spinal cord injury for nurses, Assignments of Medicine

Download spinal cord injury for nurses and more Assignments Medicine in PDF only on Docsity! SPINAL CORD INJURY INTRODUCTION: The spinal cord is a collection of nerves that travels from the bottom of the brain down your back. There are 31 pairs of nerves that leave the spinal cord and go to your arms, legs, chest and abdomen. The spinal cord runs through the spinal canal which is surrounded by the vertebrae which make up your back bone. A spinal cord injury occurs when there is damage to the spinal cord either from trauma, loss of its normal blood supply, or compression from tumor or infection. DEFINITION:  A spinal cord injury (SCI) is damage to the spinal cord that causes changes in its function, either temporary or permanent.  Spinal cord injury: Trauma or damage to the spinal cord, the major column of nerve tissue that is connected to the brain and lies within the vertebral canal and from which the spinal nerves emerge INCIDENCE  11,000 Americans suffer spinal cord injuries each year.  People who were at least 61 years of age when injured increased from 4.7% of patients with spinal cord injury in the 1970’s to 11% currently.  Motor vehicle crashes accounts for 50%, falls 24%, violence 11%, sports injury 9%, and other miscellanous causes 6%. RELATED ANATOMY AND PHYSIOLOGY The nervous system consists of the brain, spinal cord, sensory organs, and all of the nerves that connect these organs with the rest of the body. Together, these organs are responsible for the control of the body and communication among its parts. The brain and spinal cord form the control center known as the central nervous system (CNS), where information is evaluated and decisions made. The sensory nerves and sense organs of the peripheral nervous system (PNS) monitor... conditions inside and outside of the body and send this information to the CNS. Efferent nerves in the PNS carry signals from the control center to the muscles, glands, and organs to regulate their functions. Structure and function of the spine: The spine is made up of:  vertebrae, sacrum and coccyx – bony sections that house and protect the spinal cord (commonly called the spine) o The vertebral body I s the biggest part of a vertebra. It is the front part of the vertebra, which means it faces into the body.  spinal cord – a column of nerves inside the protective vertebrae that runs from the brain to the bottom of the spine  disc – a layer of cartilage between each vertebra that cushions and protects the vertebrae and spinal cord  also known as glial cells, act as the “helper” cells of the nervous system. Each neuron in the body is surrounded by anywhere from 6 to 60 neuroglia that protect, feed, and insulate the neuron. Because neurons are extremely specialized cells that are essential to body function and almost never reproduce, neuroglia are vital to maintaining a functional nervous system. FIG 1: Structure of spine 1. Traumatic  Traumatic blow to spine that fractures, dislocates, crushes or compresses one or more of vertebrae.  It also may result from a gunshot or knife wound that penetrates and cuts your spinal cord. 2. Non-traumatic  Arthritis  Cancer  Inflammation  Infections  Disk Degeneration of the spine. Common causes are:  Motor vehicle accidents.  Falls.  Acts of violence.  Sports and recreation injuries.  Alcohol.  Diseases RISK FACTORS  Being male.  Being between the ages of 16 and 30.  Being older than 65.  Engaging in risky behavior.  Having a bone or joint disorder. PATHOPHYSIOLOGY Acute impact injury is a concussion of the spinal cord. Hypoperfusion of the gray matter. Increases in intracellular calcium and reperfusion injury Cellular injury, and occur early after injury. Necrosis Compression,Increased parenchymal pressure Spinal cord compression / injury FIG 2: Pathophysiology of spinal cord injury The pathophysiology of spinal cord injury can be categorized as acute impact or compression. Acute impact injury is a concussion of the spinal cord. This type of injury initiates a cascade of events focused in the gray matter, and results in hemorrhagic necrosis. The initiating event is a hypoperfusion of the gray matter. Increases in intracellular calcium and reperfusion injury play key roles in cellular injury, and occur early after injury. The extent of necrosis is contingent on the amount of initial force of trauma, but also involves concomitant compression, perfusion pressures and blood flow, and administration of pharmacological agents. Preventing or quelling this cascade of events must involve mechanisms occurring in the initial stages. Spinal cord compression occurs when a mass impinges on the spinal cord causing increased parenchymal pressure. The tissue response is gliosis, demyelination, and axonal loss. This occurs in the white matter, whereas gray matter structures are preserved. Rapid or a critical degree of compression will result in collapse of the venous side of the microvasculature, resulting in vasogenic edema. Vasogenic edema exacerbates parenchymal pressure, and may lead to rapid progression of disfunction. Treatment of compression should focus on removal of the offending mass. CLINICAL MANIFESTATION The symptoms of spinal cord injury depend on where the spinal cord is injured and whether or not the injury is complete or incomplete. In incomplete injuries, patients have some remaining function of their bodies below the level of injury, while in complete injuries they have no function below the level of injury. Common signs and symptoms are:  Problems walking  loss of control of the bladder or bowels  Inability to move the arms or legs  Feelings of spreading numbness or tingling in the extremities  Unconsciousness  Headache  Pain, pressure, and stiffness in the back or neck area  Signs of shock  Unnatural positioning of the head  Spinal cord injuries in the upper neck can cause difficulty breathing DIAGNOSTIC EVALUATION  Complete spine films: To assess for vertebral fracture  X- rays: visualizing C1 through T1 are done to document the presence of vertebral injury.  CT Scan: To assess the stability of the injury, location and degree of bony injury, and degree of bony injury.  MRI : To assess the for soft tissue and neural changes and when there is unexplained neurologic deficit or worsening of neurologic status.  Neurological examination and assessment of the head, chest, an abdomen: For additional trauma or injury. MANAGEMENT Prehospital treatment  C-6 to C-7: Tetraplegia with some arm/hand movement allowing some independence in ADLs.  C-7 to T-1: Tetraplegia with limited use of thumb/fingers, increasing independence.  T-2 to L-1: Paraplegia with intact arm function and varying function of intercostal and abdominal muscles.  L-1 to L-2 or below: Mixed motor-sensory loss; bowel and bladder dysfunction. NURSING DIAGNOSIS  Acute pain related to physical injury as evidenced by hyperesthesia, burning pain, muscle spasm  Goal: to relieve pain  Interventions o Assess for presence of pain. Help patient identify and quantify pain (location, type of pain, intensity on scale of 0–10). o Evaluate increased irritability, muscle tension, restlessness, unexplained vital sign (VS) changes. o Provide comfort measures (position changes, massage, ROM exercises, warm or cold packs, as indicated). o Encourage use of relaxation techniques (guided imagery, visualization, deep- breathing exercises). Provide diversional activities (television, radio, telephone, unlimited visitors) as appropriate. o Administer medications as indicated: muscle relaxants: dantrolene (Dantrium), baclofen (Lioresal); analgesics; antianxiety agents: diazepam (Valium).  Disturbed sensory perception related to destruction of sensory tracts, transmission and integration, reduced stimuli as evidenced by measured change in sensory acuity, motor incoordination, change in usual response to stimuli  Goal: To promote sensory perception  Interventions: o Assess and document sensory function or deficit (by means of touch, pinprick, hot or cold, etc.), progressing from area of deficit to neurologically intact area. o Protect from bodily harm (falls, burns, positioning of arm or objects). o Assist patient to recognize and compensate for alterations in sensation. o Provide tactile stimulation, touching patient in intact sensory areas (shoulders, face, head). o Position patient to see surroundings and activities. o Provide diversional activities (television, radio, music, liberal visitation). o Note presence of exaggerated emotional responses, altered thought processes (disorientation, bizarre thinking).  Constipation related to neurogenic bowel, inadequate fluid intake and immobility as evidenced by lack of bowel movement or decreased bowel sounds.  To relieve from constipation  Interventions: o Auscultate bowel sounds, noting location and characteristics. o Observe for abdominal distension if bowel sounds are decreased or absent. o Note reports of nausea, onset of vomiting. Check vomitus or gastric secretions (if tube in place) and stools for occult blood. o Record frequency, characteristics, and amount of stool. o Check for presence of impaction (no formed stool for several days, semiliquid stool, restlessness, increased feelings of fullness or distension of abdomen). o Establish regular daily bowel program (digital stimulation, prune juice, warm beverage, and use of stool softeners and suppositories at set intervals. Determine usual time and routine of postinjury evacuations. o Encourage well-balanced diet that includes bulk and roughage and increased fluid intake (at least 2000 mL per day), including fruit juices. o Assist and encourage exercise and activity within individual ability and up in chair as tolerated. o Restrict intake of grapefruit juice and caffenated beverages (coffee, tea, cola, chocolate). o Consult with dietitian and nutritional support team. o Administer stool softeners, laxatives, suppositories, enemas (eg, Therevac-SB) as ordered  Impaired skin integrity related to skull long placement, immobility, and poor tissue perfusion as evidenced by reddened skin over bony prominences.  Goal: to promote skin integrity  Interventions: o Inspect all skin areas, noting capillary blanching and refill, redness, swelling. o Encourage continuation of regular exercise program. o Elevate lower extremities periodically, if tolerated, to enhance venous return o Avoid and limit injection of medication below the level of injury. o Massage and lubricate skin with bland lotion or oil. Protect pressure points o Reposition frequently, whether in bed or in sitting position o Keep bedclothes dry and free of wrinkles, crumbs. o Provide kinetic therapy or alternating-pressure mattress as indicated. COMPLICATION  Pulmonary edema, respiratory failure, neurogenic shock, and paralysis below the injury site.  In the long term, the loss of muscle function can have additional effects from disuse, including atrophy of the muscle.