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

Data taken from 126 patient admissions

Motor Vehicle Accidents

Sports Injuries

Violent Acts

Falls / Accidents

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?

MASLOWS HIERARCHY

(5) Self Actualization

(4) Community Integration

(3) Adjustment to living at home

(2) Accomplishment of ADLS

(1) Stabilization of Physiological Systems

#5 Rehabilitative Needs

#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 Let’s 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???

SELF

CONCEPT

ROLE FUNCTIONS

INTERDEPENDENCE MODE

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