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Mobility: Spinal Cord Injury
Transcript of Mobility: Spinal Cord Injury
Life beyond the hospital
Spinal Cord Injury
Quick anatomy Review
Relevance and facts about SCI:
12,000 SCI anually
4000 of those die before they reach the hospital
1000 will die of complications in the hospital
78% of SCI are male 16-30 most common age 19
SCI occurs when a mechanical force disrupts the neurological tissue or vascular supply or both (Urden, Stacy, & Lough, 2012).
Mechanism of Injury
Level of Injury
Degree of Injury
Flexion-Rotation (most unstable b/c of the ligamentous structures which stabilize the spine)
SCIs are classified as either complete or incomplete.
Total loss of sensory & motor function below the level of injury.
complete dissection of cord and its neurochemical pathways.
Results in mixed loss of voluntary motor activity & sensation below level of injury.
Can result in a variety of syndromes, which are classified according to the degree of sensory & motor loss below the level of injury.
Spinal & Neurogenic
Syndromes That occur with incomplete injury...
It is the complete loss of all muscle tone & normal reflex below the injury.
Typically lasts 24-72 hours, up to a week.
Will mask injury dysfunctions
Typically only life threatening if symptoms (BP,HR) are NOT managed.
loss of vasomotor tone, hypotension, & bradycardia. The loss of the sympathetic NS function causes peripheral vasodilation, venous pooling, and decreased cardiac output.
Is a Nursing Intervention Needed?
What other assessment information do you want?
Now your the RN at the Level 2 trauma center. How will the mechanism of injury, level of injury,& degree of injury be determined?
Tyhme is a typical 18 year old that went on an ATV trip with friends. Then her accident happened. The charge nurse informs you that you will be getting this admission.
ASIA: American Spinal Injury Association
The standard neurologic classification of spinal cord injury, which determines motor and sensory function.
Sensory index score: max 112
Motor index score: max 100
Used for visualizing C1-T1 are done to document presence of vertebral injury.
Used to assess the stability of the injury location & degree of bony injury& degree of spinal canal compromise.
Once the patient is stable.
MRI is used to assess for soft tissue and neural changes when there is unexplained neurologic defeit or worsening of neuro status.
Autonomic Nervous System
Sympathetic Nervous System
Parasympathetic Nervous System
Stimulates the body's fight or flight response, maintains homeostasis, & complements the PNS.
Rest & digest, feed & breed. Regulates the body's unconscious activity.
The spinal cord is about 18 inches long.
People are now living longer with SCIs than before and because of that we have older patients with SCIs that need special considerations.
Individual aging changes and length of time since injury can impact functional ability.
PREVENTION: is key
Fall risk in the elderly
Lets see what you know....
The RN is caring for the client who has suffered a SCI at T6. The RN further assess the patient for other signs of autonomic dysreflexia. All of the following symptoms would be consistent with AD except?
A. Severe, throbbing headache
B. Pallor of the face & neck
C. Sudden Tachycardia
D. Severe & sudden hypertension
The family of a patient with a SCI rushes to the nursing station saying that the patient needs immediate help. On entering the room, the nurse notes that the patient is diaphoretic with a flushed face and neck , and complaining of a severe headache. The patient's HR is 40 the BP is 230/100. The nurse acts quickly knowing that the patient is experiencing?
A. Spinal shock
B. Malignant hypertension
C. Pulmonary embolism
D. Autonomic dysreflexia
Experienced w/ injury @ T6 or above
Occurs in response to visceral stimulation (ex: full bladder, bowels, tight closes).
The intact ANS below the level of the injury respond to the w/ a reflex arteriole vasoconstriction, which we know raises BP.
What are signs & symptoms?
The RN is caring for patient admitted with SCI . The RN minimizes the risk of compounding the injury most effectively by which intervention?
A. Keeping the patient on the stretcher
B. Logrolling the patient on a firm mattress
C. Logrolling the patient on a soft mattress
D. Placing the patient on a stryker frame
Mobility-The state or quality of being mobile or movable (Venes, 2013).
Consequences of immobility
Levels of Trauma
Typically due to musculoskeletal problems
Low back pain experienced in 80% of adults
Get detailed patient history
Acute versus chronic pain
Teach stretches and proper body mechanics
Frequent position changes, support muscles and ligaments
Diagnostic studies to determine cause of pain
What will be our discharge teaching?
What level of trauma would you categorize Thyme into?
What is the closest hospital that has a level I Trauma Center?
Full set of vitals
Cardiac monitoring, blood tests, ultrasounds, x-rays, CT scans
Full body system effects
Adaptations to lifestyle
What did you find for articles or resources that will help us care for Tyhme?
Nursing or caregiver education
You are caring for Tyhme and she starts to complain of a headache and you see this rhythm on the monitor?
Cascade of metabolic & cellular events that lead to spinal cord ischemia from secondary injuries.
Decrease in HR
Typically quick onset...
How do you stop this response?
Raise HOB or to sitting position
Remove noxious stimuli (tight clothes, Foley kinked?)
Call medical provider or RRT
Teach patient about prevention and S&S
Goal of Rehab: Retraining of physiologic process & extensive patient, caregiver, & family teaching.
Do they need a ventilator (c1-3)
Cough reflex present (c4 poor)
Tissue Integrity (skin):
Grief & Depression
Stryker frames help immobilize patients to prevent further injury.
Will more commonly see braces or kinetic therapy bed--used to rotate patient that are immobilized.
Help keep alignment and stabilize
Redistribute pulmonary blood flow
Improve ventilation & perfusion
Decrease risk of pressure ulcers
Might have a body vest or halo to help stabilize
What's your patient at risk for?
Patient teaching needed?
Risk for: infection, skin break down, eating, airway, comfort, appearance
Teaching needed: how care for vest/skin care, pin site cares, position, s&s of infection to pin sites, halo wrench if airway issues, keeping vest clean and dry, driving?, showering? ADL cares and assistance.
How would you perform CPR on this patient?
Rehab phase.....How do we care for the whole person?
Remember the level of the injury will determine potential deficits.
Hayden was c4-c5 incomplete SCI.....so once the pressure was relieved of the SC then mobility and sensation was regained with extensive Rehab.
Let's look at other body systems effected at time of injury.......
Why was Hayden on a ventilator right after his accident?
Unopposed vagal response-bradycardia
Postural hypotension (vasopressors)
MAP goal of at or > 85-90 to perfuse spinal cord
Lack muscle tone, decreased venous return-risk for DVT's (low molecular weight heparin)
What interventions should we provide Hayden?
Fluid & Nutritional Needs:
Decrease functioning: NG tube, monitor for paralytic ileus
Risk for GI ulcers (stress ulcers)
Monitor fluid & electrolytes
High protein & calorie diet
Reduce nitrogen loss due to hypermetabolic state (TPN)
Neurogenic Bowels: (T5 & above risk for ileus)
Loss of voluntary or involuntary reflex
Start bowel programs-retrain the bowel
Neurogenic Bladder: (T1-L2 risk urinary retention)
Loss of autonomic & reflex control
Straight cath or suprapubic long-term if control is not regained
Meds: H2 receptor blockers, proton pump inhibitors, bowel meds
Meds: Antidepressants, anxiety (ativan)
Below the level of injury-no vasconstriction or heat loss through perspiration
Monitor environment and body temp closely
Don't overload with blankets or expose during baths
Extreme cases or fevers-consider cooling blankets
Reposition to prevent skin breakdown
Pressure relieving cushions
Prevent burns or frostbite
ROM to prevent contractures
Sensory deprivation-stimulate above injury level-music, food, reading etc.
Discuss concerns with patient & partners
Females remain fertile
Males depending on level injury for fertility & function
Overwhelming sense of loss
Feel useless or a burden to others
Stages: shock & denial, anger, depression, acceptance & adjustment
Emotional support & counseling
NCLEX Practice Questions
Get your clickers out.....
VIII. Assessment (In your outline)
What was Thyme risk factors for a spinal cord injury or accident?
Other Risk Factors?
Break in blood-brain barrier
Antidepressants: Duloxetine (Cymbalta), Pregabalin (Lyrica)
Antiseizure meds: Gabapentin (Nuerontin)
Implanted pumps such as baclofen (skeletal muscle relaxant)
Conservative treatments fail
Quick Stretching Break!
Baseline telemetry strip was: NSR, HR in 80's and BP 122/60
Thyme's telemetry strip is above, HR 40's, BP 90/52
Loss of motor tone and reflexes below the injury.
What do you think Thyme is experiencing?
Spasticity or muscle spasms
Botox injections or Baclofen pumps to help with muscle spasms or contractions
Dantrolene (Dantrium)-skeletal muscle relaxant
Tizanidine (Zanaflex)- alfpha 2 adrenergic agonists
Stabilize the spine
Get your Clickers out!!!