…through the Acute and the Rehabilitative Phases of Nursing Care


Risk Factors for SCI
• Each year, 11,000 people experience a SCI. • 200,000 more people are living with spinal cord injury results • Statistics show that males are highest number. Ages 16 – 30 y.o. Why do you think that is so?
High Risk Activities

Motor Vehicle Accidents

Sports Injuries
Falls / Accidents

Violent Acts

Data taken from 126 patient admissions

Examples of Injury
• Accidents (45%) – Car, van, coach 16.5% – Motorcycle 20% – Bicycle 5.5% – Pedestrian 1.5% – Helicopter 1.5% • Domestic / Industrial Accidents (34%) • Sport Injury 15%
– – – – Diving 4% “vertical compressions” Rugby 1% Horse Riding 3% Other 7%

• Assault 6%
– Self Harm 5% – Assaulted 1%

Profound Health Care Effects Average cost of care for a person with a cervical injury: •$572.491 each year after •Economic Hardship •High cost of rehab and long term care effects •90% of discharged SCI patients go home •10% of dishcarged SCI patients go to nursing home. chronic care facility.178 first year •$102. group home .

Lifelong Needs of SCI • • • • • Physical Psychosocial Financial Vocational Social Functioning .

He spent two days back in the ICU. He was admitted to the ICU and place on high doses of steroids for 24hrs. He was taken to surgery for external spinal stabilization.W. He was found to have a T10-11 fracture with paraplegia. 5 days on Step Down.CASE STUDY ONE T. is a 22 yo male patient fell 50ft from a chairlift while skiing and landed on hard snow. . He continues to have no movement to the lower extremities. and is now ready to be transferred to your rehab unit.

tear.#1 : Goal of Treatment in Acute Phase • Pathophysiology: immediate mechanical disruption of axons as a result of a laceration. the more permanent damage … CNS does not regenerate! . stretch.ischemia and cell death … Within four hours – Free Radicals released – Hemorrhage in area causes edema and compression … further damage to axons … bleeding appears within one hour … this can spread the area of injury and damage – The longer this process. or sever • Primary Injury / Secondary Ongoing Injury – Normal blood flow is disrupted to area – Spinal cord deprived of O2 ….

and cascade of secondary injury – How do we do this? • Survive the Injury • Maintain physiological stability through spinal shock . trauma.#1: Critical Nursing Care / Goals • Immediate Stabilization to prevent further injury.

ACUTE SPINAL FACTS • The extent of damage results from the primary and secondary injury and can be devastating if stabilization and early treatment were not started • Prognosis / Recovery most accurately determined 72hrs or more after injury .

– Found in the early 80s to be highly effective to reduce the length of time for spinal shock and to reduce degree of injury • Side Effects: decreased immune response. increase serum glucose. psychosis. induce depression. risk for infection. risk for GI bleed .#2: Steroid Therapy Benefits • High dose IV steroids (Solumedrol) given within frist 8hrs of injury – Reduce damage to cell membranes and decrease inflammation.

Decreased Cardiac Output – VS Changes: Hypotension. Bradycardia. Flushed extremities.#3: What is Spinal Shock? (AKA Neurogenic Shock) • Temporary Condition / Acute Phase • Sympathetic function / communication is impaired below the level of injury – Sympathetic nerves leave the spine at thoracic and lumbar areas • Parasympathetic function takes over Vasodilation . Venous Pooling. Hypoxia – Loss of Spinal Reflexes – Loss of Sensation – Flaccid Paralysis below injury • Time Frame – one week to six months • Masks the extent of injury • Spinal Shock Resolves: Reflexes return . Temperature fluctuations.

. Any increase of vagal response can further increase bradycardia and cause cardiac arrest.#3: Nursing Support • Bradycardia: – Anticholinergic “Atropine” – Temporary Pacemaker • Hypotension: – Fluids – Dopamine • Careful monitor of ABCs.

• Early mobilization prevents further complications.#4 Post Acute Phase • Stabilizing the spine and resolving spinal shock will allow for early mobilization. • What system by system complications are we concerned with ? – – – – – – Cardiovascular Respiratory Gastrointestinal / Nutrition Elimination Musculoskeletal Integumentary .

Intercostal muscle impaired) . the higher the risk! Above C4 / Below C4 (Phrenic nerve at diaphragm.Respiratory Complications • Major cause of death in the acute phase! – – – – – – – – – Pulmonary support Suctioning / Postural Drainage / Turning Coordinate with RT HHN O2 support Ventilator? Ambu at bedside Trach needed? Monitor ABGs – gas exchange Breath sounds / breathing patterns / sputum production • • • • Poor cough effort Atelectasis / Pneumonia Higher the level injury.

Cardiovascular Complications • • • • • Hypotension Bradycardia Decreased Cardiac Output Venous Pooling Impaired Tissue Perfusion • Risk for Deep Vein Thrombosis – DVT Prophylaxis! .

Gastrointestinal / Nutrition Complications • • • • • • Paralytic Ileus Septic Bowel Necrotic Bowel Stress Ulcers GIB Malnourishment What does the nurse assess? What does the nurse monitor? Abdominal assessment? NGT to suction? .

Elimination Complications • Loss of Bladder and Bowel control • Neurogenic B/B • Risk for Impaction / Retention / Incontinence / Urinary Tract Infections .

Loss of function • Bone loss • Muscle Atrophy ..Musculoskeletal Complications • Risk for Contractures – Muscle spasticity • Contractures ….

Skin Complications “Patients who do not have an ulcer state that nurses in the ICU turned them every 2 hours after injury” • Research shows that patients go to rehab with ulcers already formed – DISGUSTING nursing care! • Risk factors for skin breakdown? • Interventions? Skin Inspections? .

#5 Rehabilitative Needs MASLOWS HIERARCHY (5) Self Actualization (4) Community Integration (3) Adjustment to living at home (2) Accomplishment of ADLS (1) Stabilization of Physiological Systems .

#6 Self Care Abilities of T10-11 • Level of T2 – T12 should be independent with the wheelchair – May even walk short distances with orthotics and crutches • Manage their own ADLs • Manage their B/ B routine .

degree of paralysis.Tetraplegia (arms are rarely completely paralyzed) • Thoracic / Lumbar – (T2 – lumbar) – Paraplegia (full us of arms) .“LEVELS OF INJURY” • Symptoms. extent of injury. and disability depends on the level of cord that is injured • Cervical / Thoracic / Lumbar • Cervical (C1 – T1) .

requires w/c with breath controls – C3-4: Dependent with ADLs. may still need ventilator support – C4 and above: some sort of lifelong ventilatory support – C5: elbow flexion – C6: wrist extension – C7: finger control – Independence increases from C6 down . Incomplete – Complete : Total loss of sensory and motor function below the level of injury – Incomplete: Mixed loss of voluntary and involuntary activity and sensation • Cervical Injuries – C1-2 : limited head and trunk control .• Complete vs.

#7 Bladder Function • SCI above T12 – Spastic or Reflexic Bladder – Characterized by involuntary bladder contractions with uncontrolled voiding and incontinence. Increase fluids. Bladder program . UTIs • Goals: Avoid bladder infections. • SCI below L1 – Areflexic or Flaccid Bladder – Absent bladder contractions resulting in high volumes of residual urine and urinary retention • Risks: Renal Calculi .

• Pt Teaching: – s/ sx of infection – Intermittent cath program – Medications to help bladder with tone – Stimulate urine flow – Increase fluids – Indwelling catheter – irrigations – Cranberry juice • Meds: – Anticholinergics to suppress contraction – Antispasmotics to decrease spasticity .

fluids • Digital stimulation (avoid enemas) • Positioning • Abdominal Massage • Valsalva .#8 Bowel Training • The bowel has its own neural control that responds to distention. • Train the bowel a predictable pattern of emptying • Meds: – Stool Softeners – Stimulant Laxatives • Diet: – Fiber. This is what helps SCI patients regain control of emptying.

He has a history of pressure ulcers. P52. . RR20 He also has a history of Autonomic Dysreflexia Take a look at his medication regiman.0. He is a Incomplete C5 – C6 level of injury for 20 years after suffering a SCI after a diving accident. Vital Signs: T 96. BP 88/42.CASE STUDY #2 43 yo male pt entered the hospital with a left ischial pressure sore stage IV.

bathing.#1: INCOMPLETE? SELF CARE ABILITIES? • • • • • • Full head. grooming. dressing . wheelchair on even surfaces. drive with hand controls • Assistance: Transfers. and shoulder control Diaphragm control Should not need respiratory support Elbow flexion with some wrist extension Assistive devices for fine motor skills Independent: feeding. neck.

#2 VS Changes in SCI • Autonomic Nervous System effected with injuries above the T6 level. Low Pulse. Poiklothermia (taking on the temp of the room with periods of flushing and inability to sweat) . • There can be a loss of communication within the body with the ANS. • Inability to autoregulate – particularly VS • Low BP.

#4 Medication Regimen • Muscle Spasticity: – Baclofen – Flexeril – Valium • Vitamins • Pain and Muscle Relaxation: – Neurontin • Bladder Care – Detrol – Ditropan • Bowel Care – Colace – Suppository .

Seizure. hemorrhage.#5 Autonomic Dysreflexia • Abnormal ANS response in SCI pts with a T6 or higher • Patho: ANS cannot decipher stimulus responses rapidly coming up the spinal tract causing an abnormal ANS response “flight and flight” • Precipitated by noxious stimuli below the level of injury • “Congested communication” in spinal tract • Can be Life Threatening – cause increased ICP. Stroke • Medic Alert! .

identify noxious stimuli. monitor VS. pressure sores. infection. ingrown toenail. insect bite. treat cause . dysmennorhea. contact MD.• AD is usually brought on by B / B distention. constrictive clothing • Assess fast! – – – – – – Headache Flushing Sweating High BP Blurred vision Nausea • Act fast! – Elevate HOB. spasms. UTI. surgery site.

suggest counseling.#6 Let’s Talk About Sex Baby! • • • • Reflex erection is possible with upper motor neuron lesions Orgasm and ejaculation is not usually possible Drugs or surgery for erectile dyfunction option Poor sperm quality • Usually remain fertile and can have children • Uterine contraction not felt Allow venting of feelings. offer support. educate .

PSYCHOSOCIAL CONCERNS?? What can you come up with??? .

self care • Return to home • Integrate back into community .Collaborative Goals with SCI • Maintain optimal level of wellness • Maintain optimal functioning • Minimal or no complications of immobility • Learn new skills.

Sign up to vote on this title
UsefulNot useful