Chapter 29

1. Chapter 29 Spinal Cord Injury

2. Objectives • Discuss major causes of spinal cord injury • Discuss common spinal cord injuries and their classifications • Describe the nursing management of the client with a spinal cord injury.

3. Etiology / Pathology • Spinal Cord injury from accidents is a common and increasing cause of serious disability and death. Most people involved with spinal cord injuries are males between 18 and 25 years of age • Other causes: autos, motorcycles, surfing, other athletic events, and gunshot wounds

4. Spinal Cord Trauma • Complete cord injury: • Total transection of the spinal cord – all voluntary movement below the level of the injury is lost • Incomplete injury: partial transection of the spinal cord – some movement remains

5. Diagnostic Tests and Procedures Neurologic examination Initial evaluation of the spinal cord: injured patient provides the nurse with a baseline assessment of function and problems  Ongoing assessment necessary to monitor the effects of neurologic injury, detect related complications, and determine patient’s need for assistance in activities of daily living Focuses on the motor and sensory systems

6. Diagnostic Tests and Procedures Imaging studies Radiography Detects vertebral compression, fractures, or problems with alignment Computed tomography (CT) Noninvasive examination of the specific levels of the spinal cord to be visualized, bony vertebrae, and the spinal nerves Magnetic resonance imaging (MRI) Produces precise, clear images of internal structures Myelogram Visualizes the spinal cord and vertebrae

7. Pathophysiology of Spinal Cord Injury

8. Types of Injuries Location Cervical. Thoracic. Or lumbar Open or closed Closed: trauma in which the skin and meningeal covering that surround the spinal cord remain intact Open: damage to the protective skin and meninges Extent of damage to the cord Complete spinal cord injury occurs when the cord has been completely severed, whereas an incomplete injury results from partial cutting of the cord

9. Effects of Spinal Cord Injury Factors include extent of cut and level of injury Sometimes cannot be fully determined because the symptoms of spinal cord edema may mimic partial or complete transection With incomplete spinal cord injuries some function remains below the level of the injury Specific tracts may be involved, causing particular patterns of neurologic dysfunction

10. Figure 29-6

11. Effects of Spinal Cord Injury The higher the level of injury, the more encompassing the neurologic dysfunction Quadriplegia High cervical spine injuries; loss of motor and sensory function in all four extremities Paraplegia Injuries at or below T2 may cause paralysis of the lower part of the body

12. Respiratory Impairment Injuries at or above the level of C5 may result in instant death because the nerves that control respiration are interrupted Cervical injuries below the level of C4 spare the diaphragm but can involve impairment of intercostal and abdominal muscles

13. Spinal Shock An immediate, transient response to injury in which reflex activity below the level of the injury temporarily ceases A period of flaccid paralysis and complete loss of reflexes below the trauma The loss of systemic sympathetic vasomotor tone  vasodilation  hypotension Known as “areflexia” and is temporary Pt. may need respiratory support temporarily

14. Autonomic Dysreflexia Exaggerated response of autonomic nervous system to noxious (painful) stimuli With injury at or above the level of T6 The sympathetic nervous system is stimulated, but an appropriate parasympathetic modulation response cannot be elicited because of the spinal cord injury that separates the two divisions of the autonomic nervous system

15. Autonomic Dysreflexia • Clinical Signs • Severe bradycardia • Hypertension (systolic pressure up to 300mmHg) • Diaphoresis • “Gooseflesh” • Flushing • Dilated pupils • Blurred vision • Severe headache • Restlessness • Nausea • Nasal stuffiness • Most common causes: • DISTENDED BLADDER • FECAL IMPACTION

16. Autonomic Dysreflexia Triggered by various stimuli including a distended bladder, constipation, renal calculi, ejaculation, or uterine contractions, but also may be caused by pressure sores, skin rash, enemas, or even sudden position changes Treatment: p.712 Box 14-4 – unless contraindicated, raise head of bed immediately to reduce blood pressure; then treat cause of the reaction

17. Spasticity Muscle spasms may be incapacitating for these patients, hampering efforts at rehabilitation

18. Impaired Sensory and Motor Function Impaired motor function can affect the patient’s mobility and self-care and thus result in complications from immobility Loss of sensation puts patient at risk for skin breakdown and other injuries because pressure and pain are not perceived

19. Impaired Bladder Function During spinal shock, all bladder and bowel function ceases Once spinal shock resolves, reflex activity returns

20. Impaired Bowel Function Most spinal cord–injured patients can maintain bowel function because the large bowel musculature has its own neural center that responds to distention by the fecal mass

21. Impaired Temperature Regulations May lose these regulatory mechanisms and be unable to adapt to temperature extremes

22. Impaired Sexual Function Spinal levels S2, S3, and S4 control sexual function, so injury at or above these levels results in sexual dysfunction Ability to achieve erection and ejaculation is variable

23. Impaired Skin Integrity Because immobile patient can’t change positions, skin in sacral area and across bony prominences may break down Loss of tone results in vasodilation and pooling of blood in the periphery; impedes perfusion of the skin; and encourages the development of pressure sores

24. Altered Self-Concept and Body Image French and Phillips (1991) describe the effects of spinal cord injury on body image as occurring in four phases: impact, retreat, acknowledgment, and reconstruction

25. Medical Treatment in the Acute Phase

26. Saving the Patient’s Life:Establish Airway Conventional head-tilt–chin-lift: inappropriate - increases risk of cord damage Risk of additional damage is especially high with cervical injury Neck flexion, even that caused by a pillow or other support, must be avoided Jaw-thrust method of opening the airway is preferred for these patients

27. Saving the Patient’s Life: Establish Airway Once airway is open, administer 100% oxygen by mask and manual resuscitator Endotracheal or tracheostomy tube is placed to allow direct access to the airway and facilitate optimal oxygenation Any injury that compromises ventilation must be treated immediately

28. Preventing Further Cord Injury Traction Immobilization with skeletal traction manages cervical spinal cord injuries acutely Gardner-Wells tongs Secured just above the ears; doesn’t actually penetrate skull Crutchfield tongs Applied directly to the skull just behind the hairline Halo vest: immobilizes and aligns cervical vertebrae; placed when surgery is done to internally stabilize fractures and relieve the compression of nerve roots

29. Figure 29-7

30. Figure 29-8

31. Preventing Further Cord Injury Special beds and cushions Kinetic bed, such as the Roto-Rest bed, continually rotates the patient from side to side Overlay air mattresses: floatation devices placed on standard hospital beds Air-fluidized and floatation beds may be used after the spine has been stabilized Wedge-Stryker frame: canvas and metal frame bed that may be used to help turn the patient Types of cushions include those inflated with air, floatation devices, and gel pads

32. Figure 29-9

33. Preventing Further Cord Injury Drug therapy Methylprednisolone Reduces the damage to the cellular membrane Administered within the first 8 hours of injury Completely paralyzed patients often regain about 20% of function Partially paralyzed have regained up to 75% of function

34. Preserving Cord Function Early surgical intervention to repair cord damage Cord compression by bony fragments, compound vertebral fractures, and gunshot and stab wounds Surgery within the first 24 hours is most desirable Laminectomy Involves removing all or part of the posterior arch of the vertebra Spinal fusion If multiple vertebrae are involved Placing a piece of donor bone into area between the involved vertebrae

35. Assessment Monitor the patient’s level of consciousness, vital signs, respiratory status, motor and sensory function, and intake and output Objective: complete neuro assessment; observations

36. Health History Present illness Event that brought the patient to the hospital Specific injuries incurred in the incident Describe pain and other symptoms in detail

37. Past Medical History Other accidents or injuries and chronic illnesses such as diabetes, hypertension, heart disease, cancer, or seizure disorder Previous hospitalizations and operations Obstetric history from female patient Identify and record current medications and allergies

38. Family History Routine family history taken but not considered specifically relevant to a diagnosis of spinal cord injury resulting from trauma

39. Interventions Nursing Diagnosis: (r/t, AEB; Nanda approved) Ineffective Breathing Pattern Risk for Injury and Disturbed Sensory Perception Risk for Autonomic Dysreflexia Risk for Disuse Syndrome Bowel Incontinence Impaired Urinary Elimination

40. Interventions Nursing Diagnoses cont. Risk for Infection Ineffective Thermoregulation Feeding/Dressing/Grooming Self-Care Deficit Sexual Dysfunction Ineffective Coping Ineffective Therapeutic Regimen Management

41. Rehabilitation Activities that assist individual to achieve highest possible level of self-care and independence Well-organized interdisciplinary team that can address all aspects of function Physician, nurse, physical therapist, occupational therapist, speech therapist, dietitian, social worker, psychologist, and counselor Patient and family must be emotionally and physically prepared to make adjustments

42. Rehabilitation Team helps the patient accomplish activities of daily living and self-care and addresses successful adjustment to social integration and gainful employment in the workplace Although this phase of treatment may take more than a year, patient, family, and rehabilitation team can take pride in the realization that a life can once again be productive and happy

43. Brain Abscess AIDS

44. Brain Abscess • An accumulation of pus within the brain tissue • Can result from local or systemic infection • Primary cause: direct extension from ear, tooth, mastoid, or sinus infection • Streptococci and staphylococci are primary infective organisms

45. Brain Abscess • Clinical manifestations: • Similar to those of meningitis and encephalitis • Headache, fever, s/sx ICP (drowsiness, confusion, seizure) • Focal symptoms in local area of abscess • E.g. visual field defects with temporal lobe abscess

46. Brain Abscess • Medical Treatment • Antibiotics • Encapsulated abscesses may need to be surgically removed • Nursing interventions • Similar to those for ICP, meningitis • If surgical removal involved, nsg. Interventions similar to those for intracranial tumors

47. AIDS

48. AIDS • > 80% of advanced HIV disease patients have neurological symptoms • Clinical Manifestations • Dementia: subacute encephalitis • Global Cognitive Dysfunction: generalized impairment of intellect, awareness, and judgment • Opportunistic infections: meningitis, CMV, toxoplasmosis, herpes simplex, and primary malignant lymphoma the CNS

49. AIDS • Diagnostic Tests • Serologic studies • CSF • CT, MRI • Medical Management • Administration of medication: antiviral, antifungal, antibiotics • Radiation • Dehydration/shock: fluid volume expanders • Seizures: anticonvulsants

50. AIDS • Nursing Interventions • Safety: related to disorientation, seizures, visual impairment • Pain relief measures • Depression: provide support; maintain nonjudgmental attitude • Feeding: increased assistance; poss. TF • Incontinent care