Spinal cord injuries nursing 4 test 1

Peripheral vascular problems

- DVT common problem - pulmonary embolism is the leading cause of death

Which is an emergency

- Neurogenic is an emergency - Spinal shock is to be expected

Thermoregulation problems after spinal injury

- Poikilothermia -- body temperature = room temperature -- due to interruption of SNS -- decreased ability to sweat or shiver

Who gets AD

- T6 injury or higher - doesn't start until they recover from spinal shock

prevention of orthostatic hypotension

- abdominal binder - antiembolism stockings - sit up slowly - elevate legs and bring blood out of legs

Neurogenic shock

- affects the body systemically - can make the patient very unstable 1. sudden loss of sympathetic control - with injuries above T6 -with spinal cord edema 2. Distributive shock hypotention and bradycardia are big usually seen in cervical and high thoracic injury

Orthostatic hypotension

- blood pools in the abdomen and legs - going from lying to sitting too fast and they lack the muscular tone to compensate - causes dizziness and loss of consciousness

What stimuli normally cause AD

- bowel (put them on bowel routine) - bladder (give them catheter) - stimuli to the skin (a wrinkle in the sheet, ingrown toenail) - this trigger is always the same each time - pain

How do you size the collar

- by height of shoulder to chin - wash the inner liner prn - remove it for skin care

What happens with neurogenic pulmonary edema

- dramatic increase in sympathetic nervous system activity at the time of injury

Autonomic Dysreflexia (AD)

- exaggerated sympathetic response below injury

Cervical collars

- hard molded collars - the height of the collar is the most important

Anterior approach

- high risk for airway compromise - the bleeding can cause tracheal compression

Central cord syndrome

- incomplete lesions - loss of arm movement, but can walk see slide

Return of reflexes after spinal shock

- injuries about T12 - spinal cord blocks messages to/from brain - hyperactive reflex activity - spasticity (baclofen is good to treat this) - involuntary muscle tightening - penile erections * these can happen involuntarily and be very upsetting to the patient

Edema

- injury-induced neurochemical cascade ex. can have edema around a surgical site and end up with symptoms at a different location

Methylprednisolone

- insufficient evidence to support standard treatment - Weak evidence to support as treatment option - must be administered within 8 hours of injury - theoretically it would decrease the amount of swelling around the chord since it is anti-inflammatory

Paraplegia

- involves the legs - improved sitting balance compared to tetraplegia - bipedal ambulation with KAFO's & walker

halo traction safety

- keep a wrench nearby to take off the bolts

Surgical techniques for spinal injury

- laminectomy - surgical fusion - stabilizing rods - anterior or posterior approach

Incomplete cord injury

- mixed motor/sensation below level of injury - Six associated syndromes

GI system

- most important is that the patient has a consistent bowl regime

Quality of life

- most paraplegics and quadrplegics say they are in excellent health - the live in their own homes - they rarely return from the hospital - most can do many of the things they want to do

Complete cord injuries

- no motor or sensation below level of injury

Respiratory problems

- risk for atelactasis - pneumonia - neurogenic pulmonary edema

What is the major problem with AD?

- severe hypertension (SBP 300mmHg) Therefore: - stroke - Seizure - MI - bradycardia - severe headache - nasal congestion - vasoconstriction/vasodilation below/above the lesion

Spinal shock

- shock to the spinal cord - occurs immediately after injury - Temporary loss of reflex activity below the level of injury (flacid paralysis, areflexia) - Resolves in days to weeks

Goals of medical treatments

- traction - realignment - stabilization

urinary system nursing assessment and care

-Spastic Bladder Empty at any time without warning -Flaccid Bladder Urinary Retention Common Loss of autonomic & reflex control May result in rupture of bladder -Over distention Reflux into the kidney - ARF -Strict I&O - (keep intake ~ 2000ml/day) Regular & complete bladder drainage Indwelling urinary catheter Intermittent catheterization (Q3-4H) Cranberry juice or tablets Monitor for s/sx UTI (and Renal Calculi) Fever/Chills/Malaise Cloudy/Odor Specimen to lab for UA

Secondary injuries

1. Cellular hypoxia 2. Major reduction in blood flow 3. Systemic hypotension 4. Edema * good systemic blood pressure can prevent secondary injuries!!

Incomplete spinal cord syndromes

1. Central cord syndrome 2. Anterior cord syndrome 3. Brown- sequard syndrome

Dermatomes

1. Cervical injuries C1-C3 impact the breathing (watch for breathing problems) Apnea- unable to take deep breaths, inability to cough *ventillary dependent and unable to talk 2. C4 poor cough, diaphragmatic breathing- takes whole body to breath. hypo ventilation because cant expand lungs 3. C5 to T6 decrease resp reserve

Respiratory Rehabilitation

1. deep breathing 2. incentive spirometry 3. assisted coughing 4. ventilator care 5. diaphragmatic pacemaker

Treatment of neurogenic shock

1. fluid resuscitation 2. atropine 3. vasopressor (all attempt to bring up blood pressure)

Pscychosocial adaptation

1. grief 2. anger 3. depression

Immediate post-injury problems

1. maintain patent airway 2. adequate ventilation 3. Adequate circulating blood volume (ABCs) 4. Prevent secondary cord injury (good spinal alignment, MAP 80-90)

Assessment

1. motor 2. sensory (light touch vs. pinprick) 3. Reflexes (advanced practice) 4. ASIA scoring 5. Extent of injury (most accurate >72 hours after injury)

Skeletal traction types

1. tongs 2. halo (people with higher risk for instability)

Anterior cord syndrome

see slide - cannot move, but can sense

Logrolling

watch video

Brown-sequard syndrome

half of the spinal cord - loss of motor on one side - loss of temperature on the other side

Fluid and Nutritional Maintenance

Adequate nutrition Evaluate swallowing Gradual introduction of fluids & food once motility returns Calorie count High-calorie, high-protein diet or TPN Increased dietary fiber Daily weight

Autonomic DysreflexiaNursing Interventions

Elevate HOB 45 degrees or sit patient upright Assessment to determine the cause Notify healthcare provider Remove tight clothing Check orthotics Check catheter for kinks or occlusion Immediate catheterization for bladder distension - Lidocaine jelly first Check for fecal impaction - (after application of anesthetic ointment) Management of blood pressure - Check Q5min Alpha blocker - Terazosin (Hytrin) Arteriolar vasodilator - nitroglycerin, nifedipine (Procardia)

bowel assessment

Frequent assessment of bowel sounds Monitor for abdominal distention NG tube If motility ceases Low intermittent wall suction - relieve gastric distention Test gastric contents daily for blood Monitor electrolytes

Resp system nursing assessment

Frequent respiratory assessment is critical for all patients, but especially for those with an injury at T6 or higher. Respiratory problems are the most common cause of death in the first year after a spinal cord injury. Assess breath sounds. Monitor and report any abnormal ABG values. Tidal volume and vital capacity are more for ventilation patients or need a pulmonary function test to determine. Tidal volume - amount of air that is inhaled or exhaled in a single breath. Vital capacity - maximum amount of air expelled after maximal inhalation. Assess breathing patterns and presence of sputum or changes in color in sputum. Pink frothy sputum is pneumonia

cardiovascular system nursing assessment

The sympathetic nervous system activates the fight or flight response. Any injury above T6 reduces the sympathetic nervous system. This results in bradycardia and peripheral vasodilation. This causes a decrease in venous blood return to the heart and a decreased cardiac output which causes hypotension. Monitor VS hourly. May require medication to treat low HR and Blood Pressure. Patient are at a high risk for DVT because of lack of muscle tone, pooling of blood, sluggish venous return and immobility. DVT prevention is needed

a patient with a C4 spinal cord injury is at risk for developing decreased cardiac output related to:

a. orthostatic hypotension b. neurogenic shock c. venous pooling All of these!