Matthew Rollosson, RN

Haydom Lutheran Hospital

28 August 2014

Collaboration

Emergency personnel

Care begins at the place where the patient was injured

Doctors

Nurses

Physiotherapists

The patient’s family

Basi, kwa kuwa ninyi ni wateule wa Mungu, wapendwa na watakatifu, vaeni moyo wa huruma, wema, unyenyekevu, upole na uvumilivu.

- Wakolosai 3:12

Therefore, as God’s chosen people, holy and dearly loved, clothe yourselves with compassion, kindness, humility, gentleness and patience.

- Colossians 3:12

Causes

Trauma

Interruption of blood supply

Diseases

Cancer

Infectious diseases

Bone degeneration

Congenital defects

Mechanisms of injury

Motor vehicle accidents

Falls

Violence

Sports injuries

Demographics

≥ 80% male

Young age

20 to 40 years of age

Brain injury

Chest trauma

Abdominal injuries

Limb fracture

Patient may not feel pain below level of spinal cord injury

Vertebral column

7 cervical vertebrae

12 thoracic vertebrae

5 lumbar vertebrae

Spinal cord

From medulla oblongata

To first lumbar vertebra

Conus medullaris

Cauda equina

“Horse tail”

Quadriplegia (tetraplegia)

Impairment/loss of function of upper and lower limbs

Cervical spine injury

Most common type of spinal cord injury (55%)

Paraplegia

Impairment/loss of function of lower limbs

Thoracic, lumbar, sacral injuries

Complete

Loss of all motor and sensory function below the level of injury

Incomplete

Preservation of motor and/or sensory function below the level of injury

Spinal cord syndromes

Anterior cord syndrome

Brown-Séquard syndrome

Central cord syndrome

Nursing diagnoses:

Ineffective breathing patterns

Ineffective airway clearance

Risk for infection

Respiratory complications are the most common cause of death in people with spinal cord injuries

Cardiovascular

Decreased cardiac output

Ineffective thermoregulation

Autonomic dysreflexia

Gastrointestinal

Risk for constipation

Bowel incontinence

Genitourinary

Risk for infection

Urinary incontinence

Musculoskeletal

Risk for injury

Disuse syndrome

Integument

Risk for impaired skin integrity

Psychosocial

Anxiety

Fear

Chronic grieving

Interrupted family processes

Risk for caregiver role strain

Risk for disturbed self-concept

Risk for ineffective sexuality patterns

Risk for social isolation

Acute

Save the person’s life

Prevent secondary injuries

Subacute

Prevent complications

Rehabilitation

Prepare patient for life after spinal cord injury

Learn skills for a productive life

Nursing diagnosis:

Risk for ineffective cerebral tissue perfusion

Nursing diagnosis:

Risk for ineffective cerebral central nervous system tissue perfusion

Nursing diagnosis: Risk for ineffective central nervous system

tissue perfusion Hypotension (low blood pressure) Loss of vasomotor tone Inability to constrict blood vessels

Bradycardia (slow heart rate) Unopposed parasympathetic stimulation

Shock

Nursing diagnosis:

Risk for ineffective central nervous system tissue perfusion

Monitor vital signs

Intake and output

Abdominal binder

Compression stocking/ACE wrap legs

Prevents pooling of blood in the legs

Nursing diagnosis:

Risk for ineffective central nervous system tissue perfusion

Medical interventions:

IV fluid boluses

Vasopressor drugs

Keep mean arterial pressure ≥ 90 mmHg

MAP = [SBP + (DBP x 2)] ÷ 3

Unstable spine

Fracture

Dislocation

Thompson et al., 2012 Browner et al., 2009

Log roll

Swartz, 2014

Nursing diagnoses

Ineffective airway clearance

Risk for infection

Risk for impaired skin integrity

Risk for constipation

Loss innervation of respiratory accessory muscles, intracostal muscles, and abdominal muscles

Quad coughing:

Atrice et al., 2013

Turn every 2 hours

Log roll

Douglas et al., 2013

Establish regular bowel pattern

What time of day does the patient usually have a bowel movement?

Gastrocolic reflex

Food in the stomach increases bowel motility

Especially first meal of the day

Hot liquids

Chai

Coffee

Encourage oral fluid intake

“At least 8 glasses per day”

≈ 2 liters

High fiber diet

Digital stimulation

Gloved finger in rectum

Dilate the anal sphincter

Medications

Stool softener

Suppository

Laxative

Avoid regular use

Do not use enema Risk of autonomic dysreflexia

Life-threatening Injuries above the 6th thoracic vertebra (T6)

Risk begins after the return of spinal reflexes

3 to 6 weeks after injury

Uncontrolled sympathetic discharge from the spinal cord

Hypertension (high blood pressure)

Sudden rise to 20 to 40 mmHg above baseline

Bradycardia (slow heart rate)

Headache

Blurred vision

Sweating, flushing (red skin), goose bumps above the level of injury

Cool, pale skin below the level of injury

Complications:

Seizures (convulsions, fits)

Stroke

Retinal detachment (blindness)

Death

Cause

Painful stimulation, irritation below the level of injury

Most commonly caused by

Distended bladder

Kinked, blocked catheter

Distended bowel

Constipation

Fecal impaction

Treatment

Remove the cause

Check catheter tubing

Check for stool in the rectum

Look for other sources of noxious stimulation

Put patient in sitting position

Short-acting antihypertensive medications

Nifedipine

Captopril

How will the patient’s injury affect his family?

How will the patient’s injury affect his community?

What resources are available in the community?

What can be done to prevent spinal cord injuries?

Hatimaye, ninyi nyote muwe na nia moja, mhurumiane, mpen dane kama ndugu, muwe na mioyo ya upole na ya unyenyekevu.

- 1 Petro 3:8

Finally, all of you, be like-minded, be sympathetic, love one another, be compassionate and humble.

- 1 Peter 3:8

Chuma hunoa chuma, Ndivyo mtu aunoavyo uso wa rafiki yake.

- Mithali 27:17

As iron sharpens iron, so one person sharpens another.

- Proverbs 27:17

Atrice, M. B., Morrison, S. A., McDowell, S. L., Ackerman, P. M., Foy, T. A., & Tefertiller, C. (2013). Traumatic spinal cord injury. In D. A. Umphred, G. U. Burton, R. T. Lazaro, & M. L. Roller (Eds.), Umphred's neurological rehabilitation, 6th Ed., pp. 459-520. St. Louis: Mosby.

Browner, B. D., Jupiter, J. B., Levine, A. M., Trafton, P. G., & Krettek, C. (2009). Skeletal trauma, 4th Ed. Philadelphia: Saunders

Carpenito, L. J. (2002). Nursing diagnoses: application to clinical practice, 9th Ed. Philadelphia: J. B. Lippincott Company.

Daroff, R. B., Fenichel, G. M., Jankovic, J. & Mazziotta J. C. (Eds.). (2012). Bradley's neurology in clinical practice, 6th Ed. Philadelphia: Elsevier.

Douglas, G., Nicol, F., & Robertson, C. (2013). Macleod's clinical examination, 13th Ed. Edinburgh: Elsevier.

Jones, H. R., Burns, T. M., Aminoff, M. J., & Pomeroy, S. L. (Eds.) (2013). Netter collection of medical illustrations: spinal cord and peripheral motor and sensory systems, 2nd Ed. Philadelphia: Saunders.

Kaminsky, D. A. (Ed.) (2011). Netter collection of medical illustrations: the respiratory system, 2nd Ed. Philadelphia: Saunders.

Sands, J. K. (2003). Spinal cord and peripheral nerve problems. In W. J. Phipps, F. D. Monahan, J. K. Sands, J. F. Marek, and M. Neighbors (Eds.) Medical-surgical nursing: health and illness perspectives, 7th Ed. St. Louis: Mosby.

Swartz, M. H. (2014). Textbook of physical diagnosis, 7th Ed. Philadelphia: Saunders.

Thompson, S. R. & Zlotolow, D. A. (2012). Handbook of splinting and casting. Philadelphia: Mosby.