SPINAL CORD INJURY

through the Acute and the Rehabilitative Phases of Nursing Care

K. BROOKS, RN, MSNEd

Risk Factors for SCI

Each year, 11,000 people experience a SCI. 200,000 more people are living with spinal cord injury results Statistics show that males are highest number. Ages 16 30 y.o. Why do you think that is so?
High Risk Activities

Motor Vehicle Accidents

Sports Injuries
Falls / Accidents

Violent Acts

Data taken from 126 patient admissions

Examples of Injury
Accidents (45%) Car, van, coach 16.5% Motorcycle 20% Bicycle 5.5% Pedestrian 1.5% Helicopter 1.5% Domestic / Industrial Accidents (34%) Sport Injury 15%
Diving 4% vertical compressions Rugby 1% Horse Riding 3% Other 7%

Assault 6%
Self Harm 5% Assaulted 1%

Profound Health Care Effects

Average cost of care for a person with a cervical injury: $572,178 first year $102,491 each year after

Economic Hardship
High cost of rehab and long term care effects 90% of discharged SCI patients go home 10% of dishcarged SCI patients go to nursing home, chronic care facility, group home

Lifelong Needs of SCI

Physical Psychosocial Financial Vocational Social Functioning

CASE STUDY ONE

T.W. is a 22 yo male patient fell 50ft from a chairlift while skiing and landed on hard snow. He was found to have a T10-11 fracture with paraplegia. He was admitted to the ICU and place on high doses of steroids for 24hrs. He was taken to surgery for external spinal stabilization. He spent two days back in the ICU, 5 days on Step Down, and is now ready to be transferred to your rehab unit. He continues to have no movement to the lower extremities.

#1 : Goal of Treatment in Acute Phase

Pathophysiology: immediate mechanical disruption of axons as a result of a laceration, stretch, tear, or sever Primary Injury / Secondary Ongoing Injury
Normal blood flow is disrupted to area Spinal cord deprived of O2 .ischemia and cell death Within four hours Free Radicals released Hemorrhage in area causes edema and compression further damage to axons bleeding appears within one hour this can spread the area of injury and damage

The longer this process, the more permanent damage CNS does not regenerate!

#1: Critical Nursing Care / Goals

Immediate Stabilization to prevent further injury, trauma, and cascade of secondary injury
How do we do this?

Survive the Injury Maintain physiological stability through spinal shock

ACUTE SPINAL FACTS

The extent of damage results from the primary and secondary injury and can be devastating if stabilization and early treatment were not started
Prognosis / Recovery most accurately determined 72hrs or more after injury

#2: Steroid Therapy Benefits

High dose IV steroids (Solumedrol) given within frist 8hrs of injury
Reduce damage to cell membranes and decrease inflammation. Found in the early 80s to be highly effective to reduce the length of time for spinal shock and to reduce degree of injury

Side Effects: decreased immune response, risk for infection, increase serum glucose, induce depression, psychosis, risk for GI bleed

#3: What is Spinal Shock?

(AKA Neurogenic Shock)
Temporary Condition / Acute Phase Sympathetic function / communication is impaired below the level of injury Sympathetic nerves leave the spine at thoracic and lumbar areas Parasympathetic function takes over Vasodilation , Venous Pooling, Decreased Cardiac Output
VS Changes: Hypotension, Bradycardia, Temperature fluctuations, Flushed extremities, Hypoxia Loss of Spinal Reflexes Loss of Sensation Flaccid Paralysis below injury

Time Frame one week to six months Masks the extent of injury Spinal Shock Resolves: Reflexes return

#3: Nursing Support

Bradycardia:
Anticholinergic Atropine Temporary Pacemaker

Hypotension:
Fluids Dopamine

Careful monitor of ABCs. Any increase of vagal response can further increase bradycardia and cause cardiac arrest.

#4 Post Acute Phase

Stabilizing the spine and resolving spinal shock will allow for early mobilization. Early mobilization prevents further complications.

What system by system complications are we concerned with ?

Cardiovascular Respiratory Gastrointestinal / Nutrition Elimination Musculoskeletal Integumentary

Respiratory Complications
Major cause of death in the acute phase!
Pulmonary support Suctioning / Postural Drainage / Turning Coordinate with RT HHN O2 support Ventilator? Ambu at bedside Trach needed? Monitor ABGs gas exchange Breath sounds / breathing patterns / sputum production

Poor cough effort Atelectasis / Pneumonia Higher the level injury, the higher the risk! Above C4 / Below C4 (Phrenic nerve at diaphragm.
Intercostal muscle impaired)

Cardiovascular Complications
Hypotension Bradycardia Decreased Cardiac Output Venous Pooling Impaired Tissue Perfusion

Risk for Deep Vein Thrombosis DVT Prophylaxis!

Gastrointestinal / Nutrition Complications

Paralytic Ileus Septic Bowel Necrotic Bowel Stress Ulcers GIB Malnourishment

What does the nurse assess? What does the nurse monitor? Abdominal assessment? NGT to suction?

Elimination Complications

Loss of Bladder and Bowel control Neurogenic B/B Risk for Impaction / Retention / Incontinence / Urinary Tract Infections

Musculoskeletal Complications
Risk for Contractures
Muscle spasticity

Contractures .. Loss of function Bone loss Muscle Atrophy

Skin Complications
Patients who do not have an ulcer state that nurses in the ICU turned them every 2 hours after injury Research shows that patients go to rehab with ulcers already formed DISGUSTING nursing care!

Risk factors for skin breakdown? Interventions? Skin Inspections?

#5 Rehabilitative Needs
MASLOWS HIERARCHY (5) Self Actualization (4) Community Integration (3) Adjustment to living at home (2) Accomplishment of ADLS (1) Stabilization of Physiological Systems

#6 Self Care Abilities of T10-11

Level of T2 T12 should be independent with the wheelchair
May even walk short distances with orthotics and crutches

Manage their own ADLs Manage their B/ B routine

LEVELS OF INJURY
Symptoms, degree of paralysis, extent of injury, and disability depends on the level of cord that is injured Cervical / Thoracic / Lumbar Cervical (C1 T1)
- Tetraplegia (arms are rarely completely paralyzed)

Thoracic / Lumbar (T2 lumbar)

Paraplegia (full us of arms)

 Complete vs. Incomplete

Complete : Total loss of sensory and motor function below the level of injury Incomplete: Mixed loss of voluntary and involuntary activity and sensation

Cervical Injuries
C1-2 : limited head and trunk control , requires w/c with breath controls C3-4: Dependent with ADLs, may still need ventilator support C4 and above: some sort of lifelong ventilatory support C5: elbow flexion C6: wrist extension C7: finger control Independence increases from C6 down

#7 Bladder Function
SCI above T12 Spastic or Reflexic Bladder
Characterized by involuntary bladder contractions with uncontrolled voiding and incontinence.

SCI below L1 Areflexic or Flaccid Bladder

Absent bladder contractions resulting in high volumes of residual urine and urinary retention

Risks: Renal Calculi , UTIs Goals: Avoid bladder infections. Increase fluids. Bladder program

 Pt Teaching:
s/ sx of infection Intermittent cath program Medications to help bladder with tone Stimulate urine flow Increase fluids Indwelling catheter irrigations Cranberry juice

Meds:
Anticholinergics to suppress contraction Antispasmotics to decrease spasticity

#8 Bowel Training
The bowel has its own neural control that responds to distention. This is what helps SCI patients regain control of emptying. Train the bowel a predictable pattern of emptying Meds: Stool Softeners Stimulant Laxatives Diet: Fiber, fluids Digital stimulation (avoid enemas) Positioning Abdominal Massage Valsalva

CASE STUDY #2
43 yo male pt entered the hospital with a left ischial pressure sore stage IV. He is a Incomplete C5 C6 level of injury for 20 years after suffering a SCI after a diving accident. He has a history of pressure ulcers. Vital Signs: T 96.0, BP 88/42, P52, RR20 He also has a history of Autonomic Dysreflexia Take a look at his medication regiman.

#1: INCOMPLETE? SELF CARE ABILITIES?

Full head, neck, and shoulder control Diaphragm control Should not need respiratory support Elbow flexion with some wrist extension Assistive devices for fine motor skills Independent: feeding, grooming, bathing, wheelchair on even surfaces, drive with hand controls Assistance: Transfers, dressing

#2 VS Changes in SCI
Autonomic Nervous System effected with injuries above the T6 level. There can be a loss of communication within the body with the ANS. Inability to autoregulate particularly VS Low BP, Low Pulse, Poiklothermia (taking on
the temp of the room with periods of flushing and inability to sweat)

#4 Medication Regimen
Muscle Spasticity: Baclofen Flexeril Valium Vitamins Pain and Muscle Relaxation: Neurontin Bladder Care
Detrol Ditropan

Bowel Care
Colace Suppository

#5 Autonomic Dysreflexia
Abnormal ANS response in SCI pts with a T6 or higher

Patho: ANS cannot decipher stimulus responses rapidly coming up the spinal tract causing an abnormal ANS response flight and flight Precipitated by noxious stimuli below the level of injury Congested communication in spinal tract Can be Life Threatening cause increased ICP, hemorrhage, Seizure, Stroke Medic Alert!

 AD is usually brought on by B / B distention, UTI, spasms, pressure sores, infection, ingrown toenail, insect bite, dysmennorhea, surgery site, constrictive clothing Assess fast!
Headache Flushing Sweating High BP Blurred vision Nausea

Act fast!
Elevate HOB, contact MD, monitor VS, identify noxious stimuli, treat cause

#6 Lets Talk About Sex Baby!

Reflex erection is possible with upper motor neuron lesions Orgasm and ejaculation is not usually possible Drugs or surgery for erectile dyfunction option Poor sperm quality

Usually remain fertile and can have children Uterine contraction not felt

Allow venting of feelings, offer support, suggest counseling, educate

PSYCHOSOCIAL CONCERNS??
What can you come up with???

Collaborative Goals with SCI

Maintain optimal level of wellness Maintain optimal functioning Minimal or no complications of immobility Learn new skills, self care Return to home Integrate back into community