Spinal Cord Injury Overview

Spinal Cord Injury

• An injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral discs caused by trauma

• Spinal cord injuries can be partial or complete, temporary, or permanent loss of function, sensation, and/or mobility

• Types can include concussion, contusion, laceration, or transection

At Risk Groups

• Younger people and males are more likely to experience
• Alcohol and illicit drug use increase the risk
• Head injuries increase the risk
• Auto accidents increase the risk
• High-risk activities and violence increase the risk

Signs and Symptoms

• Focus on assessing the patient physically, completing a detailed neurological exam

Diagnostics

• CT and MRI scans are used to identify
• Continuous ECG monitoring is indicated
• Bradycardia and asystole are common in acute SCI patients

Management: Nursing Interventions

• Focus on respiratory and cardiovascular systems, neuromuscular system, neurogenic bladder, gastrointestinal, renal, integumentary
• Assess respiratory status, especially in injuries C4 and up
• Monitor ABGs, maintain mechanical ventilation if needed
• Encourage deep breathing and incentive spirometer use
• ECG monitoring can reveal cardiac dysrhythmias include bradycardia, sinus node arrest, or supraventricular tachycardia
• Assess for signs of shock, primarily neurogenic shock
• Monitor for orthostatic hypotension when repositioning patient
• Assess neurological, motor, and sensory status to determine injury level and monitor changes
• Assess absence of sensation, hypo-sensation or hyper-sensation
• Immobilization promotes healing and prevents further injury

Neurogenic Bladder

• Loss of bladder control due to nerve damage
• Catheterization management depends on injury level
• Bladder management for spastic bladders above L1 involve condom or indwelling catheters
• Flaccid bladder management, below L1 involves indwelling catheters

Additional Interventions

• Assess abdomen for distention and hemorrhage due to GI issues
• Maintain fluid and electrolyte balance, monitoring for urinary tract infections and calculi
• Assess skin integrity frequently, turning patients every two hours
• Surgical interventions post-op includes monitoring for respiratory impairment, vital signs, and fluid/electrolyte imbalances

Medications

• Corticosteroids decrease secondary spinal cord injury by reducing inflammation, but increases infection rates
• Vasopressors treat hypotension during neurogenic shock

Neurogenic Shock

• Develops from loss of autonomic nervous system function below the lesion level
• Common in SCI injuries T6 and above
• Can cause irreversible damage to body tissue
• Symptoms include hypotension, bradycardia, severe vasodilation, and increased temperature

Spinal Shock

• Characterized by sudden depression of reflex activity below the injury level, resulting in flaccid paralysis and absent reflexes,
• Muscle paralysis includes complete flaccidity
• Hypotension and paralytic ileus also occur

Autonomic Dysreflexia

• Also called autonomic hyperreflexia
• Acute, life-threatening emergency due to exaggerated autonomic responses in patients with T6 level injuries and above
• Rapid assessment is needed
• Severe hypertension can lead to increased ICP or stroke
• Treat with high fowler's position, antihypertensive medications, and identify/remove the cause of distention

Hemorrhagic Stroke

• Caused by aneurysm, AVM, trauma, or hypertension (top reason)

• Types include intracerebral hemorrhage-bleeding in the brain or subarachnoid hemorrhage- bleeding between the brain and the skull

• The stroke location and what it will affect:

  • Frontal Lobes- Motor, speech, behavior, bowel and bladder, long-term memory
  • Parietal lobes- Sensation (pain and temperature) and interpretation, coordination, orientation in space
  • Temporal lobes- hearing, interpretation, reading, short term memory
  • Occipital lobes- vision

• Right sided brain affected:

  • left sided weakness/paralysis
  • Left visual field deficit
  • Spatial-perceptual deficits
  • Poor judgement, highly distractible
  • Impulsive behavior
  • Lack of awareness of deficits or unconcerned of loss
  • HIGH FALL RISK, ensure precautions are in place and patient area is safe
  • Might need a sitter for the impulsivity

• Left side of the brain affected:

  • Paralysis/weakness on the right side
  • Right visual field deficit
  • Aphasia includes Altered intellectual ability
  • Frustration and/or depression
  • Slower paced, more cautious behavior

Diagnostics

• Severe headache - "worst headache of their life"
• Nuchal rigidity and pain may also occur

Complications

• Monitor for hypoxia/hypoperfusion, vasospasms and increased ICP
• Monitor for dehydration and fluid/electrolyte imbalances

What Interventions

• Aneurysm that hasn't ruptured, use surgical options or flow diversion
• Antihypertensives and DVT prophylaxis can support

Ischemic Stroke

• May be preceded by a TIA (Transient Ischemic Attack)
• Types from blood loss, including Thrombotic, Embolic, and Lacunar
• Location and effect include the Frontal Lobes, Parietal lobes, Temporal lobes, and Occipital lobes
• Risk factors include HTN, Diabetes, High cholesterol, Carotid or artery disease and habits such as alcohol/smoking/drug/Poor diet

TIA

• Transient Ischemic Attack: temporary neurological deficits that resolve within 24 hours and are usually caused by atherosclerotic plaque

Male Reproductive Health

• Acute Prostatitis: acute onset of lower urinary tract symptoms due to painful inflammation/infection of the prostate, most commonly caused by E. coli.
• Treatment includes antibiotics & NSAIDs, and catheterization if unable to urinate, along with Education on S/S and TX
• Benign Prostatic Hypertrophy (BPH): slow prostate enlargement with hypertrophy/hyperplasia, causing urethral compression. Common in aging men
• Testing includes a urinalysis (to determine if UTI), PSA Test (Prostate-Specific Antigen), and a DRE (Digital Rectal Exam)

What is involved

• Invasive therapies include urodynamic studies, urethrocystoscopy, and an ultrasound
• Post Op management includes monitoring for hemorrhage, continuous bladder irrigation, and s/s of UTI
• Medications include antibiotics (Ciprofloxacin, bactrim) and NSAIDS
• Smooth muscle relaxers can only be used for a few days and are typically contraindicated with viagra

Prostate Cancer

• This is a slow growing malignancy and the most common cancer in men
• If elevated PSA w/ DRE → requires confirmation w/ prostate biopsy*
• Implement active surveillance to monitor every 3-6 months, unless they advance
• "low -risk" men that are dx w/ prostate cancer can be monitored
• Radiation, is used alone or with surgery

Testicular Cancer

• Perform TSE and self-exams for early detection in common testicular cancers
• TSE (testicular self-examination) monthly on the same day after a warm shower
• Orchitis (one or both testicles) from Viral, bacterial, spirochetal or parasitic organisms, but can leave to infertility

Erectile Dysfunction

• Inability to maintain an erection, but can be due to multiple causes
• Psychogenic (Anxiety, fatigue, depression)
• Organic (Cardio, endocrine, or trauma to pelvic area)
• Perform complete hx and physical exam for more accurate diagnosis.

Bladder Cancer

• Arise from prostate, colon, and rectum cancer in males, or gynecologic caner in women
• Most common symptom is visible, painless hematuria, a frequent symptom
• Cystoscopy - visualization of the bladder- is the key
• Urine should be treated as a biohazard
• Maintain a close watch of output after bladder installation or removal

Musculoskeletal (Bursitis/Tendonitis)

• Inflammatory condition that normally occurs within the shoulder for both

• Bursitis is the inflammation w/ the bursa

• Tendonitis is the inflammation w/ the tendons

• Treat by resting the extremities, intermittent hot/cold therapy, with NSAIDS or Corticosteroids

• Carpal Tunnel Syndrome- Entrapment neuropathy

• Causes median nerve (at wrist) is compressed

• Results in Pain, Numbness, Paraesthesia/Weakness

• Treat with splints and medication and/or surgery

Bone health

• Osteomalacia- Deficiency in activated vit D leads to inadequate absorption of Ca into the bone, where the Bones soften and weaken
• Paget's Disease: Disorder of localized rapid bone turnover with unknown etiology
• Diseased bones are highly vascularized and weak
• Osteoarthritis (degenerative joint disease) Primary → idiopathic

Osteomyelitis

Infection of the bone that results in inflammation

• Causes Older pt,Obese/poorly nourished, and Impaired immune systems
• DX: X-ray and MRI

SIADH

• Syndrome of inappropriate antidiuretic hormone
• Failure of the negative feedback system that regulates the release of ADH
• Usually a nonendocrine origin (carcinoma or tumor)
• Treat by giving lasix and treating underlying cause

Diabetes Insipidus (DI)

• Pituitary disorder
• Extreme thirst
• Desmopressin therapy trail is often a choice.

Hyperglycemic Hyperosmolar Syndrome

• Treat with Treatment of HHS requires a four-pronged approach: (1) vigorous intravenous rehydration, (2) electrolyte management, (3) intravenous insulin, and (4) diagnosis and management of precipitating and coexisting problems.
• The main focus should be on rehydrating and decreasing BS/electrolytes

Hepatitis

• Caused by Hep A which is → fecal-oral route, or Hep B/C which is Bloodborne