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Vol. 6 No.

Recovery Strategies from the OR to Home

In This Issue
Acute Stages of educatio
T
g
Spinal-Cord Injuries n
he annual incidence of spinal cord injury

nf
(SCI) is approximately 7,800 new cases

continui
each year. SCI primarily affects young

or nursin
adults, most frequently from motor vehicle
accident. However, the percentage of persons By Mary G. Carey (Adams) RN, PhD, and
older than 60 years of age with SCI is increas- Madonna Lakso RN, CCRN
ing. Pressure sores are the most common
secondary condition among people with SCI g
along with respiratory complications, urinary

I
tract infections, spasticity, and scoliosis. In
their article Dr. Carey and Ms. Lasko describe n May 27, 1995, Christopher Reeve’s
the nursing management during the acute headfirst tumble from a horse in Vir- When synaptic connections are sud-
stages of SCI to help ensure survival through ginia resulted in severe damage to his denly interrupted, the following events
this critical period. second cervical spinal vertebra (C2), rapidly ensue:
turning him into a quadriplegic. Thus, 1. The impact of force damages nerve
More than 56,000 Americans were diagnosed began his courageous, decade-long battle cells.
with bladder cancer in 2004 and about one- to reclaim his life. As an actor, he played 2. There is a loss of normal blood flow,
third of the cases are invasive. More than Superman; as a man, he was a hero for swelling of tissue, breakdown of
12,000 Americans will die of bladder cancer people with spinal-cord injuries. cell structure, and loss of myelin
this year and the expected prognosis for people In the United States, 7,800 spinal- sheathing.
with advanced bladder cancer that has spread cord injuries (SCI) are reported annu- 3. The flow of ionic current is disrupted
to other organs is less than one year. For inva- ally. However, many feel that spinal-cord when the higher concentrated
sive bladder cancer, the surgeon may remove injuries are significantly under-reported, calcium ions on the exterior of the
a portion or the entire bladder (cystectomy). because they are not recorded in the fol- nerve cells leak interiorly and flood
Once the bladder is removed, surgeons must
construct another way for urine to leave the
lowing cases: people who die instantly, the neuron.
body – a continent urinary diversion. people with little or no remaining neuro-
logical deficit, and people who have neu- In the process of regaining ionic con-
Ms. Sims in her article describes the several rological problems secondary to tumor centrations, calcium sets off a cascade of
different types of continent urinary diversions
and the nursing-care consideration to minimize
that are not classified as SCI. self-destructive cellular events. Enzymes
postoperative complications. SCIs occur more often in the sum- that digest tissue (phospholipase) are re-
mer months, on Saturdays, and during leased from the broken cell membrane.
Visit us on the Web at daylight hours. Not surprisingly, motor This results in the release of free radicals,
www.perspectivesinnursing.org vehicle accidents (48%) account for the which contribute to the imbalance by at-
majority of SCI, while falls (21%), violent tacking nearby healthy cells. This activity
crimes (15%), sports (14%; mostly diving triggers a process called lipid peroxida-
Advisory Board accidents), and medical tumors (2%) ac- tion. The oxygen breakdown of essential
count for the remainder. Men (82%) are cell lipids leads to more swelling, as water
Lois Dixon, MSN, RN much more likely to suffer from SCI. Re- enters tissue from the blood and cerebro-
Clinical Nurse Educator,
Genesis Medical Center, Davenport, IA gardless of gender; substance abuse and spinal fluids. Cellular breakdown acceler-
Jan Foster, RN, PhD, MSN, CCRN alcohol intoxication are substantial risk ates with the release of toxic substances
Asst. Professor for Adult Acute and Critical Care Nursing factors for SCI.1 that compromise blood flow. Injury pro-
Houston Baptist University, TX motes the release of neural substances,
Mikel Gray, PhD, CUNP, CCCN, FAAN Pathophysiology of a spinal-cord such as serotonin, catecholamines, and
Nurse Practitioner and Professor of Urology, injury endorphins. Glutamate, normally the main
School of Nursing, University of Virginia,
Charlottesville, VA Regardless of the mechanism, spi- excitatory transmitter, expresses its toxic-
nal-cord injuries have the following three ity in large doses by overloading neuronal
Tracey Hotta, RN, BScN, CPSN
Past-president, American Society of Plastic Surgery Nurses common abnormalities that lead to tissue circuits.3
Toronto, Ontario, Canada damage2: The most obvious symptom is paraly-
Victoria-Base Smith, PhD(c), MSN, CRNA, CCRN ● destruction from direct trauma sis due to swelling of the spinal cord. This
Clinical Assistant Professor, Nurse Anesthesia, ● compression by bone fragments or paralysis may improve as swelling sub-
University of Cincinnati, OH disk matter sides, usually three or more weeks after
Mary Sieggreen, MSN, RN, CS, NP ● ischemia secondary to impingement the initial injury. Within a year, most
Nurse Practitioner, Vascular Surgery, of the spinal arteries Continued on page 5
Harper Hospital, Detroit, MI

Supported by an educational grant from Dale Medical Products Inc.


Bladder Cancer Surgery: The neobladder allows for a more
anatomically natural urinary diversion, as
it is anastomosed to the native urethra.
Postoperative Care of Patients This procedure goes by many names, in-
cluding the Camey, Chimney, Hautmann
or Hemi-Kock. A detubularized segment of
with Continent Urinary Diversions intestine, usually ileum about 50- to 70-cm
long, is used to construct a reservoir for
by Terran W. Sims, ACNP,MSN, RN
urine storage. The ureters are implanted
into the reservoir, which in turn is anasto-

M
mosed to the native urethra. The external
ore than 56,000 Americans The goal of any technique is to urethra is intact, so the patient is poten-
were diagnosed with bladder create8 tially continent. In most cases, patients
cancer in 2004.1 While the ma- ● high-capacity, low-pressure pouch experience daytime continence and have
jority of bladder cancers are ● anti-refluxing approach with some risk of nighttime incontinence with
superficial, i.e., they do not invade the continent mechanism large urine volumes. The Chimney modi-
bladder wall muscle, about one-third are ● catheterizable stoma fication uses an extra length of reservoir
invasive. Superficial tumors respond well to reach the native urethra with less ten-
to local therapy, but the recurrence rate The most common reservoirs are the sion.8,9
can be as high as 30-70% and the risk of Kock and ileocecal pouches. The Kock
progression to invasive cancer during fol- pouch uses >90 cm of ileum and small Potential complications
low-up can be as high as 10-30%.2 More bowel to create a reservoir with a nipple The Kock and ileocecal pouches have
than 12,000 Americans will die of bladder valve.4 While it provides the necessary potential complications that patients must
cancer this year and the expected progno- components of any reservoir, the Kock consider preoperatively. Metabolic com-
sis for people with advanced bladder can- pouch has mixed reviews for success. Ex- plications with the Kock pouch may arise
cer that has spread to other organs is less perienced surgeons report success rates from the segment of intestine that is used.
than one year.1,3 for daytime continence as high as 94%.5 These and other complications include
Other indications for bladder surgery However, its use is limited, as other di- metabolic acidosis, hypokalemia, hypo-
include6: version options, which incorporate large magnesia, and chronic renal insufficiency
● neurogenic bladder that threatens bowel segments and report lower compli- due to increasing blood urea nitrogen
kidney function cation rates, have come into vogue. (BUN) and creatinine levels. Other issues
● congenital abnormalities, including The ileocecal pouch incorporates are the formation of urinary calculus,
bladder entrophy, epispadias, or large bowel segments from the right co- ureteral reflux, and stoma incontinence.
cloacal exstrophy lon and distal ileum. Several types exist, Based on these potential complications,
● fibrosis including the Miami, Florida, Mainz, and many surgeons have chosen to use the
● cystitis arising from exposure to Indiana pouches. large bowel procedure to construct an
external beam radiation or interstitial The Indiana pouch was developed at Indiana pouch or similar variation.
radiation for cancers, such as pelvic the University of Indiana and incorporates Complications of the ileocecal pouch
or gynecological cancers. an ileocecal valve as part of the conti- include stoma incontinence, difficult cath-
nence mechanism.6 This pouch is created eterization, urinary calculus, leakage at
During bladder surgery (cystectomy), with detubularized bowel. The surgeon the anastomosis, altered bowel resorp-
the surgeon may remove a portion of the transects the bowel to create a low-pres- tion, pyelonephritis, bacteriuria, stomal
patient’s bladder (partial cystectomy), sure but high-capacity reservoir. The ure- stenosis, electrolyte abnormalities, and
section of bladder wall (segmental cys- ters are implanted into the side of the res- vitamin B12 deficiency, secondary to the
tectomy), or the entire bladder (radical ervoir. A nipple valve is constructed, then use of terminal ileum. Pouch rupture is a
or total cystectomy). Once the bladder attached to the skin. A segment of bowel rare complication, as the valve may leak,
is removed, surgeons must construct an- wall is used to form a stoma at the exit causing urinary incontinence before rup-
other way for urine to leave the body ­– a site. The ureters may be anastomosed in a ture. Long-term incontinence may develop
continent urinary diversion. refluxing or non-refluxing manner, based as a secondary problem.
There are several options for con- on surgical preference. With the neobladder, potential com-
struction of a continent urinary diversion Another technique is the Mitrofanoff plications include metabolic abnormali-
for urinary drainage. The surgeon and pa- procedure, which uses the appendix to ties, such as metabolic acidosis (which
tient may choose a diversion that drains form a subepithelial anti-refluxing tunnel may resolve over time with adaptation),
urine continuously to a pouch (ileal con- that leads to a continent catheterizable vitamin B12 deficiency (secondary to mal-
duit) or a dry diversion with an ileoce- vesicostomy stoma.7 This stoma can be absorption with use of terminal ileum),
cal pouch that contains urine for later placed at the umbilicus for a more cos- urinary retention, incontinence, stenosis
catheterization (Indiana, Florida, Miami, metic effect. The Mitrofanoff procedure is of the urethral anastomosis, fistula, or uri-
or Mainz pouch) or regular voiding (neo- thought to alleviate the problem of main- nary calculi. Rupture of the neobladder is
bladder). Knowledge of each option is key taining continence in a surgically recon- a rare complication, secondary to a poor
to understanding nursing-care consider- structed bowel. sensation of fullness, coupled with poor
ations in the postoperative period. Both approaches are widely used bladder emptying.
today. Combining a reconstructed bowel
Continent urinary reservoirs reservoir with the Mitrofanoff procedure Preoperative considerations for
A variety of continent urinary res- provides the best of both worlds, allow- continent urinary diversions
ervoirs have been developed since 1950. ing for excellent continence, both daytime Selection of the best diversion for
Common ileocecal pouches, ileal pouch- and nighttime. each patient is crucial. Patients are en-
es, and orthotopic bladders (i.e., neoblad- The stoma of an ileocecal pouch is couraged to have a second choice of uri-
ders) vary, depending on the type of bow- small and flush with the skin. Its location nary diversion, if the first choice is not
el that is used for its creation and the flap can be midline, at the umbilicus, or in the possible intraoperatively, secondary to
or valve design. lower right abdominal quadrant. contradictions. The most common reason


for not creating the selected diversion Table 1. Postoperative Issues
is cancer in the surgical margins, which
prevents a curative operation and/or ana- Security of ureteral stents Dislodgment requires immediate notification of the surgeon for
tomical impossibilities due to the lack of evaluation
sufficient bowel for creation of a pouch or Output from surgical drains An increase in JP or Penrose drainage may represent a urine
neobladder. leak or bleeding; the surgical team should be notified. A fluid
The patient’s motivation for self- sample should be sent to the laboratory for evaluation.
care after surgery and over the long term
is key to success; it should be assessed Malecot and Foley catheter These devices should be patent and draining at all times.
preoperatively. If the patient will require Decreased urine output should be investigated. Gentle irrigation
a caregiver, an ileal conduit may be the of the Malecot catheter should restore drainage. If urine does
best choice for ease of care. Preoperative not drain after irrigation and removal of mucous plugs, the
education will depend on which diver- surgical team should be notified. This problem could lead to
sion is selected. The idea that the patient undue tension on surgical anastomoses, secondary to obstruc-
may awaken from surgery with a differ- tion. Dehydration could be the issue; assessment of fluid input
ent diversion than the first choice must be and output should be assessed and recent serum lab markers
emphasized, as intraoperative challenges evaluated for renal function.
may affect the final choice of surgical pro- Pain Immediate postoperative pain can be managed effectively with
cedure. an epidural and parenteral narcotics for breakthrough pain. After
Patients, family, and support-system GI motility is established, oral pain medication can be used.
members should be involved early to an- Cardiovascular and pulmonary DVT prophylaxis should include heparin and compression
ticipate home care, until the patient can issues stockings as well as early ambulation, which helps to prevent
function independently with the diver- cardiovascular and pulmonary complications, such as PE,
sion. Unrealistic expectations can lead to atelectasias, pleural effusions, and pneumonia.
patient and caregiver frustration postop-
eratively. Self-care and irrigation of The nursing staff should teach the patient/family caregiver to
Preoperative selection of the best sto- catheters irrigate the Malecot and Foley catheters every 3-4 hours for
ma location should be performed, even if consistent drainage and removal/flushing of mucous plugs.
the patient believes that they have a good Home care is supportive, but it cannot provide complete care in
chance of a neobladder or cutaneous every 24-hour period. Self-care and caregiver support should be
pouch. The pouch stoma can be located in taught early to prepare the patient for home care.
an alternative area, even if a stoma site is
marked for an ileal conduit. This selection
can lead to the discussion of flexibility for mentation is not required. stockings at home for several more days
surgical choice of a diversion, based on In selected cases when poor wound to assist in the mobilization of postopera-
intraoperative findings. healing is anticipated, e.g., post-pelvic ra- tive fluid. Incentive spirometry, coughing,
The patient who selects a neobladder diation, immediate postoperative hyperali- deep breathing, and turning can help to
preoperatively should learn about clean mentation may be useful until bowel func- prevent respiratory complications.
intermittent catheterization (CIC) in an- tion returns and the patient shows signs While postoperative care of a conti-
ticipation that it may be needed until good of granulating tissue. A nasogastric tube nent urinary diversion and new ileal con-
bladder emptying habits are established. is placed to provide gastric drainage and duit is similar, some special differences
Learning CIC is useful, in case complica- bowel decompression. Once the patient exist. Patients with an ileocecal pouch
tions, such as anastomotic strictures or passes flatus, the nasogastric tube can have abdominal drains and tubes to rid
urinary retention, arise. be removed and the patient’s diet can be the body of serous sanguineous fluid and
Bowel preparation is completed prior slowly advanced, starting with ice chips urine and to prevent tension on suture
to surgery. Usually patients have a clear and clear liquids. lines and internal anastomoses. Because
liquid diet for 1-3 days preoperatively and Epidural catheters can be used for many anastomoses are found in the inter-
use laxatives (e.g., Fleets Phospho-Soda postoperative pain management, supple- nal reservoir, there is need for consistent
and bisacodyl tablets) for mechanical mented with parenteral narcotics for irrigation and monitoring of fluid input
cleansing on the day before surgery. Pa- breakthrough pain. Once bowel function and output. Continuous monitoring of flu-
tients may receive oral antibiotics, such as has returned, the epidural may be discon- id input and output volumes and ensuring
neomycin or erythromycin, for reduction tinued. The patient can switch to an oral that drains and tubes are free of kinks and
of bowel flora.8 regimen and may receive a stool softener obstructions are important nursing-care
to prevent constipation. considerations.
Postoperative care Early ambulation is key in moving the An ileocutaneous pouch has ureteral
Postoperative nursing care employs recovery process forward and preventing stents, a Malecot catheter for irrigation
all general principles of surgical nursing, cardiovascular and pulmonary complica- and drainage, a Foley catheter through the
with special attention to the drains and tions. It can be initiated as early as post- stoma or, with the neobladder, through the
catheters for continent urinary diver- operative day one. The patient’s drains urethra, to provide drainage immediately
sion. The general care of these patients and tubes will need to be supported dur- after surgery, and a left lower abdominal
includes a need for early ambulation and ing ambulation, but this necessity should Jackson-Pratt or Penrose drain. The pa-
a focus on return of bowel function. While not deter the staff or patient. tient may have more than one drain, de-
the length of hospitalization can range Preventing deep venous thrombosis pending on the extent of pelvic surgery.
from 7-10 days, it depends on these two (DVT) is key, based on length of surgery Stents are placed through stab
factors. and immobilization. The use of subcutane- wounds. They are temporary, yet so impor-
When bowel function has returned, ous heparin and compression stockings is tant. While in place, they drain the largest
as evidenced by the passing of flatus and standard for any abdominal surgery and volume of urine. They can be connected
small stools, the patient can be switched continues throughout hospitalization with to individual drainage bags or placed in-
to oral pain medication and an advancing discontinuation at discharge. Patients side a urostomy pouch for urine collection
dietary regimen. Bowel function usually with lower extremity edema may elect and drainage. They are placed to allow for
returns in 7 days, so parenteral hyperali- to continue to use support/compression healing of the ureteral anastomosis and


Table 2. Postoperative irrigation of continent urinary diversions be placed over the exit sites.
Diversion with Immediate Before Home After Foley Before discharge, the patient must
Malecot/Foley postoperative discharge regimen removal be able to irrigate the pouch, manage the
care drains and Foley-catheter collection bags,
Ileocecal pouch Every 2-3 hours Every 4 hours with
and show a clear understanding of the
Every 4 hours, Self-catheterization
Indiana pouch and with any day and night option of every 5 every 2-3 hours
proper care techniques. A lack of urine
decrease in urine hours at night after and bedside
output is a medical emergency that must
output 1st clinic visit, drainage at night
be immediately reported to the surgi-
postoperative cal team. This point cannot be stressed
week 3, and Foley enough to patients, as a lack of urine
removal output may be caused by an obstruction,
which may cause tension and eventually
Neobladder Every 2-3 hours Every 4 hours, Every 4 hours Voiding every 2-3 rupture the sutures. Gentle irrigation may
and with any day and night until 1st clinic hours day time unblock an obstruction; if unsuccessful,
decrease in urine visit, postopera- and every 4 at the surgical team must be notified.
output tive week 3, and night with PVR The neobladder differs from the il-
Foley removal check, option of eocecal pouch in several ways that are
bedside drainage worth noting. Postoperative drains and
bag at night tubes are similar, but they are placed in
different anatomical locations. Ureteral
prevention of hydronephrosis. Nurses tubes while the patient is ambulating. It stents enter through stab wounds in the
should monitor them to ensure that they can be removed while the patient lies in skin: a 22- to 24-French Malecot catheter
remain open until healing occurs. An bed and put on before the patient arises to in the suprapubic area, lower abdominal
urologist removes the stents prior to dis- ensure that stents are not dislodged and to JP drains (left and right, depending on the
charge. relieve tension on drains. extent of surgical resection), and a 16- to
The Malecot catheter, usually 22-24 Initially, every 2-3 hours, the nurse 20-French Foley catheter. The stents are
French, is placed through an abdominal will verify consistent drainage of urine connected to drainage bags or may be
stab wound. This catheter is essential for from the stents and Malecot catheter, then placed in urostomy drainage pouches for
continuous drainage of the pouch to pre- irrigate the catheter with 30-60 ml of ster- collection and monitoring of urine output.
vent distention and tension on the anasto- ile solution to prevent any obstruction by Continuous drainage of the neoblad-
moses. This site for irrigation and drain- mucous. The urine and irrigation fluid may der during the healing of anastomoses
age of urine prevents tension on suture drain through the Malecot or Foley cath- occurs and provides for a watertight res-
lines and, later, provides an outlet while eter. ervoir. As with pouches, the stents are
the patient learns self-catheterization. The JP or Penrose drain removes removed before discharge. The Malecot
Keeping the pouch decompressed in the serosanguineous fluid, which collects in catheter remains in place for several
early postoperative period allows for im- the pelvis. An increase in JP drainage out- weeks as a way to ensure consistent ir-
proved healing and deceases the chance put or increasing pain or swelling in this rigation and drainage. A lack of urine
of a urine leak through the reservoir su- area may signal a urine leak or internal drainage from either the Malecot or Foley
ture lines. bleeding. Inflammation and excoriation catheter necessitates gentle in-and-out
The pouch can accumulate mucous; due to leakage will increase pain. These irrigation to dislodge any clots or mucous.
irrigation and drainage tubes provide an symptoms, along with increased drainage If continuous drainage cannot be re-estab-
outlet until the pouch is healed and wa- output and/or decreased urine output, are lished, the surgical team must be notified
tertight. A 16- to 20-French Foley catheter important to communicate to the surgical to resolve the obstruction, which may cre-
will drain any urine not voided by the team for investigation. ate tension on new anastomoses.
Malecot catheter. Securing the Foley cath- It is not surprising that many patients Initially, the nurse irrigates the neo-
eter to the leg with appropriate tension feel overwhelmed postoperatively with bladder with 50-100 ml of sterile saline
is important. The surgeon often secures tubes and drains. Patient and family edu- every 2-3 hours postoperatively, progress-
it with a tube holder, such a Dale Foley cation is important to build confidence, as ing to 4-hour intervals during recovery. At
Catheter Holder (See Figure 1), to ensure postoperative recovery progresses. One first, saline is input through one catheter
that no tugging, pulling, or changing of goal is for the patient and family to learn and output through the other. Postopera-
tension occurs in the early postoperative the irrigation technique by day 4-5 and to tive irrigation schedules are followed
period. practice it, with return demonstration and closely to ensure adequate drainage of
An abdominal binder, such those with observation, throughout hospitalization. urine and mucous.
Velcro® closures (Dale Medical Prod- The intervals are lengthened to every 4 If obstruction appears to be a prob-
ucts), can secure abdominal drains and hours with consistent drainage (See Table lem, the Malecot catheter is clamped
2). The patient is taught to irrigate more
often if the urine volume decreases or
stops.
After discharge, the patient will con-
tinue this regimen (even at night), until re-
turning to the surgeon’s office for the next
stage of postoperative care: drain removal
and x-rays to verify a watertight pouch.
Once the stents and JP drain(s) are re-
moved, the only drains for home care are
the Malecot and Foley catheters. The exit
sites of stents and drains may leak after
initial removal, so protection of the skin is
important until healing occurs; petroleum
Figure 1. Foley Catheter Holder (Dale Medical Products)
jelly-impregnated gauze or dry gauze can Abdominal Binder (Dale Medical Products)


during irrigation, while the nurse gen- ization method can be used to secure an
tly instills 50 ml of saline through the up-stream specimen for accurate culture Acute Stages of
Foley catheter to aspirate any mucous and sensitivity evaluation. Treatment Spinal-Cord Injuries — Continued
plugs. This procedure can be repeated, if should be guided by laboratory results.
neceesary.8 It is vital to secure the Foley people experience an improvement in
catheter to the patient’s leg with a tube Conclusion their initial level of injury of at least one
holder to maintain the proper tension, The decision for continent urinary or occasionally two spinal cord levels.
which is established by the surgical team diversion is complex. It requires multiple
during cystectomy. discussion sessions with patients and Diagnosis
Throughout hospitalization, the nurs- family support members before surgery. Definitive diagnosis of spinal-cord
ing staff needs to be in close contact with After surgery, postoperative hospital injuries is made with a variety of imaging
the surgical team to report any alteration and home care is the key to a successful studies, including radiographic studies,
in expected outcomes. Home-care nursing outcome. The patient must be taught how standard X-ray (flexion and extension
may be necessary and should be estab- to irrigate the tubes and drains and should films), computerized tomography (CT),
lished by the discharge planning team pri- be able to return demonstrate this skill and magnetic resonance imaging (MRI).
or to discharge for optimal home results. consistently before discharge. The idea A thorough physical and patient history
of going home with a Malecot and Foley by a neurologist helps to determine the
Long-term considerations catheter must be consistently addressed, mechanism of injury. Because there is a
This type of surgery has several po- starting in the preoperative planning 15% chance of finding a second vertebral
tential long-term complications. Ureteral- period. injury, once the first injury is identified;
anastomosis structure, neobladder-to-ure- It is important to emphasize that, by maintaining strict stability of the vertebral
thral stricture, and reservoir rupture are investing in proper care and maintain- column is of the utmost importance post-
rare but must be discussed preoperatively. ing consistent postoperative schedules, injury.
Metabolic complications are monitored by patients can achieve the life-long benefit Spinal-cord injuries can be classified
regular laboratory testing and addressed of a well-healed urinary reservoir. The as either permanent or temporary, based
with medication. The formation of renal surgical team of the urologist, operative the extent of damage and mechanism of
or urinary reservoir calculi is problematic nurses, surgical inpatient nurses, enter- injury.
and should be watched for. In patients ostomal therapy (ET) or wound ostomy ● Tetraplegia (formerly known as
with preoperative bladder cancer, physi- continence (WOC) nurse, and clinical quadriplegia) is injury to the cervical
cians must monitor for tumor recurrence. staff, along with the patient’s family sup- region, causing complete loss of
Incontinence as the result of a failed port network all play important roles in motor function in all extremities.
pouch or neobladder sphincter can be helping the patient to achieve a successful ● Paraplegia is injury to the lower
a frustrating outcome for patients and outcome after cystectomy and continent thoracic lumbar or sacral region,
caregivers. Often this problem can be urinary diversion. causing incomplete to complete
addressed surgically, but it must be care- paralysis.
fully evaluated. If incontinence arises in
patients with neobladder and an intact References As defined recently in the Interna-
sphincter but poor emptying, then the 1. American Cancer Society. Cancer facts & figures 2004.
tional and American Spinal Injury Asso-
Accessed March 6th, 2005, at: http://www.cancer.org/
regimen of CIC can be used to ensure de- downloads/STT/CancerFacts&Figures2002TM.pdf ciation (ASIA) Neurological Classification
compression and slow return of reservoir 2. Messing EM. Urothelial tumors of the urinary tract. of Spinal Cord Injury, the term ‘incom-
tone. In: Walsh PC, Retik AB, Vaughan ED, Wein AJ (eds).
plete’ has been specified to a greater
Campbell’s Urology, 8th edition. Philadelphia: Lippincott-
Sexuality may be affected by cystec- Williams & Wilkins, 2002, pp. 2732-84. extent and now indicates a person with
tomy. For women, this surgery may alter 3. Dreicer R. Locally advanced and metastatic bladder preservation of motor or sensory func-
sexual function, as the uterus and ovaries cancer. Curr Treat Opt Oncol 2001;2:431-6.
tion in the last sacral segment (S4-5). This
are usually removed, leading to symptoms 4. Kock NG et al. The continent ileal reservoir (Kock pouch)
definition addresses the patient who has
for urinary diversion. World J Urology 1985;3:146.
of menopause, such as hot flashes or vagi- an injury at a given level, some preserved
5. Boyd SD, Lieskovsky G, Skinner DG. Kock pouch bladder
nal dryness. If part of the vagina is re- replacement. Urol Clin N Am 1991;18(4):641-8. sensation or motor function, but loss of
moved during surgery, sexual intercourse 6. Rowland RG, Mitchell ME, and Birhle R. The cecoileal function below that level. Spinal-cord in-
may be difficult. For men, surgery may continent urinary reservoir. World Journal of Urology
1985;3:185-8. juries are further categorized to an ASIA
damage the nerves that control erections, 7. Mitrofanoff P. ( 1980). Trans-appendicular continent Impairment Scale to describe the type of
resulting in erectile dysfunction (impo- cystostomy in the management of the neurogenic injury. Better-known classifications are1:
tence). Fortunately, many treatments are bladder. Chirurgie Pediatrique 1980;21(4):297-305.
Central cord syndrome is more often
available to address this problem. 8. Krupski T, Theodorescu D. Orthotopic neobladder
following cystectomy: indications, management, associated with hyperextension of the
Skin issues can be rare but bother- and outcomes. J Wound Ostomy Continence Nurses neck and acceleration or deceleration of
some for patients with an ileocecal or 2001;28(1):37-46.
the cervical spine. Patients have greater
Indiana pouch. Since the pouch may pro- 9. Lippert MC, Theodorescu D. The Hautmann neobladder
with chimney: a versatile modification. J Urol motor strength in the upper limbs than in
duce a small amount of mucous at the exit 1997;158:1510-1512. the lower limbs.
site, a small bandage or gauze dressing Brown-Sequard syndrome is ipsilat-
can be placed over the stoma to prevent Terran Warren Sims, MSN, RN, ACNP-C, CNN, eral (affecting the same side of the body)
leakage on clothing. Many patients use is a nurse practitioner at the Health Services loss of posterior column sensation, con-
mineral oil to keep the stoma moist be- tralateral pain, and temperature loss be-
Foundation, Departments of Urology and He-
tween catheterizations. low the lesion.
Patients and caregivers should be matology/Oncology, Charlottesville, Virginia.
She is a Practice of Medicine mentor at the
Anterior cord syndrome is a com-
taught to recognize the signs and symp- plete loss of motor function below the
toms of urinary tract infection, a rare University of Virginia School of Medicine and a
level of the lesion and loss of light touch
complication. Fever and flank pain may be board-certified nursing specialist in acute care, and sensation but preservation of the pos-
signs of pyelonephritis or pouchitis. Ab- nephrology, and WOC. terior column function.
dominal pain may signal infection, which Caudal equine lesion is due to a lum-
may or may not be localized to the urinary bar injury, fracture, or lumbosacral nerve
reservoir. If urine is needed for laboratory root injury that compromises the bladder,
evaluation of infection, a double catheter- bowel, and lower limbs.


Table 1. Corresponding Level of Injury with severe vasodilation due to neurogenic occurs during this phenomenon, flaccid
a Physical Examination 2 shock. paralysis, including bowel and bladder,
occurs and sustained priapism may devel-
Level of
Spine Sensation Muscle Nutrition op. Spinal shock tends to last a few hours
Serious nutritional challenges ac- to days, until reflex arcs below the level of
C2 Occipital -- company spinal-cord injuries. Specifically, injury recover.2
C3 Supraclavicular fossa -- patients go through an initial period of
C4 Acromioclavicular joint -- decreased metabolic demand with accom- Neurogenic shock
C5 Lateral antecubital fossa Elbow flexors panying nitrogen excretion, which creates A further complication of spinal-cord
C6 Thumb Wrist extensors a negative nitrogen balance. Thus, stud- injury is neurogenic shock, which is mani-
C7 Middle finger Elbow extensors ies have reported that, within four weeks, fested by the triad of hypotension, brady-
C8 Little finger Finger flexors patients with SCI may lose up to 10-20% cardia, and hypothermia. Shock tends to
C9 -- -- of their body weight.5 Thus, it is important occur more commonly in injuries above
T1 Medial antecubital fossa Small finger abductor to initiate enteral feeding early to reduce T6 (the 6th thoracic spine), secondary
T2 Apex of axilla -- the incidence of respiratory, wound, and to disruption of the sympathetic outflow
T3 Third intercostal space -- urinary tract infections, which lead to from T1-L2 (the 1st thoracic to the 2nd
T4 Nipple line -- prolonged ventilation, antibiotic treat- lumbar spine) and unopposed vagal tone,
T10 Umbilicus -- ment, longer lengths of stay, and delayed leading to decreased vascular resistance
L2 Mid-anterior thigh Hip flexors recovery. with associated vascular dilation. Treat-
L5 Dorsum of foot Long toe extensors ment may require the use of potent vaso-
S1 Lateral heel Ankle plantar flexors Bowel and bladder constrictors (e.g., phenylephrine) to as-
S4-5 Perianal area Rectal tone The spinal cord transmits electrical sure an adequate arterial blood pressure
impulses between the brain and rest of in order to maintain perfusion.2 Of note,
Conus medullaris syndrome results the body to control movement, posture, neurogenic shock can be differentiated
from injury to the lumbar nerve roots and and respiration (“C3, 4, and 5 keep the from hypovolemic shock, which manifests
sacral cord. Sacral segments may show diaphragm alive”) heart rate, heat regu- itself by tachycardia.
preserved reflexes. lation, circulation, and bowel, bladder,
and sexual function (“S2, 3, and 4, urine, Conclusion
Management feces hit the floor!”).6 In the acute phases Overall, 85% of SCI patients who
Ventilatory of SCI, the bladder may be distended and survive the first 24 hours are still alive
As with all life-threatening injuries, loss of peristalsis (ileus) may occur. Thus, 10 years later, compared with 98% of the
care begins with the ABCs – airway, bowel and bladder incontinence should non-SCI population of similar age and sex.
breathing, and circulation. With spinal- be expected. Bladder management may Today, the most common cause of death
cord injuries, acute medical management include the use of a Foley catheter. To in SCI patients is respiratory ailment,
often includes oral intubation with ventila- minimize catheter movement, a commer- whereas, in the past, it was renal failure.
tory support, which may be temporary or cially available Foley catheter holder may As in the general population, an increas-
permanent. Tracheotomies are performed be used to secure the device. Holders can ing number of people with SCI are dying
to provide a mechanism for long-term me- prevent meatal irritation, which is a caus- of unrelated causes, such as cancer or
chanical ventilation and can be done un- al factor in nosocomial infections, such as cardiovascular disease.4 Mortality rates
der local anesthesia. Surgeon determined, urinary tract infections, and may minimize are significantly higher during the first
the surgical incision may be either verti- skin breakdown. year after injury than during subsequent
cal or horizontal but the general rule of With stabilization, aggressive bowel years.
thumb is the least amount of anatomical and bladder rehabilitation may enable the Significant improvements have been
disturbance is best. To minimize trauma patient to effectively manage their elimi- made in post-SCI quality of life. For ex-
to the trachea, the tracheotomy is usually nation pattern. ample, with C6 level injury, it is possible,
performed between the second and third with practice, for an individual to drive
tracheal ring. Once a tracheostomy tube is Other considerations an automatic-transmission car with hand
placed, it is secured with a tracheostomy Although controversial, the use of controls or a manually operated comput-
tube holder to prevent accidental decan- methylprednisolone within 12 hours post- er. For those with high cervical injuries,
nulation – a major complication of trache- injury has been said to decrease spinal- voice-recognition software is very useful
ostomy. cord edema and may lessen the severity in improving quality of life.
of SCI.7 Bracken and colleagues8 reported Future directions include pharma-
Cardiovascular that methylprednisolone when given as cological agents and stem cell research.3
In the acute phase of spinal-cord a bolus of 30 mg per kilogram of body Spinal-cord injury affects everyone in the
injuries, the primary clinical strategy is weight, followed by infusion at 5.4 mg per injured person’s life, including spouse, im-
to maintain hemodynamic stability and kilogram per hour for 23 hours in patients mediate family, and friends. It may cause
prepare for surgical intervention, if indi- with acute spinal-cord injury, neurologic loss of financial security and indepen-
cated.4 A primary nursing responsibility recovery improves when given in the first dence. Much has been done to improve
includes diligent monitoring of the pa- eight hours. It is contraindicated in acute survival outcome and quality of life. Job
tient’s vital signs, including but not limited penetrating spinal injuries. retraining, mechanisms to maintain inde-
to: heart rate and rhythm, blood pressure pendent mobility, and advances in medi-
(preferably arterial waveform), respira- Complications cine have improved the survival rate by as
tory waveform, and oxygenation satura- Spinal shock much as 10 years. Importantly, healthcare
tion. Importantly, continuous monitoring A state of transient physiological professionals can help to improve survival
should be maintained. If transportation reflex depression, spinal shock is associ- rates by continuing their education about
outside of the intensive care unit is neces- ated with an initial increase in blood pres- spinal-cord injuries.
sary (e.g., for a CT scan), then a transport sure (related to catecholamine release), References
monitor is required. Pharmacologically, which is quickly followed by hypotension. 1. National Spinal Cord Injury Association. Spinal Cord
intravenous phenylephrine and epineph- Spinal shock is due to the lack of blood Statistics. 1995.
rine are often used to maintain vasomo- perfusion at and below the level of injury. Continued
tor tone, which may be compromised by Because loss of all sensorimotor function


Case Study: Acute phase of SCI This continuing nursing education activity
was approved by the Vermont State Nurses
Ron, a 20-year-old, was brought to Emergency after he volume control (PRVC), tidal volume (TV) of 500 ml, Association Inc. (VSNA) an accredited approver
was found with a single gunshot wound to the head, and positive end expiratory pressure (PEEP) of 5. He
inferior to the left ear, with no exit wound. According continued to require frequent pulmonary toileting to
by the American Nurses Credentialing Center’s
to the police report, Ron was shot “execution style”, prevent desaturation and aggressive suctioning. The Commission on Accreditation.
i.e., at close range with the intention to kill. He was TICU team maintained Ron on ranitidine 150 mg daily
initially found with pulseless electrical activity (PEA). As for stress ulcer prophylaxis, Lovenox (30 mg After reading this article, the learner should be
per the Advanced Cardiac Life Support (ACLS) protocol, subcutaneously), along with sequential compression able to:
he was intubated and resuscitated at the scene. Ron devices (SCDs) and thrombolytic embolic decompres-
arrived hemodynamically stable, although unrespon- sion (TED) stockings for thrombolytic prophylaxis. 1. Identify the classification system of spinal
sive, with minimal effort to breathe and pupils reactive
bilaterally. On admission, Ron’s CT of the head showed
cord injuries
Specifically, Ron’s consultations included:
that the bullet had entered beneath the left ear, 1. Cardiology for evaluation of pacemaker therapy for 2. Explain the initial management of spinal
passing posteriorly across cervical cord segments II, III, the bradycardic episodes. Given that the episodes
and IV, completely transecting the spinal cord. The were due to hypoxic spells, Ron did not receive a
cord injuries
bullet was lodged in the right upper chest with no pacemaker. 3. List two of the acute complications related
pneumothorax and initially no injury to the trachea or 2. Psychiatry to evaluate Ron’s depression, as
esophagus. A steroid protocol was initiated and expressed by tears and withdrawal from staff.
to spinal cord injuries
aggressive fluid resuscitation (including blood Psychiatry prescribed antidepressants (Sertraline 4. Describe the differences between
transfusions) was started, given his poor prognosis. 50 mg) and spiritual care by the hospital’s priest.
With emergency care, including intubation, fluid 3. Orthopedics continued to manage Ron’s cervical continent and incontinent urinary
recitation, and surgical repair, Ron survived. spine, recommending that the cervical collar diversions
remain in place for an additional month.
Ron’s first few trauma intensive care unit (TICU) days 4. The wound care nurse was consulted about Ron’s 5. Identify postoperative complications of
were tenuous. He remained in critical condition, skin condition, because not unexpectedly given continent diversions and the nursing care
hemodynamically labile, despite the infusion of Ron’s initial acuity; he had a stage I to II sacral to prevent them
vasopressors, sedation, and neuromuscular blockades. decubitus. Duoderm application, Foley catheter,
He developed acute respiratory distress syndrome and a Flexicare bed were recommended for
(ARDS), requiring bronchoscopies and was decubitus prophylaxis. Instructions
aggressively resuscitated from multiple profound 5. Despite the fact Ron no grown fungal elements on
bradycardia episodes (Figure 1) secondary to periods any cultures, Infectious Disease recommended
1. Read both articles.
of hypoxia (oxygenation saturation less than 90%). Diflucan (400 mg daily) to treat his continued 2. Complete the post-test on page 8. (You
Two days after Ron’s admission, he received a febrile spikes of unknown origin, which persisted may make copies of the answer form).
tracheostomy and, a week later, a percutaneous throughout the first month.
endoscopic gastrostomy (PEG) tube replaced the 3. Complete the participant evaluation.
nasogastric (NG) tube. Ron’s nutrition included 240 ml With the classification of a complete spinal-cord injury, 4. Mail or fax the complete answer and
of TraumaCal every 4 hours. Ron was diagnosed as a high-leveled tetraplegic. His
evaluation forms to address on back page.
TICU course was primarily aimed at establishing
Ron remained in the TICU for about two months. He respiratory stability, as the loss of his diaphragmatic 5. To earn 1.9 contact hours of continuing
had multiple infectious bouts and nurses were unable control caused him to be ventilatory-dependent. education, you must achieve a score of
to wean him from mechanical ventilation. Given that Eventually, after nearly three months, Ron was
he was unable to show signs of spontaneous
70% or more. If you do not pass the test
transferred to rehabilitation for spinal cord-injured
respiration, despite PCO2 levels of up to 60 mm Hg, patients, where he continues to regain respiratory and you may take it one more time.
Ron remained on the ventilator with settings of 40% physiological stability. 6. Your results will be sent within four weeks
oxygenation, ventilation mode of pressure-regulated
after form is received.
7. The fee has been waived through an
educational grant from Dale Medical
Products Inc.
8. Answer forms must be postmarked by
December 15, 2007.
Figure 1. Bradycardic episode. Profound bradycardia with one premature ventricular contraction (PVC) and
sustained asystole.
Perspectives, a quarterly newsletter focusing
on postoperative recovery strategies, is dis-
2. Spinal cord injury: Definition, epidemiology, tributed free-of-charge to health professionals.
pathophysiology. emedicine.com, 2001. (Accessed March Perspectives is published by Saxe Healthcare
21, 2005). Mary G. Adams Carey, RN, PhD, has a doctor-
ate in physiological nursing from the Univer- Communications and is funded through an edu-
3. Forchheimer M, McAweeney M, Tate DG. Use of the
SF-36 among persons with spinal cord injury. Am J Phys cational grant from Dale Medical Products Inc.
sity of California, San Francisco, and Masters
Medi Rehabil 2004;83(5):390-5. The newsletter’s objective is to provide nurses
4. Faden A. Therapeutic approaches to spinal cord injury. degree in critical care nursing. She is an as- and other health professionals with timely and
Adv Neurol 1997;72:377-86. sistant professor in the School of Nursing at relevant information on postoperative recovery
5. Kearns PJ, Thompson JD, Werner PC, et al. Nutritional strategies, focusing on the continuum of care
and metabolic response to acute spinal-cord injury. JPEN the State University of New York, Buffalo, and
J Parenter Enteral Nutr. 1992;16:11–5. works as a clinical nurse in the Trauma and from operating room to recovery room, ward,
6. Mattera C. Spinal trauma: New guidelines for assessment or home.
and management in the out-of-hospital environment. J Surgical Intensive Care Unit at Erie Country
Emerg Nurs 1998;24(6):523-38. Medical Center, Buffalo, New York. In 2005, The opinions expressed in Perspectives are those
. Short DJ, El Masry WS, Jones PW. High-dose of the authors and not necessarily of the editorial
methylprednisolone in the management of acute
she received the United University Professions’ staff, or Dale Medical Products Inc. The publisher,
spinal cord injury: a systematic review from a clinical Individual Development Award. and Dale Medical Corp. disclaim any responsi-
perspective. Spinal Cord 2000 May;38(5):273-86
2000;38(5):273-86. Madonna L. Lakso, RN, CCRN, is a board- bility or liability for such material.
7. Richards JS, Elliott TR, Shewchuk RM, Fine PR. certified nursing specialist in basic, advanced We welcome opinions and subscription requests
Attribution of responsibility for onset of spinal cord
injury and psychosocial outcomes in the first year post- cardiac, advanced trauma, and advanced from our readers. Please direct your correspon-
injury. Rehabil Psychol 1997;42(2):115-24. burn life support. She is Senior Staff Nurse at dence to:
8. Bracken MB, Shepard MJ, Collins WF, Holford TR, Young
W, Baskin DS, Eisenberg HM, Flamm E, Leo-Summers Erie Country Medical Center, Buffalo, and a Saxe Healthcare Communications
L, Maroon J, et al. A randomized, controlled trial of consultant at Edwards LifeSciences, Buffalo, P.O. Box 1282, Burlington, VT 05402
methylprednisolone or naloxone in the treatment of
acute spinal-cord injury. Results of the Second National New York. Fax: (802) 872-7558
Acute Spinal Cord Injury Study. N Engl J Med. 1990 May sshapiro@saxecommunications.com
17;322(20):1405-11.
© Copyright: Saxe Communications 1998-2005


1. Methylprednisone is contraindicated in the 7. At what spinal level was Christopher Reeve’s 12. Patients may prefer neobladder over the Indiana
patient with: injury? pouch because:
a. Patient with injury to the spinal cord a. C1 a. It offer normal micturition
b. Patient with stable lumbar fracture who is b. C2 b. It is a shorter surgery and easier to withstand
neurologically intact c. C4 c. It functions with no self care post operatively
c. Patient with an unstable thoracic fracture d. L1 d. Reduces chance of recurrent cancer
d. None of the above
8. Cystectomy and urinary diversion can be 13. The Ileal conduit maybe chosen for patient verus
2. Maintaining strict cervical stability post-injury necessary when bladder cancer is: the continent diversion because:
with an unstable C3 fracture a. Papillary a. It is the gold standard for all patients
is extremely important in order to: b. Fulgurated and lasered b. Patients cannot learn sterile catheterizations
a. Maintain alignment of the lumbar spine c. Invasive c. It prevents cancer recurrence
b. Correct cervical fracture d. Recurrent d. It is the shorter surgery with ease of construction
c. Prevent further injury to an already unstable and fewer complications
fracture 9. A patient has an Indiana pouch and calls the
d. None of the above clinic post week 2 with abdominal pain and no 14. Patients with orthotopic neobladder should be
urine output for 2 hours. What should the clinic taught clean intermittent
3. Life expectancy of a patient post SCI has nurse instruct the patient to do? catheterization (CIC) because:
improved due to: a. Wait 1 hour and call back if not output a. They will perform CIC for months following surgery
a. Early improved surgical interventions b. Increase fluids and call back in 2 hours b. It is not taught because they will not need it
b. Better pharmacological therapies available c. Gently irrigate the Malecot and Foley catheter to c. It may be needed in cases of poor bladder
c. Increased expertise of nursing and medical staff identify mucous plug obstruction emptying
d. All of the above d. The pouch is not yet functioning, following surgery d. It is an integral aspect of neobladder care
4. Neurogenic shock can be differentiated from 10. Early ambulation is stressed after surgery 15. The patient with a neobladder asks the nurse
hypovolemic shock which manifest itself by because: when the Foley catheter can be removed. She
tachycardia. a. The leg bag needs to be tried before discharge answers:
a. True b. Reduces postoperative pain a. In 1 week when he can void spontaneously
b. False c. Promotes wound healing b. When urine is normal color and character
d. Prevents postop pulmonary complications c. Postop week 3 when cystogram shows watertight
5. Neurogenic shock is manifested by the triad of: healing of the pouch
a. Hypotension, tachycardia, hypothermia 11. The patient choosing continent diversion should d. Before he leaves the surgical unit since he is ready
b. Hypotension, bradycardia, hypothermia understand: to catheterize
c. Hypertension, tachycardia, hypothermia a. Home health nursing will be key in all home care
after surgery 16. Post operatively the urinary stents in the indiana
d. None of the above pouch become dislodged but the nurse knows:
b. It will work with no need for self care after surgery
6. Each year what percent of the spinal cord injured c. Self care will be key in success
a. This is not a problem because she was going to
are re-admitted to the hospital? remove them anyway
d. It is a good choice for another care giver to assist b. She can simply push them back in the exit site and
a. Less than 10% with
b. 10-20% re-tape
c. 30-50% c. The surgeon should be notified
d. More than 77% d. These are not connected to the actual urine in the
pouch so unimportant


Mark your answers with an X in the box
Participant’s Evaluation next to the correct answer
What is the highest degree you have earned 1. Diploma 2. Associate 3. Bachelor’s A B C D A B C D
(circle one) ? 4. Master’s 5. Doctorate 1 9
Indicate to what degree you met the objectives for this program: Using 1 = Strongly disagree to
A B C D A B C D
6 = strongly agree rating scale, please circle the number that best reflects the extent of your
agreement to each statement.  10
Strongly Disagree Strongly Agree
A B C D A B C D
1. Identify the classification system of spinal-cord 1 2 3 4 5 6  11
injuries
A B C D A B C D
2. Explain the initial management of spinal-cord injuries  1
1 2 3 4 5 6
A B C D A B C D
3. List two of the acute complications related to spinal
cord injuries. 1 2 3 4 5 6  1
A B C D A B C D
4. Describe the differences between continent and  1
incontinent urinary diversions 1 2 3 4 5 6
A B C D A B C D

5. Identify postoperative complications of continent  1


diversions and the nursing care to prevent them 1 2 3 4 5 6
A B C D A B C D
8 1
Name & Credentials How long did it take you to complete this
Position/Title home-study program?
Address What other areas would you like to cover through
City State Zip home study?
Phone Fax
email address

Mail to: Saxe Communications, PO Box 18, Burlington, VT 00 • Fax: (80) 8-8 Vol. No.


Supported by an educational grant from Dale Medical Products Inc.

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