Spinal Cord Injury – (SCI)

1. Spinal Cord Injury – (SCI) Adult Health II Spinal Cord Injury – Part 2 Jerry Carley RN, MA, MSN, CNE Summer, 2010

2. Concept Map: Selected Topics in Neurological Nursing PATHOPHYSIOLOGY Traumatic Brain Injury Spinal Cord Injury Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntington’s Disease Alzheimer’s Disease Huntington’s Disease Myasthenia Gravis Guillian-Barre’ Syndrome Meningitis Parkinson’s Disease ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation ICP Monitoring “Neuro Checks” Lab Monitoring PHARMACOLOGY --Decrease ICP --Disease / Condition Specific Meds Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, Discharge Planning, more…based On Nursing Process: A_D_P_I_E Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary

3. SCI PART 2 Objectives • Explain pathophysiology of various SCIs and related conditions • Detail signs & symptoms and functionality of different level SCIs • Differentiate between Neurogenic Shock and Spinal Shock • Explain Autonomic Dysreflexia / Hyperreflexia and list appropriate nursing interventions • Discuss overall medical & nursing management of SCIs

4. SCI Goals of Care • There's no way to reverse damage • Treatment focuses on: 1. Preventing further injury 2. Enablingpeople to return to an active and productive life within the limits of their disability

5. Treatment • Spinal Immobilization / Traction • High doses of corticosteroid drug Methylprednisolone (Medrol) STAT ! must be within eight hours of injury • A few days after injury medical reassessment and repeat of diagnostic tests will help determine the severity of the injury and likely extent of recovery • Surgeryas indicated

6. Tong Care to Prevent Infection

7. Stryker Frame Traction Bed

8. Log Rolling Technique

10. SCI Meds • Glucocorticoids(Decadron – suppress immune response) • Vasopressors (treat hypotension) • Plasma extenders (treat shock) • Atropine(treat bradycardia) • Muscle relaxants • Anti-Spasmodics(Dantrium) • Analgesics • Antidepressants • Zantac, Ranitidine (prevent gastric ulcers) • Stool Softeners • Vasodilaters(Hydralazine, nitroglycerin to treat HTN such as AD) • Anti-Seizure (gabapentin, phenytoin)

11. NeurogenicShock • Occurs in acute stage of SCI (first hour per ATI) • Usually in injuries ABOVE T6 • D/T interruption of the CNS … …causing disruption of sympathetic outflow from T1 to L2 …with unopposed vagal tone

12. NeurogenicShock: S & S’s • Warm and DRY skin… does not perspire on the paralyzed parts of body d/t blocked sympathetic activity • Hypotension + Bradycardia + Hypothermia (d/t vascular dilation …therefore blood pooling )

13. Spinal Shock • D/t concussive effect of the primary SCI on the nervous system • Can last days or months • Interferes with definitive diagnosis of permanent deficit • Effect causes temporary (transient) depression of all reflexes = - paralysis (flaccid) - loss of sensation - loss of autonomic function - loss of B & B control (Sometimes priapism) • Spasticity or hyperreflexia signals end of this shock

14. Autonomic Dysreflexia ( Hyperreflexia) • SCI acute syndrome of excessive uncontrolled sympathetic output • Occurs ONLY after spinal shock has resolved • SCI above T6 • Life-threatening HTN emergency

15. A. D. (Hyperreflexia) Below T6 intact sensory nerves transmit noxious impulses up the spinal cord… ….BUT … Sympathetic inhibitory impulses above T6 are blocked THEREFORE

16. Sympathetic outflow continues… causing release of norepinephhrine and dopamine

18. Result… Severe Vasoconstriction H/A + Sudden HTN

19. Result above the SCI… Sweating + Flushing

20. Other Distinctive S & S • Bradycardia • Blotching of the Skin • Restlessness • Goose bumps • Stuffy nose (nasal congestion)

21. Autonomic Dysreflexia / Autonomic Hyperreflexia • Clients with spinal cord injuries at Thoracic 6 – 10 (T6 -T10) may be susceptible • Patients with Thoracic 10 (T-10) and below are usually not susceptible • The older the injury the less likely the person will experience autonomic dysreflexia

22. Common Causes • The most common cause of noxious stimuli is distension of the hollow viscera (80%), such as the urinary bladder or bowel 1.Urinary Retention 2.Constipation • Simple kinks in the tubing or plugs in the urinary catheter can trigger autonomic dysreflexia

23. Crede’s Method • Credé's method is a manual suprapubic pressure exerted with a clenched fist or fingers, used to initiate micturition, in patients with spinal cord injury (SCI) who have neurovesical dysfunction. • However, it is currently NOT recommended practice because of the risk of bladder rupture. Sources: Hockenberry, M.J. (2003). Wong’s Nursing Care of Infants and Children. (7th ed.). St. Louis: Mosby, pp. 1326-1328. Reinberg Y., Fleming T., & Gozalez, R. (1994). Renal Rupture After the Crede Maneuver. Journal

24. Treatment… • Assist to sitting position to lower the BP through lower-extremity vascular pooling • Loosen restrictive garments (shirts, belts, slacks, straps and even shoes) • Monitor Vitals • Look for Cause & Eliminate!

25. Treatment… • Ensure catheter patency(make sure catheter not kinked or pulled too tight, and is actually draining urine) • Catheterize to decompress bladder • Assess for signs of urinary tract infection, such as dark, cloudy urine or sediment in catheter tubing • If bowel is distended, disimpact after inserting anesthetic jelly or ointment per rectum Hypertension should be treated medically if it persists

26. Still Can’t Find Cause ? !!! • Cause may not be readily found… • Careful physical exam is imperative during this crisis • Other causative agents usually not considered in medical emergencies include skin irritations, wounds, pressure sores, burns, broken bones, pregnancy, ingrown toenails, appendicitis, and other medical complications Still cannot find cause? …. focus on decreasing the blood pressure!

27. Antihypertensive Meds • Nifedipine(Adalat) 10 mg orally - instruct the patient to bite the capsule, then swallow it • Nitroglycerinsublingual or topical paste (1/2 inch) • Prazosin (Minipress) • Clonidine(Catapres) 0.1- 0.2 mg PO • Hydralazine(Apresoline) 10 - 20 mg IM/IV

28. Client Teaching • Provide education about early recognition and treatment of A.D. • Encourage the client tocarry some type of medic alert identification (It is estimated that approximately 85% of spinal cord injury patients at level T-6 will suffer at least one episode of autonomic dysreflexia)

29. Client Teaching Prevention: • Frequent pressure relief in bed/chair • Avoid sun burn/scalds (avoid overexposure, use of #15 sunscreen, watch water temperatures) • Faithful adherence to bowel program • Keep catheters clean and remain faithful to catheterization schedule • Well balanced diet and adequate fluid intake • Compliance with medications

30. SCI Recovery • Recovery typically starts between a week and six months after injury, if it occurs, with the majority of recovery taking place within one year • Doctors generally regard any impairment remaining after 12 to 24 months as likely to be permanent

31. SCI Nursing Interventions • Bowel retraining program • ROM • Sexual function adaptive strategies • PT • OT • Assistive devices • Q2H turns – skin care • Nutrition

32. SCI Nursing Interventions Referrals: • Social Services • Support Groups • Appropriate specialists

33. SCI Rehabilitation • Initial rehabilitation emphasizes regaining leg and arm strength, redeveloping fine-motor skills and learning adaptive techniques to accomplish day-to-day tasks • Then long-term rehab typically includes exercise and training with: Modern wheelchairs - Improved, lighter weight wheelchairs are more mobile and more comfortable. The Food and Drug Administration has even approved a wheelchair that can climb stairs and elevate a seated passenger to eye level to reach high places without help Computer devices - Computer-driven tools and gadgets can help with daily routines. Voice-activated computer technologies to answer and dial a phone, or to use a computer and pay bills. Computer-controlled technologies can also help with bathing, dressing, grooming, cleaning and reading

35. Complications Urinary tract problems - urinary incontinence increases risk of urinary tract infections, kidney infection, kidney or bladder stones. d/t ongoing catheterizations Bowel management difficulties– Reduced peristalsis and fecal incontinence Pressure sores - particularly susceptible to pressure sores because the injury reduces or eliminates sensations, making it difficult to know when a sore is developing Deep vein thrombosis and pulmonary embolism Lung and breathing problems- Difficult to breathe and cough with weakened abdominal and chest muscles, so people with cervical and thoracic spinal cord injury may develop pneumonia, asthma or other lung problems

36. Complications… Spasticity – some people develop muscle spasms and jumping of their arms and legs because some of the nerves in the lower spinal cord become more sensitive after injury and cause muscle contractions. However, because of the spinal cord injury, the brain can no longer send signals to the lower nerves to regulate the contractions Weight control issues - Weight loss and muscle atrophy are common. But the change in lifestyle and activities may eventually cause weight gain, which can make it difficult for the pt lift themselves — or be lifted — from place to place

37. Concerns Pain - It's possible to feel pain in areas where there's little or no sensation - May also experience pain from overusing muscles in one part of the body. Many people develop shoulder tendinitis from manually operating a wheelchair for a long period of time - Any kind of pain can have a negative impact on daily living . New Injuries - Susceptible to injury of any part of the body that has impaired sensation - May even receive a burn or cut without realizing it

38. Male Concerns… Sexual Dysfunction • Still have erections, even with little sensation in the genital area • But erections may not be firm enough or last long enough for sexual activity • Fertility also can be affected: - 99% aren't able to ejaculate during intercourse - Low sperm counts - Poor sperm motility ***** However, men can be sexually active and father a child

39. Female Concerns… Sexual Dysfunction • Mosthave no physical change that inhibits sexual intercourse or pregnancy • But may lose ability to produce vaginal lubrication or control vaginal muscles • Many experience changes in body image that affect sexuality • Any pregnancy will likely be considered high risk • There may be amenorrhea for about 6 months after SCI

40. Coping Grieving Healthy part of recovery. It's natural and important to grieve the loss of the way the person was before. Then…necessary to set new goals and find a way to move forward with life *** Depression and alcohol abuse*** Taking control Education about injury and options for reclaiming an independent life Because the costs can be overwhelming, find out about economic assistance or support services from the state or federal government or from charitable organizations Talking Friends and family may respond in different ways

41. COPING……….Continued… • Dealing with intimacy • Self - Care • Looking ahead …