfusion Impaired skin integrity Constipation Impaired urinary elimination Risk for autonomic dysreflexia

Question 39

Nursing planning goals

Answer 39

1 maintain optimal level of neurological function 2 minimal to no complications related to immobility 3 learn skills and gain knowledge and acquire behaviors to care for themselves 4 return home to their community

Question 40

Immobilization interventions

Answer 40

Proper immobilization involves maintenance of a neutral position. Stabilize neck to prevent lateral rotation of cervical spine. - A blanket or towel - Hard cervical collar - Backboard Body should always be correctly aligned. Turn client so that he or she is moved as a unit to prevent movement of spine (log rolling). Skeletal traction - Realignment or reduction of injury - Provided by rope over a pulley that has weights attached at end - Traction must be maintained at all times. - Stabilize head if dislodged, and then call for help. - Sites of pin insertion can become infected. - Clean twice daily. Cervical collars for postsurgical stabilization are used on the basis of surgeons’ preference (ie Aspen) – more padded With new techniques and better surgical stabilization, a collar is not required postoperatively. Halo traction is the most commonly used method of stabilizing cervical injuries. - Hanging weights may be incorporated. - May be attached to a body vest that allows ambulation. Thoracic or lumbar spine injuries - Custom thoracolumbar orthosis (TLSO brace) - Meticulous skin care is critical.

Question 41

Respiratory Dysfunction interventions

Answer 41

During first 48 hours, spinal cord edema increases level of dysfunction. Respiratory distress may occur. Injury at or above C3 - Client is exhausted. - Laboured breathing/ABGs deteriorate. - Endotracheal intubation/tracheostomy - Mechanical ventilation Respiratory arrest a possibility Other potential problems - Pneumonia and atelectasis - Nasal stuffiness and bronchospasms Aggressive chest physiotherapy Adequate oxygenation Proper pain management

Question 42

What to regularly assess with respiratory dysfunction?

Answer 42

1 breathing sounds 2 breathing patterns 3 ABGs 4 Tidal volume 5 skin colour 6 amount and colour of sputum 7 subjective comments 8 vital capacity

Question 43

Cardiovascular instability interventions

Answer 43

Heart rate is slow (<60 beats per minute) because of unopposed vagal response. Any increase in vagal stimulation can result in cardiac arrest. Vagal stimulation can happen with; 1 suctioning 2 turning Bearing down Frequently assess vital signs. Anticholinergic for bradycardia Temporary/permanent pacemaker Compression gradient stockings - Remove every 8 hours for skin care. Prophylactic low-molecular-weight heparin

Question 44

Fluid and nutritional maintenance interventions

Answer 44

During first 48–72 hours, GI tract may stop functioning. Nasogastric tube may be inserted. Fluid and electrolyte needs must be carefully monitored. Oral foods and liquids can be given once bowel sounds are present or flatus has passed. High-protein, high-calorie diet (or TPN) Evaluate swallowing in high cervical cord injuries before starting oral feedings. If client is not eating, cause should be thoroughly assessed.

Question 45

Bladder and bowel management interventions

Answer 45

Immediately after injury - Urine is retained. - Loss of autonomic and reflex control of bladder and sphincter - Bladder overdistension can result in reflux into kidney with eventual renal failure > - Intermittent catheterization program (Urinary tract infections) Constipation - Problem during spinal shock - No voluntary or involuntary evacuation of bowels occurs. - Rectal stimulant (suppository or mini-enema) inserted daily

Question 46

Temperature control interventions

Answer 46

Below level of injury - Vasoconstriction - Piloerection - Heat loss through perspiration Temperature is largely external to client. Nurse must monitor environment and body temperature.

Question 47

Stress ulcer interventions

Answer 47

Physiological response to severe trauma or physiological stress High-dose corticosteroids (w antacids and food) Peak incidence occurs 6–14 days after injury.

Question 48

Sensory deprivation interventions

Answer 48

Stimulate client above level of injury. Conversation, music, strong aromas, and interesting flavours Every effort should be made to prevent client from withdrawing.

Question 49

Reflexes intervetions

Answer 49

Return of reflexes may complicate rehabilitation. - Hyperactive - Exaggerated responses - Penile erections - Spasms Client or family may see this as return of function.

Question 50

Autonomic Dysreflexia

Answer 50

Serious complication of spinal cord injury when injury is above T 6. a massive, uncompensated CV reaction mediated by the CNS occurs in response to visceral stimulation once spinal shock is resolved with spinal cord lesions pathway involves the stimulation of sensory receptors below cord lesion, the intact ANS below level of lesion responds to the stimulation with a reflex arteriolar vasoconstriction that increases BP. Baroreceptors in carotid sinus and the aorta detect HTN and stimulate parasympathetic system. Results in decreased HR, but the visceral and peripheral vessels do not dilate because of efferent impulses can not pass through cord lesions impulses are cut off between brain and area of stimulus so body does not respond

Question 51

Signs and symptoms of autonomic dysreflexia

Answer 51

Severe hypertension (>300mgHg) Pounding headache Flushing Piloerection Diaphoresis (hairs standing on end) Dilated pupils Nasal stuffiness Bradycardia (pulse <60 bpm) – vagal nerve is trying to respond Nausea

Question 52

Why does autonomic dysreflexia

Answer 52

Most common precipitating factor is distended bladder or rectum. Can also occur with stimulation of skin or pain receptors (ie pants too tight, etc) NOTE: It is important to measure BP (looking for a source) when a client with a SCI c/o headache

Question 53

Autonomic dysreflexia interventions

Answer 53

Elevate head of bed at 45 degrees, or sit client upright. Notify physician. Assess cause. Provide immediate catheterization. Teach client and family causes and symptoms. (bladder, bowel, restricted clothing)

Question 54

Rehabilitation and home care of SCI

Answer 54

Organized around individual client’s goals and needs Client should expect: - To be involved in therapies - To learn self-care Can be very stressful Frequent encouragement

Question 55

Respiratory rehab for SCI

Answer 55

Phrenic nerve stimulators or electronic diaphragmatic pacemakers increase mobility. Teach cervical level injury clients who are not ventilator dependent. - Assisted coughing - Regular use of spirometry or deep breathing exercises

Question 56

Neurogenic bladder

Answer 56

Any type of bladder dysfunction related to abnormal or absent bladder innervation (most patients with spinal cord injury) Common problems - Urgency, frequency, incontinence, inability to - void, and high bladder pressures resulting in reflux of urine into kidneys

Question 57

Neurogenic bowel

Answer 57

Voluntary control may be lost. High-fibre diet and adequate fluid intake Suppositories, small-volume enemas, or digital stimulation by client or nurse Carefully record bowel movements.

Question 58

Neurogenic skin

Answer 58

Prevention of pressure ulcers and other types of injury to insensitive skin is essential. Teach these skills and provide information about daily skin care. Careful positioning and repositioning should be done every 2 hours with gradual increase in time Pressure-relieving cushions must be used in wheelchairs. Protect skin by avoiding thermal injury. Teach family members skin care as well.

Question 59

Sexuality

Answer 59

Important issue regardless of client’s age or gender Nurse must - have an awareness and an acceptance of personal sexuality. - have knowledge of human sexual responses. - use medical terminology.

Question 60

Grief and depression

Answer 60

May feel an overwhelming sense of loss May believe they are useless and burdens to their families Response and recovery differ from those experiencing loss from amputation or terminal illness.