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Spinal Cord Injury – (SCI). Adult Health II Spinal Cord Injury – Part 2. Jerry Carley RN, MA, MSN, CNE Summer, 2010. Concept Map: Selected Topics in Neurological Nursing. PATHOPHYSIOLOGY Traumatic Brain Injury Spinal Cord Injury Specific Disease Entities : - PowerPoint PPT Presentation
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Adult Health IISpinal Cord Injury Part 2Jerry Carley RN, MA, MSN, CNESummer, 2010Spinal Cord Injury (SCI)1Concept Map: Selected Topics in Neurological NursingPATHOPHYSIOLOGY
Traumatic Brain InjurySpinal Cord Injury
Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntingtons Disease Alzheimers Disease Huntingtons Disease Myasthenia Gravis Guillian-Barre Syndrome Meningitis Parkinsons DiseasePHARMACOLOGY
--Decrease ICP--Disease / Condition Specific MedsASSESSMENTPhysical Assessment Inspection Palpation Percussion Auscultation ICP MonitoringNeuro Checks Lab MonitoringCare PlanningPlan for client adls, Monitoring, med admin.,Patient education, Discharge Planning, morebasedOn Nursing Process: A_D_P_I_ENursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary2ObjectivesExplain pathophysiology of various SCIs and related conditions
Detail signs & symptoms and functionality of different level SCIs
Differentiate between Neurogenic Shock and Spinal Shock
Explain Autonomic Dysreflexia / Hyperreflexia and list appropriate nursing interventions
Discuss overall medical & nursing management of SCIs 3SCI PART 23SCI Goals of CareThere's no way to reverse damage
Treatment focuses on:
1. Preventing further injury
2. Enabling people to return to an active and productive life within the limits of their disability44TreatmentSpinal Immobilization / Traction
High doses of corticosteroid drug Methylprednisolone (Medrol) STAT !must be within eight hours of injury
A few days after injury medical reassessment and repeat of diagnostic tests will help determine the severity of the injury and likely extent of recovery
Surgery as indicated
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Tong Care to Prevent Infection67
Stryker Frame Traction Bed7Log Rolling Technique8
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99SCI MedsGlucocorticoids (Decadron suppress immune response)Vasopressors (treat hypotension)Plasma extenders (treat shock)Atropine (treat bradycardia)Muscle relaxantsAnti-Spasmodics (Dantrium)AnalgesicsAntidepressantsZantac, Ranitidine (prevent gastric ulcers)Stool SoftenersVasodilaters (Hydralazine, nitroglycerin to treat HTN such as AD)Anti-Seizure (gabapentin, phenytoin)
1010Neurogenic ShockOccurs in acute stage of SCI (first hour per ATI)
Usually in injuries ABOVE T6
D/T interruption of the CNS
causing disruption of sympathetic outflow from T1 to L2
with unopposed vagal tone
1111Neurogenic Shock: S & SsWarm and DRY skin does not perspire on the paralyzed parts of body d/t blocked sympathetic activity
Hypotension + Bradycardia + Hypothermia (d/t vascular dilation therefore blood pooling )
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12Spinal ShockD/t concussive effect of the primary SCI on the nervous system
Can last days or months
Interferes with definitive diagnosis of permanent deficit
Effect causes temporary (transient) depression of all reflexes =- paralysis (flaccid)- loss of sensation- loss of autonomic function- loss of B & B control (Sometimes priapism)
Spasticity or hyperreflexia signals end of this shock
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Autonomic Dysreflexia ( Hyperreflexia )SCI acute syndrome of excessive uncontrolled sympathetic output
Occurs ONLY after spinal shock has resolved
SCI above T6
Life-threatening HTN emergency1414A. D. (Hyperreflexia)Below T6 intact sensory nerves transmit noxious impulses up the spinal cord
. BUT
Sympathetic inhibitory impulses above T6 are blocked
THEREFORE
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15Sympathetic outflow continues causing release of norepinephhrine and dopamine16
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1717ResultSevere Vasoconstriction H/A + Sudden HTN 18
18Result above the SCISweating + Flushing
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19Other Distinctive S & SBradycardia
Blotching of the Skin
Restlessness
Goose bumps
Stuffy nose (nasal congestion)20
20Autonomic Dysreflexia / Autonomic HyperreflexiaClients with spinal cord injuries at Thoracic 6 10 (T6 -T10) may be susceptible
Patients with Thoracic 10 (T-10) and below are usually not susceptible
The older the injury the less likely the person will experience autonomic dysreflexia 2121Common CausesThe most common cause of noxious stimuli is distension of the hollow viscera (80%), such as the urinary bladder or bowel
1. Urinary Retention2. Constipation
Simple kinks in the tubing or plugs in the urinary catheter can trigger autonomic dysreflexia2222Credes MethodCred's method is a manual suprapubic pressure exerted with a clenched fist or fingers, used to initiate micturition, in patients with spinal cord injury (SCI) who have neurovesical dysfunction.
However, it is currently NOT recommended practice because of the risk of bladder rupture. Sources:
Hockenberry, M.J. (2003). Wongs Nursing Care of Infants and Children. (7th ed.). St. Louis: Mosby, pp. 1326-1328. Reinberg Y., Fleming T., & Gozalez, R. (1994). Renal Rupture After the Crede Maneuver. Journal 2323TreatmentAssist to sitting position to lower the BP through lower-extremity vascular pooling
Loosen restrictive garments (shirts, belts, slacks, straps and even shoes)
Monitor Vitals
Look for Cause & Eliminate!
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24TreatmentEnsure catheter patency (make sure catheter not kinked or pulled too tight, and is actually draining urine)
Catheterize to decompress bladder
Assess for signs of urinary tract infection, such as dark, cloudy urine or sediment in catheter tubing
If bowel is distended, disimpact after inserting anesthetic jelly or ointment per rectum
Hypertension should be treated medically if it persists
2525Still Cant Find Cause ? !!!Cause may not be readily found
Careful physical exam is imperative during this crisis
Other causative agents usually not considered in medical emergencies include skin irritations, wounds, pressure sores, burns, broken bones, pregnancy, ingrown toenails, appendicitis, and other medical complications
Still cannot find cause? . focus on decreasing the blood pressure!
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26Antihypertensive MedsNifedipine (Adalat) 10 mg orally - instruct the patient to bite the capsule, then swallow it
Nitroglycerin sublingual or topical paste (1/2 inch)
Prazosin (Minipress)
Clonidine (Catapres) 0.1- 0.2 mg PO
Hydralazine (Apresoline) 10 - 20 mg IM/IV
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27Client TeachingProvide education about early recognition and treatment of A.D.
Encourage the client to carry some type of medic alert identification
(It is estimated that approximately 85% of spinal cord injury patients at level T-6 will suffer at least one episode of autonomic dysreflexia)
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28Client TeachingPrevention:
Frequent pressure relief in bed/chair
Avoid sun burn/scalds (avoid overexposure, use of #15 sunscreen, watch water temperatures)
Faithful adherence to bowel program
Keep catheters clean and remain faithful to catheterization schedule
Well balanced diet and adequate fluid intake
Compliance with medications2929SCI RecoveryRecovery typically starts between a week and six months after injury, if it occurs, with the majority of recovery taking place within one year
Doctors generally regard any impairment remaining after 12 to 24 months as likely to be permanent 30
30SCI Nursing InterventionsBowel retraining programROMSexual function adaptive strategiesPTOTAssistive devicesQ2H turns skin careNutrition3131SCI Nursing InterventionsReferrals:
Social ServicesSupport GroupsAppropriate specialists3232SCI RehabilitationInitial rehabilitation emphasizes regaining leg and arm strength, redeveloping fine-motor skills and learning adaptive techniques to accomplish day-to-day tasks
Then long-term rehab typically includes exercise and training with:
Modern wheelchairs - Improved, lighter weight wheelchairs are more mobile and more comfortable. The Food and Drug Administration has even approved a wheelchair that can climb stairs and elevate a seated passenger to eye level to reach high places without help
Computer devices - Computer-driven tools and gadgets can help with daily routines. Voice-activated computer technologies to answer and dial a phone, or to use a computer and pay bills. Computer-controlled technologies can also help with bathing, dressing, grooming, cleaning and reading333334
34Complications
Urinary tract problems - urinary incontinence increases risk of urinary tract infections, kidney infection, kidney or bladder stones. d/t ongoing catheterizations
Bowel management difficulties Reduced peristalsis and fecal incontinence
Pressure sores - particularly susceptible to pressure sores because the injury reduces or eliminates sensations, making it difficult to know when a sore is developing Deep vein thrombosis and pulmonary embolism
Lung and breathing problems - Difficult to breathe and cough with weakened abdominal and chest muscles, so people with cervical and thoracic spinal cord injury may develop pneumonia, asthma or other lung problems3535ComplicationsSpasticity some people develop muscle spasms and jumping of their arms and legs because some of the nerves in the lower spinal cord become more sensitive after injury and cause muscle contractions. However, because of the spinal cord injury, the brain can no longer send signals to the lower nerves to regulate the contractions
Weight control issues - Weight loss and muscle atrophy are common. But the change in lifestyle and activities may eventually cause weight gain, which can make it difficult for the pt lift themselves or be lifted from place to place
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36ConcernsPain
- It's possible to feel pain in areas where there's little or no sensation- May also experience pain from overusing muscles in one part of the body. Many people develop shoulder tendinitis from manually operating a wheelchair for a long period of time- Any kind of pain can have a negative impact on daily living. New Injuries
- Susceptible to injury of any part of the body that has impaired sensation- May even receive a burn or cut without realizing it
3737Male ConcernsSexual Dysfunction
Still have erections, even with little sensation in the genital area
But erections may not be firm enough or last long enough for sexual activity
Fertility also can be affected:
- 99% aren't able to ejaculate during intercourse- Low sperm counts- Poor sperm motility
***** However, men can be sexually active and father a child
3838Female ConcernsSexual Dysfunction
Most have no physical change that inhibits sexual intercourse or pregnancy
But may lose ability to produce vaginal lubrication or control vaginal muscles
Many experience changes in body image that affect sexuality
Any pregnancy will likely be considered high risk
There may be amenorrhea for about 6 months after SCI
3939CopingGrieving
Healthy part of recovery. It's natural and important to grieve the loss of the way the person was before. Thennecessary to set new goals and find a way to move forward with life
*** Depression and alcohol abuse***
Taking control
Education about injury and options for reclaiming an independent life
Because the costs can be overwhelming, find out about economic assistance or support services from the state or federal government or from charitable organizations
Talking
Friends and family may respond in different ways 4040COPING.ContinuedDealing with intimacy
Self - Care
Looking ahead
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