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Most common locations of spinal cord injuries cervical (1, 2, 4-7), and T1–L2 lumbar vertebrae Locations reflect most mobile portions of vertebral column and the locations where the spinal cord occupies most of the vertebral canal
Degenerative Disorders of the Spine are Degenerative disk disease (DDD) Spondylolysis Spondylolisthesis Spinal stenosis Low back pain Herniated intervertebral disk
S&S of injury at the level of L 4 – 5 pain in hip, groin, post-lateral thigh, dorsal surface of foot Difficulty walking on heels
S&S of injury at the level L 5 – S 1 pain mid gluteal, post thigh, calf down to heel, outer surface of foot Difficulty walking on toes
Sensory deficits in affected areas Diminished or lost reflexes Back movement restricted Spastic paravertebral muscles Difficulty, pain with straight leg raise Aggravated by cough, sneeze or strain Are all S&S of..... LUMBAR AREA
Stiff neck Radiating shoulder pain down arm into hand Paresthesias and sensory disturbances in hand Are all S&S of..... CERVICAL
POST OPERATIVE ASSESSMENT CSF leakage Acute urinary retention & paralytic ileus Arachnoiditis, diskitis Larngeal and tracheal edema with anterior cervical laminectomy Donor site for autologous graft for spinal fusion
Progressive weakness of lower extremities Loss of sphincter control, anal numbness Urinary retention Notify MD; may require emergency decompression CAUDA EQUINA SYNDROME
NURSING DIAGNOSES FOR DISC DISEASE Acute and chronic pain Deficit knowledge Risk for perioperative positioning injury Disturbed sensory perception
NIC LABELS FOR INTERVERTEBRAL DISC DISEASE Pain management, analgesic administration Teaching disease process Positioning, intraoperative Health education
MECHANISMS OF INJURY Hyperflexion Hyperextension Vertical compression or axial loading Excessive rotation
IMMEDIATE CARE & ASSESSMENT Respiratory pattern & airway (use jaw thrust) Determine circumstances of injury Correct immobilization & transport
DEGREE OF INJURY Complete permanent loss of motor & sensory function below level of injury
DEGREE OF INJURY Incomplete some nerve fibers preserved distal to point of injury
Ischemia and edema Within 1 hour calcium flood accompanies dying cells Free radicals scavenge oxygen from healthy cells In 6 to 12 hours secondary wave of immune cells clear injured cells & also destroy live nerve SECONDARY INJURY CASCADE
occurs immediately after injury Spinal shock also can lead to Neurogenic shock too
occurs after spinal shock resolves in injuries above T-6 Autonomic dysreflexia
SPINAL SHOCK Below level of injury: Loss of sensation to Pain, touch, temperature & pressure Absence of all voluntary activity (flaccid paralysis) and reflex neurologic activity Bowel and bladder dysfunction
Loss of ability to shiver and retain heat or perspire to release heat Body temperature varies with the environment Monitor for temperature extremes POIKILOTHERMIA
Flaccid paralysis Bradycardia Hypotension Occasional paralytic ileus Priapism SCI above T6 SIGNS & SYMPTOMS
Loss of vasomotor tone (hypotension) Generalized vasodilation in PVS Interruption of sympathetic NS Decreased cardiac output Rx with sympathomimetic drugs phenylephrine, dopamine atropine for bradycardia Neurogenic Shock
Medical emergency – severe hypertension up to 240-300 mm Hg Occurs with SCI above T-6 Exaggerated sympathetic response to noxious stimulus (usually full bladder) Complimentary parasympathetic system unable to balance below level of injury AUTONOMIC DYSREFLEXIA
S/S OF DYSREFLEXIA Hypertension Bradycardia Flushing & diaphoresis above SCI level Severe headache Nasal stuffiness Blurred vision
DYSREFLEXIA MANAGEMENT Sit upright to produce orthostatic hypotentsion (First action) Monitor BP every 5 minutes Check Foley Catheter for patency or bladder for distension (Empty bladder) Assess for fecal impaction using local anesthetic Notify MD
MEDICAL TREATMENT Order to irrigate catheter, use only 30 mL Obtain order for anesthetic gel (Lidocaine or Nupercaine) Medications if needed: nitropaste, nifedipine (Procardia), hydralazine (Apresoline) Key treatment – Prevention!!
Nursing Diagnoses in Subacute Phase Risk for ineffective breathing pattern R/T Neuromuscular impairment Ineffective tissue perfusion: peripheral R/T interruption of venous flow DVT occurs in 80% SCI patients
PULMONARY COMPLICATIONS C4 and higher affects all muscles controlling breathing
PULMONARY COMPLICATIONS C4 – T6 diaphragm function preserved; different degrees of accessory muscle function
PULMONARY COMPLICATIONS T6 – T12 ability to cough impaired
NURSING MANAGEMENT IN SUBACUTE PHASE Risk for impaired skin integrity R/T decreased sensation, immobility & vasodilation Altered urinary elimination and constipation R/T neurogenic bowel and bladder Risk for nutritional deficit R/T hypermetabolism & high caloric needs
Intermittent catheterization Force fluids to 2500 mL/ day Fluids to acidify urine Limit milk, dairy products, carbonated beverages BLADDER RETRAINING INTERVENTIONS
Constipation can trigger dysreflexia Establish consistent time for elimination 30 min to 1 hour after eating High fluid intake & high fiber diet Rectal stimulation with or without suppositories Stool softeners BOWEL RETRAINING INTERVENTIONS
Key is prevention Weight shift every 15 min 2 hour turning schedule Back tilt position 60 - 65 degrees DECUBITUS ULCERS
MALE SEXUALITY & SCI Sexual function controlled S 2 – 4 Men with UMN: 70% with complete injury & 80% with incomplete able to have intercourse Reflex erection Loss of psychogenic or fantasy responses Psychogenic erection present 19% incomplete UMN
MALE SEXUALITY Three performance factors Erection Function of parasympathetic NS Requires intact sacral reflexes Ejaculation Function of sympathetic NS Fertility Decreased sperm quality and motility
FEMALE SEXUALITY & SCI Lack sensation during intercourse,Childbearing age–can become,pregnant,Hormonal BCP’s increase,Vaginal delivery possible,Risk of autonomic dysreflexia in labor,Pregnancy Complicated by loss of sensation,increases in BP,& possible precipitation of AD
MEDICAL PROBLEMS Heterotrophic ossification HO calcification around a joint, most often hip. 20% TBI or SCI exhibit within 12 weeks after injury
_______ cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Central
_________ cord syndrome results in motor and sensory loss but not reflexes. Anterior
_________ syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function. Brown-Séquard
_________is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis. Autonomic dysreflexia (Autonomic reflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system)
________is the most important goal for a patient with a high cervical fracture. Maintaining a patent airway
the most common cause of autonomic dysreflexia is bladder irritation/constipation
__________ is a common problem accompanying spinal cord injury during the first 3 months Deep vein thrombosis
What is most important action for a patient who has a suspected cervical spinal injury? A patient with a suspected cervical spine injury should be immobilized with a hard collar and placed on a firm surface.
About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as... spinal shock
Look under the Slide tab for autonomic dysreflexia and spinal cord pic slide tab
C5 spinal cord injury highest priority? airway
Rehabilitation goals for a patient with a spinal cord injury at the C6 level include ability to assist with: transfer and perform some self-care; feed self with hand devices; push wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent computer use with adaptive equipment; and needing attendant care only for 6 hours per day.
A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have the flu because he has a bad headache and nausea. What is your initial action? It is important to measure blood pressure when a patient with a spinal cord injury complains of a headache. You must monitor blood pressure frequently during the episode. An α-adrenergic blocker or an arteriolar vasodilator may be administered.
A positive Brudzinski’s sign is seen in meningitis
Created by: troop27