Spinal Cord Injury
Sexuality Females
Fertility not usually affected -Pregnancy complicated -Risk for precipitous delivery Female sexual activity -Urinary catheterization -Planning for bowel evacuation prior -Incontinence -Lubrication
Syndromes Associated with Incomplete SCI
Five major syndromes are associated with incomplete injuries: •central cord syndrome •anterior cord syndrome •Brown-Séquard syndrome •cauda equina syndrome •conus medullaris syndrome This figure shows areas of damage for four of the five syndromes.
Clinical Manifestations Peripheral Vascular Problems
Venous thromboembolism (VTE) -Deep vein thrombosis (DVT) may be difficult to detect Pulmonary embolism -Leading cause of death
Classification of SCI
-Mechanism of injury -Level of injury -Degree of injury
Neurogenic Skin
-Prevention essential -Patient teaching -Comprehensive daily exam -Teach to reposition: At least every 2 hours while in bed, Every 15 to 20 minutes when in a chair -Pressure-relieving cushion or mattress -Adequate nutrition -Protect from thermal injury
Autonomic Dysreflexia Manifestations
-Hypertension (up to 300 mm Hg systolic) -Throbbing headache -Marked diaphoresis above level of injury -Bradycardia (30 to 40 beats/minute) -Piloerection -Flushing of skin above level of injury -Blurred vision or spots in visual field -Nasal congestion -Anxiety -Nausea
Evaluation
-Adequate ventilation -Adequate circulation and BP -Intact skin -Adequate nutrition -Bowel management -Bladder management -No autonomic hyperreflexia
Rehabilitation and Home Care
-Complex -Goal to function at highest level of wellness -Retraining focus -Interprofessional team effort: rehabilitation nurses, HCPs, physical therapists, occupational therapists, speech therapists, vocational counselors, psychologists, therapeutic recreation specialists, prosthetists, orthotists, case managers, social workers, and dietitians. -Organized around patient's goals and needs -Patient expected: To be involved in therapies, To learn self-care -Can be very stressful Frequent encouragement
Incomplete SCI Anterior Cord Syndrome
-Damage to anterior spinal artery → compromised blood flow -Typically results from acute compression of anterior portion of the spinal cord, often due to flexion injury. -Motor paralysis and loss of pain and temperature sensation below level of injury -Because posterior cord tracts are not injured, sensations of touch, position, vibration, and motion remain intact.
Incomplete SCI Central Cord Syndrome
-Damage to central spinal cord -Most commonly cervical region -More common in older adults -Motor weakness and sensory loss -Lower extremities are not usually affected -Dysesthetic burning pain in upper extremities
Incomplete SCI Brown-Séquard Syndrome
-Damage to one-half of cord -Typically results from penetrating injury to SC -Ipsilateral (same side as injury) loss of motor function and pressure, position, and vibration sense -Contralateral (opposite side of injury) loss of light touch, pain, and temperature sensation
Grief and Depression
-Depression is common -Overwhelming sense of loss -Loss of control -Adjustment more than acceptance -Wide fluctuation in emotions -Allow mourning while encouraging hope -Sympathy not helpful -Encourage patient participation -Consistency of care -Psychiatric consult if needed -Caregiver and family counseling -Support group
Spinal cord injury (SCI): Long-term issues remain
-Disruption in growth and development -Altered family dynamics -Economic loss -Round-the-clock care * •With improved treatment strategies, even the very young patient with an SCI can anticipate a long life. •The potential for disruption of individual growth and development, altered family dynamics, economic loss in terms of employment issues, and the high cost of rehabilitation and long-term health care make spinal cord injury a major problem. •Although many people with SCIs can care for themselves independently, those with the highest level of injury may require round-the-clock care at home or in a long-term care facility.
Autonomic Dysreflexia Nursing Interventions
-Elevate head (45 degrees), sit upright -Notify HCP -Assess for and remove cause -->Immediate catheterization -->Remove stool impaction if cause -->Remove constrictive clothing/tight shoes -Monitor and treat BP -Patient and caregiver teaching: to recognize the causes and symptoms of autonomic hyperreflexia. They must understand the life-threatening nature of this dysfunction and know how to relieve the cause, and activate the emergency response system (ERS) if needed.
SCI Mechanism of Injury
-Flexion -Hyperextension -Flexion-rotation: the most unstable because ligaments that stabilize the spine are torn. This injury most often contributes to severe neurologic deficits -Extension-rotation -Compression 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.
Clinical Manifestations of SCI
-Related to level and degree of injury -Incomplete → variable -Sequelae more serious with higher injury * •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.
Cauda Equina Syndrome
-Result from damage to cauda equine (lumbar and sacral nerve roots) -Asymmetrical distal weakness , patchy sensation in lower extremities -Flaccid paralysis of lower extremities -Complete loss of sensation in saddle area (legs and over buttocks, inner thighs, and backs of legs) -Areflexic (flaccid) bladder and bowel -Severe, radicular, asymmetric pain
Degree of Injury Conus Medullaris Syndrome
-Result from damage to conus medullaris (lowest portion of spinal cord) -Motor function in legs may be preserved, weak, or flaccid -Decrease in or loss of sensation in perianal area -Areflexic bladder and bowel -Impotence
Spinal cord injury (SCI)
-Trauma or damage to spinal cord -It can result in either a temporary or permanent alteration in the function of the spinal cord. -Highest in men ages 16-30 -↑ In older adults. This increase is related to people with SCI living longer and older age at the time of injury -↓Mortality
Interprofessional Care Surgical Therapy
-Used following acute SCI to fix instability and decompress the spinal cord -Surgery within first 24 hours associated with improved neurologic outcome -Posterior approach -Anterior approach -Fusion: attaching metal screws, plates, or other devices to the bones of the spine to help keep them aligned. This procedure is usually done when two or more vertebrae have been injured. Small pieces of bone may also be attached to the injured bones to help them fuse into one solid piece. The bone used for this procedure can be obtained from the patient's spinal bone harvested during surgery, from another bone in the patient's body (autologous), or from donor bone (allograft).
Neurogenic Bowel
-Voluntary control may be lost -High-fiber diet -Adequate fluid intake -Suppositories -Small-volume enemas -Digital stimulation: Mandatory for upper motor neuron injury -Stool softener -Oral stimulant laxatives -Valsalva maneuver with manual stimulation -Use of gastrocolic reflex -Timing to not interrupt therapy
Pain Management
Acute pain -Assess, evaluate, and treat routinely -Analgesics -Massage and repositioning Chronic pain -May be result of overuse of muscles -Sleep may be disrupted -May refer to pain management specialist
Neurogenic Bladder
Areflexic (flaccid), hyperreflexic (spastic), or dyssynergia Common problems -Urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux of urine into kidneys Drug therapy -Anticholinergic drugs -α-Adrenergic blockers -Antispasmodic drugs Drainage methods -Bladder reflex training -Indwelling, intermittent, external catheterization -Urinary diversion surgery Patient teaching: family how to accomplish successful self-management. Inform them about the various management techniques, how to obtain necessary supplies, care of supplies and equipment, and when to seek health care.
Diagnostic Studies
CT scan: preferred imaging study to diagnose the location and degree of injury as well as degree of spinal canal compromise. Cervical x-rays are obtained when CT scan is not readily available. However, visualizing C7 and T1 on a cervical x-ray is often difficult, and the ability to fully evaluate cervical spine injury is compromised. MRI is used to assess for soft tissue injury, neurologic changes, unexplained neurologic deficits, or worsening of neurologic condition. Perform a comprehensive neurologic examination with assessment of the head, chest, and abdomen for additional injuries or trauma. Patients with cervical injuries who demonstrate altered mental status may also need a CT angiogram to rule out vertebral artery damage. Duplex Doppler ultrasound, impedance plethysmography, venous occlusion plethysmography, venography, and clinical examination are used to diagnose DVT.
Spasticity
Can be both beneficial and undesirable -Aids with mobility, improves circulation by promoting venous return and decreases orthostatic hypotension and the risk of DVT. -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. Ashworth and modified Ashworth scales Treatment -ROM exercises -Antispasmodic drugs -Botulinum toxin injections
Clinical Manifestations Respiratory System
Closely correspond to level of injury Above level of C4 -Total loss of respiratory muscle function Below level of C4 -Diaphragmatic breathing → respiratory insufficiency Cervical and thoracic injuries -Paralysis of abdominal and intercostal muscles → ineffective cough → risk for aspiration, atelectasis, pneumonia Risk for neurogenic pulmonary edema * •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 addition, pulmonary edema may occur in response to fluid overload. •To improve respiratory function for patients with spinal cord injury, resistive inspiratory muscle training may be effective.
SCI Degree of Injury
Complete -Total loss of sensory and motor function below level of injury Incomplete (partial) -Mixed loss of voluntary motor activity and sensation -Some tracts intact * •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. •>The degree of sensory and motor loss depends on the level of the injury and the specific damaged nerve tracts.
Skin Care
Comprehensive visual and tactile examination -Areas most vulnerable to breakdown include the sacrum, ischia, trochanters, and heels. Assess surgical incisions for healing and integrity of the skin under collars and braces. Careful positioning and repositioning every 2 hours Specialty mattresses, pressure-relieving cushions Assess nutritional status -Adequate intake of protein is essential for skin health. Evaluation of prealbumin, total protein, and albumin can help identify inadequate protein intake. Stress the importance of nutrition for skin health.
Clinical Manifestations Gastrointestinal System
Decreased GI motor activity -Gastric distention -Development of paralytic ileus -Gastric emptying may be delayed -Excessive release of HCl may cause stress ulcers -Dysphagia may be present Intraabdominal 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.
Nursing Implementation
Health Promotion -Identify: High-risk populations, Counseling, Teaching -Support legislation to: -->Prohibit texting while driving, -->Mandate use of seat belts in cars, -->Mandate helmets- motorcyclists/ bicyclists -->Mandate child safety seats -->Recommend tougher penalties for drunk-driving -Referring to programs: smoking cessation classes, recreation and exercise programs, and alcohol treatment programs -Performing routine physical exams for non-neurologic problems -Facilitate wheelchair-accessible health care screening, exam rooms, etc.
Nursing Assessment: Subjective Information
Health history Functional health patterns -Health perception-health management -Activity-exercise: Loss of strength, movement, and sensation below level of injury; dyspnea, inability to breathe adequately ("air hunger") -Cognitive-perceptual: Presence of tenderness, pain at or above level of injury; numbness, tingling, burning, twitching of extremities -Coping-stress tolerance: Fear, denial, anger, depression
Interprofessional Care Prehospital
Immediate goals -Patent airway -Adequate ventilation/breathing -Adequate circulating blood volume -Prevent extension of spinal cord damage Immobilization -Rigid cervical collar -Backboard with straps -Spinal immobilization with penetrating trauma not recommended Maintain systolic BP >90mm Hg: Systemic and neurogenic shock must be treated to maintain systolic BP greater than 90 mm Hg *•After stabilization at the injury scene, the person should be transferred by the most appropriate mode of transportation available to the nearest medical facility, preferably one that specializes in acute SCI care. A thorough assessment allows evaluation of the degree of deficit and establishes the level and degree of injury.
Acute Care
Immobilization -Maintain neutral position -Stabilize to prevent lateral rotation: Hard cervical collar, Backboard -Keep body in correct alignment -Turn as a unit (logrolling)
Sexuality
Important issue regardless of patient's age or gender Nurse must -Have an awareness and an acceptance of personal sexuality -Have knowledge of human sexual responses Use medical terminology
Gerontologic Considerations
Increased incidence Increased complications -Hospitalized linger -Increased mortality rates Health promotion and screening •Daily skin inspections and UTI prevention measures are critical. •Monthly breast examinations for women and regular prostate cancer screening for men are recommended. •Cardiovascular disease is the most common cause of morbidity and mortality among older adults with SCI. The lack of sensation, including chest pain, in persons with high-level injuries may mask acute myocardial ischemia. •Altered autonomic nervous system function and decreases in physical activity can place patients at risk for cardiovascular problems, including hypertension. •To decrease the risk of injuries, instruct patients and caregivers on fall prevention strategies (e.g., using a stepstool or a long-handled reacher to access high shelves, install handrails on stairs). Rehabilitation lengthened
Interprofessional Care Acute Care
Initial care -Cervical injury requires more intense support -Obtain history, emphasizing incident -Assess extent of injury -Initial assessment: Managing ABCs and vital signs -Medical interventions and diagnostics -Complete neurologic assessment using ASIA tool Additional assessment -Brain injury and/or vertebral artery injury --> History of unconsciousness --> Signs of concussion --> Increased intracranial pressure -Musculoskeletal injuries -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. Move the patient in alignment as a unit (logroll) Monitor respiratory, cardiac, urinary, GI functions
Clinical Manifestations Cardiovascular System
Injury above T6 leads to dysfunction of sympathetic nervous system Leads to neurogenic shock -Bradycardia -Peripheral vasodilation -Hypotension -->Relative hypovolemia because of ↑ in capacity of dilated veins -->Reduced venous return decreasing cardiac output * •Any cord injury above T6 leads to dysfunction of the sympathetic nervous system. •The result is 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.
Sexuality Male
Injury level and completeness of injury impacts function Psychogenic versus reflex erection -Psychogenic erections begins in the brain with sexual thoughts. Signals from the brain are then sent through the nerves relayed to the penis and trigger an erection. -Reflex erection occurs with direct physical contact to the penis or other erotic areas. A reflex erection is involuntary and can occur without sexually stimulating thoughts. These reflex erections are often short-lived and uncontrolled and cannot be maintained or summoned at the time of coitus. Treatments for erectile dysfunction -Drugs -Vacuum devices -Surgical procedures Fertility issues: causing poor sperm quality and ejaculatory dysfunction
Interprofessional Care Drug Therapy
Low-molecular-weight heparin -Prevent VTE -Contraindications include internal bleeding, abnormal kidney function, and recent surgery. Vasopressor agents -Maintain mean arterial pressure >85-90 mm Hg -Significant risk of complications:ventricular tachycardia, troponin elevation, metabolic acidosis, and atrial fibrillation. Altered drug metabolism → ↑ risk for interactions
Autonomic Dysreflexia
Massive uncompensated cardiovascular reaction mediated by sympathetic nervous system -SNS responds to stimulation of sensory receptors - parasympathetic nervous system unable to counteract these responses. -Hypertension and bradycardia Most common precipitating factor is distended bladder or rectum
Spinal Shock
May occur following an acute SCI Characterized by -↓ Reflexes - Loss of sensation - Absent thermoregulation - Flaccid paralysis below level of injury Lasts days to weeks
Respiratory Rehabilitation
Mechanical ventilation for injury above C3 -Round-the-clock caregiver -Respiratory hygiene -Tracheostomy care Phrenic nerve stimulator Diaphragmatic pacemaker Mobile ventilators Patient teaching
SCI Etiology
Most common cause is trauma -Motor vehicle collisions -Falls -Violence -Sports injuries -Other miscellaneous cases
Pain Management
Musculoskeletal nociceptive pain -Antiinflammatory drugs -Opioids Visceral nociceptive pain -Diagnostic imaging to evaluate cause Neuropathic pain -Gabapentin (Neurontin) or pregabalin (Lyrica) -Teach about pain triggers and relaxation therapy
Clinical Manifestations Metabolic Needs
NG suctioning → metabolic alkalosis -Monitor electrolytes, especially sodium and potassium ↑Nutritional needs -Nutritional support to focus on caloric and nitrogen needs -Prevent skin breakdown, reduce infection, decrease muscle atrophy *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.
Bladder Management
Neurogenic bladder initially Indwelling urinary catheter -Strict aseptic technique -↑Fluid intake Intermittent catheterization program -Every 4-6 times daily -Monitor for signs and symptoms of urinary tract infections: cloudy, strong, chills, fever, malaise
Clinical Manifestations Urinary System
Neurogenic bladder: Bladder dysfunction related to abnormal or absent bladder innervation -No reflex detrusor contractions (flaccid, hypotonic) -Hyperactive reflex detrusor contractions (spastic) -Lack of coordination between detrusor contraction and urethral relaxation (dyssynergia) Acute phase -Urinary retention -Bladder atonic, overdistended, fails to empty -Indwelling catheter Postacute phase -Bladder may become hyperirritable -Loss of inhibition from brain -Reflex emptying and failure to store urine * •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 •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.
Bowel Management
Neurogenic bowel initially Bowel program started during acute care -Daily rectal stimulant -->Suppository or small-volume enema -Digital stimulation or manual evacuation Adequate fluid and fiber intake Increased activity and exercise
Temperature Control
No vasoconstriction, piloerection (Erection of body hair), or heat loss through perspiration below level of injury Temperature control is external Monitor environment and body temperature Do not use excessive covers or unduly expose patient
Clinical Manifestations Pain
Nociceptive Pain -Musculoskeletal pain dull or aching, worsens with movement -Visceral pain in thorax, abdomen, pelvis - dull, tender, or cramping Neuropathic Pain -Located at or below level of injury -Hot, burning, tingling, pins and needles, cold, shooting -May be extremely sensitive to stimuli
Nursing Assessment: Objective Information
Objective Data -Poikilothermism: unable to regulate heat -Warm, dry skin (neurogenic shock) -Respiratory difficulties -Bradycardia, hypotension -Decreased or absent bowel sounds -Abdominal distention -Constipation, incontinence, impaction -Urinary retention -Flaccid or spastic bladder -Priapism: Loss of sexual function -Paralysis -Hyperactive deep tendon reflexes -Muscle atony, contractures
Planning
Overall Goals -Optimal level of neurologic functioning -Minimal to no complications of immobility -Learn skills, gain new knowledge, and acquire new behaviors to care for self -Return to home at optimum level of functioning
Fluid and Nutritional Maintenance
Paralytic ileus may occur, requiring NG tube Monitor fluid and electrolytes Nutrition should be started within 72 hours -Individualized solutions/additives -High-protein, high-calorie diet -Possible parenteral nutrition Inadequate nutritional intake -Assess for cause -Contract with patient -General measures: Pleasant eating environment, Adequate time -Calorie count -Dietary supplements -Increased dietary fiber
Pin Site Care
Potential for infection at sites of tongs or halo pin insertion -Preventive care based on hospital protocol -Common protocol involves: -->Cleansing with ½ strength peroxide and normal saline twice a day -->Applying antibiotic ointment to act as a mechanical barrier to the entrance of bacteria.
Clinical Manifestations Integumentary System
Potential for skin breakdown -Pressure ulcers can occur quickly and can lead to major infection and sepsis. Poikilothermism: adjustment of the body temperature to the room temperature. -Interruption of SNS -↓Ability to sweat or shiver below the level of injury -More common with high cervical injury
Neurogenic Shock
Results from loss of vasomotor tone due to injury Characterized by -Hypotension -Bradycardia Loss of SNS innervation -Peripheral vasodilation -Venous pooling -↓Cardiac output These effects are generally associated with a cervical or high thoracic injury T6 or higher injury
Reflexes
Return of reflexes may complicate rehabilitation -Hyperactive -Exaggerated responses -Penile erections -Spasms Patient teaching Antispasmodic drugs -baclofen (Lioresal), dantrolene (Dantrium), and tizanidine (Zanaflex). Botulism toxin injections may also be given to treat severe spasticity.
Cardiovascular Instability
Risk for bradycardia and cardiac arrest Chronic low blood pressure with postural hypotension ↑ Risk for DVT Dysrhythmias may occur Frequently assess vital signs -Anticholinergic drug/pacemaker -Fluid replacement, vasopressor agent If blood loss occurred -Monitor hemoglobin and hematocrit -Possible blood administration Assess orthostatic BP -Abdominal binders/compression stockings -Drug therapy Assess for signs of DVT -Prophylactic low-molecular-weight heparin or low-dose heparin -Sequential compression devices and/or gradient stockings -Assess thighs and calves every shift -Range-of-motion exercises and stretching
Sensory Deprivation
Secondary to absent sensations -Stimulate patient above level of injury -Conversation, music, and interesting foods -Prism glasses to read and watch TV -Help patient avoid withdrawing from the environment. Promote adequate rest and sleep and assess for changes in mood.
Immobilization
Skeletal traction -Realignment or reduction of injury -->Crutchfield, Gardner-Wells, or halo: a rope that extends from the center of the device over a pulley to weights attached at the end. -->Rope, pulley, and weights -Traction maintained at all times -If displacement occurs, hold head in neutral position and get help Kinetic therapy -Continual side-to-side rotation -Prevent pulmonary complications -Prevent pressure ulcers Stable thoracic or lumbar spine injuries -Custom thoracolumbar orthosis (TLSO or body jacket) -Jewett brace Profound effects of immobility -Meticulous skin care critical -Fit immobilizers properly *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 other forms of immobilization to prevent skin breakdown in the coccygeal and occipital areas. Fit cervical collars properly. Inspect areas under the halo vest or jacket or under braces or orthoses to assess the skin.
SCI Level of injury
Skeletal vs. neurologic level Level of injury may be -Cervical -Thoracic -Lumbar -Sacral Tetraplegia (quadraplegia) Paraplegia * •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).
Respiratory Dysfunction
Spinal cord edema may increase during first 48 hours May need intubation and mechanical ventilation ↑ Risk for pneumonia and atelectasis: due to reduced vital capacity and loss of intercostal and abdominal muscle function, resulting in diaphragmatic breathing, pooled secretions, and an ineffective cough. Regular assessment 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. Intervene to maintain ventilation -Administer oxygen -Provide ventilator support -Chest physiotherapy -Assisted (augmented) coughing -Tracheal suctioning -Incentive spirometry -Appropriate pain management
Interprofessional Care Nonoperative Stabilization
Stabilization of injured spinal segment -Eliminates damaging motion -Prevent secondary damage Decompression -Traction or realignment Early realignment -Closed reduction -Craniocervical traction
A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for a.return of reflexes. b.bradycardia with hypoxemia. c.effects of sensory deprivation. d.fluctuations in body temperature.
b.bradycardia with hypoxemia. Rationale: Neurogenic shock is due to loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia, which are important clinical clues. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. These effects are generally associated with a cervical or high thoracic injury (T6 or higher). 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 almost always occurs with diaphragmatic respirations because of the decrease in vital capacity and tidal volume, which occurs as a result of impairment of the intercostal muscles. Cervical and thoracic injuries cause paralysis of abdominal muscles and often intercostal muscles. Therefore the patient cannot cough effectively enough to remove secretions, leading to atelectasis and pneumonia. An artificial airway provides direct access for pathogens, making bronchial hygiene and chest physiotherapy extremely important to reduce infection. 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 addition, pulmonary edema may occur in response to fluid overload.
A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to a.breathe with respiratory support. b.drive a vehicle with hand controls. c.ambulate with long-leg braces and crutches. use a powered device to handle eating utensils
b.drive a vehicle with hand controls. A patient with injury at the level of C7 to C8 may have the following rehabilitation potential: ability to transfer self to wheelchair; roll over and sit up in bed; push self on most surfaces; perform most self-care; use wheelchair independently; and drive a car with powered hand controls (in some patients); attendant care 0 to 6 hours/day.
During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which finding would concern the nurse the most? a.A heart rate of 92 b.A reddened area over the patient's coccyx c.Marked perspiration on the patient's face and arms d.A light inspiratory wheeze on auscultation of the lungs
c.Marked perspiration on the patient's face and arms Rationale: Autonomic dysreflexia is a massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system. It occurs in response to visceral stimulation once spinal shock is resolved in patients with spinal cord lesions. The condition is a life-threatening situation that requires immediate resolution. If resolution does not occur, this condition can lead to status epilepticus, stroke, myocardial infarction, and even death. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion, bradycardia (30 to 40 beats/min), piloerection (erection of body hair) as a result of pilomotor spasm, flushing of the skin above the level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea.
Etiology and Pathophysiology Secondary Injury
•Ongoing, progressive damage that occurs after initial injury •Several theories on what causes ongoing damage at molecular and cellular levels -Vascular changes -Free radical formation -Lipid peroxidation -Release of glutamate -Uncontrolled calcium influx •Apoptosis (programmed cell death) for weeks after injury and may contribute to post-injury demyelination -Lead to scar tissue formation, irreversible nerve damage, and permanent neurologic deficit •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 * •Possible causes include vascular changes due to hemorrhage, vasospasm, thrombosis, loss of autoregulation, breakdown of the blood-brain barrier, and infiltration of inflammatory cells that cause ischemia, edema, and cellular necrosis. •Free radical formation, lipid peroxidation, release of glutamate, and disruption of the ionic balance of potassium, sodium, and calcium lead to neuronal cell death and reduced spinal cord blood flow. •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.
Etiology and Pathophysiology Primary Injury
•SCI due to cord compression by -Bone displacement -Interruption of blood supply -Traction from pulling on cord •Penetrating trauma → tearing and transection * •The spinal cord is wrapped in tough layers of dura and is rarely torn or transected by direct trauma. The initial mechanical disruption of axons as a result of stretch or laceration is referred to as the primary 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.
SOMI Brace
•The need for surgery is determined after the spine is reduced. •After cervical fusion or other stabilization surgery, the patient may wear a hard cervical collar or sternal-occipital-mandibular immobilizer brace.
Events Leading to Second Injury
•The resulting hypoxia reduces the oxygen levels below the metabolic needs of the spinal cord. •Lactate metabolites and an increase in vasoactive substances, including norepinephrine, serotonin, and dopamine, occur. •High levels of these vasoactive substances cause vasospasms and hypoxia with subsequent necrosis. •Unfortunately, the spinal cord has minimal ability to adapt to vasospasm.
Halo Vest
•When a patient can begin to mobilize after a stable injury (for which surgery is not needed), the halo frame can be attached to a special vest (Halo vest). •This allows the patient to mobilize and ambulate while cervical bones fuse. •However, the halo is not indicated if the patient has ligament instability from the injury. That patient will require surgery.
Stress Ulcers
↑Risk secondary to severe trauma and physiologic stress Monitor stool, gastric contents, and hematocrit (monitor for low drop) Prophylactic medications -Histamine (H2)-receptor blockers (e.g., ranitidine [Zantac], famotidine [Pepcid]) or proton pump inhibitors (e.g., pantoprazole [Protonix], omeprazole [Prilosec]) may be given prophylactically to decrease the secretion of HCl acid and prevent the occurrence of ulcers during the initial phase.