SPINAL CORD INJURY (SCI)

I. DEFINITION: The damage to any part of the spinal cord or nerves at the end of the spinal canal which involves the loss of motor function, sensory function, reflexes and control of elimination.

II. COMMON CAUSES: 1 Moto vehicle accidents (38.5%) 2 Falls (21.8%) 3 Acts of violence e.g, gun wound shots ( 24.5%) 4 Sports and recreation injuries (7.2%) 5 Other events (8%) III. TYPES OF SCI

SCI can be divided into two main types of injury:

Complete injury. Complete injury means that there is no function below the level of the injury--either sensation and movement--and both sides of the body are equally affected. Complete injuries can occur at any level of the spinal cord. Incomplete injury. Incomplete injury means that there is some function below the level of the injury--movement in one limb more than the other, feeling in parts of the body, or more function on one side of the body than the other. Incomplete injuries can occur at any level of the spinal cord.

IV.

LEVELS OF INJURY

High-Cervical Nerves (C1 C4)

Most severe of the spinal cord injury levels Paralysis in arms, hands, trunk and legs Patient may not be able to breathe on his or her own, cough, or control bowel or bladder movements. Ability to speak is sometimes impaired or reduced. When all four limbs are affected, this is called tetraplegia or quadriplegia. Requires complete assistance with activities of daily living, such as eating, dressing, bathing, and getting in or out of bed May be able to use powered wheelchairs with special controls to move around on their own Will not be able to drive a car on their own

Requires 24-hour-a-day personal care

Low-Cervical Nerves (C5 C8)

Corresponding nerves control arms and hands. A person with this level of injury may be able to breathe on their own and speak normally. C5 injury o Person can raise his or her arms and bend elbows. o Likely to have some or total paralysis of wrists, hands, trunk and legs o Can speak and use diaphragm, but breathing will be weakened o Will need assistance with most activities of daily living, but once in a power wheelchair, can move from one place to another independently C6 injury o Nerves affect wrist extension. o Paralysis in hands, trunk and legs, typically o Should be able to bend wrists back o Can speak and use diaphragm, but breathing will be weakened o Can move in and out of wheelchair and bed with assistive equipment o May also be able to drive an adapted vehicle o Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment

Nerves control elbow extension and some finger extension. Most can straighten their arm and have normal movement of their shoulders. Can do most activities of daily living by themselves, but may need assistance with more difficult tasks May also be able to drive an adapted vehicle Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment

Nerves control some hand movement. Should be able to grasp and release objects Can do most activities of daily living by themselves, but may need assistance with more difficult tasks May also be able to drive an adapted vehicle Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment

Thoracic vertebrae are located in the mid-back. Thoracic Nerves (T1 T5)

Corresponding nerves affect muscles, upper chest, mid-back and abdominal muscles. Arm and hand function is usually normal. Injuries usually affect the trunk and legs(also known as paraplegia). Most likely use a manual wheelchair Can learn to drive a modified car Can stand in a standing frame, while others may walk with braces

Thoracic Nerves (T6 T12)

Nerves affect muscles of the trunk (abdominal and back muscles) depending on the level of injury. Usually results in paraplegia Normal upper-body movement Fair to good ability to control and balance trunk while in the seated position Should be able to cough productively (if abdominal muscles are intact) Little or no voluntary control of bowel or bladder but can manage on their own with special equipment Most likely use a manual wheelchair Can learn to drive a modified car Some can stand in a standing frame, while others may walk with braces.

Lumbar Nerves (L1 L5)

Injuries generally result in some loss of function in the hips and legs. Little or no voluntary control of bowel or bladder, but can manage on their own with special equipment Depending on strength in the legs, may need a wheelchair and may also walk with braces

Sacral Nerves (S1 S5)

Injuries generally result in some loss of functionin the hips and legs. Little or no voluntary control of bowel or bladder, but can manage on their own with special equipment Most likely will be able to walk

V.

POSSIBLE NURSING DIAGNOSIS Ineffective Breathing Pattern related to paralysis of respiratory muscles or diaphragm Impaired Physical Mobility related to motor dysfunction Risk for Impaired Skin Integrity related to immobility and sensory deficit Urinary Retention related to neurogenic bladder Constipation or Bowel Incontinence related to neurogenic bowel Risk for Injury: autonomic dysreflexia and orthostatic hypotension Powerlessness related to loss of function, long rehabilitation, depression Sexual Dysfunction related to erectile dysfunction and fertility changes Chronic Pain related to neurogenic changes

VI.

NURSING INTERVENTIONS Attaining an Adequate Breathing Pattern 1. For patients with high-level lesions, continuously monitor respirations and maintain a patent airway. Be prepared to intubate if respiratory fatigue or arrest occurs. 2. Frequently assess cough and vital capacity. Teach effective coughing, if patient is having difficulty. 3. Provide adequate fluids and humidification of inspired air to loosen secretions. 4. Suction as needed; observe vagal response (bradycardia should be temporary). 5. When appropriate, implement chest physiotherapy regimen to assist pulmonary drainage and prevent infection . 6. Monitor results of ABG values, chest X-ray, and sputum cultures. 7. Tape halo wrench to body jacket or halo traction in the event the jacket must be removed for basic or advanced life support or respiratory distress.

Promoting Mobility 1. Place patient on firm kinetic turning bed until spinal cord stabilization. After stabilization, turn every 2 hours on a pressure reduction surface, ensuring good alignment. 2. Logroll patient with unstable SCI.

3. Perform ROM exercises to prevent contractures and maintain rehabilitation potential. 4. Monitor BP with position change in the patient with lesions above midthoracic area to prevent orthostatic hypotension. 5. Encourage physical therapy and practicing of exercises as tolerated. Functional electrical stimulation may facilitate independent standing and ambulation. 6. Encourage weight-bearing activity to prevent osteoporosis and risk of kidney stones. Protecting Skin Integrity 1. Pay special attention to pressure points when repositioning patient. Seating and mobility requirements must be determined. 2. Obtain pressure relief mattress and appropriate wheelchair and cushion.

3. Inspect for pressure ulcer development daily over bony prominences, including the back of head, ears, trunk, heels, and elbows. Observe under stabilization devices for pressure areas, particularly on the scapulae. Use a risk assessment tool to determine risk of developing pressure ulcer. 4. Keep skin clean, dry, and well-lubricated. 5. Turn a minimum of every 2 hours, and instruct patient to perform wheelchair weight shifts every 15 minutes. Place the patient in prone position at intervals, unless contraindicated. 6. Institute treatment for pressure ulcers immediately, and relieve pressure to promote healing. Bowel and Bladder Function 1.Spastic neurogenic bladder Clients who have upper motor neuron injuries will develop a spastic bladder after the neurogenic shock resolves. Bladder management options for male clients include condom catheters and stimulation of the micturition reex by tugging on the pubic hair. Female clients will need to use an indwelling urinary catheter due to the unpredictably of the release of urine. 2.Flaccid neurogenic bladder Clients who have lower motor neuron injuries will develop a accid bladder. Bladder management options for males and females include intermittent catheterization and Creds method (downward pressure placed on the bladder to manually express the urine).

3. Neurogenic bowel functioning does not differ a lot between upper and lower motor neuron injuries. Daily use of stool softeners or bulk-forming laxatives is recommended to keep the stool soft. A bowel movement can be stimulated daily or every other day by administration of a bisacodyl (Dulcolax) suppository or digital stimulation (stimulation of the rectal sphincter with a gloved and lubricated nger) only if requested by the provider. Digital stimulation should be used cautiously to avoid provoking a vagal response, which can result in bradycardia and syncope.

4. Development of a schedule as part of bladder and bowel training is critical in preventing complications related to immobility and promoting adequate nutrition and uid balance.