Basic Medical Surgical Nursing PDF

Basic Medical Surgical Nursing Care of the Patient with a Spinal Cord Injury  Spinal Cord Injuries (SCIs) Complete vs Incomplete Types of Injuries Primary Related to the initial injury Secondary Worsens the injury Can be: Hemorrhage Ischemia I...

Basic Medical Surgical Nursing Care of the Patient with a Spinal Cord Injury  Spinal Cord Injuries (SCIs) Complete vs Incomplete Types of Injuries Primary Related to the initial injury Secondary Worsens the injury Can be: Hemorrhage Ischemia Impaired tissue perfusion from shock Hypovolemia Local Edema Incomplete injury – could still have some parts of nerve running that works; left leg might work but left arm might not ○ only part of spinal cord is damaged ○ still some function or alteration in sensation, not everything is decreased Brushing patient could feel like hitting them – due to overactive nerves Won’t know until you assess patient Complete injury – nothing will work under it ○ complete separation from upper and lower portion of spinal cord ○ can happen at any level in spinal cord primary injury – like overextending and over flexing part of neck ○ example – diving in a pool and having head compressed against bottom of ground secondary injury 2 ○ could be a hemorrhage inside spinal cord that makes spinal cord not work (from increased pressure) ○ ischemia – impaired tissue perfusion from shock ○ shock – more talked about in complex med surg class ○ hypovolemia – not enough volume → not enough perfusion to spinal cord  Risk Factors Young males Educate patients to: not engage in risk-taking Trauma behaviors Motor Vehicle Crashes (MVCs) Wear protective Falls gear/equipment for potentially Acts of Violence (gunshot traumatic sports or recreational wounds) activities Sports Wear seatbelts while operating a motor vehicle Recreational activities (alcohol or illicit drug use) Avoid impaired driving (including alcohol, marijuana, and other impairing substances) Importance of prevention Avoid diving in shallow water (water must be at least 9 ft) highest risk = young males ○ should be educated not to engage in risky behaviors like jumping off 2-story buildings ○ wear protective equipment or gear for intense sports motor vehicle crashes, falls, acts of violence (esp gunshot wounds), sports related injuries, dangerous recreational activities (illicit drugs) seatbelts while driving needs to be highly encouraged NO DIVING IN LESS THAN 9 FT 3  Level of Injury Level of injury 🡪 depends on where the injury occurred -plegia vs -paresis Tetra- (aka quadri-) Para- C3-C5 Respiratory compromise Sensation Complete loss vs hyper-/hypoesthesia the higher we go with spinal cord injury – highest is = cervical spine injury ○ issues with paralysis or change to sensation below level of injury C4 – injury would cause quadriplegic plegia = paralysis paresis = weakness C3-C5 – high risk for respiratory compromise ○ nerves in that region innervate the diaphragm ○ not always a loss of sensation hyper-/hypoesthesia = overactive sensations where small touch feels very painful ○ also might have decreased sensations ○ 4  Signs & Symptoms Cardiovascular: Neuromuscular: Bradycardia, hypotension, hypothermia Loss of movement (plegia vs paresis) Must keep SBP > 90 mm Hg to keep adequate perfusion to the Numbness , tingling or loss/change to sensation spinal cord in extremities Potential for cardiac dysrhythmias Immobility Unsteady Gait Respiratory: Difficulty breathing related to paresis or plegia of the Pain or pressure in the head, neck or back diaphragm (C3-5) Psychosocial: Difficulty clearing secretions Changes in sexual function Gastrointestinal: Loss of bowel control Genitourinary: Loss of bladder control low HR low BP and difficulties with having normal temp ○ hypothermia -important for spinal cord patients to keep their BP greater than 90 for systolic (to encourage perfusion) as risk of cardiac distress C3-C5 ○ have issues breathing, moving muscles, clearing secretions ○ at risk of getting pneumonia have loss of control of their bowels and bladder – monitor I/Os can have loss of movement or weakness trouble moving around, unsteady gait acute spinal cord injury – can feel pain and pressure in specific location sexual functioning – changes with this as well as educating patients on this; empathize  Diagnosis CT or MRI of the spine X-ray of spine CMP (or BMP) and CBC For baseline typically done with CT or MRI of spine used to determine the degree and extent of damage to spinal cord look for things like blood or bone that has gone into spinal cord Xray – series of xrays can be done to see if there are any vertebral fractures, any changes to the spinal cord CMP or BMP – might be ordered by some doctors to see a baseline and to see what else could be going on  Initial Care of SCIs ABCs are the priority Spinal precautions Log roll patients C3-5 Keep cervical collar on until Respiratory assessment cleared by healthcare provider Cervical collar on ALL suspected or confirmed SCIs Helps keep patients' spine in neutral alignment Evaluate: HR, BP & peripheral perfusion (pulse strength and capillary refill) Assess for hemorrhage (hypovolemia) Frequent Glasgow Coma Scale (GCS) Cognitive impairment can be indication of other injuries or substance use Assess patient’s sensory perception Spinal Shock Syndrome important to focus on airway-breathing-circulation ○ check airway, make sure they can breathe patients can have bradycardia, potential cardiac arrhythmias ○ hypertension most patients suspected trauma or suspected spinal cord injury – will have cervical collar ○ stabilizes spine and keeps it in neutral alignment until spinal injury is determined check HR want to do frequent GCS checks to look for potential cognitive impairments ○ initial scene about every hour at first (to confirm no brain bleed) assess sensory perception – any changes in feeling? spinal shock syndrome – occurs immediately after injury happens ○ can have complete (tho temporary) loss of potential motor sensory reflex, autonomic functions ○ lasts 48 hours spinal precautions ○ bedpan usage ○ skin assessments and dressing changes, assess any wounds ○ if they have surgical collar – keep on until provider says it’s okay to remove incase of high cervical injury  Treatments Medications Surgical Atropine sulfate (Isopto Atropine): given to treat a patient Surgical: many different types of spinal surgeries with symptomatic bradycardia Priority is to stabilize the spine IV medications to raise BP: can be used to treat severe Post-operative care will depend on level of injury and hypotension specifc surgery completed Midodrine (ProAmatine): oral (PO) med that can be used Patient will need to wear a specific orthosis (brace) while to treat mild hypotension the body heals Proton pump inhibitors (ex: pantoprazole, omeprazole, lansoprazole): can be given to help prevent stress ulcers Muscle relaxers (ex: baclofen (Lioresal) or methocarbamol Non-Surgical (Robaxin)): may be given to help prevent muscle spasticity Immobilization of the spine with a specific orthosis (brace) or pain Examples of orthotics: cervical collar, halo crown, Fluids (IV or PO hydration): goal is to maintain adequate thoracic-lumbar sacral orthosis (TLSOs) hydration. Regardless of the orthosis, must monitor skin integrity anterior cervical discectomy fusion – not related to spinal injury but if injury is compressing disc, disc could be removed TLSO, orthotic collar – help protect spine Most of time surgery + orthotics will be used post op medication – typically won’t fix injury itself, but alleviate symptoms of spinal cord injury ○ atropine sulfate – symptomatic bradycardia tx, speeds up HR ○ midodrine – raises BP surgical ○ anterior cervical discectomy fusion – not related to spinal injury but if injury is compressing disc, disc could be removed ○ sometimes patients might want to wear cervical collar instead of surgical brace (which some doctors are okay with at times ○ halo crown – keeps spinal cord and bones of spine in place ○ thoracic lumbar sacral orthosis – also keeps spine in alignment  SCI Complications Respiratory Autonomic Dysreflexia Mobility Potentially life-threatening hypertensive emergency Cardiovascular Severe, sudden increase in BP puts patient at Integumentary risk of hemorrhagic stroke Genitourinary Signs & Symptoms: Flushing & Profuse sweating above level of injury Gastrointestinal Blurred vision, spotty vision Venous thromboembolisms Nasal congestion Severe, throbbing headache Bradycardia Dysreflexia Reverse Trendelenburg patient to make sure they’re still angled upwards Immobility – high risk of blood clots some complications are chronic and some acute risk of breathing issues cough assist – RN places hand on chest of patient and have them inhale and exhale; nurse presses on chest to help patient clear excretions watch oxygenation watch for signs of SIRS and check sputum – pneumonia signs pressure injury risk advocate for DVT prophylaxis pad bony prominences and turn patients often cardiovascular ○ difficulty stabilizing BP and HR straight cath the patient every 4-6 hours to avoid autonomic dysreflexia – abnormal overreaction of involuntary ANS to  stimulation ○ causes change in – HR, excessive sweating, high BP ○ too much pressure in bladder too much pressure in bowels can lead to autonomic dysreflexia assess for regular bowel movements and I/O for urination sudden BP increase makes them at risk for hemorrhagic stroke ○ s/s – flushing, profuse swelling above level of injury, blurred vision, severe headache  Autonomic Dysreflexia Causes: Gynecological-urological (GU), gastrointestinal (GI) or vascular stimulation Examples: urinary tract infection, full bladder, fecal impaction, bowel distention, irritation of hemorrhoids, pain, circumferential constriction of the body (i.e., tight clothing), excess pressure, sharp or hard objects Treatment: Sit patient upright Remove the stimulus (Ex: straight cath patient with full bladder) Treat the patient’s blood pressure If pressure on ankles – pressure injury could develop for people that have issues with sensation UTI with a bladder that is too full; i.e. went too long without a straight cath for 8 hours overfull bladder causes BP to go up first – sit the patient upright to lower BP, then remove stimulus (straight cath patient) ○ if it STILL hasnt dropped, treat BP with BP meds (ACE, ARBs, calcium channel blockers possibly not beta blockers bc it can affect the HR and drop it more main thing – SIT UP patient, recognize stimulus causing pressure (even tight clothes or belts too) make sure not to leave objects on bed that could cause pressure and also cause this reaction 10