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Why is it useful to think of spinal shock like a concussion?
CAN’T TELL PATIENTS OUTCOME UNTIL SPINAL SHOCK RESOLVES
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What are dermatomes?
- AREA CONTROLLED BY EACH SPINAL NERVE AT THE SKIN LEVEL
- LOWER (L5-6) ARE DISTAL TO THE DERMATOMES (I.E. FEET)
- LIDOCANE PATCH IS A GOOD EXAMPLE OF TREATING DERMATOMES
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Where do Upper motor neurons (UMN) originate?
the brain (above T12)
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Where do lower motor neurons (LMN) originate?
the spinal cord
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A DECREASE IN SENSATION of dermatomes, FROM BASELINE ESPECIALLY IN A UPPER DERMATOMES IS REASON TO CALL MD, why?
- WORSENING SYMPTOM
- PROGRESSIVE (SECONDARY INJURY) – MAKING INITIAL INJURY
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When UMN (above T12) are involved what are the S/S?
- SPINAL SHOCK – ONCE THIS RESOLVES THEN THE OTHERS START
- SPASTICITY – PARALYSIS – FAMILY THINKS THEY’RE MOVING (WILL EVENTUALLY CAUSE CONTRACTURES – MUST TRY TO PREVENT)
- HYPERTONIC MUSCLE
- HYPER REFLEXIC
- +BABINSKI
- LOST VOLUNTARY CONTROL OF DEFECATION BUT LEAVE STOOL IN THE VAULT (HARD STOOL WITH SMEARING) – REGULARLY TIMED BOWEL PROGRAM, MOM, STOOL SOFTENERS, FLUIDS, FIBER – MAY NEED STIMULATION
- UNCONTROLLED VOIDING OF URINE (HIGH RESIDUALS LEFT BECAUSE OF SPASMING) CONDOM CATH, PUREWICK, ANTICHOLINERGICSREFLEX ERECTION AND EJACULATION (ANTISPASMOTICS – BACLOFEN)
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When LMN (below T12) are involved what are the S/S?
- FLACCID PARALYSIS
- HYPOTONIC MUSCLES
- HYPO REFLEXIC
- EARLIER ATROPHY
- S2-S4 REFLEX ARC
- FLACCID RECTUM – HARD FORMED STOOL – REQUIRES DISIMPACTION (SUPPOSITORY, DIGITAL STIMULATION) – MUST HAVE AN ORDER. MAY CONSIDER OSTOMY, ABDOMINAL BINDER OR MASSAGE
- RETAINS URINE, OVERFLOW URINATION, MANUALLY PUSH ON THE BLADDER TO FACILITATE EMPTYING
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What is spinal shock?
A complete absence of all reflexes
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Name the 5 different mechanisms of injury for SCI
- ►Hyperflexion injury (C5-C6) – HEAD SUDDENLY AND FORCEFULLY MOVES FORWARD
- ►Hyperextension injury – REAR END
- ►Axial loading – LANDING ON FEET/BUTTOCKS, BLOW TO HEAD
- ►Rotation injuries
- ►Penetrating injuries
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This type of SCI happens when the head suddenly and forcefully moves foreward:
Hyperflexion injury
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This type of injury happens when a person falls and lands on feet or buttocks or takes a blow to the head
axial loading injury
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This type of SCI happens when a person is rear ended
hyperextension injury
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What are the four types of damage that occur with primary spinal cord injury?
- ►Compression
- ►Contusion - BRUISING
- ►Shear injury - FRICTION
- ►Transection –TOTALLY TRANSECTS THE AREA
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With a secondary spinal cord injury, how does damage occur?
- INCREASED METABOLIC NEEDS = INCREASED HYPOXIA AND TISSUES NOT GETTING PROFUSED - this occurs with edema, fever, electrolyte imbalances...
- SWELLING LEADS TO SECONDARY INJURY
- ABSOLUTELY WORSENS THE PRIMARY INJURY
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What are the different functional classifications of SCI?
COMPLETE – TOTAL PARALYSIS BELOW THE LEVEL OF INJURY (transection of cord)
- INCOMPLETE – PARTIAL OR SOME FUNCTIONING BELOW THE LEVEL OF INJURY
- Tetraplegia (Quadriplegia)
- Quadriparesis
- Paraplegia
- Paraparesis
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With anterior cord syndrome what is the level of function?
Able to feel POSITION, VIBRATION, TOUCH
Loss of movemement, pain, temperature
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Name the incomplete cervical SCI injuries
- Anterior cord syndrome
- Central cord syndrome
- Brown-Séquard syndrome
- cauda equina or conus medullaris
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With Central cord syndrome what is the level of function?
- Can sing and dance but cannot play the piano
- MUD
- MOTOR: AFFECTS MOTOR MORE THAN SENSORY
- UPPER VS LOWER
- DISTAL IS GREATER THAN PROXIMAL
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With Brown-Sequard syndrome what is the level of function?
- IPSILATERAL (SAME SIDE) LOSS OF PROPRIOCEPTION, LIGHT TOUCH, MOTOR FUNCTION
- CONTRALATERAL (OPPOSITE SIDE) LOSS OF PAIN, TEMP AND SENSATION
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With lumbar/sacral injuries what is the level of function?
- END OF SPINAL CORD AND CONTINUING ON OF NERVE ROOTS - CAN HAPPEN WITH A LUMBAR DISC HERNIATION
- BOWEL
- BLADDER
- SEX
- SEE FOOT DROP
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What is spinal shock?
- TEMPORARY SUPPRESSION OF REFLEXES BELOW THE LEVEL OF INJURY
- Flaccid paralysis
- Absent reflexes
- Absence of bowel & bladder control
- Males (with cervical injury)- may have priapism – UNCONTROLLED BLOOD FLOW (PARASYMPATHETIC)
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What are the S/S of spinal shock?
- LOW BP: Profound vasodilation drops blood pressure
- Skin: is warm and dry
- BRADYCARDIA: Parasympathetic is opposed which causes bradycardia
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Which diagnostic test should be ordered to R/O SCI?
1.Plain x-rays
2.Computed tomography
3. Magnetic resonance Imaging
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What additional diagnostic tests should be performed for SCI?
- CBC
- Coags
- Chemistry (electrolytes)
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What type of med do we use to increase BP?
Vasopressors (constrict vessels)
Fluids
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What are the PRIMARY assessment priorities?
- Airway
- Breathing
- Circulation – give fluids, assess bleeding
- Disability
- Environment, exposure, infection control
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What are the SECONDARY assessment priorities?
- Full set of V/S
- Give comfort measures
- Head to toe
- Inspect posterior surfaces
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How do we test for spinal shock?
bulbocavernosus reflex
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How is the bulbocavernosus reflex tested?
- squeezing of the clitoris or penis
- causes anal sphincter to contract
if the anal sphincter DOES NOT contract then the patient is in spinal shock
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What drugs should be given for the initial management of a SCI?
DEXTRAN HAS HIGH OSMOTIC PRESSURE - TO KEEP PLASMA IN THE CELLS – FILLS UP AND HOLDS IT IN THE SPACE
ATROPINE FOR BRADYCARDIA – BECAUSE THEY HAVE LOST FIGHT OR FLIGHT – UNIQUE TO NEUROGENIC SHOCK – WILL END UP WITH PACEMAKER
DOPAMINE - for severe hypotension
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What is neurogenic shock?
Hemodynamic instability
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What are the S/S of Neurogenic Shock?
SEVERE BRADYCARDIA
PERIPHERAL VASODILATION: WARM DRY SKIN
SEVERE HYPOTENSION
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Name some respiratory complications related to SCI's
- respiratory failure (ventilatory muscles damaged)
- pulmonary edema
- pneumonia
- pulmonary embolism
- impaired clearance of secretions
- ineffective cough
- atelectasis
- hypoventilation
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SCI's at C3 and above will need what?
ventilator to breath
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What are nursing safety priorities with a Halo device?
- never move or turn by holding device
- do not adjust screws
- check skin frequently
- make sure one finger fits between skin and jacket
- assess neuro status
- tape wrench to vest for emergencies
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Patient and family teaching for Halo device
- fall risk: weight of device alters balance
- wear loose clothing
- wash under lambs wool to prevent rashes
- sponge bath or bathtub
- support the head when sleeping
- keep as active as possible
- do not drive
- small pieces of food to avoid choking, use straws
- wrap pins with cloth in cold weather
- observe pin sites daily for infection or loosening
- increase fluids/fiber
- use a position of comfort during sexual activity
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How is the log-roll done?
- three people required
- person at the head ALWAYS makes the call (on the count of three...
- the side rollers cross over the middle hands
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What chronic complications result from SCI?
- Cardiovascular:
- Autonomic hyperreflexia
- CAD
- VS changes- hypotension, bradycardia, orthostatic hypotension
- Pulmonary:
- Pneumonia
- VTE / PE – NEED PROPHYLAXIS
URINARY: CAN’T FEEL FOR BACK PAIN, ETC. NEED TO WATCH FOR FEVER, FOUL SMELLING URINE
SEXUAL DYSFUNCTION: DEPENDS ON THE LEVEL OF INJURY
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What is autonomic hyperreflexia? (formerly Autonomic Dysreflexia)
Exaggerated sympathetic response that occurs in patients with cord injuries at T6 or above, occurs after spinal shock is resolved
THIS IS A PROBLEM OF HYPERTENSION - SOMETHING TRIGGERS THEIR SYMPATHETIC (UNCONTROLLED OVER STIMULATION) – MEDICAL EMERGENCY
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What are S/S of autonomic hyperreflexia?
- Severe hypertension
- Bradycardia
- Severe headache
- Sweating
- Flushing
- Blurred vision
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Nursing priorities with autonomic hyperreflexia?
- Sit them up
- Search immediately for the cause: impacted stool, kinked foley cath, retention, remove tight fitting clothes
- Notify the provider
- Can give nitro, nifedipine, captopril, hydralazine
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How is the micturition center affected?
UMN injury: results in spastic bladder - frequent and uncontrolled voiding. intermittent catheterization or condom cath, stroke or pull hair to stimulate voiding
LMN injury: results in autonomous, flaccid bladder - manually push on bladder (Crede)
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How is the spinal defecation center impaired?
UMN = hard stool with smearing - add irritant cathartics (MOM, lactulose...), bowel program, digital stimulation
LMN = hard stool requiring disimpaction by suppository or digital manipulation, abd binder or massage. Ostomy last resort.
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Where is the reflex arc located?
S2-S4
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How is the sexual reflex center affected?
UMN – NEED STIMULATION
LMN – PSYCHOGENIC ERECTION POSSIBLE
- No matter upper or lower – will have sexual dysfunction
- 90% of males with SCI do not ejaculate
- Female sexual responses are impaired, ovulation and menstruation are intact
- REMEMBER THAT SEXUAL RESPONSE IS FOREVER ALTERED
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What chronic complications result from SCI?
- ►Bone metabolism- osteoporosis & heterotrophic ossification
- ►Musculoskeletal- contractures
- ►Pressure ulcers
- ►Spasticity
- ►Pain syndromes
- ►Neurologic deterioration
- ►Syringomyelia
- ►Psychiatric - HIGHER RATES OF SUICIDE, ESPECIALLY IN THE FIRST YEAR, DEPRESSION, DRUG ADDICTION
- ►Thermoregulatory - SPECIFICALLY AT T6, NEUROPATHWAYS AND HYPOTHALAMUS, CAN’T SELF REGULATE
- ►Functional deficits
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What interventions will the nurse perform for pain?
- ALIGNMENT
- STABILITY
- ANTIEPILEPTICS (gabapentin)
- ANTISPASMODICS (baclofen)
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What nursing diagnoses are applicable to a client with an SCI?
- Risk for respiratory distress/failure
- Ineffective tissue perfusion
- Pain
- Impaired physical mobility
- Self-care deficit
- Impaired urinary elimination and/or constipation
- Impaired adjustment
- Imbalanced nutrition
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What interventions will the nurse perform for Respiratory Distress/Failure?
- Cough assist (quad cough)
- incentive spirometry
- Respiratory therapy
- monitor breathing and lung sounds
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