Handout Orthopedic Nursing Spinal Cord Injury

Spinal Cord Injury (SCI) DEFINITION OF THE DISEASE Injuries affecting the spinal cord commonly results from trauma, gunshot wounds and motor vehicle accidents. Many cases of SCI are caused by falls, sports-related injury and minor trauma. The principal risk factors for SCI include age, gender, and alcohol and drug use. Males are affected four times more often than females. Over half of the victims are 16 to 30 years of age. The most common vertebrae involved in SCI are the 5th, 6th and 7th cervical, the 12th thoracic, and the 1st lumbar. These vertebrae are the most vulnerable because there is a greater range of mobility in the vertebral column in these areas. Damage to the spinal cord ranges from transient concussion, to contusion, laceration and compression of the cord substance, to complete transection of the cord. Injury can be categorized as primary which is usually permanent or secondary wherein nerve fibers swell and disintegrate as a result of ischemia, hypoxia, edema, and hemorrhagic lesions. The type of injury on the other hand, refers to the extent of injury to the spinal cord itself. Incomplete spinal cord lesions are classified according to the area of spinal cord damage: central, lateral, anterior, or peripheral. A complete spinal cord injury can result in paraplegia, which is paralysis of the lower body or quadriplegia which is the paralysis of all four extremities.

Signs & Symptoms Neurologic Level The neurologic level refers to the lowest level of the injury of the cord. •

Total sensory and motor paralysis below the neurologic level

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Loss of bladder and bowel control (usually with urinary retention and bladder distention)

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Loss of sweating and vasomotor tone below the neurologic level

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Marked reduction of blood pressure from loss of peripheral vascular resistance

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If conscious, patient reports acute pain in back or neck; patient may speak of fear that the

is broken Respiratory Problems •

Related to compromised respiratory function; severity depends on level of injury

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Acute respiratory failure is the leading cause of death in high cervical cord injury

neck or back

PATHOPHYSIOLOGY

DIAGNOSTIC EXAM Diagnosis of SCI is based on physical examination, radiologic examination, CT scan, MRI and myelography. Diagnostic x-rays such as lateral cervical spine x-rays and CT scanning are usually performed initially. An MRI scan may be ordered as a further work up if a ligamentous injury is suspected, since significant spinal cord damage may exist even in the ansence of bony injury. Continuous electrocardiographic monitoring may be indicated if a cord injury is suspected since bradycardia and asystole are common in acute spinal injuries. NURSING CARE Promoting Adequate Breathing

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Detect potential respiratory failure by observing patient, measuring vital capacity, and monitoring oxygen saturation through pulse oximetry and arterial blood gas values.

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Prevent retention of secretions and resultant atelectasis with early and vigorous attention to clearing bronchial and pharyngeal secretions.

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Suction with caution, because this procedure can stimulate the vagus nerve, producing bradycardia and cardiac arrest.

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Initiate chest physical therapy and assisted coughing to mobilize secretions.

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Supervise breathing exercises to increase strength and endurance of inspiratory muscles, particularly the diaphragm.

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Ensure proper humidification and hydration to maintain thin secretions.

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Assess for signs of respiratory infection: cough, fever, and dyspnea.

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Discourage smoking.

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Monitor respiratory status frequently.

Improving Mobility

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Maintain proper body alignment; place patient in dorsal or supine position.

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Turn patient every 2 hours; monitor for hypotension in patients with lesions above the midthoracic level. Assist patient out of bed as soon as spinal column is stabilized.

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Do not turn patient who is not on a turning frame unless physician indicates that it is safe to do so.

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Apply splints to prevent footdrop ans trochanter rolls to prevent external rotation of the hip joint; reapply every 2 hours.

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Perform passive range-of-motion exercises within 48 to 72 hours after injury to avoid complications such as contractures and atrophy.

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Provide a full range of motion at least every four or five times daily to toes, metatarsals, ankles, knees & hips.

Maintaining Skin Integrity

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Change patient’s position every 2 hours and inspect the skin, particularly under cervical collar.

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Assess for redness or breaks in skin over pressure points; check perineum for soilage; observe catheter for adequate drainage; assess general body alignment and comfort.

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Wash skin every few hours with a mild soap, rinse well, and blot dry. Keep pressure sensitive areas well lubricated and soft with

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bland cream or lotion; gently perform massage using a circular motion.

Teach patient about pressure ulcers and encourage participation in preventive measures.

Promoting Urinary Elimination

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Perform intermittent catheterization to avoid overstreatching the bladder and infection. If this is not feasible, insert an indwelling catheter.

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Show family members how to catheterize, and encourage them to participate in this facet of care.

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Teach patient to record fluid intake, voiding pattern, amounts of residual urine after catheterization, quality of urine, and any unusual feelings.

Promoting Adaptation to Disturbed Sensory Perception

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Stimulate the area above the level of the injury through touch, aromas, flavorful food, conversation, and music.

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Provide prism glasses to enable patient to see from supine position.

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Encourage use of hearing aids, if applicable.

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Provide emotional support; teach patient strategies to compensate for or cope with sensory deficits.

Improving Bowel Function

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Monitor reactions to gastric intubation.

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Provide a high-calorie, high-protein, and high-fiber diet. Food amount may be gradually increased after bowel sound resume.

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Administer prescribed stool softener to counteract effects of immobility and pain medications, and institue a bowel program as early as possible.

Providing Comfort

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Reassure patient in halo traction that he/she will adapt to steel frame.

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Cleanse pin sites daily, and observe for redness, drainage, and pain; observe for loosening; keep a torque screwdriver readily available.

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Assess skull for signs of infection, including drainage around halo-vest tongs.

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Check back of head periodically for signs of pressure. Massage at intervals, taking care not to move the neck.

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Shave hair around tongs to facilitate inspection. Avoid probing under encrusted areas.

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Inspect skin under halo vest for excessive perspiration, redness, and skin blistering, especially on bony prominences.

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Open vest at the sides to allow torso to be washed. Do not allow vest to become wet; do not use powder inside vest.

REFERENCE Smeltzer, S. Et Al.. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (Lippincott Williams & Wilkins. 10th edition,2004) Huether, S. Et Al. Understanding Pathophysiology (Mosby, Inc. 2nd edition. 2000)

University of Pangasinan College of Nursing Dagupan City, Philippines

NURSING CARE PLAN Alias/age: Medical Dx:

Date Handled: Date Submitted:

Assessment

SUBJECTIVE: “Hindi ako makagalaw” (I can’t move) as verbalized by the patient. OBJECTIVE: Paralysis Muscle atrophy Irritability V/S taken as follows: T: 37.3 P: 92 R: 19 BP: 120/80

Nursing Diagnosis Impaired

physical mobility related to neuromascular impairment.

Nursing Analysis

Spinal cord injury may result from trauma, vascular disruption, infection, tumor, and other insults. The injury may be partial or complete and vary from a mild cord concussion with transient numbness to complete cord transaction causing immediate and permanent tetraplegia. The most common sites of injury are the cervical areas C5, C6, and C7, and the junction of the thoracic and lumbar vertebrae, T12 and L1. Clinical manifestations vary with the location and severity of cord damage. In general, complete Transaction causes loss of all function below the level of lesion, and incomplete cord damage results in a variety of regional deficits. Complications include shock,

Expected Outcome

After 8 hours of nursing interventions, the patient will demonstrate techniques or behaviors that enable resumption of activity.

Nursing Interventions

Independent: • Continually asses motor function (as spinal shock or edema resolves) by requesting patient to perform certain actions. • Provide means to summon help. • Assist in range of motion exercises on all extremities and joints, using slow, smooth movements. • Plan activities to provide uninterrupted rest periods. Encourage involvement within individual tolerance or ability. • Reposition periodically even when sitting in chair. Teach patient how to use weightshifting techniques. • Inspect the skin daily. Observe for pressure areas, and provide meticulous skin care. Collaborative: • Consult with physical or occupational therapist. • Administer muscle relaxants or antispasticity as prescribed.

Rationale

• Evaluates status of individual situation (motor-sensory impairment may be mixed and/ or not clear) for a specific level of injury, affecting type and choice of intervention. • Enables patient to have sense of control, and reduces fear of being left alone. • Enhances circulation, restores or maintains muscle tone and joint mobility, and prevent disuse contractures and muscle atrophy. • Prevents fatigue, allowing opportunity for maximal efforts or participations by patient. • Reduces pressure areas, promotes peripheral circulation. • Altered circulation, loss of sensation, and paralysis potentiate pressure sore formation. • Helpful in planning and implementing individualized exercise program and identifying or developing assistive devices to maintain function, enhance mobility and independence. • May be useful in limiting or reducing pain associated with

Evaluation After 8 hours of

nursing interventions, the patient was able to demonstrate techniques or behaviors that enable resumption of activity.

________________________ Clinical Instructor/Agency

Paul Christian P. Santos UPCN-SN/Shift