Unit 13 - Mobility
What type of cardiovascular problems can occur in those with cervical injuries?
-BP instability (particularly hypotension d/t loss of tone in blood vessels and blood pooling in distal arteries) -damage to the cardiac accelerator nerves can cause bradycardia or arrhythmias (arrhythmias usually appear in the first 2 weeks after injury)
S/sx of spinal shock
-HR decrease -BP decrease -respirations decrease -vasodilation -decreased CO
S/sx of Autonomic Dysreflexia
-HTN -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 activity -Goose bumps below the level of the lesion -Flushing of the skin above the level of the lesion - Especially in the face, neck, and shoulders; this is a frequent symptom -Blurred vision -Nasal congestion - A common symptom
Anterior Cord Syndrome Location/Cause
-Incomplete SCI -injury to the anterior two thirds of the spinal cord, especially the anterior spinal artery
What determines the extent and type of physical manifestations the client experiences after spinal cord injury?
-The vertical location of the injyr along the spinal column (the level of injury) -the specific area of the spinal cord or nerve that is damaged *All systems below the level of injury will be affected by damage to the spinal cord, so the higher the injury, the greater the extent of motor and sensory deficits.
Central Cord Syndrome Location/Cause
-incomplete SCI - hyperextension of the neck, especially from falls and MVA -damage to teh center of the spinal cord
Initial/Emergency Care of someone with an acutal or suspected SCI
-maintain client's ability to breathe -prevent movement that could cause more damage -immobilize the spine with neck collar/backboard -prevent shock
Anterior Cord Syndrome Symptoms/Prognosis
-paraplegia below the level of injury -bilateral loss of pain and temperature sensations with preservation of proprioception and vibratory senses below the level of injury -the worst prognosis for recovery of neuro function and require long periods of rehab (only 10-20% experience motor recovery)
Secondary Spinal Cord Injury
D/t ischemia, hypoxia, or hemorrhage, often reversible/preventable during the first 4-6 hours after injury.
What type of individuals does autonomic dysreflexia develop in?
Develops in individuals with a neurologic level of spinal cord injury at or above the sixth thoracic vertebral level (T6)
If left untreated, what can autonomic dysreflexia lead to?
If left untreated, autonomic dysreflexia can cause seizures, retinal hemorrhage, pulmonary edema, renal insufficiency, myocardial infarction, cerebral hemorrhage, and, ultimately, death. Complications associated with autonomic dysreflexia result directly from sustained, severe peripheral hypertension.
Hemiplegia
One half of the body is paralyzed when divided along the median sagittal plane.
What is KEY for prevention of autonomic dysreflexia?
Proper bladder and bowel care (ie, preventing fecal impaction, bladder distention) are mainstays in preventing episodes of autonomic dysreflexia.
What do you do if a pin falls out from a halo?
Provide manual traction and wait until the MD arrives. Stay with patient.
What is the number one cause of death in patient's with a SCI?
Pulmonary Embolism
Causes of Neurogenic Shock
The following can cause neurogenic shock by increasing parasympathetic stimulation or inhibiting sympathetic stimulation of the smooth muscle of blood vessels: -head injury -spinal cord trauma -insulin reactions -CNS depressant drugs -anesthesia -severe pain -prolonged exposure to heat
Neurogenic Shock
The result of an imbalance between parasympathetic and sympathetic stimulation of vascular smooth muscle. *If parasympathetic overstimulation or sympathetic understimulation persists, sustained vasodilation occurs and blood pools in the venous and capillary beds. -causes a dramatic reduction in systemic vascular resistance as the size of the vascular compartment increases -pressure in the blood vessels then becomes too low to drive nutrients across capillary membranes and cellular metabolism is impaired
Spinal Cord Injury (SCI)
The result of concussion, contusion, laceration or compression of spinal cord.
The individual that has an incomplete SCI has a better chance at recovery than someone who has a complete - T/F?
True
Complications from Immobility
-Pulmonary Embolism (most common cause of death in patients with SCI) -DVT (never rub calves or thighs) -skin breakdown -incontinence -infection (PNA, UTI, DQ) -orthostatic hypotension -contractures (develop rapidly, atrophy from disuse, ROM exercise)
Spinal Shock
-a form of neurogenic shock that occurs in persons with SCI -occurs within an hour or less of injury -areflexia: sudden depression of reflex activity below level of spinal injury: flaccid paralysis -muscular flaccidity, lack of sensation and reflexes - loss of spinal reflexes, deep tendon reflexes, motor and sensory function -bowel and bladder reflexes affected - loss of perianal reflexes -each person responds differently; can last for 6 months
S/sx of Neurogenic Shock
-bradycardia (pulse slow and bounding) occurs EARLY but tachycardia begins later as a compensatory mechanism -CVP drops as veins dilate, venous return to the heart decreases, stroke volume decreases and MAP falls -in the EARLY stages extremities are warm and pink, but as shock progresses the skin becomes pale and cool -lowered body temperature -urine output: oliguria to anuria -mental status: anxious, restless, lethargic, progressing to comatose
Spinal Cord Injury Treatment
-emergency care - spinal precautions, immobilization -respiratory therapy - oxygenate (any type of hypoxia will worsen injury) -pharmacological therapy - high dose steroids, anticoagulants, pain management, muscle relaxants -diagnostic tests - CT, MRI, x-rays. ABGS
Emergency s/sx that may indicate a spinal cord injury?
-extreme pain/pressure in the beck or back -weakness, paralysis or lack of sensation in any part of the body -loss of bladder/bowel control -impaired breathing after injury -oddly positioned or twisted neck or back -muscle spasms
Brown Sequard Syndrome Location/Cause
-incomplete SCI -hemisection of the spinal cord, usually caused by penetrating trauma
Conus Medullaris Syndrome Location/Cause
-incomplete SCI -injury to the conus medullaris, which is the tapered inferior end of the spinal cord, located at the L1 level
Brown Sequard Syndrome Symptoms/Prognosis
-ipsilateral (same side) motor paralysis and loss of proprioception and vibratory sense below the level of injury -contralateral (opposite side) loss of pain and temperature sensation below the level of injury *best prognosis of all incomplete SCI syndromes; approximately 75-90% will recover functional motor strength and ability to ambulate independently
Individuals with complete thoracic or cervical injuries often have what type of respiratory difficulties?
-lose control of respiratory muscles such as the diaphragm, intercostals, neck and ABD muscles -the higher the level of injury, the greater the loss of muscle control (someone with a SCI at level C3 or higher loses control of all four muscle groups needed for breathing, and requires immediate ventilator support). -someone with an injury below the C5 level conserves diaphragm function, but breathing tends to be rapid and shallow and the individual cannot clear secretions from the lungs because of weak thoracic muscles
Central Cord Syndrome Symptoms/Prognosis
-more severe motor loss of the upper extremities than the lower extremities -bladder dysfunction (usually retention) -varying degrees of sensory loss below the level of injury -almost all clients will have some degree of neurological recovery, starting the lower extremities moving upward. -some will have sustained functional loss
Nursing Assessment of the patient with a SCI
-obtain a health hx: overall health prior to traumatic event, specifics about the event (time, location, type of event), any meds the client is taking -perform ongoing physical assessments, s/sx client is experiencing? pain/numbness/difficulty breathing -VS -regularly assess respiratory status -neuro exam, testing key muscles for strength using the muscle function grading scale, testing areas of innervation for each spinal nerve for sensation of light touch/pin prick -score the client on the ASIA impairment scale -assess for reflexes, bowel sounds, bladder distention, pain, ABG's and other injuries from the event
Effects of SCI on the Body
-paraplegia/tetraplegia depending on the level of injury -bowel/bladder problems -respiratory and cardiovascular problems -reproductive problems -pain
Interventions to avoid Autonomic Dysreflexia
-regularly empty bladder/bowel -keep foley tubing free of kinks, keep drainage bag and tubes clean and empty -treat UTIs promptly -consume adequate fluid/fiber to prevent constipation -change posiitions frequently -regularly assess skin integrity including pressure sores and ingrown toenails -avoid burns including sunburns -do not wear clothing that is too tight -take meds as prescribed to prevent pain and other complications that may trigger autonomic dysreflexia
Conus Medullaris Syndrome Symptoms/Prognosis
-symmetrical pattern of upper and lower motor neuron dysfunction, saddle anesthesia, variable degrees of lower extremity weakness and areflexic bladder and bowel *prognosis for recovery of bowel and bladder function is poor
Treatment of Neurogenic Shock
-treat underlying injury -reduce parasympathetic stimulation or sympathetic under-stimulation -meds may include corticosteroids and vasoactive agents
Autonomic Dysreflexia
A potentially dangerous and, in rare cases, lethal clinical syndrome that develops in individuals with spinal cord injury, resulting in acute, uncontrolled hypertension
Tetraplegia
AKA quadriplegia -paralysis of the upper and lower limbs and trunk, usually associated with cervical injury
Spinal Shock Characteristics
Characterized by spinal cord swelling, decreased blood flow and blood pressure and complete lossof motor function, spinal reflexes and autonomic function below the level of injury. *During spinal shock even undamaged nerves may have trouble communicating with the brain, causing paralysis and loss of reflexes and sensations in the limbs that are unrelated to the site of injury.
Treatment for Autonomic Dysreflexia
Check the patient's blood pressure. If the blood pressure is elevated, have the person sit up immediately and loosen any clothing or constrictive devices. Sitting allows some gravitational pooling of blood in the lower extremities and reduces blood pressure. Survey the person for instigating causes, beginning with the urinary system, the most common cause of autonomic dysreflexia. -Monitor blood pressure and pulse every 2-5 minutes until the patient has stabilized; impaired autonomic regulation can cause blood pressure to fluctuate quickly during an episode of autonomic dysreflexia. -Use of an antihypertensive agent is recommended when the systolic blood pressure is at or above 150 mm Hg. -FIGURE OUT THE CAUSE AND CORRECT IT! If cause is not found, and BP is lowered d/t pharmacological intervention, it should be expected that the HTN will reoccur because the stimulus hasn't been removed.
What can cause/trigger autonomic dysreflexia?
Essentially, any painful, irritating, or even strong stimulus below the level of the injury can cause an episode of autonomic dysreflexia. Bladder distension or irritation is responsible for 75-85% of the cases. Other examples: bowel distention(2nd most common cause), fecal impaction, invasive testing, hemorrhoids, menstruation, pregnancy, gastric ulcers, DVT, ingrown toenail, burns, insect bite, blisters, temperature fluctuations, constrictive clothing, etc.
When does spinal shock usually occur?
Immediately after injury and can last from several hours to several weeks.
Primary Spinal Cord Injury
Initial trauma, usually permanent. Complete transaction, severing of spinal cord.
What is a complete SCI?
Involves a TOTAL loss of all sensory and motor function below the elevel of the injury. -usually cause irreversible damage
Incomplete SCI
Involves only a partial loss of sensory and motor function below the elevel of injury. Some individuals may detect sensation but have little or no ability to move, whereas others may have movement with little or no sensation.
Spinal Cord Injury Assessment
Monitor respirations and breathing pattern. -lung sounds and cough -monitor for changes in motor or sensory function; report immediately -assess for spinal shock -monitor for bladder retention or distention, gastric dilation and ilieus -temperature (potential hyperthermia from brain stem damage). The increased need for 02 by the brain with injury increases temperature
What type of pain does someone with SCI experience?
Neurogenic: pain resulting from damage to nerves in the spinal cord. Physiological: pain resulting from compensatory use of muscle groups (e.g. pain in shoulder muscles from pushing a W/C)
Why would someone with a SCI have bowel/bladder problems?
Occurs when nerves that innervate the muscles that control the urinary system or bowel no longer transmit signals properly. Muscles in the bladder, urethra and sphincters no longer work together effectively
Paraplegia
Paralysis of all or part of the trunk, legs and pelvic organs. -usually associated with spinal cord damage in the thoracic or lumbar regions
Spinal Decompression
Removal of debris that is compressing the spinal cord.
How does someone with a SCI's risk for blood clots compare to someone else?
They are 3x the risk for developing blood clots in comparison to others with limited mobility.