NCM116 – LEC – Midterms (Week4)

SPINAL CORD INJURY

SPINAL CORD INJURIES

 SCI is increasing in older clients, largely

due to MVAs
 ADULT MEN BETWEEN 15 AND 30
YEARS OLD
 Anyone in a risk-taking occupation
or lifestyle
 Causes (in order of frequency)
 MVA
 Gunshot wounds/acts of violence
 Falls
 Sports injuries

SPINAL CORD INJURIES

 Classification of SCI

 Flexion (bending forward)

 Hyperextension (backward)
 Rotation (either flexion - or
extension -rotation)
 Compression (downward motion)
 As to Level of Injury:
 Cervical (C-1 trough ???)  Spinal and neurogenic shock
 Thoracic (T-1 through ???)
 The loss of all neurological activity
 Lumbar (L-1 through ???)
below the level of injury, following
 As to Degree of Injury:
a spinal cord injury.
 Complete
 Total paralysis and loss of  Below the site of injury:
sensory and motor function
although arms are rarely  Total lack of function
completely paralyzed
 Decreased or absent reflexes
 Incomplete or partial transection and flaccid paralysis
 Mixed loss of voluntary motor
activity and sensation  Lasts from a week to several
months after onset.
  End of spinal shock signaled by  Clinical Manifestations
muscular spasticity, reflex  Depend on the LEVEL and
bladder emptying, hyperreflexia DEGREE of the injury!
 Quadriplegia occurs with C-1
 Anterior Cord Syndrome through C-8
 Compression of the anterior  Paraplegia occurs with T-1 thru
cord, L-4
 Usually, a flexion injury  Respiratory
 Sudden, complete motor  C1-C3: Absence of ability to
paralysis at lesion and below; breathe independently.
decreased sensation (including  C4: poor cough,
pain) and loss of temperature diaphragmatic breathing,
sensation below site. hypoventilation
 Touch, position, vibration and  C5-T6: decreased
motion remain intact. respiratory reserve
 Posterior Cord Syndrome  T6-T7-L4: functional
 Associated with cervical respiratory system with
hyperextension injuries adequate reserve.
 Dorsal area of cord is damaged  Clinical Manifestations
resulting in loss of Respiratory
proprioception  The Phrenic Nerve
 Pain, temperature sensation  The phrenic nerve stimulates
and motor function remain the diaphragm to contact.
intact.  Two phrenic nerves (right and
 Brown-Sequard Syndrome left) - injury to one or the other
 Damage to one half of the cord paralyzes contraction of only
on either side. one half of the diaphragm but
 Caused by penetrating trauma even hemi - (half) paralysis can
or ruptured disk, ischemia, or significantly interfere with
infectious or inflammatory breathing for patients with lung
diseases such as tuberculosis, disease.
or multiple sclerosis, spinal cord  The nerve arises from branches
tumor, of the C3, 4, and 5 nerve roots.
 A rare SCI syndrome which Cardiovascular System
results in  C1-T5 shows decreased or
 Weakness or paralysis on absent sympathetic nervous
one side of the body system (SNS) influence.
(hemiplegia) and  BRADYCARDIA AND
 A loss of sensation on the HYPOTENSION (due to
opposite side vasodilation)
(hemianesthesia). Peripheral Vascular System
  Deep vein thrombosis is  Carafate and antacids later
common and is not detected as prophyaxis
easily  Intraabdominal bleeding
 Pulmonary embolism a (Remember, no pain or
significant cause of death tenderness to warn you)
 Doppler studies, measurement Integumentary System
of extremity girth  Pressure ulcers
The VAGUS Nerve  Muscle atrophy in flaccid
 The longest of the cranial paralysis
nerves - exits out of the  Contractures in spastic paralysis
medulla and ends in the  Poikilothermism - the
abdomen adjustment of body temp to
 It supplies sensory and motor room temperature
function to the pharynx  Decreased ability to sweat
 Supplies motor function to the below lesion
muscles of the abdominal Acute Interventions
organs  Immobilization
 Provides parasympathetic  Crutchfield tongs
activity to the heart, lungs, and  Halo vest
most of the digestive system  Head Halter Traction
Urinary System  Stryker bed
 Atonic bladder with RETENTION
in spinal shock. Crutchfield tongs
 Post-acute phase - irritability
causing dribbling or frequent
urination.
 Urinary infection and calculi
from retention and distention
 REQUIRES INTERMITTENT
CATHETERIZATION!
Gastro-Intestinal System
 Decreased motility
 Paralytic ileus
 Gastric distention - requires Halo vest
intermittent naso-gastric (NG)
suctioning
 Increased H2
 Administer H2 inhibitors
such as Zantac or Pepcid in
initial stages
  ALWAYS HAVE CLIENT
CLOSE EYES OR LOOK
Head Halter Traction AWAY! If he can see what
you're doing, he will answer
accordingly.
 Assess for head injury and ICP
 X-ray, CT scan, EMG

Nursing Problems

 Impaired Gas Exchange r/t muscle

fatigue and body weakness as
Stryker bed manifested by:
 Decreased Pao2, increased
PaCO2
 Fatigue
 Diminished breath sounds
 Inability to sustain spontaneous
ventilation r/t diaphragmatic fatigue or
paralysis evidenced by:
 Dyspnea
 Use of accessory muscles
 Abnormal ABG
 Post Injury Assessment  Decreased cardiac output r/t venous
 Goals: pooling of blood and immobility as
 Sustain life evidenced by:
 Prevent further cord  Hypotension
damage:  Tachycardia
 Assessment of muscle groups;  Restlessness
motor status  Oliguria
 Against gravity  Decreased pulmonary artery
 Against resistance pressures
 Both sides of the body  Impaired skin integrity r/t immobility
 Ask to move legs, hands, and poor tissue perfusion
fingers, wrists, then shrug  Constipation r/t location of injury,
shoulders decreased fluid intake, diet, or
 Thorough motor examination immobility as evidenced by:
including position sense and  Lack of BM in over 2 days
vibration  Decreased bowel sounds
 Sensory examination  Palpable impaction
 Pinprick starting at toes and  Hard stool or incontinence
working upward
  Urinary Retention r/t injury and limited  Provide chest PT
fluid intake as e/b:  Assist with mechemical
 Decreased output ventilation
 Bladder distention  Provide emotional support
 Involuntary emptying of  Decreased cardiac output:
bladder  Monitor blood pressure, pulse
 Risk for AUTONOMIC DYSREFLEXIA and cardiac rhythm
 a potentially dangerous clinical  Administer vasopressors to
syndrome that develops in maintain MAP at 80-110
individuals with injury at or mm/Hg
above T6 resulting in life-  Apply pneumatic compression
threatening hypertension. boots or stockings
 If left untreated, it can cause:  Perform ROM at least q8h to
 Seizures, aid in muscle contraction and
 Retinal hemorrhage, venous return
 Pulmonary edema,  Impaired skin integrity:
 Renal insufficiency,  Inspect skin and areas around
 Myocardial infarction, pins or tongs
 Cerebral hemorrhage, and  Turn at least q2h and use
 Death kinetic table or other specialty
 Other Problems. care devices.
 Impaired physical mobility  Insure adequate nutritional
 Altered nutrition: < body intake
requirements  INFORM family and client about
 Sexual dysfunction risk of pressure ulcers
 Risk or injury r/t sensory deficits  Constipation:
 Altered family processes  Auscultate bowel sounds and
 Risk for ineffective individual monitor abdominal distention
coping  Note and report any nausea
 Body image disturbance and vomiting
Nursing Interventions  Begin bowel program when BS
 Impaired gas exchange: return and teach to client and
 Assess respiratory status q 2 family
hours  Administer suppositories and
 Assess strength of cough stool softeners
 Monitor ABGs  Ensure appropriate fluid and
 Maintain patent airway fiber intake
 EDBCE  Bowel Program
 Suction secretions  Needs to be consistent
 Inability to sustain spontaneous
ventilation
  Give laxative suppository after Improves blood flow and
meal and place on toilet approx reduces edema in the SC
30 minutes after.  Increases the recovery of
 Do this at same time each day! function. IV bolus then
 Fiber, fluids and activity are continuous IV over a 23-hour
important period.
 Constipation leads to  Other drugs to reduce symptoms for:
AUTONOMIC DYSREFLEXIA!!!  GI problems - zantac, tagamet,
 Urinary Retention: pepcid
 Palpate bladder every shift  Bradycardia - atropine
 During acute phase, insert  Hypotension - vasopressors
indwelling catheter  Bladder spasticity -
 Begin intermittent anticholinergics
catheterization program when  Autonomic dysreflexia -
appropriate antihypertensive drugs.
 Keep I and O and end fluids
 Monitor BUN and creatinine Surgical Therapy
 Credé's maneuver when  Anterior decompression and spinal
voiding/catheterizing fusion
 Risk for AUTONOMIC DYSREFLEXIA:  Reduces injury and stabilizes the SC
 Assess for HTN, bradycardia,  Done for:
headache, sweating, blurred  Compression
vision, flushing, nasal  Compound fracture
stuffiness/congestion  Bony fragments in the cord
 Reduce or eliminate noxious  Penetrating trauma
stimuli such as impaction, urine
retention, tactile stimulation
and skin lesions or pain!
 Elevate HOB 43 degrees
 Administer antihypertensives as
ordered
 Call physician if interventions
are not effective

Drug Therapy
 Vasopressors (Dopamine) to keep
mean arterial pressure greater than
80mm to 90mm/Hg so that PROFUSION
TO CORD is improved
 Methylprednisolone (Solu-medrol)