Adult II Exam 3: Spinal Cord Injury

ASIA impairment scale

• The American Spinal Injury Association (ASIA) Impairment Scale is recommended for classifying the severity of impairment resulting from spinal cord injury. • It combines assessments of motor and sensory function to determine neurologic level and completeness of injury. • The ASIA Impairment Scale is useful for recording changes in neurologic status and identifying appropriate rehabilitation goals. • Movement and rehabilitation potential related to specific locations of the SCI are described in Table 60-4 . In general, sensory function closely parallels motor function at all levels.

SYNDROMES ASSOCIATED WITH INCOMPLETE SPINAL CORD INJURIES

• Five major syndromes are associated with incomplete injuries: • central cord syndrome • anterior cord syndrome • Brown-Séquard syndrome • cauda equina syndrome • conus medullaris syndrome

clinical manifestations: cardiovascular system

- Any cord injury above T6 leads to dysfunction of the sympathetic nervous system. - This leads to neurogenic shock, resulting in bradycardia, peripheral vasodilation, and hypotension. - Peripheral vasodilation causes a relative hypovolemia because of the increase in the capacity of the dilated veins. It also reduces venous return of blood to the heart. Cardiac output then decreases, leading to hypotension. Other injuries can also cause hemorrhagic shock and further reduce BP. It is important to identify all causes of hypotension in the person with SCI.

nursing interventions for autonomic hyperreflexia

- Autonomic hyperreflxia is a life-threatening situation that requires immediate resolution. If resolution does not occur, it can lead to status epilepticus, stroke, myocardial infarction, and even death. - Nursing interventions in this serious emergency include elevating the head of the bed 45 degrees or sitting the patient upright, notification of the physician, and assessment to determine the cause. - The most common cause is bladder irritation. Immediate catheterization to relieve bladder distention may be necessary. Lidocaine jelly should be instilled in the urethra before catheterization. If a catheter is already in place, it should be checked for kinks or folds. If plugged, perform small-volume irrigation slowly and gently to open the catheter, or insert a new catheter. - Stool impaction can also cause autonomic hyperreflexia. Perform a digital rectal examination (if trained) only after application of an anesthetic ointment to decrease rectal stimulation and to prevent an increa

cardiovascular instability

- Because of unopposed vagal response, the heart rate is slowed, often to less than 60 beats/minute. Any increase in vagal stimulation, as occurs with turning or suctioning, can cause cardiac arrest. - Loss of sympathetic nervous system tone in peripheral vessels results in chronic low blood pressure with potential postural hypotension. - The lack of muscle tone to aid venous return can cause sluggish blood flow and predispose the patient to DVT. - Dysrhythmias may also occur. - Frequent assess vital signs. - If bradycardia is symptomatic, administer an anticholinergic drug such as atropine. A temporary or permanent pacemaker may be inserted in some patients. - Maintain SBP greater than 90 mm Hg at all times and keep MAP between 85 and 90 mm Hg for the first 7 days following SCI. Manage hypotension with fluid replacement and a vasopressor agent, such as phenylephrine (Neo-Synephrine) or norepinephrine (Levophed). - If blood loss has occurred from other injuries, hemoglobin and hematocr

bowel management

- Constipation is generally a problem during spinal shock because no voluntary or involuntary (reflex) evacuation of the bowels occurs (neurogenic bowel). - A bowel program should be started during acute care. - This involves choosing a rectal stimulant (suppository or small-volume enema) to be inserted daily at a regular time of day followed by gentle digital stimulation or manual evacuation until evacuation is complete. - Initially the program may be done in bed in the side-lying position. However, as soon as the patient has resumed sitting, the patient should be in the upright position on a padded bedside commode chair. These programs typically require 30 to 60 minutes to complete. - Constipation can be reduced with adequate fluid intake, a healthy diet of fiber and vegetables, and increased activity and exercise.

clinical manifestations: gastrointestinal system

- Decreased GI motor activity contributes to gastric distention and development of paralytic ileus. - Gastric emptying may be delayed, especially in patients with higher level SCI. - Excessive release of HCl acid in the stomach may cause stress ulcers. - Dysphagia may also be present in patients who require mechanical ventilation, tracheostomy, and anterior spine surgery. - Intra-abdominal bleeding may be difficult to diagnose because the person with SCI may not experience pain or tenderness. Continued hypotension and decreased hemoglobin and hematocrit may indicate bleeding. Expanding girth of the abdomen may also be noted.

grief and depression

- Depression after SCI is common and disabling. Patients with SCIs may feel an overwhelming sense of loss. - They may temporarily lose control over everyday life activities as they depend on others for ADLs and for life-sustaining measures. Patients may believe that they are useless and burdens to their families. At a life stage when independence is often of great importance, they may be totally dependent on others. - With recent advances in rehabilitation, the patient is often independent physically and discharged from the rehabilitation center before completing the grief process. - The goal of recovery is related more to adjustment than to acceptance. Adjustment implies the ability to go on with living with certain limitations. - Although the patient who is cooperative and accepting is easier to treat, expect a wide fluctuation of emotions from a patient with SCI. - Your role in grief work is to allow mourning as part of the rehabilitation process. Maintaining hope is important durin

immobilization

- For cervical injuries, closed reduction with skeletal traction is used for early realignment (reduction) after injury. - Crutchfield or Gardner-Wells tongs or halo (halo ring) can provide this type of traction, using a rope that extends from the center of the device over a pulley to weights attached at the end. - Traction must be maintained at all times. Possible displacement of the skull pins is a disadvantage of tongs. ¡ If displacement occurs, hold the head in a neutral position and get help. Immobilize the head while the surgeon reinserts the tongs. - No specific recommendations are available regarding maximum weight for traction. The surgeon may start with 10 pounds and add 5 pounds for each level to the injury. The goal is spinal reduction. Awake patients are monitored with x-ray as well as neurologic and pain assessment. Comatose patients require serial x-rays to evaluate the effects of traction

interprofessional care: prehospital

- Immediate post-injury goals include maintaining a patent airway, adequate ventilation/breathing, and adequate circulating blood volume (ABCs) as well as preventing extension of spinal cord damage (secondary injury). - Recommended immobilization includes a combination of a rigid cervical collar and supportive blocks on a backboard with straps. Spinal immobilization with sandbags and tape is insufficient, and is not recommended. - Spinal immobilization in patients with penetrating trauma is also not recommended because of increased mortality. The concern during initial management of patients with potential cervical spinal injuries is impairment of neurologic function due to movement of the injured vertebrae. - Systemic and neurogenic shock must be treated to maintain systolic BP greater than 90 mm Hg. Following cervical injury, all body systems must be maintained until the full extent of the damage can be evaluated. - After stabilization at the injury scene, the person should be transf

bladder management

- Immediately after the injury, urine is retained because of the loss of autonomic and reflex control of the bladder and sphincter (neurogenic bladder). -Because there is no sensation of fullness, overdistention of the bladder can result in reflux into the kidney and cause renal failure. - Bladder overdistention may even result in rupture of the bladder. Thus, an indwelling catheter may be inserted as soon as possible after injury. - Ensure the patency of the catheter by frequent inspection and irrigation if necessary. - In some institutions a physician's order is required for this procedure. - Strict aseptic technique for catheter care is essential to prevent infection. - During the period of indwelling catheterization, encourage a large fluid intake. - Check the catheter to prevent kinking and ensure free flow of urine. - Catheter-acquired urinary tract infection (CAUTI) is a common problem. The best method for preventing UTIs is regular and complete bladder drainage. - After the

pin site care

- Infection at the sites of tong or halo pin insertion is another potential problem. - Preventive care is based on hospital protocol. - A common protocol involves cleansing sites twice a day with half strength peroxide and normal saline solution and applying an antibiotic ointment to act as a mechanical barrier to the entrance of bacteria.

Interprofessional care: acute care

- Interprofessional care during the acute phase for a patient with a cervical injury is described in Table 60-4. Compared to cervical injury, patients with SCI of the thoracic and lumbar vertebrae require less intense support. At this level of injury, respiratory compromise is not as severe and bradycardia is usually not a problem. Other problems are treated symptomatically. - Obtain a history, with emphasis on how the incident occurred. - Assess the extent of injury perceived by the patient or by the emergency response system (ERS) personnel immediately after the event. - Initial assessment (which usually occurs in the emergency department) includes managing the person's ABCs and vital signs to ensure the airway is secure, oxygenation saturation (SaO2) is greater than 90%, and SBP is greater than 90 mm Hg. Appropriate medical interventions and diagnostics are implemented to ensure the patient is hemodynamically stable.

interprofessional care: drug therapy

- Low-molecular-weight heparin (e.g., enoxaparin [Lovenox]) is used to prevent VTE unless contraindicated. Contraindications include internal bleeding, abnormal kidney function, and recent surgery. - Vasopressor agents, such as phenylephrine (Neo-Synephrine) or norepinephrine (Levophed), are used in the acute phase as adjuvants to treatment. These agents are used to maintain the mean arterial pressure (MAP) at a level greater than 85-90 mm Hg to improve perfusion to the spinal cord. Use of vasopressors has significant risk of complications, including ventricular tachycardia, troponin elevation, metabolic acidosis, and atrial fibrillation. - Because drug metabolism is altered in patients with an SCI, drug interactions may occur. Differences in drug metabolism correlate with level and completeness of injury, with greater change apparent following cervical cord injury than injury at lower spinal levels.

acute care: additional assessment

- Mechanisms of injury that cause spinal cord trauma, especially involving the cervical cord, may also result in brain injury and/or vertebral artery injury. - Assess for a history of unconsciousness, signs of concussion, and increased intracranial pressure (see Chapter 56). - In addition, perform a careful assessment for musculoskeletal injuries and trauma to internal organs. - Because the patient has no muscle, bone, or visceral sensations, the only clue to internal trauma with hemorrhage may be a rapidly decreasing BP and increasing pulse. - Examine urine for hematuria, which also indicates internal injuries.

logrolling patient

- Move the patient in alignment as a unit (logroll) during transfers and when repositioning to prevent further injury. - Monitor respiratory, cardiac, urinary, and GI functions. - The patient may go directly to surgery after initial immobilization or to the intensive care unit (ICU) for monitoring and management.

pain management

- Musculoskeletal nociceptive pain can develop secondary to injuries to bones, muscles, and ligaments. This dull, aching pain is aggravated with movement or palpation. Antiinflammatory drugs such as ibuprofen (Motrin) may help with pain. Opioids may also be used to manage nociceptive pain. - Visceral nociceptive pain is a dull, tender, or cramping pain in the thorax, abdomen, or pelvis. This type of pain may result from the bladder and bowel. ... Assess the patient's bowel and bladder function to avoid bladder distention or constipation. Other causes of nociceptive pain include UTI and ureteral calculus. ... Notify the HCP if the patient experiences persistent pain despite treatment. Diagnostic imaging may be needed to fully evaluate its cause. - Neuropathic pain in the initial phase is usually at the level of SCI. It may occur on one or both sides of the body within the affected dermatome, and up to three levels below. The patient will complain of hot, burning, tingling, shooting, e

clinical manifestations: metabolic needs

- Nasogastric suctioning may lead to metabolic alkalosis. It is important to especially monitor sodium and potassium until suctioning is discontinued and a normal diet is resumed. - The person with SCI has increased nutritional needs due to increased metabolism and more protein breakdown. Lean body mass is lost and muscles atrophy leading to weight loss. Nutritional support should focus on a diet that addresses the person's caloric and nitrogen needs. Adequate nutrition helps prevent skin breakdown, reduce infection, and decrease the rate of muscle atrophy.

neurgonic shock

- Neurogenic shock, in contrast to spinal shock, results from loss of vasomotor tone due to injury and is characterized by hypotension and bradycardia. - Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. - These effects are generally associated with a cervical or high thoracic injury (T6 or higher).

interprofessional care: nonoperative stabilization

- Nonoperative treatments involve stabilization of the injured spinal segment and decompression, either through traction or realignment. - Stabilization methods eliminate damaging motion at the injury site. It intended to prevent secondary spinal cord damage caused by narrowing of the spinal canal, or continued contusion or compression of the spinal cord at the level of the injury. - Early realignment of an unstable fracture-dislocation injury by closed reduction through craniocervical traction has been found to be effective and safe. - Decompression ... Traction or realignment

nursing diagnoses

- Nursing diagnoses for the patient with an SCI depend on the severity of the injury and the level of dysfunction. The nursing diagnoses for a patient with an SCI may include, but are not limited to, the following: • Ineffective breathing pattern related to respiratory muscle fatigue, neuromuscular paralysis, and/or retained secretions • Imbalanced nutrition: less than body requirements related to paralytic ileus and metabolic demands of body • Ineffective peripheral tissue perfusion related to hypotension and lack of mobility • Impaired skin integrity related to immobility and/or poor tissue perfusion • Impaired urinary elimination related to spinal injury and/or limited fluid intake • Constipation related to neurogenic bowel, inadequate fluid intake, and/or immobility • Risk for autonomic hyperreflexia (dysreflexia) related to reflex stimulation of sympathetic nervous system

clinical manifestations: pain

- Pain following SCI differs in type and severity, and is influenced by the patient's physical functioning and emotions. The pain can be nociceptive or neuropathic. - Nociceptive pain in SCI can develop from musculoskeletal, visceral, and/or other types of injury (e.g., skin ulceration, headache). Patients often describe musculoskeletal pain as dull or aching. It starts or worsens with movement. Visceral pain is located in the thorax, abdomen, and/or pelvis, and may be dull, tender, or cramping. - Neuropathic pain in SCI occurs from damage to the spinal cord or nerve roots. The pain can be located at or below the level of injury. Patients often identify neuropathic pain as hot, burning, tingling, pins and needles, cold, and/or shooting. They may be extremely sensitive to stimuli and even light touch can cause significant pain.

Treatment for erectile dysfunction includes drugs, vacuum devices, and surgical procedures.

- Phosphodiesterase inhibitors such as sildenafil (Viagra) have become the first line treatment in men with SCI. Sexual stimulation is required to get an erection after taking the medication. - Penile injection of vasoactive substances (papaverine, prostaglandin E) is another medical treatment. Risks include priapism (prolonged penile erection) and scarring, so these substances should be considered only after failure of sildenafil. - Vacuum suction devices use negative pressure to encourage blood flow into the penis. Erection is maintained by a constriction band placed at the base of the penis. - The main surgical option is implantation of a penile prosthesis. - SCI affects male fertility, causing poor sperm quality and ejaculatory dysfunction. Recent advances in methods of sperm retrieval include penile vibratory stimulation and electroejaculation. Combined with ovulation induction and intrauterine insemination of the female partner, these techniques have changed the prognosis for men

respiratory dysfunction

- Regularly assess (1) breath sounds, (2) ABGs, (3) tidal volume, (4) vital capacity, (5) skin color, (6) breathing patterns (especially the use of accessory muscles), (7) subjective comments about the ability to breathe, and (8) the amount and color of sputum. A PaO2 (partial pressure of oxygen in arterial blood) greater than 60 mm Hg and a PaCO2 (partial pressure of carbon dioxide in arterial blood) less than 45 mm Hg are acceptable values in a patient with uncomplicated tetraplegia. A patient who is unable to count to 10 aloud without taking a breath needs immediate attention. - In addition to ongoing assessment, intervene to maintain ventilation. Administer oxygen and provide ventilatory support until ABGs stabilize. Patients who experienced chest trauma or have difficulty weaning from the ventilator may require a tracheostomy for airway management. - Chest physiotherapy and assisted (augmented) coughing help to clear secretions. Assisted coughing simulates the action of the ineffe

CLINICAL MANIFESTATIONS: RESPIRATORY SYSTEM

- Respiratory complications closely correspond to the level of the injury. - Cervical injuries above the level of C4 present special problems because of the total loss of respiratory muscle function. - Injury or fracture below the level of C4 results in diaphragmatic breathing if the phrenic nerve is functioning. - Even if the injury is below C4, spinal cord edema and hemorrhage can affect the function of the phrenic nerve and cause respiratory insufficiency. - Hypoventilation and impairment of the intercostal muscles leads to a decrease in vital capacity and tidal volume. - Cervical and thoracic injuries cause paralysis of abdominal muscles and often the intercostal muscles. - Thus the patient cannot cough effectively enough to remove secretions, increasing the risk for aspiration, atelectasis and pneumonia. - Neurogenic pulmonary edema may occur secondary to a dramatic increase in sympathetic nervous system activity at the time of injury, which shunts blood to the lungs. In additio

sexuality

- Sexuality is an important issue regardless of the patient's age or sex. - To provide accurate and sensitive counseling and teaching about sexuality, be aware of your own sexuality, as well as understand human sexual responses. When discussing sexual potential, use scientific terminology rather than slang whenever possible. - Knowledge of the level and completeness of injury is needed to understand the male patient's potential for orgasm, erection, and fertility and the patient's capacity for sexual satisfaction. - Men normally have two types of erections: psychogenic and reflex. The process of psychogenic erections begins in the brain with sexual thoughts. Signals from the brain are then sent through the nerves of the spinal cord to the T10-L2 levels. The signals are then relayed to the penis and trigger an erection. Men with low-level incomplete injuries are more likely to have psychogenic erection than men with higher-level incomplete injuries. Men with complete injuries are

Level of Injury

- Skeletal level of injury is the vertebral level with the most damage to vertebral bones and ligaments. - Neurologic level is the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body. The level of injury may be cervical, thoracic, lumbar, or sacral. - Cervical and lumbar injuries are most common because these levels are associated with the greatest flexibility and movement. - If the cervical cord is involved, paralysis of all four extremities occurs, resulting in tetraplegia (formerly quadriplegia). The degree of impairment in the arms following cervical injury depends on the level of injury. The lower the level, the more function is retained in the arms. - If the thoracic, lumbar, or sacral spinal cord is damaged, the result is paraplegia (paralysis and loss of sensation in the legs). Figure 60-3 shows affected structures and functions at different levels of cord injury. - Tetraplegia (quadriplegia; all 4 limbs are affected that complete

spasticity

- Spasticity can be both beneficial and undesirable. It aids with mobility, especially for the patient with incomplete SCI. Spasticity improves circulation by promoting venous return and decreases orthostatic hypotension and the risk of DVT. - Unfortunately, the patient with marked spasticity and tone may have difficulty with positioning and mobility secondary to the spasms. Spasms can cause significant pain and make activities of daily living (ADLs) difficult for the patient. - The Ashworth and modified Ashworth scales are used to evaluate spasticity (www.scireproject.com/outcome-measures-new/ashworth-and-modified-ashworth-scale-mas). - Treatment strategies include ROM exercises to prevent muscle and joint tightness and reduce the risk of contracture. Antispasmodic medications such as baclofen or tizanidine may be administered. Botulinum toxin injection is useful for specific muscle involvement. - The more spastic you are, the more painful it is... results in invasive treatment

immobilization: kinetic therapy

- Special beds are often used in the management of the patient with an SCI. - Kinetic therapy involves continuous side-to-side rotation of a patient to 40 degrees or more to help prevent pulmonary complications. - This lateral rotation also redistributes pressure, helping prevent pressure ulcers. - Patients with stable thoracic or lumbar spine injuries may be immobilized with a custom thoracolumbar orthosis (TLSO or body jacket) to inhibit spinal flexion, extension, and rotation. Alternately, a Jewett brace may be used to restrict forward flexion. Unstable injuries may require surgical decompression and fusion in addition to the TLSO or lumbosacral orthotic (LSO). - Immobilization of the neck of the patient with SCI prevents further injury, but the effects of immobility are profound. Meticulous skin care is critical because decreased sensation and circulation make the patient more susceptible to skin breakdown. Remove the patient's backboard as soon as possible and replace it with othe

characterizations of spinal shock

- Spinal shock may occur following acute SCI and is characterized by decreased reflexes, loss of sensation, and flaccid paralysis below the level of the injury. - This syndrome lasts days to weeks and may mask post-injury neurologic function. - Absent thermoregulation (taking on room environment, immediately) - Wherever spinal cord is compressed, there down is where you will see signs and symptoms

degree of injury

- The degree of spinal cord involvement may be either complete or incomplete (partial). - Complete cord involvement results in total loss of sensory and motor function below the level of the injury. - Incomplete cord involvement results in a mixed loss of voluntary motor activity and sensation and leaves some tracts intact. (ex: can feel touching pinky toe vs not feeling touch to big toe) .... The degree of sensory and motor loss depends on the level of the injury and the specific damaged nerve tracts.

classification of spinal cord injury: major mechanism of injury

- The major mechanisms of injury are flexion, hyperextension, flexion-rotation, extension-rotation, and compression. - The flexion-rotation injury is the most unstable because ligaments that stabilize the spine are torn. This injury most often contributes to severe neurologic deficits.

clinical manifestations

- The manifestations of SCI are generally related to the direct result of trauma that causes cord compression, ischemia, edema, and possible cord transection. - Manifestations of SCI are related to the level and degree of injury. - The patient with an incomplete injury may demonstrate a mixture of manifestations. - Sequelae more serious with higher injury

manifestations of autonomic hyperreflexia

- The most common precipitating cause of autonomic hyperrreflexia is a distended bladder or rectum. - However, autonomic hyperreflexia can be caused by any sensory stimulation, including contraction of the bladder or rectum, stimulation of the skin, or stimulation of the pain receptors. - Manifestations include ... hypertension (up to 300 mm Hg systolic) ... throbbing headache ... marked diaphoresis above the level of the injury ... bradycardia (30 to 40 beats/minute). o Piloerection (goose bumps, result of pilomotor spasm) o Flushing of skin above level of injury o Blurred vision or spots in visual field o Nasal congestion o Anxiety o Nausea

Planning: overall goals

- The overall goals are that the patient with an SCI will (1) maintain an optimal level of neurologic functioning (2) have minimal or no complications of immobility (3) learn new skills, gain new knowledge, and acquire new behaviors to be able to care for self or successfully direct others to do so .... return to home at an optimal level of functioning.

autonomic dysreflexia

- The return of reflexes after the resolution of spinal shock means patients with an injury level at T6 or higher may develop autonomic hyperrreflexia. - Autonomic hyperreflexia (also known as autonomic dysreflexia) is a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system. - It involves stimulation of sensory receptors below the level of the SCI. The intact sympathetic nervous system below the level of the injury responds to the stimulation with a reflex arteriolar vasoconstriction that increases BP, but the parasympathetic nervous system is unable to directly counteract these responses via the injured spinal cord. - Baroreceptors in the carotid sinus and aorta sense the hypertension and stimulate the parasympathetic system. - This results in a decrease in heart rate, but visceral and peripheral vessels do not dilate because efferent impulses cannot pass through the injured spinal cord.

clinical manifestations: integumentary system

- The risk for skin breakdown over bony prominences in areas of decreased or absent sensation is a major consequence of immobility related to SCI. Pressure ulcers can occur quickly and can lead to major infection and sepsis. - Poikilothermism is the adjustment of the body temperature to the room temperature. It occurs in SCI because interruption of the sympathetic nervous system prevents peripheral temperature sensations from reaching the hypothalamus. - Spinal cord disruption is also marked by decreased ability to sweat or shiver below the level of the injury, which also affects the ability to regulate body temperature. - The degree of poikilothermism depends on the level of injury. High cervical injuries are associated with a greater loss of the ability to regulate temperature than are thoracic or lumbar injuries.

Etiology and Pathophysiology of Primary Injury Spinal Cord Injury due to cord compression by...

- The spinal cord is wrapped in tough layers of dura and is rarely torn or transected by direct trauma. - Spinal cord injury can result from cord compression by bone displacement, interruption of blood supply to the cord, or traction resulting from pulling on the cord. - Penetrating trauma, such as gunshot and stab wounds, can cause tearing and transection. - The initial mechanical disruption of axons as a result of stretch or laceration is referred to as the primary injury.

reflexes

-Once spinal cord shock is resolved, the return of reflexes may complicate rehabilitation. - Lacking control from the higher brain centers, reflexes are often hyperactive and produce exaggerated responses. - Penile erections can occur from a variety of stimuli, causing embarrassment and discomfort. - Spasms ranging from mild twitches to convulsive movements below the level of the injury may also occur. - The patient or caregiver may interpret this reflex activity as a return of function. Tactfully explain the reason for the activity. Inform the patient of the positive use of these reflexes in sexual, bowel, and bladder retraining. - Spasms may be controlled with the use of antispasmodic drugs such as baclofen (Lioresal), dantrolene (Dantrium), and tizanidine (Zanaflex). Botulism toxin injections may also be given to treat severe spasticity.

the effect of SCI on female sexual response is less clear.

- The woman of childbearing age with an SCI usually remains fertile. - The injury does not affect the ability to become pregnant or to deliver normally through the birth canal. - Menses may cease for as long as 6 months after injury. - If sexual activity is resumed, protection against an unplanned pregnancy is needed. - A normal pregnancy may be complicated by UTI, anemia, and autonomic hyperreflexia. - Because uterine contractions are not felt, a precipitous delivery is always a danger. - Care should be taken not to dislodge an indwelling catheter during sexual activity. If an external catheter is used, instruct the patient to refrain from fluids and remove the catheter before sexual activity. The bowel program should include evacuation the morning of sexual activity. - Encourage the patient to inform the partner that incontinence is always possible. The woman may need a water-soluble lubricant to supplement diminished vaginal secretions and facilitate vaginal penetration.

sensory deprivation

- To prevent sensory deprivation, compensate for the patient's absent sensations by stimulating the patient above the level of injury. - Conversation, music, and interesting foods can be a part of the nursing care plan. - If the head of the bed must remain flat, provide prism glasses to help the patient read and watch television. - Help the patient avoid withdrawing from the environment. Promote adequate rest and sleep and assess for changes in mood. Depression is a common problem.

clinical manifestations: urinary system

- Urinary dysfunction occurs in the majority of patients following SCI. - Neurogenic bladder describes any type of bladder dysfunction related to abnormal or absent bladder innervation. After spinal cord shock resolves, depending on the completeness of the SCI, patients usually have some degree of neurogenic bladder. Normal voiding requires nervous system coordination of urethral and pelvic floor relaxation, with simultaneous contraction of the detrusor muscle. - Depending on the injury, a neurogenic bladder may (1) have no reflex detrusor contractions (flaccid, hypotonic), (2) have hyperactive reflex detrusor contractions (spastic), or (3) lack coordination between detrusor contraction and urethral relaxation (dyssynergia). - Common problems with a neurogenic bladder include urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux of urine into the kidneys.

Clinical manifestations of urinary system: acute and postacute phases

- Urinary retention is a common development in acute SCIs and spinal shock. - While the patient is in spinal shock, the bladder is atonic, becomes overdistended, and fails to empty. An indwelling catheter is inserted to drain the bladder. - In the postacute phase of SCI, the bladder may become hyperirritable. A loss of inhibition from the brain resulting in reflex emptying and failure to store urine (urinary incontinence.

clinical manifestations: peripheral vascular problems

- Venous thromboembolism (VTE) is a common problem accompanying SCI during the first 3 months. - Detecting a DVT may be difficult in a person with an SCI because the usual signs and symptoms, such as pain and tenderness, will not be present. - Pulmonary embolism is one of the leading causes of death in patients with SCI.

etiology and pathophysiology of secondary injury

- Within 24 hours, permanent damage may occur because of edema - Extent of damage and prognosis for recovery most accurately determined 72 hours or more after injury - Greatest improvement occurs in first 3 to 6 months following injury - Within 24 hours or less, permanent damage may occur because of the development of edema. Edema secondary to the inflammatory response is particularly harmful because of limited space for tissue expansion. Thus compression of the spinal cord occurs. Edema extends above and below the injury, thus increasing the ischemic damage. - Because secondary injury progresses over time, the extent of the injury and prognosis for recovery are most accurately determined at least 72 hours or more after injury. Important signs of improvement include muscular strength and pinprick sensation below the level of injury. The greatest improvement occurs in the first 3 to 6 months following injury, and can continue over years in 20% of cases.

spinal shock characterization

- look for sphincter tone as long as reflexes

Mechanisms of injury

Many situations may produce these injuries. This only shows some examples. A, Flexion injury of the cervical spine ruptures the posterior ligaments. B, Hyperextension injury of the cervical spine ruptures the anterior ligaments. C, Compression fractures crush the vertebrae and force bony fragments into the spinal canal. D, Flexion-rotation injury of the cervical spine often results in tearing of ligamentous structures that normally stabilize the spine.