Spinal Assessment

1. Spinal Assessment Rebecca Humphreys, BSN, RN Unit Based Educator, 5 East St. Luke’s Health System, Boise

2. Housekeeping • Who am I? • Why am I here? • What are my goals for today? • Let’s make this fun! • Ask questions. Stop me anytime. • Who are you? • What are your goals for today?

3. Objectives • Spinal Assessment: • Adult • Pediatric • NICU • Epidural Assessment: • Adult • Pediatric (Brief) • What are the norms? • What is not normal? • What do we do when something is not normal? • What can we anticipate?

4. Spinal Anatomy

6. Spinal Assessment - NICU • What would we see in a NICU patient? • spina bifida/myelomeningocele • cord tethering • tumors • Focus: Physical Assessment • Neck • Spine • Sacral Area • Motor Function • What are the norms? • What is not normal? • What do we do when something is not normal? • What can we anticipate?

7. Spinal assessment - NICU • Palpate for masses • Assess for webbing or redundant skin • Cystic hygroma- (fluid filled sacs, lymph system defect) • Inspect clavicles for fractures

8. Spinal Assessment – NICU • Extra folds in plump infant • Extra fold due to edema • Mild webbing in infant with Turners • Marked increase in skin folds

9. Spinal Assessment – Adults/Peds • Focus: Physical and Sensory • Physical • Motor • Sensory

10. Spinal Assessment – Post Operative • To identify potential or actual spinal cord (nerve root) injury by assessing strength and sensation at multiple dermatome levels. What is the goal of the post-operative spine assessment?

11. Spinal Assessment – Post Operative • Assessing Strength: Muscle strength is rated using a scale of 0 to 5. Strength values: • 5=Normal (Active movement against resistance) • 4=Good (Active movement against some resistance) • 3=Fair (Active movement against gravity) • 2=Poor (Active movement, gravity eliminated) • 1=Trace (Palpable or visual contraction) • 0=Total paralysis

12. Spinal Assessment – Post Operative • Assessing Strength: 1. Know the pre-operative and PACU muscle strength assessment. • Pre-op assessments in computer! • PACU assessments on paper!

13. Spinal Assessment – Post Operative • Assessing Strength: 2. Know the previous RN’s muscle strength assessment. • If a patient has any muscle strength deficits, the RN to RN report must be done at the patient’s bedside.

14. Spinal Assessment – Post Operative • Assessing Strength: 3. Know the patient’s level of surgery/injury and document same. 4. Test muscle strength at the following levels: • At the level of surgery/injury • One level above surgery/injury • All levels below surgery/injury within the region

15. Spinal Assessment – Post Operative • Assessing Strength: 5. Ask the patient to move a muscle actively against gravity and then ask the patient to move the muscle with resistance. 6. Compare the muscle strength on the opposite side. Note differences. Ask if new or different since surgery.

16. Spinal Assessment – Post Operative • Assessing Strength: 7. Use the Comment box to note any factors affecting your assessment. • The patient appeared sedated at the time of assessment. • The patient reported pain as an obstacle to participating in the assessment.

17. Spinal Assessment – Post Operative • Assessing Strength: • Notify the physician of ANY deterioration. • Focus note ANY deterioration.

18. Spinal Assessment – Post Operative • Review Questions: Where can I find a copy of the pre-op and PACU motor strength assessment for my spine patient? • Pre-op assessments in computer! • PACU assessments on paper!

19. Spinal Assessment – Post Operative • Review Questions: True or False I should assess my patient’s motor strength at the level of surgery/injury, one level above and one level below the surgery/injury.

20. Spinal Assessment – Post Operative False!

21. Spinal Assessment – Post Operative What is a Dermatome? • Sensory nerves (“dermatomes”) give sensation to the skin area. Assessing dermatomes in the Pediatric population may take some special consideration …

22. Spinal Assessment – Post Operative • Sensory function is rated on a 0 to 2 scale. • Sensory Values: • 2 = Normal • 1= Impaired (Numbness or Tingling) • 0= Absent

23. Spinal Assessment – Post Operative • Assessing Sensory: 1. Know the pre-operative and PACU sensory assessment. • Pre-op assessments in computer! • PACU assessments on paper!

24. Spinal Assessment – Post Operative • Assessing Sensory: 2. Know the results of the previous RN’s sensory assessment. • If a patient has any altered sensation, the RN to RN report must be done at the patient’s bedside. • Do not selectInitial Assessment or Reassessment.

25. Spinal Assessment – Post Operative • Assessing Sensory: 3. Know the patient’s level of surgery/injury and document same. 4. Test sensation at the following levels: • At the level of surgery/injury • One level above surgery/injury • All levels below surgery/injury

26. Spinal Assessment – Post Operative • Assessing Sensory: 5. Test sensation using a “Hands Off ~ Hands On” approach: • “Hands Off” ~ Ask the patient to identify the location of any current areas of altered sensation. • “Hands On” ~ Determine the patient’s ability to perceive touch with the patient’s eyes closed.

27. Spinal Assessment – Post Operative • Assessing Sensory: 6. Use the Sharp (Prick) Sensory Scale with the sharp end of a Q-tip if sensation is absent in any dermatome. 7. Use the Comment box to note any factors affecting your assessment. • The patient appeared sedated at the time of assessment. • The patient reported pain as an obstacle to participating in the assessment.

28. Spinal Assessment – Post Operative • Assessing Sensory: 8. Notify the physician of ANY deterioration. 9. Focus note ANY deterioration.

29. Spinal Assessment – Post Operative • Review Questions: What is a Dermatome? Sensory nerves (“dermatomes”) give sensation to the skin area.

30. Spinal Assessment – Post Operative • Review Questions: True or False: Altered sensation must be documented in a focus note.

31. Spinal Assessment – Post Operative True!

32. Spinal Assessment – Post Operative • Review Questions: When should I use the Sharp (Prick) Sensory Scale? Use the Sharp (Prick) Sensory Scale with the sharp end of a Q-tip if sensation is absent in any dermatome.

33. Spinal Assessment – Post Operative • Review Questions: When should I call the physician? Notify the physician of ANY deterioration.

34. Spinal Assessment – Red Flags Assessment Red Flags • Diminished saddle sensation (decreased sensation in groin and upper thigh)Ask patient to touch their perineum or scrotum. • Progressive difficulty voiding. • Progressive difficulty in swallowing. • Progressive neurologic deficit in sensory or motor functions

35. Spinal Assessment –Areas of Focus • Pain – Medicate, Medicate, Medicate. • Use adjunct therapies and bimodal techniques • Mobility • The more you move, the better you will feel. • Bowel Care • My motto: “You can’t die from diarrhea, but you can die from constipation.” • Drain Management • The drains are there for a reason, make sure they are working.

36. Spinal Assessment – Post Operative • What is the most important thing to look for in a post-operative spine assessment? Changes!