Disorders of Neuromuscular Function

Sub-acute

(1-14 days) •neuroimmune response: (neutrophils, lymphocytes) •BSCB breakdown/inflammation, vicious cycle •upregulation of axonal growth inhibitors/initiation of scar •neuropathic pain

Hyperacute

(instant) Axons are severed & blood vessels rupture from mechanical forces

areflexic bowel

(lower motor neuron bowel syndrome) caused by lesion below T10, loss of peristalsis and slow stool propulsion. No spinal cord mediated reflex occurs, leading to constipation with leaking of stool

Chronic

(months) •decreased neurotrophic support •Scar firmly established around lesion site •demyelination •axonal growth failure

Acute

(seconds-minutes) •uncontrolled influx of blood & blood proteins, •hypoxia/ischemia •release of excitatory (excitotoxic) neurotransmitters

Hyperreflexic bowel

(upper motor neuron bowel syndrome) caused by lesion above T10, involuntary contractions of muscles of the rectum and anus remain intact; there is an inability to voluntarily relax the anal sphincters and defecate, leading to constipation

Management of pressure ulcers

-Regular/frequent skin checks -Extra vigilance required for patients with darker skin -Follow patients repositioning schedules -Use pressure-reducing surfaces -Assess nutrition and provide supplementation, if needed -When an ulcer occurs, documentation of each ulcer (e.g., size, location, infection) and appropriate staging are essential to the wound assessment

Respiratory dysfunction in SCI

-SCI affects innervation of abdominal muscles and compromises the ability to generate coughs, which causes retention of secretions during infections -Injuries above C3 cause virtually complete paralysis of both the muscles of inhalation and exhalation and dependence on mechanical ventilation -A patient with a complete T12 classification will have no inspiratory or expiratory impairment

Autonomic Dysreflexia

-Very serious condition often experienced by individuals with SCI usually at or above the level of T6 -Irritating stimuli below the level of injury cause activation of the sympathetic nervous system, leading to an increase in blood pressure (20-40 mmHg) -Baroreceptors in the vessels send signals to the brain, which sends message via the parasympathetic Vagus nerve to heart to slow it down -The result is high blood pressure and bradycardia, that can lead to a stroke, seizure or even death

Neurogenic bladder

-complete or partial loss of bladder control, resulting in incontinence, renal impairment, urinary tract infection, stones, and poor quality of life; -More than 80% of individuals living with SCI exhibit at least some degree of bladder dysfunction; -Most serious consequence is Autonomic Dysreflexia.

Neurogenic bowel

-complete or partial loss of bowel control; symptoms comprise constipation and fecal incontinence -In patients with SCI, up to 95% report constipation and 75% have experienced episodes of fecal incontinence; only 6% of patients with SCI require no intervention to support their bowel function -Patients with SCI report bowel dysfunction as more problematic than any of bladder dysfunction, sexual dysfunction, pain, fatigue, or perception of body image -Serious consequence is Autonomic Dysreflexia

Pressure ulcers (bed sores)

-localized injuries to the skin or underlying tissue resulting from prolonged pressure on the skin -People most at risk are those with a condition that limits their ability to change positions -often develop on the heels, ankles, hips, and tailbone; they can develop quickly

Tetraplegia (quadriplegia)

impairment or loss of motor or sensory function (or both) after damage to neural structures in the cervical segments of the spinal cord; arms, trunk, legs and pelvic organs are affected

paraplegia

impairment or loss of motor or sensory function (or both) after damage to neural structures in the thoracic, lumbar, or sacral segments of the spinal cord; affects all or part of the trunk, legs and pelvic organs (lower half)

Neurological level of injury

lowest part of spinal cord that functions normally after injury.

SCI Causes

vehicle crashes are the most recent leading cause of injury, closely followed by falls. Acts of violence (primarily gunshot wounds) and sports/recreation activities are also relatively common causes

Clinical Signs of respiratory problems in SCI

•Change is respiratory rate •Shortness of breath •Increased HR •Increased anxiety •Increased volume or thickness of secretions •Decreased oxygen saturation •Elevated temperature

Clinical Signs Neurogenic Bowel

•Constipation •Abdominal distension •Respiratory compromise •Early satiety, nausea •Evacuation difficulty •Unplanned evacuations •Rectal bleeding •Pain

clinical signs of neurogenic bladder

•Incontinence •Overactive bladder •Urinary retention •Pelvic pain •Dysuria (painful or difficult urination) •Increased spasticity •Malaise •Fever/chills •Nausea/headache

SCI

•a complete or partial damage to the neural elements of the spinal cord that causes permanent changes in sensation and loss of voluntary control below the site of injury •Vertebrae can be fractured by trauma, but unless spinal cord is injured, there will be no motor/sensory deficits

secondary SCI

Inflammation Increased intracranial pressure Hypoxia Hypotension Electrolyte disturbances Release of toxins Excitotoxicity Oxidative stress Synaptic dysfunction

B

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? A. Try to calm the patient and make the environment soothing. B. Assess for a full bladder. C. Notify the healthcare provider. D. Prepare the patient for diagnostic radiography.

B

A spinal cord injury resulting in some motor or sensory function below the level of the injury is classified as which type of injury? A.Complete spinal cord injury B.Incomplete spinal cord injury C. Secondary neurologic injury D. Focal injury

SCI Trauma

A traumatic blow to the spinal cord initiates a massive biochemical cascade resulting in both immediate and progressive changes to the cord environment:

Bladder (most common): make sure bladder is empty properly, look for signs of infection Bowel: check for impacted stool, palpate the abdomen for distention, assess bowel movement Break down of skin: assess skin regularly, protect from injury, remove binding devices Medical Emergency - Prevention - Detection - ACTION

Main causes of Autonomic Dysreflexia: 3 Big B's

People want their independence and dignity back

Recovery Priorities of SCI Population?

Zone of partial preservation

Those dermatomes and myotomes caudal to the neurologic level that remain partially innervated in complete injuries

Dermatomes

an area of the skin supplied by nerves from a single spinal root

Complete SCI

All (or almost all) sensory and motor function are lost below the spinal cord injury

Location of injury along spinal cord Severity of injury to spinal cord

Alterations in body function that results from SCI will depend on:

Sacral Injuries

Bladder reflex is absent; retain urine

A

Frequent respiratory assessment is important in acute spinal cord injury because: a.Loss of defensive respiratory muscles places them at high risk for respiratory failure b.Arterial blood gas results can be inaccurate in these patients c.They frequently develop phrenic innervation, which can be worsened by the use of steroids d.It is the third leading cause of death for quadriplegic patients

primary SCI

External lacerations Vertebral fractures Contusions Cord laceration Diffuse axonal injury

Types of SCI

Flexion Compression Extension / Hyperextension Rotation

Loss of movement Loss of sensation, including ability to feel heat, cold, touch Loss of bladder or bowel control Exaggerated reflex activities or spasms Changes in sexual function, fertility Pain in head, neck or back Difficulty breathing, coughing Pressure in neck, head, back Numbness, tingling in hands, fingers, feet, toes Oddly positioned or twisted neck or back Weakness, incoordination or paralysis in part of body.

SCI Signs & Symptoms

SCI Severity

Severity of the injury is called the "completeness"

Elevated blood pressure by at least 20 mmH from baseline Pounding headache Face and neck flushing Profuse sweating above the level of injury Shivering Cutis ansernia (goose bumps) Blurred vision Dizziness Nausea Eyes watering Pronounced bradycardia/irregular heart beats Rapid breathing A person may experience one, several, or all the symptoms with each episode

Signs and Symptoms of Autonomic Dysreflexia

Suprasacral Injuries

Suppression of the brain's ability to control the bladder reflex, resulting in urinary incontinence, residual urine volume

Incomplete SCI

There is some residual motor and/or sensory function below the level of injury; the prognosis for returning of function is better because of preservation of axonal function

E

What's the important of teaching a wheelie? A. Pressure relief B. Uneven terrains C. Ramps D. Turns E. All of these

A

Which patient is at highest risk for a spinal cord injury? A. A 25-year-old male with a history of driving while intoxicated B. A 72-year-old female with dementia C. A 12-year-old soccer player D. A patient with osteogenesis imperfecta

C

You have a patient with complete paralysis from the waist down. This condition would be labeled as A. Hemiparesis B. Tetraplegia C. Paraplegia D. Quadriplegia

Respiratory dysfunction

______ and related diseases, such as pneumonia, are common causes of death in SCI

Secondary injury

follows the primary injury and promote the spread of the injury; the tissue damage that occurs ends in progressive neurological damage. Pathologic mechanisms include vascular damage (ischemia), release of vasoactive agents and cellular enzymes (further necrosis of blood vessels and neurons)