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Chapter 61
SpinalCordInjury
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
Damageortraumatospinalcord12,000newSCIseachyear260,000AmericanslivingwithSCIHighestinmalesages1630
Inolderadults
SpinalCordInjury(SCI)
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
MortalityLongtermissuesremainDisruptioningrowthanddevelopmentAlteredfamilydynamicsEconomicloss
90%noninstitutionalized
SCI
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Causes 42%motorvehiclecollisions 27%falls 15%violence
7%sportsinjuries 8%othermiscellaneouscases
Etiology
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
J.N.,a32yroldwoman,wasbroughttotheEDafterbeingthrownfromhercarfollowingamotorvehicleaccident.
Shewasnotwearingaseatbelt. Sheisawakeandcrying.
Shestatesshecannotmoveorfeelherlegs.
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J.N.anxiouslyasksyouifshebrokeherbackandcutherspinalcord.
Shealsoasksifshewillbeparalyzedforlifeorifitcanbereversed.
Basedonyourknowledgeofthepathophysiologyunderlyingspinalcordinjury,howwillyourespondtoJ.N.?
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SCIduetocordcompressionby Bonedisplacement
Interruptionofbloodsupply Tractionfrompullingoncord
Penetratingtrauma tearingandtransection
EtiologyandPathophysiologyInitialInjury
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
PrimaryinjuryInitialmechanicaldisruptionofaxonsasaresultofstretchorlaceration
SecondaryinjuryOngoing,progressivedamagethatoccursafterinitialinjury
EtiologyandPathophysiologyInitialInjury
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SeveraltheoriesonwhatcausesongoingdamageatmolecularandcellularlevelsFreeradicalformationUncontrolledcalciuminfluxIschemiaLipidperoxidation
EtiologyandPathophysiologyInitialInjury
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Apoptosis(celldeath)forweeksormonthsafterinitialinjuryCompletecorddamagerelatedtoautodestructionHemorrhagesappearwithin1hourInfarctionby4hours
Caremanagementcriticaltolimitpermanentloss
EtiologyandPathophysiologyInitialInjury
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
EventsLeadingtoSecondInjury
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
By24hours,permanentdamagemayoccurbecauseofedema.
Extentofdamagefrombothprimaryinjuryandsecondaryinjury
Prognosiscannotbedeterminedforatleast72hours.
EtiologyandPathophysiologyInitialInjury
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C.N.scervicalspinexraysandCTrevealfracturedC78vertebrae.
Physicalexamdemonstratestotallossofreflexes,sensation,andmovementbelowthelevelofinjury.
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Yourecognizethesesymptomsasbeingcausedbyspinalshock.
Whatisspinalshock,andhowdoesitdifferfromneurogenicshock?
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Characterizedby
ReflexesLossofsensationFlaccidparalysisbelowlevelofinjury
Lastsdaystomonths
SpinalShock
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CharacterizedbyHypotensionBradycardia
LossofSNSinnervation
PeripheralvasodilationVenouspoolingCardiacoutput
T6orhigherinjury
NeurogenicShock
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MajormechanismsofinjuryareFlexionHyperextensionFlexionrotationExtensionrotationCompression
ClassificationofSCI
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Skeletalvs.neurologiclevelLevelofinjurymaybeCervicalThoracicLumbar
Tetraplegia(quadraplegia)Paraplegia
LevelofInjury
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MechanismsofInjury
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Complete
Totallossofsensoryandmotorfunctionbelowlevelofinjury
Incomplete(partial)
Mixedlossofvoluntarymotoractivityandsensation Sometractsintact
DegreeofInjury
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SyndromesAssociatedwithIncompleteSCI
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DamagetocentralspinalcordMostcommonlycervicalregionMorecommoninolderadultsMotorweaknessandsensorylossUpperextremitiesaffectedmorethanlower
IncompleteSCICentralCordSyndrome
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Damagetoanteriorspinalartery
compromisedbloodflowTypicallyresultsfromflexioninjuryMotorparalysisandlossofpainandtemperaturesensationbelowlevelofinjury
IncompleteSCIAnteriorCordSyndrome
Copyright 2014 by Mosby, an imprint of Elsevier Inc.
DamagetoonehalfofcordIpsilateral
lossofmotorfunctionandpositionandvibrationsenseContralaterallossofpainandtemperaturesensation
IncompleteSCIBrownSquard Syndrome
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CompressionordamagetoposteriorspinalarteryLossofproprioceptionPain,temperaturesensation,andmotorfunctionbelowleveloflesionremainintact.
IncompleteSCIPosteriorCordSyndrome
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Resultfromdamagetoverylowestportionofspinalcord(conus)andlumbarandsacralnerveroots(caudaequina)
Injurytotheseareasproducesflaccidparalysisoflowerlimbsandareflexic(flaccid)bladderandbowel.
DegreeofInjuryConus Medullaris Syndrome/
Cauda Equina Syndrome
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Conus lowestportionofcordCauda equina
lumbarandsacralnerverootsFlaccidparalysisoflowerlimbsAreflexic
(flaccid)bladderandbowel
ConusMedullarisSyndromeandCaudaEquinaSyndrome
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Copyright 2014 by Mosby, an imprint of Elsevier Inc.
RelatedtolevelanddegreeofinjuryIncomplete variableSequelae
moreseriouswithhigherinjury
ClinicalManifestations
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ASIAImpairmentScale
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CloselycorrespondtolevelofinjuryAbovelevelofC4
Totallossofrespiratorymusclefunction mechanicalventilation
BelowlevelofC4Diaphragmaticbreathingrespiratoryinsufficiency
ClinicalManifestationsRespiratorySystem
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CervicalandthoracicinjuriesParalysisofabdominalandintercostalmuscles
ineffectivecoughatelectasisorpneumonia
RiskforinfectionRiskforneurogenicpulmonaryedema
ClinicalManifestationsRespiratorySystem
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InjuryabovelevelT6influenceofsympatheticnervoussystemBradycardiaPeripheralvasodilationhypotensionRelativehypovolemia
becauseofinvenouscapacitance
ClinicalManifestationsCardiovascularSystem
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CardiacmonitoringnecessaryAtropineto
heartratePeripheralvasodilation Venousreturnofbloodtoheart
Cardiacoutput
IVfluidsorvasopressordrugsto BP
ClinicalManifestationsCardiovascularSystem
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AcutephaseUrinaryretentionBladderatonicandoverdistendedIndwellingcatheter
Postacute
phaseBladdermaybecomehyperirritable.LossofinhibitionfrombrainReflexemptying
ClinicalManifestationsUrinarySystem
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AboveT5
hypomotilityParalyticileusGastricdistentionNasogastrictubeMetoclopramide(Reglan)
StressulcersIntraabdominalbleeding
ClinicalManifestationsGastrointestinalSystem
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Neurogenicbowel InjurylevelofT12orbelow Bowelinitiallyareflexic
withsphinctertone
Whenreflexesreturn Sphinctertoneisenhanced.
Reflexemptyingoccurs. Regularbowelprogram Coordinatewithgastrocolic
reflex
ClinicalManifestationsGastrointestinalSystem
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PotentialforskinbreakdownPoikilothermism
InterruptionofSNSAbilitytosweatorshiverMorecommonwithhighcervicalinjury
ClinicalManifestationsIntegumentarySystem
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NGsuctioning metabolicalkalosisTissueperfusion
acidosisElectrolyteimbalancesNutritionalneedsHighproteindiet
ClinicalManifestationsMetabolicNeeds
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Deepveinthrombosis(DVT)Difficulttodetect
PulmonaryembolismLeadingcauseofdeath
ClinicalManifestationsPeripheralVascularProblems
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CTscanCervicalxraysMRIComprehensiveneurologicexaminationCTangiogram
DiagnosticStudies
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ImmediategoalsPatentairwayAdequateventilationAdequatecirculatingbloodvolumePreventextensionofcorddamage
CollaborativeCare
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InitialcareEnsurepatentairway.Stabilizecervicalspine.Administeroxygen.EstablishIVaccess.Assessforotherinjuries.Controlexternalbleeding.
CollaborativeCareEmergencyManagement
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InitialcareObtainimaging.Prepareforstabilizationwithtongsandtraction.
CollaborativeCareEmergencyManagement
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OngoingmonitoringVS,LOC,O2
sat,cardiacrhythm,urineoutputKeepwarm.Monitorforurinaryretention,hypertension.Anticipateneedforintubationifnogagreflex.
CollaborativeCareEmergencyManagement
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ThoracicandlumbarvertebraeinjuriesSystemicsupportlessintenseLessrespiratorycompromiseNobradycardiaTreatsymptomatically
CollaborativeCareEmergencyManagement
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OncestabilizedObtainhistoryofincident.ThoroughassessmentMusclegroupsSensoryexamAssociatedbraininjuryOtherinjuriesLogrollContinuousmonitoring
CollaborativeCareAcuteCare
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TostabilizeanddecompressinjuredspinalsegmentTractionorrealignmentEliminatedamagingmotion.Preventsecondarydamage.
CollaborativeCareNonoperativeStabilization
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EarlysurgeryindicatedifEvidenceofcordcompressionProgressiveneurologicdeficitCompoundfractureBonyfragmentsPenetratingwounds
Laminectomy
CollaborativeCareSurgicalTherapy
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J.N.scervicalspineisimmobilized.
Aneurosurgeonisconsulted.
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VasopressoragentsMaintainmeanarterialpressure>90mmHg
Altereddrugmetabolism riskforinteractions
CollaborativeCareDrugTherapy
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SubjectiveDataHealthhistoryFunctionalhealthpatternsHealthperceptionhealthmanagementActivityexerciseCognitiveperceptualCopingstresstolerance
NursingAssessment
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ObjectiveDataPoikilothermismWarm,dryskin(neurogenicshock)Respiratory
difficultiesBradycardia,hypotensionDecreasedorabsentbowelsoundsAddominal
distentionConstipation,incontinence,impaction
NursingAssessment
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ObjectiveDataUrinaryretentionFlaccidorspasticbladderPriapismLossofsexualfunctionParalysisHyperactivedeeptendonreflexesMuscleatony,contractures
NursingAssessment
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IneffectivebreathingpatternImpairedskinintegrityImpairedurinaryeliminationConstipationRiskforautonomicdysreflexia
NursingDiagnoses
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OverallGoalsOptimallevelofneurologicfunctioningMinimaltonocomplicationsofimmobilityLearnskills,gainknowledge,andacquirebehaviorstocareforself.Returntohomeandcommunity.
Planning
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HealthPromotionIdentifyHighriskpopulationsCounselingEducationSupportlegislationonseatbeltuse,helmetsformotorcyclists/bicyclists,andchildsafetyseats.
NursingImplementation
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HealthPromotionEducationCounselingReferraltoprogramsFacilitatewheelchairaccessiblehealthcarescreening,examrooms,etc.
NursingImplementation
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Maintainneutralposition.Stabilizetopreventlateralrotation.BlanketortowelHardcervicalcollarBackboard
Keepbodycorrectlyaligned.Logroll
Immobilization
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J.N.issenttotheORforsurgicalstabilizationofherspine.
Herfamilytellsyoutheyhadafriendwithacervicalfracturewhowastreatedwithtraction.
Theyaskyoutoexplainthedifferenceintreatment.
Whatiscervicaltraction?
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SkeletaltractionRealignmentorreductionofinjuryRope,pulley,andweightsTractionmaintainedatalltimes.Stabilizeheadinneutralpositionifdislodgedandthensummonhelp.Pinsitecare
Immobilization
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Immobilization
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KinetictherapyContinualsidetosideslowrotation>200turns/dayManualorautomaticDecreasespressuresoresandcardiopulmonarycomplicationsRiskformotionsickness
Immobilization
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RotoRest
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SOMIBrace
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HaloVest
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ThoracicorlumbarspineinjuriesCustomthoracolumbarorthosis(bodyjacket)
Meticulousskincarecriticalwithalltypesofimmobilization
Immobilization
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WhatwouldbeyourpriorityassessmentofJ.N.sconditionuponherreturnfromsurgery?
Explainyouranswer.
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Mayincreasedduringfirst48hoursMayneedintubationandmechanicalventilation
Riskforpneumoniaandatelectasis
RespiratoryDysfunction
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RegularassessmentAggressivechestphysiotherapyAdequateoxygenationProperpainmanagementAssistedcoughingTrachealsuctioningIncentivespirometry
RespiratoryDysfunction
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Riskforbradycardia andcardiacarrestChroniclowbloodpressure
withposturalhypotension RiskforDVT
CardiovascularInstability
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FrequentassessmentAnticholinergicdrug/pacemakerVasopressoragentSequentialcompressiondevicesand/orgradientstockingsRangeofmotionexercisesProphylacticheparin
CardiovascularInstability
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InitialparalyticileusandnasogastrictubeMonitorfluidandelectrolytes.Graduallyintroduceoralfoodandfluids.Highprotein,highcaloriediet
FluidandNutritionalMaintenance
74
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InadequatenutritionalintakeAssessforcauseContractwithpatientPleasanteatingenvironmentCaloriecountDietarysupplementsDietaryfiber
FluidandNutritionalMaintenance
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J.N.isconcernedabouthowshewillbeabletocontrolherbladderandbowelwithhercurrentstatus.HowwillyourespondtoJ.N.?
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IndwellingurinarycatheterinitiallyStrictaseptictechniqueFluidintake
IntermittentcatheterizationprogramEvery34hoursMonitorfors/sofurinarytractinfections
BladderManagement
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BowelprogramstartedduringacutecareDailyrectalstimulantDigitalstimulationormanualevacuationUprightpositionwhenable
BowelManagement
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Novasoconstriction,piloerection,orheatlossthroughperspirationbelowlevelofinjuryTemperaturecontrolexternalMonitorenvironmentandbodytemperature.Donotoverloadorundulyexposepatient.
TemperatureControl
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RisksecondarytoseveretraumaandphysiologicstressMonitorstool,gastriccontents,andhematocrit.Prophylacticmedications
StressUlcers
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SecondarytoabsentsensationsStimulatepatientabovelevelofinjury.Conversation,music,strongaromas,andinterestingflavorsPrismglassestoreadandwatchTVPreventpatientfromwithdrawing.
SensoryDeprivation
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Returnmaycomplicaterehab.HyperactiveExaggeratedresponsesPenileerectionsSpasms
PatientteachingAntispasmodicdrugs
Reflexes
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SomeofC.N.sreflexeshavereturned.Youwalkintoherroomonemorningtofindherpaleanddiaphoretic.Sheiscomplainingofapoundingheadache.YouassesshervitalsignsandfindherBPis206/100andherheartrateis56bpm.
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WhatdoyoususpectisgoingonwithJ.N.?
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MassiveuncompensatedcardiovascularreactionmediatedbysympatheticnervoussystemSNSrespondstostimulationofsensoryreceptors
parasympatheticnervoussystemunabletocounteracttheseresponses.Hypertensionandbradycardia
AutonomicDysreflexia
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Whatwouldbethemostlikelycauseofautonomicdysreflexia inJ.N.?
CaseStudyComstock/Thinkstock
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Mostcommonprecipitatingfactorisdistendedbladderorrectum.ManifestationsHypertensionThrobbingheadacheMarkeddiaphoresisabovelevelofinjuryBradycardia
AutonomicDysreflexia
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Forwhatotherclinicalmanifestationsofautonomicdysreflexia
willyouassessJ.N.?
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ManifestationsPiloerectionFlushingofskinabovelevelofinjuryBlurredvisionorspotsinvisualfieldNasalcongestionAnxietyNausea
AutonomicDysreflexia
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WhatareappropriatenursinginterventionsforJ.N.atthispoint?
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NursinginterventionsElevatehead,notifyHCPAssessforandremovecauseimmediatecatheterizationremovestoolimpactionifcauseremoveconstrictiveclothingandtightshoes
Patientandfamilyteaching
AutonomicDysreflexia
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ComplexGoaltofunctionathighestlevelofwellnessRetrainingfocusInterdisciplinaryendeavor
RehabilitationandHomeCare
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OrganizedaroundindividualpatientsgoalsandneedsPatientexpectedTobeinvolvedintherapiesTolearnselfcare
CanbeverystressfulFrequentencouragement
RehabilitationandHomeCare
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RehabilitationandHomeCare
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RespiratoryRehabilitation
PhrenicnervestimulatorDiaphragmaticpacemakerMobileventilatorsPatientteachingHomeventilatorcareAssistedcoughingIncentivespirometryDeepbreathingexercises
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Areflexic
(flaccid),hyperreflexic(spastic),ordyssynergiaCommonproblemsUrgency,frequency,incontinence,inabilitytovoid,andhighbladderpressuresresultinginrefluxofurineintokidneys
NeurogenicBladder
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DrugtherapyAnticholinergicdrugsAdrenergicblockersAntispasmodicdrugs
DrainagemethodsBladderreflextrainingIndwelling,intermittent,externalcatheterizationUrinarydiversionsurgery
Patientteaching
NeurogenicBladder
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Voluntarycontrolmaybelost.HighfiberdietAdequatefluidintakeSuppositoriesSmallvolumeenemasDigitalstimulationMandatoryforuppermotorneuroninjury
NeurogenicBowel
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StoolsoftenerOralstimulantlaxativesValsalva
maneuverwithmanualstimulationForlowermotorneuroninjuries
Useofgastrocolic reflex
NeurogenicBowel
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PreventionessentialPatientteachingComprehensivedailyexamCarefullyrepositionevery2hours.PressurerelievingcushionormattressAdequatenutritionAvoidthermalinjury.
NeurogenicSkin
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J.N.isworriedhowthisSCIwillaffecthersexualabilities.
Whatwillyouteachher?
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ImportantissueregardlessofpatientsageorgenderNursemustHaveanawarenessandanacceptanceofpersonalsexuality.Haveknowledgeofhumansexualresponses.Usemedicalterminology.
Sexuality
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Injurylevelandcompletenessofinjuryimpactsfunction.PsychogenicversusreflexerectionTreatmentsforerectiledysfunctionDrugsVacuumdevicesSurgicalprocedures
Fertilityissues
Sexuality
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FemalesexualissuesLubricationOrgasminabout50%ofwomen
FertilitynotusuallyaffectedPregnancycomplicatedRiskforprecipitousdelivery
Sexuality
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OpendiscussionAlternativemethodsUrinarycatheterizationPlanningforbowelevacuationpriorWatersolublelubricant
Sexuality
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OverwhelmingsenseoflossLossofcontrolAdjustmentmorethanacceptanceWidefluctuationinemotionsAllowmourningwhileencouraginghope.
GriefandDepression
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CaregiverandfamilycounselingSupportgroupSympathynothelpfulEncouragepatientparticipation.ConsistencyofcarePsychiatricconsultifneeded
GriefandDepression
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AdequateventilationIntactskinBowelmanagementBladdermanagementNoautonomicdysreflexia
Evaluation
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Establishesabowelmanagementprogrambasedonneurologicfunctionandpersonalpreference.Maintainsabowelmovementeveryotherday.
Evaluation
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Establishesabladdermanagementprogrambasedonneurologicfunction,caregiverstatus,andlifestylechoices.Developsnocomplicationsofimmobility.Experiencesnoepisodesofdysreflexia.
Evaluation
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IncreasedincidenceIncreasedcomplicationsHealthpromotionandscreeningRehabilitationlengthened
GerontologicConsiderations
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ApatientisjustadmittedtothehospitalfollowingaspinalcordinjuryatthelevelofT4.Apriorityofnursingcareforthepatientismonitoringfor
a. returnofreflexes.b. bradycardiawithhypoxemia.c.
effectsofsensorydeprivation.d. fluctuationsinbodytemperature.
Audience Response Question
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A young adult is hospitalizedafteran accident that resultedin a
complete transectionof the spinal cord at the level of C7. The
nurse informsthe patient that after rehabilitation, the level of
functionthat is most likely to occur is the ability to
a. breathe with respiratorysupport.b. drive avehicle with hand
controls.c. ambulate with longleg braces and crutches.d. use a
powered deviceto handle eating utensils.
AudienceResponseQuestion
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Duringassessmentof apatientwithaspinal cordinjuryatthelevel of
T2attherehabilitationcenter,whichfindingwouldconcernthenursethemost?
a. Aheartrateof 92b. Areddenedareaover thepatientscoccyxc.
Markedperspirationonthepatientsface
andarmsd. Alightinspiratory wheezeonauscultation
of thelungs
AudienceResponseQuestion
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