Transcript French video x 4

Chicago
Pediatric Specialty Care
Orthopaedics, Cleft Lip and
Palate, Spinal Cord Injury
Back to School
after
a Spinal Cord Injury
Patricia Mucia, BSN, RN, CRRN
West Virginia School Nurses
November 4, 2016
Objectives
At the conclusion of this program the participant should be able to:
1. Have a basic understanding of Spinal Cord Injuries
2. Describe how a Spinal Cord Injury (SCI) changes normal bodily
functions and activities of daily living
3. Name three important things that challenge a student with a SCI
4. Develop an understanding of Spinal Cord Injury and the role of the
nurse in the school setting.
Central Nervous System & Spine
 Brain
 Spinal cord
 Made of a jello-like substance
 Comprised of nerve fibers which
carry messages between the brain and the body
 Spine
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33 bony structures
Cervical
7
Thoracic
12
Lumbar
5
Sacral
5
Coccygeal
4
C1-C7
T1-T12
L1-L5
S1-S5
fused
Spinal Nerves
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Spinal nerves exit from the spinal cord through the vertebrae.
They branch out to supply and receive impulses to each area of
the body.
They are:
 Cervical
8
 Thoracic
12
T1-T12
 Lumbar
5
L1-L5
 Sacral
5
S1-S5
 Coccygeal
1
C1-C8
Levels of Impairment
Causes of Spinal Cord Injuries

Damage to the spinal cord may be caused by pressure or actual severing
of the cord.

Traumatic injury in children
 Motor vehicle crash
 Birth injuries
 Sports injuries
 Diving accidents
 Trampoline accidents
 Violence ( gun shot/stab wounds)
 Falls
 Non Traumatic Injuries
 Transverse Myelitis
 Guillien Barre Syndrome
 AVM (Arterio-Venous Malformation)
 Surgical Complication
 S.C.I.W.O.R.A.
SCI in the USA


276,000 Americans are spinal cord injured.
12,500 new cases each year

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Annual incidence-approximately 40 cases per million
in children- 1,455 per year
11.6% of total Spinal Cord Injuries per year
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In Children:
60-75% occur in the neck area
20% in the chest or upper back
5-20% in the low back
Acute Care
 A traumatic event that results in Spinal Cord Injury is
devastating to the child and the family.

Trauma surgery and Stabilization
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Spine Surgery
Halo traction/vest
Associated injuries
Recovery from infectious illness
 Intensive care
 Respiratory Support
 Length of stay: 1970’s = 24 days
since 2010= 11 days
Acute Care

Pediatric Transfer of Care
 Contact with Shriners Hospital for Children-Chicago
Philadelphia
 Nurse or Social Worker
Sacramento
 Discharge planner
 Case Manger
 Care Coordinator
 Medical history
 Diagnostic tests
 Current condition
 Air Medical transport
 Cincinnati Shriners Transport
Rehabilitation


Length of stay: 1970’s = 98 days
since 2010 = 36 days
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Medical management
Physical Therapy
Occupational Therapy
Nursing
Psychology
Social Work
Discharge planning
Transition to home and community setting
Skin
Skin Care
Prevention of Pressure Ulcers
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Occur in all age groups
Occur in hospital, long term care facility and in the home
Serious complication

Medical complications
 Malnutrition
 Sepsis
 Osteomyelitis
 Cost
 Hospitalization
 Surgery
 Loss of time in school and/or work
 Loss of Skin integrity
Skin
Pressure Ulcer Prevention

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Pressure reliefs
Seating evaluation, cushions, pressure mapping
Skin inspection
Education
 developmentally appropriate
 Repetitive
 Safety measures
Skin
Skin Safety
Burns
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Food
Cooking
Laptop computers
Radiator or heat vents
Hot pads, electric blankets
Weather : sunburn or frostbite
 Positioning of extremities
 Clothing and shoes
BLADDER MANAGEMENT
 Diseases of the urinary system account for 3.5% of
deaths among individuals with SCI.
 Diseases of the urinary system are contributing
factors in another 5.2% of deaths of individuals with
SCI.
 Individuals with SCI are 10.9% more likely to die of
diseases of the urinary tract.
Management of Neurogenic Bladder
Management of neurogenic bladder
GOALS
1. Preservation of renal function
2. Prevention of complications
3. Social continence
BLADDER MANAGEMENT
 The bladder is interlaced with
smooth muscle, called detrusor.
 Two sphincters control the
bladder outlet.
 Internal sphincter-smooth
muscle, like the detrusor.
 External sphincter-striated
muscle, like skeletal muscle.
BLADDER MANAGEMENT
 The ureters propel urine into the
bladder. The bladder is a holding
or storage tank.
 500ml=approximate adult
bladder capacity.
 150ml=awareness of the need to
void.
 400ml=we are seeking an
appropriate toilet.
BLADDER MANAGEMENT
Normal Micturation (voiding)
Bladder filling and emptying requires coordination
between the bladder and the nervous system.
Filling: (sympathetic)- increases tone at the base
decreases tone at neck of the bladder
decreases tone of detrusor muscle.
Emptying: parasympathetic nerves release
acetylcholine near bladder smooth muscle causing
contraction of the detrusor.
tone decreases at the base, relaxing the sphincter to
release urine.
BLADDER MANAGEMENT
Detrusor Sphincter Dysnergia
 Bladder filling stimulates the detrusor to contract.
 At the same time the sphincter is contracted and
closed causing increased pressure and preventing
the urine from leaving the bladder.
 Resulting in:

intermittent voiding, leaking,
incontinence

urinary retention

bladder distention

reflux
BLADDER MANAGEMENT
 Neurogenic Bladder
 Voluntary control of urination requires
communication between the brain and the lower
urinary tract (bladder).
 Without input from the brain, we have “neurogenic”
or “neuropathic” bladder.
 Spinal Cord Injury
 Any lesion above the sacrum-detrusor areflexia:
inability to contract causing urinary retention.
 Spinal Shock-lasts a few months-up to two years.
 When reflex returns-bladder is able to contract.
BLADDER MANAGEMENT
Vesicoureteral reflux
 occurs when the bladder is
stiff, high pressure, low
compliance
 the increased pressure
creates a path for urine to
flow back up to the kidneys
(reflux)
 results in hydronephrosis
Management of Neurogenic Bladder
Medical Management
 Routine scheduled evaluations with a urologist
 Baseline studies:
 VCUG
 Urodynamics
 renal ultrasound
 Bladder Emptying
 Intermittent Catheterization
 Timed Voiding (based on urodynamics results)
 Surgical Procedures
 Bladder Augmentation
 Appendicovesicostomy
 Monti
 Urethral sling
 Medications
 Anticholinergics
 Antibiotics ( for treatment of UTI or prophylaxis)
BLADDER MANAGEMENT
Urodynamic Studies include:
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Uroflowmetry
Cystometry
Urethral pressure studies
Voiding studies
Sphincter EMG
Video urodynamics
Pharmacologic testing
BLADDER MANAGEMENT
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 Renal Ultrasound
Sound waves create real time images of kidneys &
bladder.
Primary use is to show hydronephrosis.
Also shows kidney/bladder stones, tumors or cysts.
Non-invasive & painless.
 VCUG
A real time study of bladder filling and emptying.
A radio opaque solution is used to fill the bladder.
A radiologist is present to assess the flow of the
contrast solution.
If possible, patient voids to empty their bladder at the
end of the study.
BLADDER MANAGEMENT
BLADDER MANAGEMENT
VCUG
voiding cystourethragram
showing reflux and
hydronephrosis
Mitrofanoff Surgical Intervention
Cutaneous Anastamosis
Appendix
Mitrofanoff Principle
• Continence mechanism based on flap valve
• Reservoir pressure is transmitted against wall of conduit
Bladder Management
BLADDER MANAGEMENT
Bladder Emptying
 Intermittent Catheterization
 Timed Voiding (based on urodynamics
results)
 Indwelling catheter
 Suprapubic catheter
BLADDER MANAGEMENT
Catheterization:
• Intermittent
achieved by the insertion of a
small diameter tube (catheter)
into the bladder through the
urethra or catheterizeable stoma
and removed after emptying
• Indwelling (foley)
remains in place to drain urine
BLADDER MANAGEMENT
Clean Intermittent Catheterization
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prevents bladder overdistention
prevents urethral irritation
allows the bladder to fill and empty naturally
exercises the muscles to prevent shrinkage and
increased pressures.
BLADDER MANAGEMENT
Suggested guidelines
Clean intermittent catheterization- every 4 hours around
the clock until no volumes exceed 500ml in the
previous 48 hours. Then every 4-6 hours while awake.
Overdistended bladder-remove no more than 1000ml at
one time. Rapid changes in fluid balance can release
pressure on the pelvic blood vessels, causing blood
pressure and circulatory changes.
BLADDER MANAGEMENT
Helpful Tips
Size and type of catheter usually
prescribed by a urologist.
Infants- 4-5 french
Older toddlers/preschoolers- 6-10 french
School age- 8-12 french
Adolescents-12-14 french
Adult-14 -16 french
Management of Neurogenic Bowel
Management of neurogenic bowel
GOALS
1. Complete and regular bowel movements
2. Prevention of constipation or diarrhea
3. Continence
4. Independence
Neurologic Impairment
UPPER MOTOR NEURON(REFLEXIC)
(Cervical and thoracic level injuries above T12)
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Spinal cord and colon innervations remain intact.
Reflex pathways continue to function.
Loss of conscious sphincter control.
Anal sphincter remains tight.
Reflex peristalsis.
Responds to digital stimulation and stimulant
medications.
 Susceptible to Autonomic Dysreflexia.
Neurologic Impairment
LOWER MOTOR NEURON (AREFLEXIC)
(Lumbar and sacral injuries)
 Reduced reflex control of anal sphincter
 Flaccid bowel
 Require more frequent evacuation to remain
continent.
 Decreased peristalsis
 Increase in transit time
 LMN bowel may not respond usual bowel intervention
s: digital stimulation.
 Keep the stool well-formed and rectal vault clear to
prevent embarrassing accidents.
BOWEL MANAGEMENT
 What is our poop telling us?
 Which type do you have?
 Which type is ideal?
Bowel Management
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CONSISTENCY
Bulky, soft, and formed stool is the goal.
Easiest to evacuate
More likely to be retained
Affected by:
Diet
Fluid intake
Medications
Activity
Supplements
Stimulant laxatives
BOWEL MANAGEMENT
REGULARITY
 Maintain child’s previous schedule
 Plan 30-60 minutes after a meal (gastrocolic reflex)
 Same time every day or every other day
 Be loyal to the routine
BOWEL MANAGEMENT
POSITIONING
Sitting upright with trunk supported:
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Provides stability
Pelvic floor relaxes
Allows for more complete and timely emptying
Assistance from gravity (physics)
Adequate seat padding to prevent pressure
Management of Neurogenic Bowel

Bowel program provides regular, predictable emptying of the
bowel
 Initiated at approximately 2-4 years of age
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Necessities for success
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PATIENCE-takes time to establish
Regularity frequency and time of day
Privacy
Position; sitting on toilet or commode
Use of medications
 Laxatives
 Stool softeners
 Rapidly acting suppositories
 Magic Bullet (bisacodyl in water-soluble medium)
 Enemeez (docusate sodium) mini enema
BOWEL MANAGEMENT
RECTAL STIMULATION
 Digital stimulation:

stimulates the reflex relaxation of internal anal sphincter and
contraction of the smooth muscle of the rectal vault.
 Use water-soluble lubricant on gloved finger(s)
 Use a circular motion following the contour of the rectal vault.
 Can be repeated every 5-10 minutes until evacuation is complete
 Complete evacuation is indicated if two consecutive digital
stimulations yield no more stool.
 CAUTION: may cause autonomic dysreflexia
BOWEL MANAGEMENT
BOWEL MANAGEMENT
MEDICATIONS:
ORAL
Osmotic agents: attract fluid into the bowel and cause colonic
distention and peristalsis.
Polyethylene glycol-electrolyte solutions:
MiraLax
Lactulose products
Milk of Magnesia
Stimulant laxatives: alter the transport of electrolytes within
intestinal mucosa, causing water retention and stimulates
peristalsis.
Senekot
Dulcolax
Lubricant laxative: lubricates stool for easy passage.
Mineral oil
BOWEL MANAGEMENT
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MEDICATIONS:
RECTAL
Chemical agent to move stool into the rectum for
evacuation
Stimulate peristalsis.
Provide more predictability
Must be retained long enough to melt
Inexpensive
Glycerin
Dulcolax
Magic bullet
 Mini enemas
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
Babylax, pedilax
Enemeez
BOWEL MANAGEMENT
vs
Autonomic Dysreflexia
What Is It?
 Life threatening complication
 Over reaction of the nervous system in response to a
noxious stimulus below the level of injury
 Most commonly occurs in patients with SCI level at T6
or above
 Hyper reflex causes vasoconstriction and hypertension
 Uncontrolled high blood pressure may cause STROKE,
SEIZURES, and DEATH
Autonomic Dysreflexia
Causes
 Bladder
 Infection, Foley catheter, plugged, kinked or overfilled
 Bowel
 Constipation, Impaction
 Skin
 Pressure ulcers, Burns, Open wounds, Tight or wrinkled
clothing,
 Painful stimulation (cuts, bruises, pressure on body)
 Temperature changes
 Other
 Sexual activity, Menstruation, Ingrown toenail
Autonomic Dysreflexia
Clinical Manifestations
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Hypertension
Bradycardia
Sweating
Anxiety
Nausea
Goose bumps
Pounding headache
Flushing above the level of injury
Vasoconstriction below the level of injury
 Irritability, sleepiness in a young child
Autonomic Dysreflexia
 Management of Autonomic Dysreflexia
 Remove the cause (empty the bladder, remove
painful stimulus)
 Prevention (consistent bowel and bladder
program)
 Education (family, community, teachers and aides)
 Carry medical alert information (card, bracelet)
Latex Allergy
At risk population
 SCI
 Myelmeningocele
 Health care workers
 Prevention
 Education
 Avoidance of all latex containing devices/materials
School Age (6-12 years)
Industry vs. Inferiority
Characteristics
increasing independence
thinking in more logical terms
Peer approval becoming more
important
Experience lapses in their ability
to perform self-care
Concerned about privacy
Development of self-concept
School Age (6-12 years)
Industry vs. Inferiority
Challenges:
May want to do bladder care
independently, but may need help
Needs reminders to perform care and
chores
May become very embarrassed by
incontinence
Wants to please parents
Peer pressure beginning
Interventions:
Social continence is very important for self
esteem.
Independence should be encouraged.
Proficiency (or direction) with selfcatheterization should be encouraged and
achieved.
Instructions should be written and visual.
Care givers must provide reminders and
encouragement.
Privacy should be provided.
Positive reinforcement and praise for
adherence to schedule and proper technique.
Learn about genitourinary system and dangers
of reflux and UTI’s.
Assist family in providing school with
catheterization technique, schedule and
patient’s level of independence.
Parent should be taught to provide supplies
for managing accidents at school.
Reinforce education about Autonomic
Dysreflexia.
Clean change of clothes should be kept at
school for accidents.
Adolescents (12-19 years)
Identity vs. Role Confusion
Characteristics
Struggling with independence
Concerned with body image and appearances
Think “in the moment,” feel invincible, and may not consider future
effects of current behavior
May experiment with drugs, alcohol, and sex
Acceptance from peers is
a priority and may take
precedence over self-care
Privacy is extremely
important
Adolescents (12-19 years)
Identity vs. Role Confusion
Challenges:
Rebellion
Body image very important
Strong peer pressure.
Does not want to be “different” from peers
May not adhere to bowel & bladder
management schedule
Interventions:
Social continence is essential
Independence with bowel & bladder
management (or direction) achieved
Parents must gradually allow the
adolescent to assume responsibility for
bowel & bladder management
Parents should monitor compliance
Encourage a schedule for self care
rather than “when I feel I need to…”
Continue to reinforce education about
Autonomic Dysreflexia.
Reinforce teaching about Anatomy and
Physiology of the genitourinary system,
especially reflux and prevention of UTI’s.
Discourage intentional constipation
used to prevent accidents
Adolescents (12-19 years)
Identity vs. Role Confusion
Confidence and selfesteem are strongly
impacted by the
challenge of being
incontinent in a
continent world.
Coordination of Care
 Comunication
 Parents
 Hospital personnel (care manager)
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IEP/504
Medications at school
Transportation
Preparation and Prevention
Team Work
Enhance Knowledge of the
Transition Process
What happens while in the apartment
 Families prepare child for therapy
 Therapy and nursing assist families in working out
kinks of home life
 Questions arise
 A routine begins
 Cooking group
The Gap Between Hospital
and Home
Enhance Knowledge of the Transition
Process
What helps families related to discharge planning and transition
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Space restrictions
Home schedule development
Confidence in independence of care
Smooth transition to the “real world”
Community reintegration
Questions???????
Thank you
West Virginia
School Nurses
References
Merenda, L.A. & Hickey, K.J. (2005). Key elements of bladder
and bowel management for children with spinal cord injuries.
SCI Nursing, (22)1, 8-14.
Specialty of Rehabilitation: A Core Curriculum.
Bristol stool chart via:
http://www.continence.org.au/pages/bristol-stool-chart.html