SCI Nursing Notes PDF

Primary SCI: - Impact with consistent compression: most common mechanism (vertebral fractures with bone fragments or dislocation injuries) - Impact with intermittent compression: hyperextension injuries - Distraction: two adjoining vertebrae have been pulled apart causing the spine...

Primary SCI: - Impact with consistent compression: most common mechanism (vertebral fractures with bone fragments or dislocation injuries) - Impact with intermittent compression: hyperextension injuries - Distraction: two adjoining vertebrae have been pulled apart causing the spine to stretch and tear - Transection and laceration: object or bone fragments tear or sever spinal cord Complete SCI: severe, causes loss of all sensation and ability to control movement below the level of injury Incomplete: client can somewhat retain some sensation or movement below injury Secondary SCI: can result immediately following initial injury due to impaired blood flow to the spinal cord - Caused by inflammation, hematoma formation, blood loss, hypovolemic shock which causes hypoperfusion to the spinal cord ASIA SCI grading scale: A = complete SCI, no sensory or motor function saved B = incomplete sensory injury, complete motor function loss C = incomplete motor injury, less than half the muscle groups can lift against gravity D = incomplete motor injury, more than half the muscle groups can lift against gravity with a full range of motion E = normal finding Recovery of function occurs during first 3 months but can be up to 18 months later Clients younger than 65: most common cause of SCI = motor vehicle accidents Clients older than 65: most common cause of SCI = falls Other causes of SCIs = violence, gunshots, sport-related accidents Comorbidities of SCI: hypertension, arthritis, diabetes, hyperlipidemia, obesity, depression, alcoholism, spasticity, UTI, chronic pain, sexual dysfunction, bowel/bladder dysfunction, sleep problems, contractures - High risk for pressure injuries, kidney stones, bone loss, chronic pain Clients with SCIs age faster than those without Cervical injuries have the highest incidence. SCI at C4 and above have a loss of movement in all extremities    Cauda equina: bundle of nerve roots towards the lower portion of the spinal cord that allows movement/sensations in the bladder and legs Cervical plexus = neck muscles, skin of the neck, chest, head, diaphragm, vagus nerve Brachial plexus = movement/sensation of the upper extremities Lumbar plexus = movement/sensation of external genitals, thigh, abdominal wall Sacral plexus = movement/sensation of thigh, leg, foot Coccygeal = skin surrounding the tailbone Tetraplegia: injuries from C1-T1 - Problems with neck, upper extremities, internal organs, and proprioception (body's sense of how it is positioned in the space) - Can use a "sip and puff" device or chin controlled joystick for mobility Paraplegia: injuries from T1-down - Have arm and hand function, use manual wheelchairs - Sacral injuries can walk with the use of assistive devices C1-C4: ventilator dependence C1-C8: limited proprioception T1-T8: affects trunk movement, lack of abdominal control T9-T12: limited abdominal control L1-S5: loss of bowel and bladder functioning, affects sexual function Spinal shock: transient, occurs right after SCI happens, loss of muscle tone and reflexes below the injury, loss of anal sphincter tone, absence of bowel and bladder control Respiratory complications are the leading cause of death in clients with SCIs Glasgow coma scale: assess best eye, motor, and verbal response - Scored 3-15 with 3 being no responses and 15 being normal Complications of SCIs: - Venous thromboembolism (VTE): due to stagnation of blood in lower extremities, risk is highest during initial phase of injury, s/s = pain, edema, tenderness, redness of skin in the affected leg - Atelectasis / Pneumonia: need to be on aspiration precautions, SCI clients have decreased cough strength which increases risk for both of these,  - Heterotopic ossification (HO): abnormal bone growth in non skeletal areas, causes jagged joints and limited ROM, more common in males Autonomic dysreflexia (AD): happens in SCIs above T6, triggered by pain and other noxious stimuli, usually during the first year after initial injury, high risk of stroke and death during these episodes - Manifestations above LOI = high BP/HR, throbbing headache, diaphoresis, tingling, facial flushing - Manifestations below LOI = low BP, cold, pale, clammy skin - Treatment = immediately have client sit up with their legs dangling, remove any tight clothing to lower BP, identify/resolve the stimulus (tight socks, wrinkle in bed sheet, urinary/bowel retention), use anesthetic gel if catheterization or anal assessment is necessary, assess existing catheter for patency/obstruction, assess for fecal impaction, nifedipine and nitrates can be administered to lower BP Clients with C1-C4 injuries are at high risk for respiratory problems - Need to assess circulation and tissue perfusion regularly Neurogenic shock: usually above T6, caused by a reduction in sympathetic tone in blood vessels which causes low BP/HR, and hypothermia Traumatic hemorrhages: rigid abdomen, abdominal distention, pain Upper motor neuron lesion: causes bowel/bladder spasticity which = stool/urine leakage Lower motor neuron lesion: causes flaccidity and bowel/bladder cannot expel stool/urine - Neurogenic pain = intense burning, tingling, stabboing - Musculoskeletal pain = caused by injury, overuse of muscles, wear and tear of joints, usually from using a wheelchair and transferring - Visceral pain = constipation, kidney/gallstones, appendicitis Airway Breathing = identify resp. distress or failure from primary injury Circulation = signs of hemorrhage, spinal shock, neurogenic shock, hypoperfusion to the spinal cord - Hypotension treatment: vasopressor, dopamine, fluid resuscitation - Bradycardia treatment: atropine sulfate TENS unit = electrodes placed on the skin that send currents that block pain signals High cervical injury = mechanical ventilation via a tracheostomy Lower cervical / thoracic injury = temporary mechanical ventilator support, wean into independent breathing SCI clients should get vaccinated against pneumococcus and influenza once stable Perform respiratory assessment every 4 hours during acute phase Wrenches and tools need to be attached to halo fixation vest in case of emergency Pin care for halo fixation device: performed daily or every other day, cleansed with hydrogen peroxide, betadine, or another antiseptic, any crusts are removed using cotton swabs to prevent infection, use separate supplies for each pin site, neither nurses nor patients should adjust the pin sites SCI clients need to increase their fluid and fiber intake  Suprapubic catheters are for clients who are unable to perform self-catheterization Oxybutynin can decrease spasm induced incontinence Paralytic ileus: functional motor paralysis of GI tract, peristalsis stops, fluid/gas build up Encourage clients to decrease the number of unnecessary strokes in a wheelchair and use more wrist motion in order to prevent and upper body injury Ibuprofen: NSAID, treats mild to moderate pain, can cause constipation and prolonged bleeding **Gabapentin: antiepileptic, decreases seizure activity and helps neuropathic pain** - **Alleviates pain that may remain after amputation** Dopamine: inotropic / vasopressor, increases BP, CO, and renal blood flow Atropine: anticholinergic / antimuscarinic, used to treat cardiac arrhythmias Enoxaparin: anticoagulant, inhibits thrombus formation to prevent blood clots (VTE) - Remember the E medication for E- embolism Baclofen: antispasticity / skeletal muscle relaxant, inhibits spinal cord reflexes, used to decrease muscle spasticity and improve bowel and bladder function Morphine: opioid analgesic, used for moderate to severe neuropathic and musculoskeletal pain, can cause constipation, urinary retention, low BP, HR, respiratory depression Venlafaxine: antidepressant / SSNRI, manage depression and neuropathic pain Docusate sodium: stool softener Polyethylene glycol: laxative, brings water into the GI tract to flush it out Tamsulosin: peripherally acting antiadrenergic, decrease manifestations of prostatic hyperplasia (nocturia, urinary hesitancy and urgency) Sildenafil: erectile dysfunction agent, increases blood flow which causes an erection Morphine and Baclofen can be administered through an intrathecal pump so they are directly given to the spinal cord Natalizumab: integrin receptor antagonist, used for relapsing forms of MS (RRMS, SPMS, CIS), increases risk of severe brain infection called PML Glatiramer acetate: immodulator, used for relapsing forms of MS (RRMS, SPMS, CIS) Interferon beta-1a: beta interferons, reduces relapses in clients with MS Mitoxantrone: antineoplastic / immune modifier, slows progression of MS Fingolimod: receptor modulator, decreases frequency of MS relapses Methylprednisolone: corticosteroids, suppress inflammation and normal immune response in MS  Multiple Sclerosis - Demyelination occurs which is loss or destruction of the myelin sheath around nerves, this causes messages to be disrupted throughout the brain, spinal cord, and body - Causes burning pain, vision impairments, optic neuritis, diplopia, paresthesia, loss of sensation, muscle weakness, paresthesia, cognitive and memory issues, coordination and balance issues, urinary/bowel incontinence, sensitivity to heat - Comorbidities: thyroid disease, IBS, diabetes, hypertension, cardiovasc. Disease - Epstein-Barr virus is associated with MS - Diagnosis = MRI for comorbidities, McDonald's MS Criteria: - Client must have evidence of damage to CNS in multiple areas and over time - Sclerotic plaques in the white matter of the brain are consistent with MS - Types:  - Relapse remitting MS (RRMS): most prevalent type, episodes of new or increasing neurological manifestations called exacerbations followed by episodes of limited or complete remission, persistent manifestations become permanent - Primary progressive MS (PPMS): progressive worsening from the onset of manifestations, no early remissions, goes between active and progressing - Secondary progressive MS (SPMS): initial remission like RRMS, turns into progressive worsening like PPMS - Clinically isolated syndrome (CIS): first occurance of neurological manifestations lasting at least 24h, is not diagnosed with MS yet, if an MRI identifies lesions on the brain it is highly likely the client has MS - Trigeminal neuralgia: stabbing pain in face/jaw, intermittent and unpredictable - Lhermitte's sign: happens when client bends neck forward, indicating cervical spine damage, pain is like an electrical shock from the back of head down the spine - MS hug: feels like a blood pressure cuff tightening around the client's trunk - Paroxysmal spasms: intermittent painful spasms of muscles - Illness, fatigue, and extreme temperatures can make manifestations worsen - Progressive Multifocal Leukoencephalopathy (PML) manifestations: memory loss, vision difficulty, progressive weakness of extremities, loss of coordination, clumsiness, aphasia - Clients taking natalizumab are at a higher risk of developing PML Four Ps of Mobility for MS: - Pacing: integrate short breaks into activities to avoid overexertion - Prioritization: complete important tasks before less important - Planning: organize which tasks need to be completed and when - Positioning: use good body mechanics and place supplies within reach Spinal Stenosis: spaces in the spine narrow, causing increased pressure on the cord and nerve roots originating from spinal cord - Causes burning pain / numbness in legs and feet, arm / neck pain - C6-C7 herniation = wrist drop in second and third fingers - Lumbar herniation = leg / butt cramps, loss of sensation in the legs, foot drop - Clients like to lean forward in order to relieve pressure on their back which increases the risk for falls - Can get epidural steroidal injections, laminectomy, discectomy and fusion - Diagnosed with MRI / CT Degenerative Disk Disease: as we age, discs lose the ability to reabsorb fluid which causes them to become brittle and flatten which makes us shorter - Pain increases when sitting, bending, lifting, twisting - Causes foot drop, numbness, tingling - Diet = whole grains, leafy green veggies, fruit, healthy protein and fats - Encourage walking, swimming, hydration, and healthy weight - Comorbidities = hypothyroidism, hypertension, diabetes, peripheral vasc. disease - Diagnosed with x-ray, MRI, CT Cauda equina syndrome = condition that occurs when a spinal disc presses on nerve roots, cutting off sensation and movement - Without immediate treatment, permanent paralysis can occur - Affects bowel / bladder control, sexual sensation / ability, pain / weakness in legs - Surgery within 48 hours improves sensory and motor function which improved bowel function and increases strength in legs Lumbar puncture goes into the subarachnoid space to obtain CSF.  Neurologic conditions that impair mobility = Parkinson's, Huntington's, ataxia Effects of immobility: - Confusion, depression, lack of confidence and cognitive function - Decreased CO, venous stasis, orthostatic hypotension, DVTs - Pneumonia, decreased cough reflex, atelectasis, decreased lung expansion - Swallowing difficulties, incontinence, constipation, fecal impaction, anorexia, heartburn, aspiration, increased intestinal gas, urinary retention, UTIs - Pressure injuries, infections, friction and shear Older adult changes: thinner cartilage, loss of muscle mass, rigid and brittle tendons Synovitis: inflammation of the synovial membrane, caused by sprains and contusions - Ultrasound, MRI, synovial fluid aspiration Arthritis: inflamed and stiff joints caused by aging, autoimmune disorders, infections, damage to the articular cartilage - X-rays, ultrasound for arthrocentesis Osteoporosis: softening of the bones  - Primary = caused by aging, gonadal insufficiency, decreased calcium, low vitamin D, post-menopausal clients - Secondary = caused by CKD, COPD, multiple myeloma, endocrine disorders, RA, malabsorption syndromes - Can cause thoracic compression which leads to kyphosis, cervical lordosis, SOB - X-ray, blood testing Osteoarthritis: most common joint disease, loss of joint cartilage which causes bone on bone contact causing bone hypertrophy - Usually in weight bearing joints like knees, hips, vertebrae Post hip arthroplasty: teach the client to avoid crossing their legs, perform neurovascular checks, obtain a raised toilet seat Older adults are at risk for soft tissue injuries due to proprioception issues, impaired reflexes, and osteoporosis.  Clients with osteomyelitis (infection or inflammation of bone tissue), osteomalacia (softening of bones that leads to brittleness), osteoporosis, cancer, and infection are at risk for fractures. Osteogenesis imperfecta: genetic disorder that leads to brittle bones that fracture easily Transverse = across the long axis of the bone Oblique = at an angle on the bone Spiral = result of rotational injury, usually from child abuse Comminuted = more than 2 breaks Avulsed = bone fragment pulling off bone with tendon Impacted = part of bone pushed up into the rest of the bone, resulting in a shortening  Torus = cortex of bone buckles, only seen in children Greenstick = only one side of bone fractured, only seen in children There is always a risk for bleeding after a fracture Infection of a bone (osteomyelitis) can impair the healing of the bone Complex regional pain syndrome: cause by prolonged inflammation and pain, spontaneous pain, pallor and cool limb, edema below the limb Compartment syndrome: increased pressure in the fascia (the thin tissue that surrounds bones), the pressure compresses nerves and blood supply which reduces perfusion distal to the injury - Client may have to get a fasciotomy surgery to relieve the compression Pulmonary embolism: pelvic / hip fractures are at high risk, manifestations = acute SOB, pleuritic chest pain, high HR / resp, coughing up blood, need a chest x-ray, heparin, and fluids - Fat embolism: fractured long bone like femur / humorous is at high risk due to the release of fat and marrow after the fracture Post laminectomy = HOB can only be 45 degrees Causes of back pain: dissecting aortic aneurism, abdominal aortic aneurism, angina, osteoarthritis