Spinal Cord Injury EMERGENCY NURSING. Objectives After this presentation we will able to: 1-Discuss the nursing assessment of patients with spinal cord.

Spinal Cord Injury

EMERGENCY NURSING

Objectives

After this presentation we will able to:

1-Discuss the nursing assessment of patients with spinal cord and/or vertebral column trauma.

2-Identify appropriate nursing diagnoses and expected outcomes associated with patients with spinal cord and/or vertebral column trauma.

3-Plan appropriate interventions for patients with spinal cord and/or vertebra! column trauma.

Spinal Cord Injurycomplete Vs. incomplete lesions.

1-INCOMPLETE SPINAL CORD LESIONS

-  incomplete structural damage.-   preservation of some motor or sensory

function below the level of the injury.-   Sacral sparing(Perianal sensation, anal

sphincter tone, and great toe flexor function).only in absence of spinal shock.

-   4 subtypes ( syndromes ): 

A-central cord syndrome (the most common)

Spinal tract involved ?? Etiology: hyperextention injuries Swelling in

the center of the cord -> bony abnormality may be absent .

-Symptoms : loss of sensory and motor function below the level of the lesion

-greater loss in arms than in legs. 

B- anterior cord syndrome,(common).

Spinal tract involved: spinothalamic,corticospinal(pyramidal) Etiology :acute anterior cord compression,disruption of

blood flow. Symptoms :loss of motor function, loss of pain

temperature, crude touch ,crude pressure. Intact proprioception ,fine touch fine pressure ,vibration.

C- posterior cord syndrome (rare)

Spinal tract involved : posterior tract ( dorsal ) Etiology: acute posterior cord compression . Symptoms :loss of proprioception ,fine touch ,fine

pressure ,vibration ,intact pain, temperature, crude touch ,crude pressure.

D- Brown Sequard syndrome (uncommon) 

Spinal tract involved :dorsal on same side ,spinothalamic on the opposite side ,corticospinal on the same side .

Etiology: transverse hemisection of the cord (usually penetrating injury )

Symptoms :loss of motor function proprioception ,vibration (epailateral)

Loss of pain and temperature ( contralateral)

  2-complete SPINAL Cord LESION

-results in loss of all motor and sensory function below the level of the lesion.

-shock is frequently the initial response resulting in loss of motor, sensoty, and reflex function below the level the injury.

-The patient may also develop neurogenic shock resulting in loss of autonomic function.

Complete spinal cord lesion

Complete spinal cord lesion

Sings AND Symptoms

- loss of motor function below the level of the injury; initially flaccid paralysis.

-     Bilateral external rotation of the legs at the hips-     Loss of sensory function below the level of theinjury; loss of

pain, touch, temperature, deep pain, vibration, and proprioception.

-     Neurogenic shock.( Loss autotonomic nervous system function)-     Hypotension ,bradycardia .?-     Poikilothermia . -     loss of voluntary bowel and bladder function .-     loss of reflexes, if spinal shock is present .-     priapism. 

NURSING CARE OF THE PATIENT WITH A SPINAL CORD AND VERTEBRAL COLUMN

TRAUMA

1 -Assessment

history

-General: MIVT

-Specific :1-neck or back pain ?

2-Spontaneous movement in extremities or altered sensation?

( hematoma ,edema )

2-physical assessment

assessment of airway ,breathing , circulation, and disability.

- Inspection:

assess breathing effectiveness and rate of respirations.

-C3 - C5 interferes with diaphragmatic function.

- C6 spare the diaphragm, edema formation and hemorrhage may affect respiratory effort.

-T2-T8 may spare the diaphragm but result in loss of irnercostal muscle function.

Physical assessment cont…

- Palpation

- Palpate pulse rate and quality.

- palpate skin temperature.

- assess all four extremities for muscle strength.

Physical assessment cont…

-assess sensory function The use of a touch stimulus to determine levels of sensory

function should begin at the area of no feeling and proceed toward the area of feeling. This will aid in localizing the level of injury .

 - C5 Top of shoulder.- T4 Nipple line.- T10 Umbilicus.- L4 Great toe.

Physical assessment cont…

•gently palpate the vertebral column for pain, tenderness, or step deformities between vertebrae.

 •palpate the anal sphincter for presence or

absence of tone.•Assess for sacral sparing.

Physical assessment cont…

Test reflexes

-In the presence of spinal shock, the patient will present with areflexia .

-A Babinski’s sign is a pathologic reflex, because of dysfunction of upper motor neurons of the corticospinal tract.

DIAGNOSTIC PROCEDURES

radiographic studies

- Vertebral column radiographs.

-initial cross-table lateral view of the cervical spine.

-Additional views can determine the exact site and nature of the bony injury.

- Thorough radiographic evaluation is indicated if the patient has an altered mental status.

 - CT scan ,MRI.

ANALYSIS, NURSING DIAGNOSES, INTERVENTIONS.

NURSING DIAGNOSIS

Ineffective airway clearance related to??

Interventions:

- Open airway with jaw Thrust or chin lift while maintaining cervical spine immobilization.

- suction airway.

- Obtain blood sample for ABGs as indicated.

-Assist with endotracheal intubation

NURSING DIAGNOSIS

Aspiration related to ??

Interventions

- Maintain spinal immobilization and stabilization

- Position patient

- Open and clear airway

- insert oro- or nasopharyngeal airway

- Consider and assist with endo tracheal intubation, as indicated

- Insert gastric tube and evacuate stomach contents.

NURSING DIAGNOSIS

Impaired gas exchange related to ??Interventions- Administer oxygen via a nonrebreather mask.- Ventilate with 100% oxygen via a bag-valve-mask

device- Monitor oxygen saturation with continuous pulse

oximetry -Assist with intubation

NURSING DIAGNOSIS

fluid volume deficit related to ??Interventions- Cannulate two veins with large- bore catheters and

initiateinfusion of lactated Ringer’s solution or normal saline;

monitor rate carefully- Consider vasopressors as needed- insert urinary catheter - Monitor hemodynamics

NURSING DIAGNOSIS

altered tissue perfusion

Interventions

-control bleeding

-IV infusion

-Blood transfusion

NURSING DIAGNOSISIneffective thermoregulation

Interventions-warm environment-warm IV fluids NURSING DIAGNOSISinjury ,risk for injuryInterventions- immobilization-sedative or short-acting paralytic agent-methylIprednisolone…

NURSING DIAGNOSIS

Ineffective coping

Interventions

- Provide support to the patient and family

- Provide information and answer questions

- Make appropriate referrals for support

NURSING DIAGNOSIS

Impaired skin integrity.

Interventions

- Remove patient from backboard as soon as possible

- -Avoid allowing a paralyzed patient to lie on backboard for more than 2 hours

- Consider placement on special bed

Planning and Implementation

-Immobilize vertebral column

-Suction airway, as needed

- intravenous fluids :

If neurogenic shock is present, blood pressure will not usually be restored with fluid infusion; judicious use of vasopressors may be indicated. Attempts to restore blood pressure with fluid may lead to volume overload and pulmonary edema

-Steroids:

Effects :limitation of cord edema ischemia, and the prevention of cellular death.

 Dose : 30 mg/kg IV loading dose over 15 minutes. Wait 45 minutes; then initiate a 5.4 mg/kg /hr over the next 23 hours. For maximum effect, the initial dose must be administered within the first eight hours of injury.

-Insert a gastric tube.

-Provide psychosocial support.

-Keep the patient warm.

-Initiate skin care early.

-Assist with the application of skeletal tongs.

-prepare for interfacility transfer.

Evaluation and Ongoing Assessment

-Monitoring breathing effectiveness.

-Monitoring changes in sensory and/or motor .function.

-Monitoring temperature to avoid hypothermia.

 -  Any polytrauma patient is suspect of having an unstable spine fracture until the contrary is proven,

-The vital prognosis is threatened in the first days essentially by the assault on respiratory muscles and cardiovascular troubles induced by the breach of the autonomous

. nervous system - Medical management is made as early as possible in the pre-hospital setting.- Exploration of the spine by conventional face and profile radiographs remains the basic examination.- The maintenance of the spinal cord blood flow is an essential objective of the resuscitation begun in the pre-hospital setting.

summary

THANK YOU

Reference :trauma nursing core course 5th

edition