Transcript PN 141 Day 7

Chapter 29
Spinal Cord Injury
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.
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
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
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
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
Pathophysiology of
Spinal Cord Injury
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
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
Figure 29-6
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
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
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
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
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
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
Spasticity
• Muscle spasms may be incapacitating for
these patients, hampering efforts at
rehabilitation
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
Impaired Bladder Function
• During spinal shock, all bladder and bowel
function ceases
• Once spinal shock resolves, reflex activity
returns
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
Impaired Temperature Regulations
• May lose these regulatory mechanisms and
be unable to adapt to temperature extremes
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
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
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
Medical Treatment in the Acute Phase
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
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
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
Figure 29-7
Figure 29-8
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
Figure 29-9
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
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
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
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
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
Family History
• Routine family history taken but not
considered specifically relevant to a
diagnosis of spinal cord injury resulting from
trauma
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
Interventions
•
•
•
•
•
•
•
Nursing Diagnoses cont.
Risk for Infection
Ineffective Thermoregulation
Feeding/Dressing/Grooming Self-Care Deficit
Sexual Dysfunction
Ineffective Coping
Ineffective Therapeutic Regimen
Management
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
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
Brain Abscess
AIDS
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
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
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
AIDS
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
AIDS
• Diagnostic Tests
– Serologic studies
– CSF
– CT, MRI
• Medical Management
– Administration of medication: antiviral, antifungal,
antibiotics
– Radiation
– Dehydration/shock: fluid volume expanders
– Seizures: anticonvulsants
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
Other Disorders of the
Neurological System
Disturbances in Muscle Tone and Motor
Function
– Etiology/pathophysiology
• Damage to the nervous system causes serious
problems in mobility
–E.g. pt. with cerebral palsy
Disturbances in Muscle Tone and Motor
Function
– Clinical manifestations/assessment
• Flaccid: muscle is weak, soft, flabby; lacks
normal muscle tone
• Hyperreflexic muscle tone: increased reflex
actions
• Clumsiness or incoordination
• Abnormal gait
Disturbances in Muscle Tone and Motor
Function
• Assessment of patients with motor problems:
– Subjective Data: patients understand of the
problem and possible causes; initial onset of sx.,
any improvement; presence of clumsiness or
incoordination; abnormal sensations
– Objective Data: coordination, muscle strength,
muscle tone, presence of muscle atrophy;
response to checking of reflexes; abnormal gait
Disturbances in Muscle Tone and Motor Function
– Diagnostic Tests: EMG
– Medical management/nursing interventions
• Muscle relaxants to treat spasticity
– E.g. Baclofen; Valium
•
•
•
•
Protect from falls
Assess skin integrity
Positioning
Prefeeding and feeding exercises; Sit up and tuck chin
when eating
• Encourage patient to assist with ADLs
• Emotional support
Disturbances in Muscle Tone and Motor
Function
• Nursing Interventions
– Safety needs.
•
•
•
•
•
Protection from falls
Use of siderails and chair support
Watch for signs of unilateral neglect
Eye care on the paralyzed side
Skin Assessment: pressure relief aids
– Turning and positioning schedule
– Inspect skin daily and prn
Disturbances in Muscle Tone and Motor
Function
• Nursing Interventions cont.
– Activity needs: care and positioning of affected
extremities
•
•
•
•
•
Risk for contractures if unattended to
ROM – active, passive
OT, PT may provide splints and braces
Prevent foot drop and wrist drop
Appropriate positioning
Disturbances in Muscle Tone and Motor
Function
• Nursing Interventions cont.
– Nutritional Needs: patience and persistence while
giving food and fluids to patients with hemiplegia
• Aspiration Precautions
• Checking cheeks for accumulated food
• Special utensils/assistive devices may be used
– ADLs – promote maximum independence
• OT, Nursing, PT
Disturbances in Muscle Tone and Motor
Function
• Nursing Interventions cont.
– Psychological Adjustments:
•
•
•
•
•
To body changes
Changes in abilities
Fears of rejection
Self-esteem issues
Referrals, support, networking
Disturbed Sensory and Perceptual Function
• Etiology/pathophysiology
– The presence of a lesion anywhere along the
sensory system pathway alters the transmission or
perception of sensory information
– The parietal cortex of the brain is of major
importance in interpretation and sensation
– Any alteration lessens the patient’s ability to be
completely protected from inadvertent injury
Disturbed Sensory and Perceptual Function
• Etiology/ pathophysiology cont.
– One specific loss: Proprioception (the ability to
know the position of the body and its parts
without looking at it)
– Other loss: Agnosia (total or partial loss of the
ability to recognize familiar objects or people).
Disturbed Sensory and Perceptual Function
• Assessment:
– Subjective Data: pts. Understanding of the sensory
disturbance; measures that relieve symptoms;
presence of symptoms that occur with the sensory
problem
– Objective Data: note pt. ability to perform useful
movement or recognize familiar objects
Disturbed Sensory and Perceptual Function
• Medical Management: per alterations in
muscle tone and motor function
• Nursing Interventions:
– Most Important: teaching the patient protective
measures!
• Learning to inspect parts of his/her body that have no
feeling
• Protect sensitive parts of the body that are at risk:
– i.e. avoid bedding rubbing over toes