BSN 4-A
Introduction
The spinal cord contains the nerves that carry messages between your brain and your body. The cord passes through your neck and back. A spinal cord injury is very serious because it can cause paralysis below the site of the injury.
It can cause myelopathy or damage to white matter or myelinated fiber tracts that carry signals to and from the brain. It also damages gray matter in the central part of the brain, causing segmental losses of interneurons and motorneurons
usually begins with a sudden, traumatic blow to the spine that fractures or dislocates vertebrae.
damage begins at the moment of injury when displaced bone fragments, disc material, or ligaments bruise or tear into spinal cord tissue. Most injuries don't completely severe it, instead, an injury is more likely to cause fractures and compression of the vertebrae, which then crush and destroy the axon. An injury to the spinal cord can damage a few, many, or almost all of these axons. Some injuries will allow almost complete recovery. Others will result in complete paralysis.
The SPINAL CORD is a thick length of nerve tissue that extends from the base of the brain, down the back, through the spinal column.
The SPINAL COLUMN is made up of bones called vertebrae that protect the spinal cord.
The spinal cord is made up of motor and sensory nerve cells called neurons.
The motor nerves are grouped together and transmit motor commands from the brain to the muscles and initiate movement. The sensory nerves are also grouped together. They carry information about sensations, such as pain and temperature, to the brain.
AREAS:
cervical (neck), thoracic (chest), lumbar (lower back), and sacral (tailbone)
Each area is referred to by its first letter (C, T, L, or S) and the vertebrae within each area of the spine are numbered as follows: C1 to C8: Cervical vertebrae T1 to T12: Thoracic vertebrae L1 to L5: Lumbar vertebrae S1 to S5: Sacral vertebrae
* By adulthood, the 5 sacral vertebrae fuse to form one bone, and the 4 coccygeal vertebrae fuse to form one bone.)
Segmental Spinal Cord Level and Function Level Function C1-C6 Neck flexors Neck extensors
C1-T1
C3, C4, C5
C5, C6
Shoulder movement, raise arm (deltoid); flexion of elbow (biceps); C6 externally rotates the arm (supinates)
Extends elbow and wrist (triceps and wrist extensors); pronates wrist Flexes wrist Supply small muscles of the hand
T1 -T6
T7-L1
Thigh abduction Extension of leg at the hip (gluteus maximus) Extension of leg at the knee (quadriceps femoris) Flexion of leg at the knee (hamstrings) Dorsiflexion of foot (tibialis anterior) Extension of toes Plantar flexion of foot
L2, L3, L4
L5, S1, S2
Flexion of toes
It is estimated that there are 40,000 people in the UK alone that are paralyzed through spinal cord injury.
The
life expectancy for an individual with SCI is lower (80% to 85%) than that of a person without SCI.
Paraplegia. This paralysis affects all or part of the trunk, legs and pelvic organs.
Tetraplegia or quadriplegia. This means your arms, trunk, legs and pelvic organs are all affected by your spinal cord injury.
Risk Factors
Diseases 4.0%
Alcohol 4.0%
Clinical Manifestations
Symptoms vary somewhat depending on the location of the injury. Spinal cord injury causes weakness and sensory loss at and below the point of the injury.
Breathing difficulties (from paralysis of the breathing muscles) Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness, paralysis
Breathing difficulties (from paralysis of the breathing) Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Sensory changes Spasticity (increased muscle tone) Pain Weakness, paralysis
Loss of normal bowel and bladder control (may include constipation, incontinence, bladder spasms) Numbness Pain Sensory changes Spasticity (increased muscle tone) Weakness and paralysis
Note: The Clinical Manifestations depend on the following: The Location of the Injury The Severity of the Injury
C7 and T1 : Can usually straighten their arms but still may have dexterity problems with the hand and fingers. C7 is generally the level for functional independence
T1 to T8 : Most often have control of the hands, but lack control of the abdominal muscles so control of the trunk is difficult or impossible. Effects are less severe the lower the injury.
T9 to T12 : Allows good trunk and abdominal muscle control, and sitting balance is very good. Lumbar and Sacral injuries: The effect of injuries to the lumbar or sacral region of the spinal canal are decreased control of the legs and hips, urinary system, and anus. yield decreasing control of the hip flexors and legs.
immediate mechanical damage to neural and other soft tissue, including endothelial cells of the vasculature
Chemical & metabolic changes in the spinal cord tissues include increase tissue lactate & increase norepinephrine concentration
Cord swelling
ASIA C = Incomplete; intact motor function distal to neurologic LOI, and more than half of key muscles distal to LOI have muscle grade less than 3.
ASIA D = Incomplete; intact motor function distal to neurologic LOI, and more than half of key muscles distal to LOI have muscle grade greater than or equal to 3. ASIA E = Normal; intact motor and sensory function.
POSSIBLE COMPLICATIONS
Blood pressure changes - can be extreme (autonomic hyperreflexia) Complications of immobility: Deep vein thrombosis Pulmonary infections Skin breakdown Contractures Increased risk of injury to numb areas of the body Increased risk of kidney damage Increased risk of urinary tract infections Loss of bladder control Loss of bowel control Loss of sensation Loss of sexual functioning (male impotence) Muscle spasticity Pain Paralysis of breathing muscles Paralysis (paraplegia, quadriplegia) Shock
Diagnostic Evaluation
A CT scan or MRI of the spine - may show the location and extent of the damage and reveal problems such as blood clots (hematomas). Myelogram - (an x-ray of the spine after injection of dye) may be necessary in rare cases. Somatosensory evoked potential (SSEP) testing or magnetic stimulation - may show if nerve signals can pass through the spinal cord.
Urodynamic studies
- include urine flow to detect bladder outlet obstruction and/or impaired bladder contractility; cystometrogram to determine bladder sensation, compliance, and capacity; sphincter EMG and other studies. If DVT or pulmonary emboli are suspected, an ultrasound of the lower extremity or ventilation/perfusion scan is performed. Heterotopic ossification may be diagnosed in the inflammatory stages using ultrasound. Alkaline phosphatase and ESR are typically elevated.
Nutritional status should be assessed using nutritional history, anthropometric measurements, prealbumin (half-life 12 to 36 hours) and transferrin (half-life 6 to 10 days). Total lymphocyte count and creatinine height index are also used to establish nutritional risk.
Spine Xrays may show fracture or damage to the bones of the spine.
Nursing Assessment
Assess cardiopulmonary status and vital signs to help determine degree of autonomic dysfunction, especially in patients with tetraplegia. Determine LOC and cognitive function indicating TBI or other pathology. Perform frequent motor and sensory assessment of trunk and extremities as the extent of deficits may increase due to edema and hemorrhage. Later, increasing neurologic deficits and pain may indicate development of syringomyelia.
Note signs and symptoms of spinal shock, such as flaccid paralysis, urine retention, absent reflexes.
Assess bowel and bladder function. Assess quality, location, severity of pain. Perform psychosocial assessment to evaluate motivation, support network, financial or other problems. Assess for indicators of powerlessness, including verbal expression of no control over situation, depression, nonparticipation, dependence on others, passivity.
Nursing Diagnosis
Ineffective Breathing Pattern related to paralysis of respiratory muscles or diaphragm
Impaired Physical Mobility related to motor dysfunction Risk for Impaired Skin Integrity related to immobility and sensory deficit Urinary Retention related to neurogenic bladder
Nursing Interventions
Emergency Actions
1. Maintaining clients ability to breathe.
2. Keeping client from going into shock. 3. Immobilizing the neck to prevent further spinal cord damage.
5. When appropriate, implement chest physiotherapy regimen to assist pulmonary drainage and prevent infection.
6. Monitor results of ABG values, chest X-ray, and sputum cultures. 7. Tape halo wrench to body jacket or halo traction in the event the jacket must be removed for basic or advanced life support or respiratory distress.
Promoting Mobility
1. Place patient on firm kinetic turning bed until spinal cord stabilization. After stabilization, turn every 2 hours on a pressure reduction surface, ensuring good alignment.
4. Monitor BP with position change in the patient with lesions above midthoracic area to prevent orthostatic hypotension. 5. Encourage physical therapy and practicing of exercises as tolerated. Functional electrical stimulation may facilitate independent standing and ambulation. 6. Encourage weight-bearing activity to prevent osteoporosis and risk of kidney stones.
2. Obtain pressure relief mattress and appropriate wheelchair and cushion. 3. Inspect for pressure ulcer development daily over bony prominences, including the back of head, ears, trunk, heels, and elbows. Observe under stabilization devices for pressure areas, particularly on the scapulae. Use a risk assessment tool to determine risk of developing pressure ulcer.
5. Turn a minimum of every 2 hours, and instruct patient to perform wheelchair weight shifts every 15 minutes. Place the patient in prone position at intervals, unless contraindicated.
6. Institute treatment for pressure ulcers immediately, and relieve pressure to promote healing.
REMINDERS:
Additional movement may cause further damage to the nerves in the cord and can sometimes mean the difference between life and death. DO NOT move the injured person even a little bit, unless it is absolutely necessary (like getting someone out of a burning car).
If in doubt about whether a person has a spinal injury, assume that he or she DOES have one.
Health Teachings
Teach patient and family about the physiology of nerve transmission and how the SCI has affected normal function, including mobility, sensation, bowel and bladder function.
Reinforce that rehabilitation is lengthy and involves compliance with therapy to increase function.
Explain that spasticity may develop 2 weeks to 3 months after injury and may interfere with routine care and ADLs.
Teach patient to protect skin from pressure ulcer development by frequent repositioning while in bed, weight-shifting and liftoffs every 15 minutes while in a wheelchair, and avoiding shear forces and friction.
Teach inspection of skin daily for development of pressure ulcers, using a mirror if necessary. Teach importance of seat belts.
Medications.
Methylprednisolone (Medrol) is a treatment option for an acute spinal cord injury. It appears to work by reducing damage to nerve cells and decreasing inflammation near the site of injury. However, this is not a cure for a spinal cord injury.
Surgery.
Often, surgery is necessary to remove fragments of bones, foreign objects, herniated disks or fractured vertebrae that appear to be compressing the spine. Surgery may also be needed to stabilize the spine to prevent future pain or deformity.
Immobilization.
You may need traction to stabilize your spine, to bring the spine into proper alignment or both.
New technologies:
Rehabilitation
Inventive medical devices can help people with a spinal cord injury become more independent and more mobile. Some devices may also restore function. These include:
Electronic aids to daily living. Essentially any device that uses electricity can be controlled with an electronic aid to daily living (EADL Electrical stimulation devices. These sophisticated devices use
electrical stimulation to produce actions. They're often called functional electrical stimulation (FES) systems, and they use electrical stimulators to control arm and leg muscles to allow people with a spinal cord injury to stand, walk, reach and grip.
Prevention:
Maintain your gait and posture.
Drive safely.
Take precautions when playing sports.
Prevent falls
Have a healthy lifestyle.
say NO to alcohol.
Take Care.
Halong gd.
Ingatz!
-The end-