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Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

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Page 1: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Traumatic Spinal Cord Injury

Marnie Quick, RN, MSN, CNRN

Page 2: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

A. Pathophysiology/etiologyNormal spinal cord as it relates to SCI Spinal cord begins at

the foramen magnum in the cranium

Cord ends at the L1-L2 vertebra level

Spinal nerves continue to the last sacral vertebra

Page 3: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Normal protection of spinal cord from injury: Bones- vertebral column

Page 4: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Protection of spinal cord from injury Disc between

vertebra Internal and external

ligaments

Page 5: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Protection of Spinal Cord from Injury Meninges CSF in subarachnoid

space allow for movement within spinal canal

Page 6: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Normal spinal cord as relates SCI: Autonomic Nervous System & Cord ANS can be affected

by SCI Sympathetic chains

on both sides of the spinal column

Parasympathic nervous system is the cranial-sacral branch

Page 7: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Normal spinal cord: White tracks send messages to and from the brain Pyramidal- Voluntary

movements Posterior column

(Dorsal)- touch, proprioception, and vibration sense

Lateral spinothalamic tract- pain and temperature sensation (only tract that crosses within the cord)

Page 8: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Normal spinal cord: Reflex ark in center of the spinal cord Where sensory and

motor nerves arise from cord

Sensory fibers enter posterior

Motor fibers leave from anterior

Once outside cord join form spinal nerve

Page 9: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Normal spinal cord: Dermatones Skin innervated by

sensory spinal nerves

Page 10: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Normal spinal cord: Spinal cord level When referring to spinal

cord level, it the reflex arc level not the vertebral or bone level.

Note that the thoracic, lumbar & sacral reflex arcs are higher than were the spinal nerves actually leave through the opening of there respective vertebral bone

Page 11: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Etiology of traumatic spinal cord injury MVA- most common cause Other: falls, violence, sport injuries SCI typically occurs from indirect injury

from vertebral bones compressing cord SCI frequently occur with head injuries Cord injury may be caused by direct

trauma from knives, bullets, etc

Page 12: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Hemorrhage and edema occur in the cord post injury, causing more damage to cord

Extension of the cord injury from cord edema can occur over the first few days- watch the phrenic nerve!

Initially SCI experience spinal shock- depression of all cord & ANS function below injury. Lasts from few min to wks

Page 13: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Patho: Forces resulting in SCI Flexion (hyperflexion) Most common

because of natural protection position.

Generally cause neck to be unstable because stretching of ligaments

Page 14: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Patho/forces: Hyperextention Caused by chin

hitting a surface area, such as dashboard or bathtub

Usually causes central cord syndrome symptoms

Page 15: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Patho/forces: Compression Caused by force from

above, as hit on head Or from below as

landing on butt Usually affects the

lumbar region

Page 16: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Classification of spinal cord injury:1. Complete (transection) spinal cord inj After spinal shock: Motor deficits-

spastic paralysis below level of injury

Sensory- loss of all sensation perception

Autonomic deficits- vasomotor failure and spastic bladder

Page 17: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

2. Incomplete spinal cord injury- what white tracks are working after spinal shock is over?

Page 18: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Incomplete spinal cord injury: Central cord Syndrome Injury to the center of

the cord by edema and hemorrhage

Weakness in both upper extremities- legs are spared

Varied loss of sensation

Page 19: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN
Page 20: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Incomplete spinal cord injury: Anterior Cord Syndrome Injury to anterior cord Loss of voluntary

motor (Pyramidal track) below

Loss of pain and temperature perception

Retains posterior column function

Page 21: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Incomplete spinal cord injury: Brown-Sequard Syndrome Hemisection of cord Ipsilateral paralysis Ipsilateral superficial

sensation, vibration and proprioception loss

Contralateral loss of pain and temperature perception

Page 22: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Incomplete cord injury: Horner’s Syndrome Injury to the cervical

sympathetic nerves Ipsilateral ptosis of

the eyelid Constriction of the

pupil (miosis) Facial anhidrosis

Page 23: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Horner’s Syndrome

Page 24: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Classification of spinal cord injury- 3. by level of spinal cord injury In addition to complete or

incomplete- Spinal cord injuries are

also described by the level of the injury– the cord segment or dermatome level

Such as C6; L4 spinal cord injury

Page 25: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

B. Common Manifestations and Complications by body systems Skin: pressure ulcers Neuro: pain; sensory loss; upper/lower

motor deficits; autonomic dysreflexia Cardio: dysrhythmias; spinal shock; loss of

sympathetic nervous system control over blood vessels (vasomotor control)- dec venous return, orthostatic hypotension, poikilothermic (takes on temp of room)

Page 26: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Body system cont. Resp: decrease chest expansion; cough reflex &

vital capacicty; diaphragm function-phrenic nerve GI: stress ulcers; paralytic ileus; bowel-

impaction & incontinence GU: upper/lower motor bladder; impotence;

sexual dysfunction Musculoskeletal: joint contractures; bone

demineralization; osteoporosis; muscle spasms; muscle atrophy; pathologic fractures; para/tetraplegia

Page 27: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Common manifestations/complications:Spinal shock- depression of cord & ANS Motor loss- flaccid paralysis below level injury Sensory loss- loss touch, pressure, temperature

pain and proprioception perception below injury Sympathetic NS loss results in parasympathic

dominance with vasomotor failure- Neurogenic shock, bradycardia, orthostatic

hypotension and poor temperature control (poikilothermic- takes on temp of environment)

Parasympathetic NS loss of the S 2,3,4 reflex arks results in flaccid bladder

Page 28: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Lasts from few minutes to weeks How do you know spinal shock is over? Clonus is one of the

first signs Hyperreflexia of foot Test by flexing leg at

knee & quickly dorsiflex the foot

Rhythmic oscillations of foot against hand

Page 29: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Common manifestation/complications: Upper and Lower Motor Deficits Upper motor deficits

results in spastic paralysis

Lower motor deficits are flaccid paralysis and muscle atrophy

Page 30: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Common manifestation/complications: Terms used to describe motor deficits Prefix: para- meaning two extremities;

tetra- or quadra- all four extremities Suffix –paresis meaning weakness; -plegia

meaning paralysis Quadraparesis means what?

Page 31: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Common manifestations/complications: Functional Goals for Spinal Cord Injury C1-3 usually fatal- loss phrenic innervation;

ventilator dependent; no B/B control; spastic paralysis; electric w/c with chin/mouth control

C6- weak grasp; has shoulder/biceps to transfer & push w/c; no bowel/bladder control. Considered level of independence

T1-6- full use of upper extremity; transfer; drive car with hand controls and do ADL’s; no bowel/bladder control

Page 32: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

C. Therapeutic Interventions for SCI: Diagnostic tests

X-ray of spinal column

CT/MRI Blood gases

Page 33: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Therapeutic interventions: Emergency care at scene, ER & ICU Transport with

cervical collar Assess ABC’s; O2;

tracheotomy/vent IV for life line NG to suction Foley

Page 34: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Therapeutic interventions: Medications IV metylprednisone (Solu-Medrol) within 8 hrs to

decrease cord edema Medications to control or to prevent

complications SCI and immobility: Vasopressors treat bradycardia or hypotension Histamine H2 blockers to prevent stress ulcers Anticoagulants Stool softeners Antispastomotics

Page 35: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Therapeutic interventions: Stabilization/immobilization Traction with

Gardner-Wells tongs

Page 36: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Traction

Page 37: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

External traction Halo device For patients who do

not have motor deficits

Experience less immobility complications

Page 38: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Therapeutic interventions: Casts; splints; collars; braces

Page 39: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Therapeutic interventions: Special Beds for SCI To decrease

immobility complications

Rotorest is a common one used- rotates 23 hrs a day

Page 40: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Therapeutic interventions: Surgery for SCI Manipulation to

correct dislocation or to unlock vertebrae

Decompression laminectomy

Spinal fusion Wiring or rods to

hold vertebrae together

Page 41: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN
Page 42: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

D. Nursing Assessment specific to SCI Health History Description of how and when injury occurred Other illnesses or disease processes Ability to move, breath, and associated injury

such as a head injury, fractures

Page 43: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Nursing Assessment specific SCI Physical exam LOC and pupils- may have indirect SCI

from head injury Respiratory status- phrenic nerve

(diaphragm) and intercostals; lung sounds Vital signs Motor Sensory Bowel and bladder function

Page 44: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Nursing assessment: Motor assessment Movement, strength

and symmetry Hand grips Flex and extend arm

at elbow- with and without resistance

Page 45: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Nursing assessment: Motor assessment lower extremity Flex and extend leg at

knee with and without resistance

Planter and dorsi flexion of foot

Page 46: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Nursing assessment: Motor assessment- Clonus Clonus- hyperreflexia Flex knee and quickly

dorsiflex the foot with your hand

If has return of reflex function the foot will have repetitive movements against you hand

Spinal shock is over

Page 47: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Nursing assessment: Sensory assessment With the sharp and

dull ends of a paperclip have the individual, with their eyes closed identify

Use the dermatome as reference to identify level

C6 thumb; T4 nipple; T10 naval

Page 48: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

E. Pertinent nursing problems/interventions 1. Impaired physical mobility

Log roll as a single unit; provide assistance as needed to keep alignment; teach patient

Care traction, collars, splints, braces, assistive devices for ADL’s

Flaccid paralysis- use high top tennis shoes or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)

Page 49: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Spastic paralysis- assess for clonus Prevent spasms by avoiding; sudden movements or

jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigue

Treat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmotic medications

Assess skin break down thrombophlebitis; remove TED hose at least every shift

Page 50: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Prevent/treat orthostatic hypotension Abdominal binder, calf compressors, TED hose when

individual gets up Assess BP, especially when rising Assist Physical Therapy with tilt table as individual

gradually gets use to being in an upright position

Page 51: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Use of transfer board

Page 52: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

2. Impaired gas exchange Phrenic nerve (C3-5) controls the diaphragm

bilaterally. If nerve is nonfunctioning then individual is ventilator dependent.

Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing

Page 53: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Phrenic nerve

Page 54: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Monitor vital capacity, respiratory effort, ABG’s, O2 saturation

Assess for signs of impending extension of SCI up cord to phrenic nerve level (C3-5)

Quad cough (assistive cough) as needed

Page 55: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

3. Ineffective breathing patterns Assess respiratory rate, rhythm, depth, and breath

sounds Assess need for ventilatory assistance,

tracheotomy, ventilator

Page 56: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

4. Autonomic Dysreflexia SCI above T6 Results in loss of normal

compensatory mechanisms when sympathetic nervous system is stimulated

Life threatening- if goes unchecked BP can result in cerebral hemorrhage

Page 57: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Autonomic Dysreflexia- assess

Vasodilatation

symptoms above SCI Vasoconstriction

symptoms below SCI The cause of SNS

stimulation

Page 58: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Autonomic Dysreflexia- treatment Elevate head of bed- causes orthostatic

hypotension Identify cause/alleviate- if full bladder- cath; if

skin- remove pressure, if full bowel- empty, etc Remove support hose/abdominal binder Monitor blood pressure- can get > 300 S Give PRN medication to lower BP If above not effective– call physician

Page 59: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

5. Altered urinary elimination/constipation Bladder

Bladder reflex ark- sacral 2,3,4 Flaccid bladder (lower motor neuron lesion) has

no reflex from S2,3,4. Have automatic empting of bladder. Urine fills the bladder and dribbles out. Need foley or freq intermittent self catherization

Spastic bladder (upper motor neuron lesion) has reflex ark, but no connection to or from brain. Reflex fires at will. Bladder training- trigger points to stimulate empting; self catherization

Page 60: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Upper/lower motor bladder

Page 61: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Bladder functioning: http://www.rnceus.com/course_frame.asp?

exam_id=56&directory=uro

Page 62: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Use bladder scan to see amount of urine in bladder

Goal- residual <100ml/20% bladder capacity Some individuals may need suprapubic catheter Assess effectiveness of medication

Urecholine to stimulate the parasympathic S 2,3,4 reflex to fire and cause bladder contraction

Urinary antiseptic

Page 63: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Bowel Bowel rely more on bulk than on nerves Stimulate bowels at the same time each day. Best

after a meal when normal peristalsis occurs Individual may progress from ducolax

suppository to glycerin then to gloved finger for digital stimulation

Assess bowel sounds prior to giving food for the first time– paralytic illus!

Page 64: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

6. Sexual dysfunction Assess readiness/knowledge/your ability Male sexual function- reflexogenic (S2,3,4)

erections; psychogenic erections (psychological stimulation) Ejaculation/fertility may be affected

Female- hormones more than nerves regarding fertility. C-section because of chance for autonomic dysreflexia during labor. Lack of sensation/movement affects sexual performance

Page 65: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Suggestions: empty bladder before sex; withhold fluids and antispasmodics; certain positions may increase spasms; explore new erogenous zones; penile implants

Page 66: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

7. Low self-esteem Assess thoughts on ‘quality of life’; body image;

role changes Physical and psychological support Most common SCI is 15-30 yeas old and

generally a risk taker– this greatly affects their perception of life and rehabilitation progress

Page 67: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN
Page 68: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

8. Home care Assess psychological, physical resources, need

for rehabilitation (in-house or outpatient); need for community resources

Home evaluation

Page 69: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Case Study PDS– Spinal Cord Injury

http://www.softwarefornurses.com/access/index.asp

Page 70: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

LeMone- Blackboard Case Study & Media links

http://wps.prenhall.com/chet_lemone_medicalsurg_3/0,7859,757263-,00.html

http://www.apacure.com/

http://spinalcord.org/

Page 71: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Nursing Care Plan: A Client with a SCI LeMone p. 1334

http://wps.prenhall.com/wps/media/objects/737/755395/sci.pdf

Page 72: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Additional Critical thinking questions LeMone p 1334: Nursing Care Plan: A Client with a SCI 1. Why does Jim have flaccid paralysis on

admission to ICU? 2. What symptoms indicate that he is in spinal

shock? What was done about these symptoms? 3. How will we know when he is out of spinal

shock? 4. How does progressive mobilization assist with

orthostatic hypotension? What else can be done? 5. What are realistic functional goals for Jim?

Page 73: Traumatic Spinal Cord Injury Marnie Quick, RN, MSN, CNRN

Case Study SCI

http://www.pitt.edu/~rhe001/ugcs96.htm