Med-Surg Chapter 39 Caring for Clients With Head and Spinal Cord Trauma

Spinal Cord Injury Tetraplegia

(a term that replaces quadriplegia), refers to weakness, paralysis, and sensory impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic (T1) vertebrae. Muscle spasms occur spontaneously, but they are not evidence that the client is regaining motor function. Tetraplegics may return home but require extensive physical care.

Supratentorial Cranial Surgery

(above the tentorium) approach is made through a scalp incision at the site where a particular cerebral lobe requires surgical access.

Infratentorial Cranial Surgery

(below the tentorium) approach provides an opening to the midbrain and structures of the brain stem. The incision is made at the back of the head with the client in a sitting position.

CEREBRAL HEMATOMAS

A cerebral hematoma is bleeding within the skull. The accumulation of blood forms an expanding lesion. People at high risk for cerebral hematomas are those receiving anticoagulant therapy or those with an underlying bleeding disorder, such as hemophilia, thrombocytopenia, leukemia, and aplastic anemia

CONCUSSION Pathophysiology and Etiology

A concussion results from a blow to the head that jars the brain. The force of the blow causes temporary neurologic impairment but no immediate evidence of serious damage to cerebral tissue. When concussions occur repetitively, they can result in chronic traumatic encephalopathy. Cumulative and sustained concussions, such as those that are sports related, can result in dementia, depression, Parkinson's disease, and early onset Alzheimer's

CONTUSION

A contusion is more serious than a concussion and leads to gross structural injury to the brain.

Pathophysiology and Etiology Spinal Cord Injury

Accidents (vehicular); Violence, Spinal shock (areflexia): Poikilothermia, Autonomic dysreflexia (hyperreflexia)

PHARMACOLOGIC CONSIDERATIONS Hematoma

An osmotic diuretic such as mannitol may be prescribed to reduce ICP after intracranial surgery. Inspect the mannitol vial before use. If the solution contains crystals, warm the vial in hot water and shake it vigorously. Do not administer the drug if crystals are in the solution.

Basilar Skull Fractures complications

Because basilar skull fractures tend to tear the dura, rhinorrhea, (leaking of CSF from the nose),or otorrhea, (leakage of CSF from the ear), may occur. In some cases, periorbital ecchymosis, referred to as raccoon eyes, or bruising of the mastoid process behind the ear, called Battle's sign, can be present. Conjunctival hemorrhages can occur as well. Injury to the brain tissue may result in seizures. Epilepsy can develop as a sequela of head injury.

Types of Skull Fractures Comminuted

Bone splintered into fragments

Types of Skull Fractures Depressed

Broken bone pushed inward toward the brain

Spinal Cord Injury L1-L2 COMMON SENSORY EFFECTS: No sensation below lower abdomen;

COMMON MOTOR EFFECTS: Hip adduction impaired some sensation in inner thighs FUNCTIONAL ABILITIES: Drive a car with hand controls

Spinal Cord Injury L3-L5 COMMON SENSORY EFFECTS:No sensation below upper thighs

COMMON MOTOR EFFECTS: Knee and ankle movement impaired FUNCTIONAL ABILITIES: Walk with support of walker or crutches

Spinal Cord Injury C4-C5 COMMON SENSORY EFFECTS: No sensation below clavicle

COMMON MOTOR EFFECTS: Shoulder elevation possible; ventilation support required. Breathe with ventilator assistance or possibly independently FUNCTIONAL ABILITIES: Use a power wheelchair with sip-and-puff or hand control. Drink independently using a long straw and bottle

Spinal Cord Injury C6-C8 COMMON SENSORY EFFECTS: Some sensation in arms and thumb; sensation in chest impaired

COMMON MOTOR EFFECTS: Some elbow, upper arm, and wrist movement; can do diaphragmatic breathing FUNCTIONAL ABILITIES: Eat, groom, bathe, and attain bed mobility with assistive devices Transfer from bed to chair using a slide board. Perform self-catheterization (males); more difficult for females. Use manual wheelchair in flat environment. Drive with hand controls

Spinal Cord Injury T1-T6 COMMON SENSORY EFFECTS: No sensation below midchest

COMMON MOTOR EFFECTS:Paralysis below waist; control of hands; abdominal breathing FUNCTIONAL ABILITIES: Perform personal care and household activities independently Use manual wheelchair, including up and down curbs Stand between bars with leg splints

Spinal Cord Injury S1-S5 COMMON SENSORY EFFECTS: No sensation in perineum

COMMON MOTOR EFFECTS:Varying degrees of bowel/bladder control and sexual function FUNCTIONAL ABILITIES: Walk normally without assistive devices Control bladder, bowel, and sexual functions

NUTRITION NOTES THE CLIENT WITH A SPINAL CORD INJURY

Clients have varying nutritional needs, depending on the nerves injured and the resulting complications. Tetraplegic and paraplegic clients have lower caloric requirements because their energy expenditure is reduced, and their caloric intake should be adjusted to avoid excessive weight gain. Nutrient needs, however, are stable or higher, depending on complications. For example, prolonged immobility promotes nitrogen excretion, causing an increased protein requirement. Clients with skin breakdown have increased requirements for protein (meat, milk, supplements), vitamin C (citrus fruit and juices, strawberries, "greens," tomatoes), and zinc (meat, seafood, milk, egg yolks, legumes, whole grains), which are needed to promote healing. Extended immobility accelerates calcium loss from bone, leading to hypercalcemia and hypercalciuria. A high fluid intake (up to 3 L/day) helps dilute urine, thus preventing the precipitation of calcium renal stones.

Spinal Cord Pain

Clients with spinal cord injuries may experience one or more types of pain—that which is nociceptive and that which is neuropathic. Neuropathic pain, which develops in approximately 66% of those with a spinal cord injury, is caused by an abnormal communication between spinal nerves and the brain. It is described with words such as sharp, shooting, burning, stinging, tearing, bursting, and stabbing. Some experience allodynia, pain from a stimulus that does not normally cause pain, and hyperalgesia, an increased response to a stimulus that is normally a little painful.

Preoperative Nursing Care Hematoma Surgery

Hair removal; Vital signs; Neurologic assessment; Antiembolism stockings, Restrict: Fluids administers prescribed medications, (anticonvulsant phenytoin (Dilantin) osmotic diuretic, and corticosteroids. If indicated, inserts an indwelling urethral catheter and intravenous (IV) line.

CONTUSION Assessment Findings

Hypotension; Rapid, weak pulse; Shallow respirations; Pale, clammy skin, Temporary amnesia, Effects of permanent brain damage, Diagnostic Findings: Skull radiography; CT scan; MRI

Surgical Management SPINAL NERVE ROOT COMPRESSION

If conservative therapy fails to relieve symptoms of a herniated disk with spinal nerve root compression, surgery is considered. Procedures for relieving spinal nerve root compression include the following:

Medical Management Hematoma

In some cases, the body walls off and absorbs a subdural hematoma with no treatment. However, a rapid change in LOC and signs of uncontrolled increased ICP indicate a surgical emergency.

Spinal Cord Assessment Findings Medical and Surgical Management

Initially, the head and back are immobilized mechanically with a cervical collar and back support. An IV line is inserted to provide access to a vein if shock develops. Vital signs are stabilized. Corticosteroids are given to reduce spinal cord edema, thereby decreasing potential damage to injured nerves. Riluzole (Rilutek), a neuroprotective drug that blocks the neurotoxic effects of glutamate, may be administered. BA-210 (Cethrin), a U.S. Food and Drug Administration (FDA)-approved orphan drug that is currently involved in phase III clinical trials, has shown evidence of promoting increased motor and neurologic recovery after acute spinal cord injury.

Types of Skull Fractures Simple

Linear crack without any displacement of the pieces

Differences in Cerebral Hematomas Intracerebral

Location: Blood collects within the brain. Signs & Symptoms; Client shows classic signs of increased ICP: headache, vomiting, seizures, posturing, hyperthermia, irregular breathing.

Nursing Care After Specific Spinal Surgeries Postlumbar Laminectomy or Diskectomy With Spinal Fusion

Logroll when turning client every 2 hours; maintain alignment at all times. Caution client to avoid turning self. Teach client to avoid twisting or jerking the back, sitting during the first week and prolonged sitting thereafter (client should use a straight-backed chair and not slump), and bending from the waist (client should bend from the knees and hips).

CONCUSSION Nursing Management

Neurologic assessment. Close observation: Signs of IICP Client instruction: Contact physician, return to ED if symptoms of IICP occur

SPINAL NERVE ROOT COMPRESSION Pathophysiology and Etiology

Pressure on spinal nerve roots results from trauma, herniated (ruptured) intervertebral disks, and tumors of the spinal cord and surrounding structures. Stress caused by poor body mechanics, age, or disease weakens an area in the vertebra, causing the spongy center of the vertebrae, the nucleus pulposus, to swell and herniate. This condition is commonly called a slipped disk; the displacement puts pressure on the nearby nerves. Pain along the distribution of the nerve root is common. Actions that increase pressure intensify the pain. Weakness and changes in sensation occur. The symptoms intensify with increasing nerve root compression.

Complications Spinal Cord Injury

Respiratory arrest and spinal shock are immediate complications of spinal cord injury. Long-term complications include autonomic dysreflexia, pressure ulcers, respiratory infections, urinary and fecal impairment, spasticity and contractures, weight gain or loss, calcium depletion, urinary calculi, sexual dysfunction, and pain.

Nursing Management Skull Fractures

Signs of head trauma; Drainage from the nose or ear. Halo sign. Neurologic assessments; Hourly: LOC; Pupil, motor, and sensory status. Every 15 to 30 minutes: Vital signs Prepare for the possibility of seizures.

Medical and Surgical Management Skull Fractures

Simple fracture: Bed rest; Observation for IICP. Lacerated scalp: Clean, débride, and suture. Depressed skull fracture Craniotomy; Antibiotics, Osmotic diuretics; Anticonvulsants

Signs and Symptoms Skull Fracture

Simple skull fractures produce few, if any, symptoms and heal without complications. The client may complain of a localized headache. A bump, bruise, or laceration may be visible on the scalp. Symptoms depend on the area of the brain that has been injured.

Diagnostic Findings Skull Fractures

Skull radiographs, CT scan, or MRI show brain tissue injuries such as a fracture line or embedded skull fragments.

Postoperative Nursing Care Hematoma Surgery

Supine or side-lying position. Regular monitoring; Observe for IICP. Control thrombus or embolus; Cerebral edema neurologic assessments every 15 to 30 minutes monitor the client's body temperature closely

CONCUSSION Medical Management

Temporary inactivity, Mild analgesia Observation for neurologic complications

Assessment Findings Hematoma

The rapidity and severity of neurologic changes depend on the location, the rate of bleeding and size of the hematoma, and the effectiveness of autoregulation.

CONTUSION Medical Management

The unstable client's vital functions are supported with drug therapy and mechanical ventilation if necessary.

SPINAL NERVE ROOT COMPRESSION

There are two basic types of spinal nerve root compression: intramedullary lesions that involve the spinal cord and extramedullary lesions that involve the tissues surrounding the spinal cord. The most common site of nerve root compression is at the level of the three lower lumbar disks; however, nerve root compression also occurs in the cervical spine.

Spinal Cord Functional Electrical Stimulation

While the client is undergoing physical and occupational therapy, functional electrical stimulation (FES) may be used to activate paralyzed muscles and prevent muscle atrophy. FES is used in a variety of ways. Surface or implanted electrodes attached to the quadriceps, hamstring, and gluteal muscles help paralyzed legs pedal a stationary bicycle, stand, or walk. Electrodes attached to the forearm and flexors and extensors of the hand help the hand open and close to allow grasping of objects, reduce stiffness, maintain or increase range of motion, and increase circulation. FES is also being used to restore bladder continence by stimulating the sacral nerves, causing contraction of the detrusor muscle necessary for bladder emptying. In addition, FES improves breathing; when the electrodes are implanted in respiratory muscles, they reduce the need for mechanical ventilation.

Complications Spinal Cord Injury Autonomic Dysreflexia (Hyperreflexia)

an exaggerated sympathetic nervous system response in people with spinal cord injuries above T6. It can occur suddenly at any time after spinal shock subsides. Characteristics of this acute emergency are as follows:Severe hypertension, Slow heart rate, Pounding headache, Nausea, Blurred vision, Flushed skin, Sweating Goosebumps (erection of pilomotor muscles in the skin) Nasal stuffiness, Anxiety, Uncontrolled autonomic dysreflexia can lead to seizures, stroke, and death.

Hematoma Surgery Complications

associated with intracranial surgery include cerebral edema, infection, neurogenic shock, fluid and electrolyte imbalances, venous thrombosis (especially in the arms and legs), increased ICP, seizures, leakage of cerebrospinal fluid (CSF), and stress ulcers and hemorrhage

Spinal Cord Weight Change

clients tend to lose weight initially but gain weight after weeks, months, and years of inactivity. Clients must be taught how to make healthy food choices by selecting foods that are both relatively low in calories as well as nutritious.

Surgical Management Hematoma

consists of drilling holes (burr holes) in the skull to relieve pressure, removing the clot, and stopping the bleeding. If the source of bleeding cannot be located by means of burr holes, more invasive surgery is performed. Intracranial surgery consists of three possible procedures: craniotomy, craniectomy, and cranioplasty.

Open Head Injuries

create a potential for infection because they expose internal brain structures to the environment. They are less likely to produce rapid increased ICP because the opening gives the brain some room to expand as pressure increases.

Spinal Cord Spasticity

experience intermittent spasticity, uncontrolled jerking movements, muscle stiffness, and rigidity. Spasticity occurs because nerve signals between the brain and nerves below the level of injury are interrupted. Instead of a coordinated effort, an unregulated spinal reflex may cause an overly active muscle response. Muscle spasms pull the joints into a shortened position, increasing the potential for skin impairment and contractures.

SPINAL NERVE ROOT COMPRESSION Chemonucleolysis

injection of the enzyme chymopapain into the nucleus pulposus to shrink or dissolve the disk, which then relieves pressure on spinal nerve roots

SKULL FRACTURES

is a break in the continuity of the cranium. The most common types are simple, depressed, or comminuted fractures .

A Craniotomy

is a surgical opening of the skull to gain access to structures beneath the cranial bones. It is performed to remove a blood clot or tumor, stop intracranial bleeding, or repair damaged brain tissues or blood vessels.

SPINAL NERVE ROOT COMPRESSION Diskectomy

removal of the ruptured disk

CEREBRAL HEMATOMAS Pathophysiology and Etiology

result from head trauma or cerebral vascular disorders. The types are epidural hematoma, subdural hematoma, and intracerebral hematoma. Bleeding increases the volume of brain contents and ICP, which disrupts blood flow and causes the brain to become ischemic and hypoxic.

Spinal Cord Treadmill Training

which is also known as weight-supported ambulation, is suitable only for those clients with an incomplete spinal cord injury (i.e., some remaining connections between the spinal cord and brain). Treadmill training increases the function within the remaining connections. The client is suspended in a harness above the treadmill, and therapists move the person's legs in a walking fashion

Spinal Cord Assessment Findings Medical and Surgical Management Secondary

After the client is stabilized, the injured portion of the spine is further immobilized using a cast or brace or surgical intervention. Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. Additional weight is added over the next few days to increase the space between the vertebrae and move them into correct alignment. A turning frame is used to change the client's position without altering the alignment of the spine. Depending on the extent of the injury, surgery may be necessary to remove bone fragments, repair dislocated vertebrae, and stabilize the spine. The vertebrae are fused with bone obtained from the iliac crest or stabilized with a steel rod. External immobilization with a brace or cast often is necessary.

Spinal Cord Long-Term Management

After the initial period of therapeutic care, the focus of treatment turns to rehabilitative and restorative measures.

Nursing Management Head injury

All head injuries are emergencies Nurse's role: History; Neurologic examination; Vital signs; LOC. Limb movement; Pupil reactions Trauma: Head examination; Respiratory status, Neurologic changes

Spinal Cord Urinary Impairment

Although the kidneys continue to produce urine, the muscles of the bladder and urinary sphincter may no longer be controlled voluntarily. This may result either in reflexive emptying when the bladder fills with urine or failure to empty, which causes urine to reverse-fill the ureters and kidney pelvises as the bladder becomes overly distended. Bacteria are likely to colonize the bladder because clients may not completely empty it.

Pathophysiology and Etiology Intracerebral

An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm.

Spinal Cord Injury T7-T12 COMMON SENSORY EFFECTS: Varying degrees of sensation below waist

COMMON MOTOR EFFECTS: Varying degrees of trunk and abdominal control FUNCTIONAL ABILITIES: Transfer from bed to wheelchair independently. Propel wheelchair over uneven surfaces and rough terrain. Care for bowel and bladder independently Perform light housekeeping and meal preparation Balance on legs. Walk with splints or long leg braces

Spinal Cord Injury C1-C3 COMMON SENSORY EFFECTS: Paralysis below neck;

COMMON MOTOR EFFECTS:impaired breathing; bowel and bladder incontinence; sexual dysfunction FUNCTIONAL ABILITIES:Breathe with assistance of ventilator, Swallow and speak Use a power wheelchair with movement of head and neck control, Operate computer or appliances, such as TV or lights, using voice-activation device or mouth stick

PHARMACOLOGIC CONSIDERATIONS SPINAL NERVE ROOT COMPRESSION

Clients who take a skeletal muscle relaxant or tranquilizer for a herniated intervertebral disk, back strain, or spasms of the back muscles may experience drowsiness and dizziness. They require assistance with ambulatory activities and should not drive or operate equipment.

Spinal Cord Tendon Transfer Surgery

Clients with injuries from vertebrae C5 through T1 have weak or nonfunctioning wrists and hands and may benefit from tendon transfer surgery. Tendon transfer is a surgical procedure that repositions tendons from a working muscle to a paralyzed one. The goal of the surgery is to restore a pinching motion with the thumb and flexion of the wrist. The presurgical preparation and postsurgical rehabilitation are both demanding for clients; strengthening and range-of-motion exercises and physical therapy are required.

SKULL FRACTURES Pathophysiology and Etiology

Head injuries: Open; Closed Open head injury, in which the scalp, bony cranium, and dura mater are exposed, or it may be a closed head injury, in which an intact layer of scalp covers the fractured skull.

HEAD INJURIES

Injury to the head can cause concussions, contusions, hematomas, or skull fracture.

Spinal Cord Nursing Process Assessment

Injury; Treatment at scene, Neurologic assessment: Document findings, Vital signs; Respiratory status Movement, sensation below injury level Signs, Worsening neurologic damage, Respiratory distress Spinal shock

Nursing Care After Specific Spinal Surgeries Postcervical Diskectomy

Keep a cervical collar in place at all times; do not remove without a physician's order. Instruct client to keep the neck straight in midline position until healing occurs. Support client's head, neck, and upper shoulders when moving from a lying to sitting to standing position or when getting into and out of a chair. Observe for Horner's syndrome, a complication following anterior cervical diskectomy from cervical sympathetic nerve damage. Manifestations are lid ptosis (drooping), constricted pupil, regression of eye in the orbit, and lack of perspiration on one side of the face.

Differences in Cerebral Hematomas Epidural

Location:Arterial blood collects between the skull and dura. Signs & Symptoms: Alert after initial unconsciousness but then becomes increasingly lethargic before lapsing into coma: headache, ipsilateral (same side as injury) pupil changes, and contralateral (opposite side to injury) hemiparesis (weakness or paralysis).

Differences in Cerebral Hematomas Subdural

Location:Venous blood collects between the dura and subarachnoid layers. Signs & Symptoms:Deterioration in LOC is progressive. There are ipsilateral(same side as injury)pupil changes, decreased extraocular muscle movement, and contralateral(opposite side to injury) hemiparesis, with periodic episodes of memory lapse, confusion, drowsiness, and personality changes.

Spinal Cord Cell Transplantation

Nerve cells in the central nervous system, which includes the spinal cord, lose the ability to regenerate when injured. Consequently, there is a focus on finding cells that, when transplanted, can replace the nerve cells that have been damaged. Stem cells are pluripotent, that is, they can differentiate into a variety of cell types, including spinal nerves. However, use of embryonic stem cells is currently politically and ethically controversial. Autologous stem cells from bone marrow have been collected from clients and reimplanted in the area surrounding the injured spinal cord with promising results. Other researchers are investigating the therapeutic effectiveness of using host stem-like Schwann cells and olfactory ensheathing cells harvested from the mucosa of nasal tissue for promoting nerve regeneration and growth of axons and restoring function when implanted into the injured spinal cord.

GERONTOLOGIC CONSIDERATIONS Skull Fractures

Nurses should assess older adults for risk of falls and implement appropriate preventative interventions. However, if a fall occurs, the older adult should be assessed for skull fracture.

CONTUSION Nursing Management

Periodically monitor, LOC; Neurologic changes; Respiratory distress; Signs of IICP; Vital signs Head injury prevention: Seatbelts; Infant car seats; Protective headgear; Neck restraints; No alcohol or drugs while driving

Spinal Cord Assessment Findings PHARMACOLOGIC CONSIDERATIONS

Riluzole affects the body's ability to fight infection, so white blood cell counts should be measured periodically while taking this drug. Also, riluzole should be taken on an empty stomach, 1 hour before or 2 hours after meals. Clients should avoid eating or drinking caffeine-containing products and charcoal-broiled foods.

SPINAL NERVE ROOT COMPRESSION Assessment Findings

Symptoms vary depending on the cause of compression and level involved. They usually include weakness, paralysis, pain, and paresthesia (numbness, tingling). When a herniated disk in the lumbar region compresses the sciatic nerve, the client describes feeling pain down the buttocks and into the posterior thigh and leg. Physical examination reveals weakness or paralysis of the extremity innervated by the compressed nerve. If a nerve in the lumbar or sacral area is affected, the client experiences pain when lying supine and lifting the leg without bending the knee. The pain increases when straining, coughing, or lifting a heavy object. Walking and sitting become difficult. Spinal radiography, CT, MRI, myelography, and electromyography (EMG) show displacement or herniation of an intervertebral disk, tumor, or bleeding around the nerve root.

Spinal Cord Assessment Findings

The degree and location of the spinal cord injury determine the immediate symptoms. There is pain in the affected area, difficulty breathing, numbness, and paralysis. If the injury is high in the cervical region, respiratory failure and death occur because the diaphragm is paralyzed. If the cord is completely severed, permanent loss of function below the level of the injury occurs. If damage to the cord is minimal, some function is maintained. A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, MRI, and CT scan show evidence of fracture or compression of one or more vertebrae, edema, or a hematoma.

SPINAL NERVE ROOT COMPRESSION Nursing Management

The nurse performs a neurologic examination and notes any limitation of motion and the type of movement that causes pain. For clients being treated conservatively, the nurse uses a firm mattress or applies a bed board because a firm surface supports the spine and promotes alignment. The nurse maintains the client on bed rest, placing him or her in semi-Fowler's position, with the knees and head slightly elevated to relieve lumbosacral pain. The nurse applies halo-vest traction. For intermittent pelvic or cervical skin traction, he or she attaches the skin device to the client, supports the weights, and lowers them gently to avoid a sudden and strong pull. The nurse reminds the client to roll from side to side without twisting the spine. When the client gets out of bed, the nurse reinforces the use of proper body mechanics. He or she advises clients with cervical nerve root compression to avoid extreme hyperextension of the neck and side-to-side rotation of the head. The nurse administers prescribed muscle relaxants and analgesics. He or she applies moist heat for no longer than 20 minutes but repeats several times a day. The nurse periodically evaluates the client's response to conservative therapy. It is important to note the activities and positions that increase pain and the gain or loss in motion or sensation since the previous observation. Comparison of current symptoms with those first exhibited provides an evaluation of response to therapy. It is important to note a change in symptoms when the client is removed from traction.

CLIENT AND FAMILY TEACHING HALO VEST MANAGEMENT

The nurse teaches the client as follows: Turn your whole body rather than trying to turn your head; you will not be able to look down. Do not drive a car. Walk only on level surfaces until you become accustomed to the vest; avoid stairs, curbs, and uneven terrain unless assistance is available. Take care getting in and out of vehicles to avoid bumping the halo and loosening the pins. Use a mirror to inspect the pin sites and as a guide while cleaning them. Clean the pin sites two to three times a day with cotton-tipped applicators saturated with hydrogen peroxide; remove loose crusts. Use a clean applicator after making a full circle around the pin site. Clip the hair that grows around the pin sites. Report pain, redness, drainage from pin sites, fever, or neck tingling or pain to the physician. Never independently adjust the vest if it becomes tight or loose; consult the physician. Pad the vest if it causes pressure or friction. Take sponge baths to maintain hygiene; seek assistance for areas you cannot reach such as around the anus. Use a dry shampoo or consult physician on how to shampoo hair without wetting the vest. Use pillows for support and comfort when sleeping. Wear loose-fitting clothing with wide necklines for ease in dressing. Wear shoes with flat heels that are easy to slip on and off.

Spinal Cord PHARMACOLOGIC CONSIDERATIONS

Various medications may be prescribed as muscle relaxants for clients who experience spasticity. Examples include benzodiazepines such as clonazepam (Klonopin); skeletal muscle relaxants such as baclofen (Lioresal) and dantrolene (Dantrium); and alpha-2 adrenergic agonists such as tizanidine (Zanaflex), a drug that increases inhibition of motor neurons. Botulinum toxin type A (Botox) is also injected into spastic muscles to loosen and relax them. Injections are repeated every 3-6 months.

SPINAL NERVE ROOT COMPRESSION Medical Management

When a client has a herniated intervertebral disk, conservative therapy is tried first. Metastatic spinal cord tumors also are treated conservatively because removal is not feasible. A herniated cervical disk is treated by immobilizing the cervical spine with a cervical collar or brace. Later, as inflammation subsides, the client wears the collar or brace intermittently when walking or sitting. Bed rest with a firm mattress and bed board is used for clients with a lumbar herniated disk. Skin traction, which can be applied in the home, is used to decrease severe muscle spasm as well as increase the distance between adjacent vertebrae, keep the vertebrae correctly aligned, and, in many instances, relieve pain. Treatment relieves symptoms for an extended period. Hot, moist packs are used to treat muscle spasm. Skeletal muscle relaxants, such as carisoprodol (Rela) and chlorzoxazone (Paraflex), help clients with a herniated intervertebral disk. Diazepam (Valium), a tranquilizer, is used for its twofold effect: to reduce anxiety associated with the pain of a herniated disk and to relax the skeletal muscle. Drugs such as aspirin, phenylbutazone (Butazolidin), and corticosteroids are used to treat inflammation. Reducing inflammation and muscle spasm helps ease pain, but additional analgesics are given to control pain. Clients with an inoperable spinal cord tumor are given analgesics to maintain comfort.

Spinal Cord Urinary Calculi

are at risk for forming calculi (stones) in the kidneys or bladder at a higher rate than the general population. It is assumed that crystallization is associated with reabsorption of calcium by the kidneys, urinary retention, and immobility. Bladder calculi tend to occur soon after injury, whereas renal calculi can develop both soon after the injury and years later.

Basilar Skull Fractures

are located at the base of the skull. Trauma in this location is especially dangerous because it can cause edema of the brain near the origin of the spinal cord (foramen magnum), interfere with circulation of CSF, injure nerves that pass into the spinal cord, or create a pathway for infection between the brain and middle ear, which can result in meningitis.

Spinal Cord Calcium Depletion

clients experience demineralization of their bones because physical activity is one mechanism for maintaining bone density. The loss of muscle force contributes as well. This places clients at high risk for fractures from falls or even activities of daily living as well as the consequences of hypercalciuria such as renal and bladder stones. Preventive methods include administering calcium and vitamin D supplements and ossification agents such as bisphosphonates, calcitonin, and selective estrogen receptor modulators. Functional electrical stimulation, which is discussed later, may be helpful to increase bone density.

Spinal Cord Fecal Impairment

clients may have no urge to defecate and may be prone to fecal accumulation within the bowel. The connection between the spinal cord nerves and muscles needed for bowel elimination may be severed, or the rectal sphincter may not dilate to allow the passage of stool. In either case, there is a risk of fecal impaction.

Complications Spinal Cord Injury Spinal Shock (Areflexia)

is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury. It is characterized by immediate loss of all cord functions below the point of injury. In addition to paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. If the level of injury is in the cervical or upper thoracic region, respiratory failure can occur. Bowel and bladder distention develop. The client does not perspire below the level of injury, which impairs temperature control. The client manifests poikilothermia, body temperature of the environment. Spinal shock may persist for 1 week to months until the body adjusts to the damage imposed by the injury. Until then, vital functions require medical support.

Spinal Cord Neuropathic pain

is long lasting and difficult to treat. Symptomatic pharmacotherapy is the mainstay of treatment. Currently, pain relief involves medications such as opioid and nonopioid analgesics, antidepressants such as duloxetine (Cymbalta) that are known to relieve pain, anticonvulsants such as pregabalin (Lyrica), muscle relaxants such as baclofen (Lioresal), antispasmodics such as tizanidine (Zanaflex), and topical lidocaine patch (Lidoderm). The results range from partially and transiently effective to totally ineffective, which has led to research for more efficacious treatment. One approach involves drugs that will target the glutamate release pathway, and another proposes a single spinal injection of fibronectin, a naturally produced glycoprotein. Drug therapy may be combined with psychological treatments such as relaxation techniques, biofeedback, self-hypnosis, cognitive restructuring, and individual psychotherapy.

A Craniectomy

is removal of a portion of a cranial bone. The portion of the bone removed during craniectomy may be implanted in the client's abdomen awaiting later replacement.

SPINAL CORD INJURIES

is serious and sometimes fatal. The cervical and lumbar vertebrae are the most common sites of injury. Correct emergency management at the time of injury is crucial because moving the client incorrectly can permanently damage the spinal cord and the nerves that extend from it

Cranioplasty

is the repair of a defect in a cranial bone. As an alternative, a metal or plastic plate or wire mesh is used to replace the removed bone or to reinforce a defect in a cranial bone.

Respiratory Infections Related to Spinal Cord Injury

may not be able to breathe normally and cough sufficiently to clear secretions. The spinal nerves that transmit impulses to the diaphragm, intercostal muscles, neck, and abdominal muscles may no longer function. Consequently, the risk of inadequate ventilation and pneumonia is high.

SPINAL NERVE ROOT COMPRESSION Laminectomy

removal of the posterior arch of a vertebra to expose the spinal cord. The surgeon can remove whatever lesion is causing compression: a herniated disk, tumor, blood clot, bone spur, or broken bone fragment.

SPINAL NERVE ROOT COMPRESSION Diskectomy with Spinal Fusion

removal of the ruptured disk followed by grafting a piece of bone taken from another area, such as the iliac crest, onto the vertebra to fuse the vertebral spinous process. Bone also may be obtained from a bone bank.

Spinal Cord Contractures

result from the inability to move a joint freely because of an imbalance between opposing muscle groups; a stronger muscle overpowers a weaker one. After spinal cord injury, this may be a consequence of muscle spasticity. Contractures such as flexed elbows, wrists, hips, or knees; clenched fists; and thumb-in-palm may develop any time after the injury

CONTUSION Pathophysiology and Etiology

result in bruising and or hemorrhage of superficial cerebral tissue. When head is struck directly, injury to the brain is called a coup injury. Dual bruising results if force is strong enough to send the brain ricocheting to the opposite side of the skull, called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion.

Pathophysiology and Etiology Subdural

results from venous bleeding, with blood gradually accumulating in the space below the dura. Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury. Clients with subacute and chronic subdural hematomas become symptomatic after 24 hours and up to 1 week later.

SPINAL NERVE ROOT COMPRESSION Spinal Fusion

stabilizes the vertebrae weakened by degenerative joint changes, such as osteoarthritis, and by laminectomy. It results in a firm union; the client loses mobility and must become accustomed to a permanent area of stiffness. When a portion of the lumbar spine is fused, the client usually does not feel the stiffness after a short time because motion increases in the joints above the fusion. Motion is more limited when the area of fusion is in the cervical spine. Spinal fusion also is performed for spinal cord tumors, fractures and dislocations of the spine, and Pott's disease (tuberculosis of the spine).

Pathophysiology and Etiology Epidural

stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.

CONCUSSION Assessment Findings

the client may experience a brief lapse of consciousness, with temporary disorientation, headache, blurred or double vision, emotional irritability, and dizziness. Skull (X-ray) (CT) scan, and (MRI) initially rule out a more serious head injury.

Complications Spinal Cord Injury Pressure Ulcers

up to 80% will develop them over the course of their lifetime. Risk factors include immobility, muscle atrophy, skin shear due to spasticity and traumatic transfer techniques, skin contact with urine and feces, loss of sensation, and altered nutrition.

Spinal Cord Injury Paraplegia

weakness or paralysis and compromised sensory functions of both legs and lower pelvis, occurs with spinal injuries below the T1 level.