Spinal Cord Injury - PowerPoint PPT Presentation

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Title:

Spinal Cord Injury

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interruption of blood supply to the cord. traction of the cord ... chest physiotherapy. postural drainage. incentive spirometer. suctioning. antibiotic therapy ... – PowerPoint PPT presentation

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Title: Spinal Cord Injury


1
Spinal Cord Injury
  • SCI

2
Spinal Cord Injury
  • Etiology
  • Males, 15-30 years old, risk takers
  • cord compression by bone displacement
  • interruption of blood supply to the cord
  • traction of the cord
  • A patient with a head injury must be presumed to
    have SCI
  • MVA, Falls, Sports
  • Violence related injuries on the rise
  • 8,000-10,000 NEW SCIs per year in US

3
Classification
  • Mechanism flexion, hyperextension, rotation, and
    compression
  • Level
  • cervical C1-C8--50
  • thoracic T 1- T12--33
  • lumbar L1-L5--the remainder
  • Degree complete or incomplete

4
Common Mechanisms of Injury
5
Complete SCI
  • Results in flaccid paralysis and total loss of
    sensory and motor function below the level of the
    lesion
  • If cervical cord involved, paralysis of all four
    extremities, resulting in quadriplegia
  • Thoracic or lumbar cord results in paraplegia

6
Incomplete SCI
  • Anterior Cord Syndrome
  • disrupted blood flow through the anterior spinal
    artery mixed loss of sensory and motor function
  • only the dorsal column which controls
    proprioception is fully preserved
  • Brown-Sequard
  • penetrating trauma,
  • ipsilateral motor function and proprioception is
    lost
  • contralateral pain and temperature are lost
  • The extremities that can move cant feel, and
    those that can feel cant move

7
Incomplete SCI(Good diagram in your text, page
1724)
  • Central Cord Syndrome
  • hyperextension with hemorrhaging in center of
    cord
  • U/E gt impaired than the L/E

8
Complete SCI
  • Level of Complete Injury Determines Sensory and
    Motor Functioning
  • Below Level of Injury, Patient Will have No
    Senses, No Function
  • May have some degree of Rehabability depending
    on level, patient, age, attitude, training, use
    of adaptive devices

9
Dermatones What Innervates What
10
Quadriplegia
  • C 6 Still ? respiratory reserve
  • Have full biceps, weak thumb grasp, shoulder
    rotation, back shoulder abduction
  • Some transfer, some self care with devices
  • C 7- C-8 Still ? respiratory reserve
  • Triceps, finger mvt. Better grasp
  • Self transfer, rollover sit up in bed,most self
    care, drive wheelchair and car w/ adaptive
    devices
  • C 1-3 Often Fatal
  • If lives, No Respiratory ability
  • Ventilator dependent
  • Only functioning from chin, face, tongue
  • C 4 Still no respiratory ability-Vent dependent
  • Sensory and Motor functioning from neck up
  • C5 Some respiratory ability but ? reserve
  • Havel neck, partial shoulder back, biceps
  • Some use of hands w/ supports ( feeding)

11
Paraplegia
  • T 1-T6 Full innervation of upper extremity
  • Still with ? Resp. reserve
  • ? trunk stability
  • No ambulation
  • No Bowel/Bladder
  • T7-12 Full Respiratory Reserve
  • Stable trunk
  • Ambulate/ stand w/ devices
  • No bowel/Bladder
  • L1-L2
  • Varying leg control
  • Low back instability
  • L3-L4
  • No Hamstring function
  • Full bowel and Bladder Continence

12
Emergency Care of SCI(A-B-C-D-E)
  • Airway
  • jaw thrust maneuver
  • neutral position
  • intubation
  • additional O2
  • Breathing
  • diaphragm-C3 C4 C5
  • intercostals C2-C7
  • abdominal T1-T12
  • therefore cervical lesions paralyze accessory
    muscles and threaten diaphragm function
  • manual ventilation

13
Emergency Care of SCI
  • Circulation
  • hemorrhage difficult to assess because abdominal
    pain and muscular rigidity may be absent
  • neurogenic shock masks hypovolemia
  • fluids (LR)
  • meds dobutamine and dopamine
  • Disability
  • baseline neuro evaluation
  • Exposure
  • remove clothing
  • log roll
  • poikilothermia
  • hypothermia worsens bradycardia
  • sweating lost below level of lesion

14
Spinal Shock(Neurogenic Shock)
  • Occurs quickly after SCI
  • Loss of motor, sensory, reflxic, and autonomic
    functioning below level of injury
  • Loss of sympathetic innervations causes unopposed
    parasympathetic responses
  • Vasodilatation, venous pooling, hypotension,
    bradycardia, loss of temperature control

15
Vital Signs????In Neurogenic or Spinal Shock??
  • Heart Rate????
  • SLOW--40-70 RANGE
  • Blood Pressure???
  • LOW---SBP 60-90
  • Respirations?
  • Depending on level of injury
  • Temp?
  • Depending on Environment

16
Medical Intervention in SCI
  • High dose steroids within 8 hours to limit
    swelling
  • Reduction, spine realigned through traction
    device
  • Surgery to remove bony fragments, drain hematoma
  • Fixation, stabilizing vertebral fractures with
    hardware ( Gardner Wells Tongues or halo vest)
  • Fusion attaching injured vertebrae to uninjured
    with bone grafts and steel rods
  • Immobilization devices halo vest, body cast,
    brace

17
Head to Toe Physical Exam
  • Three Clinical Manifestations
  • neck or back pain
  • sensory or motor deficits
  • spinal deformity
  • Diagnostics
  • X-ray detects most lateral Cx SCI
  • CT reveals bony fragments and spinal cord
    compression
  • MRI reveals cord impingement, hematoma and infarct

18
Nursing Interventions Respiratory
  • ASSESS
  • Breath sounds
  • ABGs
  • tidal volume
  • vital capacity
  • skin color
  • breathing patterns
  • subjective comments
  • amount and color of sputum
  • DO
  • chest physiotherapy
  • postural drainage
  • incentive spirometer
  • suctioning
  • antibiotic therapy
  • DVT protocol for PE
  • ROM

19
Nursing InterventionCardiovascular
  • Unopposed vagal response- bradycardia
  • Loss of sympathetic tone-chronic low BP
  • Diminished venous return-DVT
  • Vital Signs HR, Orthostatic Hypertension
  • Vasopressor agents dopamine and fluids
  • Compression stockings
  • DVT Protocol
  • ROM
  • Hgb, Hct-monitor for internal bleeding

20
Nursing Intervention Fluid and Nutrition
  • Paralytic Ileus NG tube to suction
  • Catabolism high protein, high calorie for energy
    and tissue repair
  • TPN prn
  • increased roughage
  • anorexia
  • pt. need for control

21
Nursing InterventionBowel and Bladder
  • Bowel (constipation)
  • suppositories, stool softeners
  • BS Q 4 hours
  • note N V
  • establish bowel routine
  • bulk, fiber, fluids
  • Urinary (retention)
  • catheter indwelling progress to intermittent
  • palpate bladder
  • fluid restrictions0
  • acidify urine
  • low calcium diet
  • BUN/Creatinine
  • Crede

22
Nursing InterventionSensory Deprivation
Reflexes
  • Sensory Deprivation
  • stimulate pt. above level of injury
  • conversation, music aromas, interesting flavors
  • prism glasses
  • altered sensorium, vivid dreams
  • disrupted sleep patterns
  • Reflexes
  • can be inappropriate and excessive
  • erections
  • spasms
  • spasticity

23
Nursing Intervention Skin Integrity, Injury, Pain
  • Skin integrity
  • inspect Q 2 hrs
  • turn Q 2 hours
  • rotational bed
  • clean and dry skin
  • Injury
  • use padded side rails
  • anticipate needs
  • Pain
  • positioning
  • antispasmodic agents
  • analgesics
  • use slow, gentle versus sudden movements

24
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25
Nursing Intervention Temperature Stress Ulcers
  • Thermoregulation
  • no vasoconstriction, piloerection, perspiration
  • temperature is largely controlled by environment
  • Stress ulcers
  • physiological response to stress
  • psychological stress
  • high dose corticosteroids
  • peak incidence 6-14 days s/p injury
  • H2 blockers prophylactically

26
Autonomic Dysreflexia
  • Hypertensive crisis in SCI above T6 (sympathetic
    outflow)
  • Noxious stimulus below the level of SCI triggers
    the SNS, causing a massive release of
    catecholamines.
  • Increased BP stimulates the baroreceptors to send
    an inhibitory signal to the medulla.
  • Cont.

27
  • The inhibitory impulses cant transverse the cord
    lesion. Vasodilatation occurs above the injury
    red, flushed, warm skin, headache and nasal
    congestion.
  • Below the lesion, the skin turns cold, producing
    goosebumps.
  • Vagal stimulation induces bradycardia as a
    compensatory mechanism to lower CO and BP. Cant
    lower BP to WNL.
  • The HTN if left untreated can lead to MI, Stroke,
    intracranial hemorrhage

28
Nursing Interventions Autonomic Dysreflexia
  • Remove noxious stimuli
  • urinary catheterization
  • fecal impaction
  • tight clothing
  • pain stimulation
  • HOB 45
  • Alpha blocker, vasodilator
  • Vital signs monitoring
  • Patient and family education

29
Will I Ever Walk Again?
  • Multidisciplinary/Team approach
  • Grieving Process shock and denial, anger,
    depression, adjustment , focus on rehab.
  • Nursing Diagnoses
  • Self-care deficit
  • Altered family processes
  • Risk for ineffective coping
  • Alteration in body images
  • Sexual dysfunction

30
Then What.
  • Keeping these individuals alive longer and
    longer huge social implications
  • Issues of an immobile lifestyle high
  • risk of Disease, Diabetes
  • GI problems Colon CA , bowel deterioration, Gall
    Bladder DX-7X freq.
  • GU Infections, Bladder CA- 9 Xfreq.
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