Lesson #6 Spinal Cord Injury

1. Lesson #6Spinal Cord Injury Rehabilitation Nursing

2. Classifications of Spinal Cord Injury

3. Level of Injury • Mutual understanding of level of spinal cord injury determined in 1983 and redone in 1992 • American Spinal Cord Injury Association(ASIA) • Defined spinal cord injury as: • Lowest level where two things remain INTACT: • Movement • Sensation

4. Qualifications of Spinal Cord Injured (SCI)

5. Terms to Know • #1 Factor: • Need to understand amount of functional ability client will gain or regain by knowing these terms: • Tetraplegia (means four) • Quadraplegia • Quadriparesis • Paraplegia • Paraparesis • Hemiplegia • Hemiparesis

6. Qualifications • #2 Factor: • Higher up the spinal injury, the more devastating • Level of injury determines 2 things on severely affected side: • Amount of function remaining • Amount of function lost • The physiatrist must consider both to determine if rehab treatment is the client’s best option

7. Qualifications • #3 Factor: • SCI classified by level of cord affected • Cord levels within spinal vertebrae in order • 31 pairs of spinal nerves which affect muscles and areas of skin

9. Qualifications • Dermatome Chart: • Map showing the nerve roots/muscles the nerves affect and function • Nurses can assess the sensory areas through touch and pain

10. Dermatome Chart

11. Messages • Ascending tracts: (blue) • up to the brain • Descending tracts: (red) • down to the spinal cord/peripheral nerves

12. Spinal cord stops at L1 • Injuries below L2 or lower, damage the tip of the spinal cord • Conus medullaris or cauda equina (L2-S5) • Spinal root damage • Different than cord damage • Central branch of sensory nerve is hurt: • Tend to be weaker than peripheral nerves • Easier to compress • Not peripheral damage • Spinal cord: • Widest cervical/lumbar areas • Increases risk for injury RT most flexible areas

13. Spinal Cord Damage at Different Levels Rehabilitation Nursing

14. Complete Injuries • Approximately 45% of SCI are complete • Complete does not necessarily mean spinal cord is cut • It does mean: • All sensation and movement is LOST Belowthe level of injury • ASIA definition of Complete Injury: • Absence of all motor or sensory function in the anal and perineal region (S-4 to S-5) • Zone of Preservation • Partial Preservation

15. Incomplete injuries • Approximately 55% of SCI injuries • Evidence of sensation or movement still intact below the level of injury • RT some areas of the cord damaged and some not damaged permitting signals to continue getting through

16. Spinal Shock • Similar to a brain concussion • Temporary shutting down of spinal accessory nerves • Affects: • All functional and natural reflexes below site of injury • Often seen when immediate injury occurs • Can be seen developing later • If no infection develops, the general course lasts 7-10 days • Signs: flaccidity of affected areas • Flaccid • Paralysis where muscles are soft and limp • Signs Spinal Shock is over

17. Nursing Concerns Spinal Cord Injured

18. Nursing Concerns • Due to advances in technology and care, SCI clients live longer • Eventually may develop overtime, other co-morbidities • SCIs affect nearly every body system • Result: Their lives will never be the same • Rehab nurses use FIM scoring to understand baseline: • Sensory function • Motor function

19. General impairments

20. Respiratory Impairment • C1-C4- need Ventilator • C2-C5 most life-threatening • C4-C5 most common cervical injury • If requires respiratory assistance, use jaw thrust • C5-C8 and T1-T5 • Weakened or paralyzed diaphragm/intercostal muscles • Decreasing chest expansion • Reduced inspiratory volume • Decreased expiratory efficiency • May require Quad cough assistance

21. Ambulation impairment(Muscle/Skeletal) • C1-T5-non-ambulatory • T6-T9- Limited ambulation with: • Braces • Lofstrand crutches • New Technology • T10 and below- Functional ambulation • May have some flaccidity below the lesion • May have some degree of spasticity below the lesion

22. Para step- Training uses micro- chip to stabilize the paraplegic

23. Exoskeleton (eLegs) by 2012for W/C bound clients

24. Spasms

25. Spasms • Uncontrolled and involuntary muscle contractions and reflex tendons are exaggerated • Spasms may always be present • Managed by: • Performing daily ROM!!! • Gentle applied firm pressure • Massage to limb

26. Spasms Benefits • Serves as warning sign of pain or other developing problems • Signals: • Infection • Kidney stone • Skin breakdown • Help maintain muscle size and bone strength • Helps decrease osteoporosis • Keeps blood circulating in lower limbs • Helps tighten lower limbs making it an easier transfer than when flaccid

27. Spasms Medications • Because of positive benefits of spasms treatment is delayed until spasms interfere with: • Sleep • Limits client’s functioning ability • Medication treatment purpose: • Decrease muscle tone • Decrease frequency of spasms • Medications used: • Valium, Dantrium, Baclofen

28. Spasms Disadvantages • Interferes with diagnostics requiring client to lay still for procedure • Nursing may be required to assist during procedure to help with immobilizing spine positioning

29. Transfer impairment • C1-C5- completely dependent • Special W/C • C6-C7- requires assistance • RT Gross motor control presence • T1-T5- requires assistance • Uses slide board • T5 or below • Should reach independence

30. Transfer impairmentsAdditional Problems • Over use syndrome • Chronic pain • Rotator cuff problems • Nerve entrapments • Wear and Tear on hands

31. Transfer ImpairmentsMore Problems • Bone changes increase in risk below the level of injury • Can change client’s ROM, which may interfere with ADLs and transfers • Bone Changes: • Osteoporosis • Heterotrophic Ossification • Fractures

32. Driving Impairment • C5-T9- use hand controls • T10 and below driving possible

33. ADLs Impairment • FIM scoring used to assess level of functioning and offers guidelines to OT • C1-C4-dependent • C5-C7-needs assistance • T1 and below • Goal is independence • Ability to reach goal will vary

34. Bowel and Bladder Impairment • C1-C7-dependent • T1-T9 • May be independent with bladder • Requires assistance with bowel • T10-T12- expect to be independent • L1-L2- independent • L4-S5- has adequate independent control of both

35. Renal Impairment • Reflex Bladder • Bladder empties only when full • Not RT: • Client relaxing to voluntarily urinate

36. Renal impairment • Non-Reflex Bladder • Bladder is flaccid- lacking tone • No reflex action present when stretches • May not feel fullness of bladder • Main problem: • Overfilling • Dribbling • Nursing Concern: • Need great teaching if managing bladder by intermittent catheterization • Obese clients require indwelling catheters

37. Renal ImpairmentsUrinary Tract infections (UTI) • Major cause of death with SCIs RT: • Poor technique • Poor care of equipment • Most clients develop colonized microbes in bladder • This does not indicate an active UTI • Normal adult signals of UTI • SCI signals of a UTI: • Increase in spasms • Foul smell to urine • Change in voiding habits • Fever • Possible autonomic dysreflexia episode

38. Renal impairmentLong Term Complications • #1 Kidney failure • #2 Hydronephrosis • #3 Increased risk for bladder CA RT intermittent catheterr use

39. Reproductive Sexual Function • Men • Can change fertility/sexual function • Above level of conusmedullaris may have reflexive erections, but few ejaculate(20%) • May require penile implants/vacuum pumps

40. Reproductive Sexual function • Women • Capable of sexual intercourse and conception • Capable of experiencing orgasm • Menses: • Disrupted after SCI injury for 3-6 months • Nurses watchful for return • Pregnancy: • Watch closely RT: • Increased Low birth weights • Increased premature births • Complications

41. Specific GI Impairment • SCI clients can also develop peptic ulcers and gallstones • Three types of bowel problems: • #1 Reflex Neurogenic Bowel • RT cervical/high thoracic injury • #2 Autonomous Reflex Neurogenic Bowel • Lower injuries where anal tone/rectal reflex now absent • #3 Uninhibited Neurogenic Bowel • From CNS trauma

42. Nursing Considerations of Bowel Care

43. Bowel function Reminders • Nurses use take advantage of the Gastrocolic Reflex: • Autonomic response occurring when food/fluids enter the stomach • Stimulating peristalsis • Client may experience urge to defecate within 30-40 minutes of oral intake • Rectum • Stretches from fecal mass sending signals to brain • Brain returns with message to voluntarily control the anal sphincter • If relaxed sphincter, can push fecal mass out of body • Gravity and contracting abdomen helps

44. Bowel Function After Injury • Spinal cord messages to brain may: • Work • Partially work • Not work at all • Location of injury/disease also plays a role

45. Uninhibited Neurogenic Bowel • Physical structures all present • Reflexes intact • Everything ready to go to work • Problem: • Body never gets the go ahead signal • Signal is lost never got to brain or there is a disruption RT damage • Major Problem: • Bowel maintenance and accidents • Nursing Interventions: • Bowel training • Time toileting

46. Reflex Neurogenic Bowel • Physical structures all present • Trouble with maintaining sphincter tone • Reflexes help involuntarily • Client unable to recognize: • Need to have BM(sensory) • Unable to hold BM even if wanted to(motor) • Major Problem: Bowel maintenance • Produces BMs at irregular times • Social issue • Nursing interventions: • Bowel training • Time toileting

47. Autonomous Neurogenic Bowel • Physical structures all present • Neuro functions of motor and sensory + reflexes are lost • No tone, no rectal reflex • Client incapable of recognizing need to have BM • Incapable of holding BM • Nursing interventions: • Suppository insertion program • Time toileting schedule • Goal: Keep client cleaned out

48. Nurses Concerns for SCIHealthy Habits of Bowel Function • Diet • Fluids • Exercise

49. Nursing InterventionsBowel Training • Goal: • Retrain/gain control over bowels to prevent social issues • Individually adjusted • Suppositories, timing, massage of abdomen, etc • Once time of scheduled toileting is decided on it should not be changed: • Achieving bowel control takes up to 6 weeks • Requires consistency of staff/caregiver to be successful • Plan on accidents at first and eventually will rarely occur • Just don’t change the time!!!!

50. Time Toileting • Body gets used to certain times for things like sleeping and eating • Body can also be taught to go to the bathroom • Timed toileting takes advantage of Gastrocolic reflex occurring after eating • Client toileted 30 minutes after eating at their agreed time • Client is positioned on toilet with knees slightly higher or at rectum level • Leans forward and abdomen massaged • Can be offered warm fluids