Spinal Cord Injuries

The nurse is caring for a 72 year old male patient on a medical-surgical floor. The nurse responds to a call light to find the patient laying on the floor. The patient sates, "I pushed the light, but I had to pee so bad I started to get up." After calling for help, what is the next priority?

Ask the patient if he has any pain.

What type of IV should the nurse anticipate?

Establish IV access with 2 large-bore catheters to infuse normal saline or lactated Ringer's solution.

What is affected a L1-2 SCI?

• Varying control of legs and pelvis • Instability of lower back

What are acute complications of the respiratory due to SCI?

•Altered respiratory muscle innervation •Decreased ability to cough and clear secretions

What are complications of neurogenic bladder and bowel from a SCI?

•Bladder sphincter muscle may be overactive •Bladder muscle may be flaccid or spastic •Urinary retention, pain, and/or incontinence • •Decreased peristalsis, higher incidence of stress ulcers •Dysphagia with high cervical lesions •Rectal sphincter may be overactive •Constipation, pain, chronic colonic distention

What are complications from autonomic dysreflexia?

•Can occur in patients with lesion T6 or above •Painful stimulus below lesion causes SNS activation, but only below the lesion (Kidneys.) Results in hypertension •Baroreceptors sense hypertension, activate PNS to counteract, but only above the lesion (Heart.) Results in bradycardia.

What is a spinal cord injury?

•Damage to the spinal cord •Traumatic or otherwise, trauma more common •Temporary or permanent alteration in function •Males 16-30 at highest risk

What are complication with prolonged immobility?

•Skin breakdown •Contractures •Risk for DVTs •Nutrition and hydration status •Significant psychosocial needs for patient and family

What are some interventions of autonomic dysreflexia?

•Treat noxious stimulus •Bowel or bladder •Pressure ulcers •Any painful stimulus •Possible atropine for bradycardia

Where is there a disruption of the SNS in a SPI?

•With lesion at T6 or above, SNS messages cannot get to lower body •Unopposed PNS stimulation can cause massive vasodilation and bradycardia (Neurogenic Shock) •Difficulty regulating temperature (Poikilothermia)

What type of imaging is appropriate for a patient with SPI

•X-ray or plain films •Computerized Tomography •Magnetic Resonance Imaging

What is anterior cord syndrome?

•anterior spinal artery disruption •Loss of pain and temperature below level of injury, paralysis below injury. Tactile sensation, proprioception, vibration remain intact

What is a central cord syndrome?

•most common partial •Neuro deficits affect upper extremities more than lower as the axons for those limbs in middle of cord. Possible loss of pain and temperature below injury.

What is Brown-Sequard syndrome?

•right or left side hemisection of cord •Ipsilateral loss motor, tactile, vibration, proprioception •Contralateral loss pain and temperature

What is a flexion injury to the SC

Flexion injury of the cervical spine ruptures the posterior ligaments

A patient with spinal cord injury has severe neurologic deficits. What is the most likely mechanism of injury for this patient?

Flexion-rotation

What is a flexion-rotation injury?

Flexion-rotation injury of the cervical spine often results in tearing of ligamentous structures that normally stabilize the spine (displacement of the vertebrae) Flexion-rotation injury is the most unstable because ligaments that stabilize the spine are torn. This injury most often contributes to severe neurologic deficits.

Assessments and interventions after a SCI

Goals immediately after injury include maintaining a patent airway, adequate ventilation/ breathing, and adequate circulating blood volume (ABCs) and preventing extension of spinal cord damage (secondary injury).

What is a hyperextension injury to the SC?

Hyperextension injury of the cervical spine ruptures the anterior ligaments.

A patient with a T4 spinal cord injury has neurogenic shock due to sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition?

Hypotension

What are systemic and neurogenic shock treated with?

IV fluids and vasopressors to maintain systolic BP (SBP) greater than 90 mm Hg.

What is affected with C1-C3 SCI?

Often fatal • Movement in neck and above, loss of innervation to diaphragm, absence of independent respiratory function

What long term care may be required for SPI?

Potential for tracheostomy and PEG tube placement PT/OT/SLP Dietary - patients with spinal cord injuries need nutritional support to maintain skin, muscle mass, and to support metabolic needs during healing. May be able to regain some functions

What is the primary injury of SCI?

Primary injury results from direct physical trauma to the spinal cord due to blunt or penetrating trauma. •Initial swelling and inflammation of chord inside spinal canal •Areas of necrosis

The nurse is caring for a 72 year old patient who is scheduled for a surgical stabilization of his C5 fracture. The patient's wife asks, "When the surgery is over, will he be able to walk again?"What is the best response?

We won't know how bad his spinal cord injury is for a few weeks, but he will need significant rehabilitation

What is a incomplete cord involvement?

a mixed loss of voluntary motor activity and sensation and leaves some tracts intact.

What are tracts of the of the spinal cord?

ascending and descending tracts

The most common early symptom of a spinal cord tumor is

back pain that worsens with activity.

What do descending tracts do?

carry motor commands to spinal cord

What do ascending tracts do?

carry sensory information to the brain

What are the five major syndromes associated with incomplete injuries?

central cord syndrome, anterior cord syndrome, Brown-Séquard syndrome, cauda equina syndrome, and conus medullaris syndrome

What are the symptoms of a secondary injury?

edema, ischemia, and inflammation. This can cause edema, ischemia, and inflammation.

During assessment of the patient with trigeminal neuralgia, the nurse should (select all that apply)

inspect all aspects of the mouth and teeth.

A patient undergoing rehabilitation for a C7 spinal cord injury tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to

measure the patient's blood pressure.

How is neurogenic shock different than spinal shock?

neurogenic (vasogenic) shock can occur in cervical or high thoracic injury (T6 or higher). It occurs from unopposed parasympathetic response due to loss of sympathetic nervous system (SNS) innervation.

During routine assessment of a patient with Guillain-Barré syndrome, the nurse finds the patient is short of breath. The patient's respiratory distress is caused by

paralysis ascending to the nerves that stimulate the thoracic area.

What is paraplegia?

paralysis of both lower limbs

What does a T6 injury result in?

paraplegia, paralysis below the chest

what does a L1 injury result in?

paraplegia, results in paralysis below the waist

What does a C6 SCI result in?

partial paralysis of hands and arms as well as lower body

What does a C4 SCI result in?

tetraplegia, complete paralysis below neck

What does the degree of sensory and motor loss depend on?

the level of injury and reflects specific damaged nerve tracts.

What is a complete cord involvement?

total loss of sensory and motor function below the level of injury.

What type of pain is involved in a SPI?

visceral or neuropathic

What will a person that recovers from a C1-C3 SCI expect?

• Able to drive electric wheelchair equipped with portable ventilator by using chin control or mouth stick, headrest to stabilize head • Computer use with mouth stick, head wand, or noise control • Attendant care 24 hr/day, able to instruct others

What to expect after a C5 SCI?

• Able to drive electric wheelchair with mobile hand supports • Indoor mobility in manual wheelchair • Able to feed self with setup and adaptive equipment • Attendant care 10 hr/day

What is affected with a C7-8 SCI?

• Able to transfer self to wheelchair • Roll over and sit up in bed • Push self on most surfaces • Perform most self-care • Independent use of wheelchair • Able to drive car with powered hand controls (in some patients) • Attendant care 0-6 hr/day

What other interventions should the nurse anticipate?

• Assess for other injuries. • Control external bleeding. • Obtain appropriate imaging

What to expect after a L3-4 SCI?

• Completely independent ambulation with short leg braces and canes • Unable to stand for long periods

What are initial interventions that a nurse would anticipate?

• Ensure patent airway and adequate breathing. • Maintain SaO2 >90%: • Apply O2 via nasal cannula, nonrebreather mask, or endotracheal tube.

What to expect after a T1-6 SCI.

• Full independence in self-care and in wheelchair • Able to drive car with hand controls (in most patients) • Independent standing in standing frame

What is affected with a T1-6 SCI?

• Full innervation of upper extremities • Back, essential intrinsic muscles of hand • Full strength and dexterity of grasp • ↓ Trunk stability, decreased respiratory reserve

What is affected with a C5 injury?

• Full neck, partial shoulder, back, biceps • Gross elbow, inability to roll over or use hands • ↓ Respiratory reserve

What to expect from a L1-2 SCI?

• Good sitting balance • Full use of wheelchair • Ambulation with long leg braces

What position should the patient remain in?

• Immobilize and stabilize cervical spine.

What should the ongoing monitoring of the patient be?

• Monitor vital signs, level of consciousness, motor and sensory function, O2 saturation, cardiac rhythm, urine output. • Anticipate need for intubation if in respiratory distress or gag reflex absent. • Maintain normal temperature.

What is affected with a L3-4 SCI?

• Quadriceps and hip flexors • Absence of hamstring function, flail ankles

What can a patient expect after a C4 SCI?

• Same as C1-3

What is affected with a C4 SCI?

• Sensation and movement in neck and above • May be able to breathe without ventilator

How do you assess the level of injury to the neurologic on a SCI?

Neurologic level is the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body.

What are compression fractures to the SC?

Compression fractures crush the vertebrae and force bony fragments into the spinal canal.

A nurse is caring for a patient newly diagnosed with chronic inflammatory demyelinating polyneuropathy (CIDP). Which statement can the nurse accurately use to teach the patient about CIDP?

"Maintenance therapy will be needed to prevent relapse."

What is tetraplegia?

"quadriplegia" Paralysis of all 4 extremities

What types of cervical lesions?

C1-C3= total loss of respiratory muscle control C3-C5 = loss of diaphragm control, poor ventilation Emergent Intubation is required

If a patient's airway is not patent, what should be done?

Intubation to secure the airway is done as soon as possible for patients with respiratory distress.

What motor and sensory functions are impaired with a SCI?

It depends on the severity of the injury and neurologic status.

During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery?

L1-2

What should a patient's BP be maintained at?

Maintain SBP >90 mm Hg.

The nurse is caring for a 72 year old male patient on a medical-surgical floor. The nurse responds to the call light to find the patient laying on the floor. The patient does not respond to voice, and the nurse notices shallow respirations. After calling out for help, what should be the nurse's next step?

Push the code blue

What are some assessment findings of blunt trauma to the spine?

Respiratory distress/difficulty breathing • Neurogenic shock: hypotension, bradycardia, cool or warm dry skin • Spinal shock • Muscle weakness, paralysis, or flaccidity • Changes in sensation: temperature, light touch, deep pressure, proprioception • Numbness, paresthesia • Pain, tenderness, deformities, or muscle spasms adjacent to vertebral column • Cuts; bruises; open wounds on head, face, neck, or back • Bowel and bladder incontinence • Urinary retention • Priapism • Decreased rectal sphincter tone

What are the classifications of a SCI?

SCI is classified by the (1) mechanism of injury, (2) level of injury, and (3) degree of injury.

What is a secondary injury of a SCI?

Secondary injury refers to the ongoing, progressive damage that occurs after the primary injury. Secondary injury causes further permanent damage. This can last for months.

How do you assess the level of injury to the bones on a SCI?

Skeletal level of injury is the vertebral level with the most damage to vertebra and related ligaments

How should a patient be handled after a SCI?

Spinal motion should be restricted with a combination of a rigid cervical collar and a supportive backboard with straps. Patients should be kept supine and may be logrolled for transfers.

What is spinal shock?

Spinal shock may occur shortly after acute SCI. It is characterized by loss of deep tendon and sphincter reflexes, loss of sensation, and flaccid paralysis below the level of injury. •As spinal shock resolves, reflexes and neurologic function may improve - Bulbocavernosus Reflex may be tested

What are the most common SCIs

The 4 most common causes are motor vehicle collisions (38%), falls (30.5%), violence (13.5%), and sports injuries (9%).

How do you assess the degree of a SCI?

The degree of spinal cord involvement may be complete or incomplete (partial).

What kind of levels are there to a SCI?

The level of injury may be cervical, thoracic, lumbar, or sacral. Cervical and lumbar injuries are most common because those areas of the spine are associated with the greatest flexibility and movement.

What are mechanisms of SPIs?

The major mechanisms of injury include flexion, flexion-rotation, hyperextension, vertical compression, extension-rotation, and lateral flexion