1 / 58

Lesson #6 Spinal Cord Injury

Lesson #6 Spinal Cord Injury. Rehabilitation Nursing. Classifications of Spinal Cord Injury. Level of Injury. Mutual understanding of level of spinal cord injury determined in 1983 and redone in 1992 American Spinal Cord Injury Association(ASIA) Defined spinal cord injury as:

asher
Download Presentation

Lesson #6 Spinal Cord Injury

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. Lesson #6Spinal Cord Injury Rehabilitation Nursing

  2. Classifications of Spinal Cord Injury

  3. Level of Injury • Mutual understanding of level of spinal cord injury determined in 1983 and redone in 1992 • American Spinal Cord Injury Association(ASIA) • Defined spinal cord injury as: • Lowest level where two things remain INTACT: • Movement • Sensation

  4. Qualifications of Spinal Cord Injured (SCI)

  5. Terms to Know • #1 Factor: • Need to understand amount of functional ability client will gain or regain by knowing these terms: • Tetraplegia (means four) • Quadraplegia • Quadriparesis • Paraplegia • Paraparesis • Hemiplegia • Hemiparesis

  6. Qualifications • #2 Factor: • Higher up the spinal injury, the more devastating • Level of injury determines 2 things on severely affected side: • Amount of function remaining • Amount of function lost • The physiatrist must consider both to determine if rehab treatment is the client’s best option

  7. Qualifications • #3 Factor: • SCI classified by level of cord affected • Cord levels within spinal vertebrae in order • 31 pairs of spinal nerves which affect muscles and areas of skin

  8. Qualifications • Dermatome Chart: • Map showing the nerve roots/muscles the nerves affect and function • Nurses can assess the sensory areas through touch and pain

  9. Dermatome Chart

  10. Messages • Ascending tracts: (blue) • up to the brain • Descending tracts: (red) • down to the spinal cord/peripheral nerves

  11. Spinal cord stops at L1 • Injuries below L2 or lower, damage the tip of the spinal cord • Conus medullaris or cauda equina (L2-S5) • Spinal root damage • Different than cord damage • Central branch of sensory nerve is hurt: • Tend to be weaker than peripheral nerves • Easier to compress • Not peripheral damage • Spinal cord: • Widest cervical/lumbar areas • Increases risk for injury RT most flexible areas

  12. Spinal Cord Damage at Different Levels Rehabilitation Nursing

  13. Complete Injuries • Approximately 45% of SCI are complete • Complete does not necessarily mean spinal cord is cut • It does mean: • All sensation and movement is LOST Belowthe level of injury • ASIA definition of Complete Injury: • Absence of all motor or sensory function in the anal and perineal region (S-4 to S-5) • Zone of Preservation • Partial Preservation

  14. Incomplete injuries • Approximately 55% of SCI injuries • Evidence of sensation or movement still intact below the level of injury • RT some areas of the cord damaged and some not damaged permitting signals to continue getting through

  15. Spinal Shock • Similar to a brain concussion • Temporary shutting down of spinal accessory nerves • Affects: • All functional and natural reflexes below site of injury • Often seen when immediate injury occurs • Can be seen developing later • If no infection develops, the general course lasts 7-10 days • Signs: flaccidity of affected areas • Flaccid • Paralysis where muscles are soft and limp • Signs Spinal Shock is over

  16. Nursing Concerns Spinal Cord Injured

  17. Nursing Concerns • Due to advances in technology and care, SCI clients live longer • Eventually may develop overtime, other co-morbidities • SCIs affect nearly every body system • Result: Their lives will never be the same • Rehab nurses use FIM scoring to understand baseline: • Sensory function • Motor function

  18. General impairments

  19. Respiratory Impairment • C1-C4- need Ventilator • C2-C5 most life-threatening • C4-C5 most common cervical injury • If requires respiratory assistance, use jaw thrust • C5-C8 and T1-T5 • Weakened or paralyzed diaphragm/intercostal muscles • Decreasing chest expansion • Reduced inspiratory volume • Decreased expiratory efficiency • May require Quad cough assistance

  20. Ambulation impairment(Muscle/Skeletal) • C1-T5-non-ambulatory • T6-T9- Limited ambulation with: • Braces • Lofstrand crutches • New Technology • T10 and below- Functional ambulation • May have some flaccidity below the lesion • May have some degree of spasticity below the lesion

  21. Para step- Training uses micro- chip to stabilize the paraplegic

  22. Exoskeleton (eLegs) by 2012for W/C bound clients

  23. Spasms

  24. Spasms • Uncontrolled and involuntary muscle contractions and reflex tendons are exaggerated • Spasms may always be present • Managed by: • Performing daily ROM!!! • Gentle applied firm pressure • Massage to limb

  25. Spasms Benefits • Serves as warning sign of pain or other developing problems • Signals: • Infection • Kidney stone • Skin breakdown • Help maintain muscle size and bone strength • Helps decrease osteoporosis • Keeps blood circulating in lower limbs • Helps tighten lower limbs making it an easier transfer than when flaccid

  26. Spasms Medications • Because of positive benefits of spasms treatment is delayed until spasms interfere with: • Sleep • Limits client’s functioning ability • Medication treatment purpose: • Decrease muscle tone • Decrease frequency of spasms • Medications used: • Valium, Dantrium, Baclofen

  27. Spasms Disadvantages • Interferes with diagnostics requiring client to lay still for procedure • Nursing may be required to assist during procedure to help with immobilizing spine positioning

  28. Transfer impairment • C1-C5- completely dependent • Special W/C • C6-C7- requires assistance • RT Gross motor control presence • T1-T5- requires assistance • Uses slide board • T5 or below • Should reach independence

  29. Transfer impairmentsAdditional Problems • Over use syndrome • Chronic pain • Rotator cuff problems • Nerve entrapments • Wear and Tear on hands

  30. Transfer ImpairmentsMore Problems • Bone changes increase in risk below the level of injury • Can change client’s ROM, which may interfere with ADLs and transfers • Bone Changes: • Osteoporosis • Heterotrophic Ossification • Fractures

  31. Driving Impairment • C5-T9- use hand controls • T10 and below driving possible

  32. ADLs Impairment • FIM scoring used to assess level of functioning and offers guidelines to OT • C1-C4-dependent • C5-C7-needs assistance • T1 and below • Goal is independence • Ability to reach goal will vary

  33. Bowel and Bladder Impairment • C1-C7-dependent • T1-T9 • May be independent with bladder • Requires assistance with bowel • T10-T12- expect to be independent • L1-L2- independent • L4-S5- has adequate independent control of both

  34. Renal Impairment • Reflex Bladder • Bladder empties only when full • Not RT: • Client relaxing to voluntarily urinate

  35. Renal impairment • Non-Reflex Bladder • Bladder is flaccid- lacking tone • No reflex action present when stretches • May not feel fullness of bladder • Main problem: • Overfilling • Dribbling • Nursing Concern: • Need great teaching if managing bladder by intermittent catheterization • Obese clients require indwelling catheters

  36. Renal ImpairmentsUrinary Tract infections (UTI) • Major cause of death with SCIs RT: • Poor technique • Poor care of equipment • Most clients develop colonized microbes in bladder • This does not indicate an active UTI • Normal adult signals of UTI • SCI signals of a UTI: • Increase in spasms • Foul smell to urine • Change in voiding habits • Fever • Possible autonomic dysreflexia episode

  37. Renal impairmentLong Term Complications • #1 Kidney failure • #2 Hydronephrosis • #3 Increased risk for bladder CA RT intermittent catheterr use

  38. Reproductive Sexual Function • Men • Can change fertility/sexual function • Above level of conusmedullaris may have reflexive erections, but few ejaculate(20%) • May require penile implants/vacuum pumps

  39. Reproductive Sexual function • Women • Capable of sexual intercourse and conception • Capable of experiencing orgasm • Menses: • Disrupted after SCI injury for 3-6 months • Nurses watchful for return • Pregnancy: • Watch closely RT: • Increased Low birth weights • Increased premature births • Complications

  40. Specific GI Impairment • SCI clients can also develop peptic ulcers and gallstones • Three types of bowel problems: • #1 Reflex Neurogenic Bowel • RT cervical/high thoracic injury • #2 Autonomous Reflex Neurogenic Bowel • Lower injuries where anal tone/rectal reflex now absent • #3 Uninhibited Neurogenic Bowel • From CNS trauma

  41. Nursing Considerations of Bowel Care

  42. Bowel function Reminders • Nurses use take advantage of the Gastrocolic Reflex: • Autonomic response occurring when food/fluids enter the stomach • Stimulating peristalsis • Client may experience urge to defecate within 30-40 minutes of oral intake • Rectum • Stretches from fecal mass sending signals to brain • Brain returns with message to voluntarily control the anal sphincter • If relaxed sphincter, can push fecal mass out of body • Gravity and contracting abdomen helps

  43. Bowel Function After Injury • Spinal cord messages to brain may: • Work • Partially work • Not work at all • Location of injury/disease also plays a role

  44. Uninhibited Neurogenic Bowel • Physical structures all present • Reflexes intact • Everything ready to go to work • Problem: • Body never gets the go ahead signal • Signal is lost never got to brain or there is a disruption RT damage • Major Problem: • Bowel maintenance and accidents • Nursing Interventions: • Bowel training • Time toileting

  45. Reflex Neurogenic Bowel • Physical structures all present • Trouble with maintaining sphincter tone • Reflexes help involuntarily • Client unable to recognize: • Need to have BM(sensory) • Unable to hold BM even if wanted to(motor) • Major Problem: Bowel maintenance • Produces BMs at irregular times • Social issue • Nursing interventions: • Bowel training • Time toileting

  46. Autonomous Neurogenic Bowel • Physical structures all present • Neuro functions of motor and sensory + reflexes are lost • No tone, no rectal reflex • Client incapable of recognizing need to have BM • Incapable of holding BM • Nursing interventions: • Suppository insertion program • Time toileting schedule • Goal: Keep client cleaned out

  47. Nurses Concerns for SCIHealthy Habits of Bowel Function • Diet • Fluids • Exercise

  48. Nursing InterventionsBowel Training • Goal: • Retrain/gain control over bowels to prevent social issues • Individually adjusted • Suppositories, timing, massage of abdomen, etc • Once time of scheduled toileting is decided on it should not be changed: • Achieving bowel control takes up to 6 weeks • Requires consistency of staff/caregiver to be successful • Plan on accidents at first and eventually will rarely occur • Just don’t change the time!!!!

  49. Time Toileting • Body gets used to certain times for things like sleeping and eating • Body can also be taught to go to the bathroom • Timed toileting takes advantage of Gastrocolic reflex occurring after eating • Client toileted 30 minutes after eating at their agreed time • Client is positioned on toilet with knees slightly higher or at rectum level • Leans forward and abdomen massaged • Can be offered warm fluids

More Related