Management of patients with spinal cord injury

Nursing care of clients with spinal injuries

1. Chapter 60 Spinal Cord Injury Copyright © 2017, Elsevier Inc. All Rights Reserved.

2. Trauma or damage to spinal cord 12,500 new SCIs each year 276,000 Americans living with SCI Highest in men ages 16-30 ↑ I n older adults Spinal Cord Injury (SCI) Copyright © 2017, Elsevier Inc. All Rights Reserved.

3. ↓ M ortality Long-term issues remain Disruption in growth and development Altered family dynamics Economic loss Round-the-clock care SCI Copyright © 2017, Elsevier Inc. All Rights Reserved.

4. Causes 38% motor vehicle collisions 30% falls 14% violence 9% sports injuries 9% other miscellaneous cases Etiology Copyright © 2017, Elsevier Inc. All Rights Reserved.

5. J.N., a 32-yr-old woman, was brought to the ED after being thrown from her car following a motor vehicle accident. She was not wearing a seat belt. She is awake and crying. She states she cannot move or feel her legs. Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

6. J.N. anxiously asks you if she “broke her back” and cut her spinal cord. She also asks if she will be paralyzed for life or if it can be reversed. Based on your knowledge of the pathophysiology underlying spinal cord injury, how will you respond to J.N.? Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

7. SCI due to cord compression by Bone displacement Interruption of blood supply Traction from pulling on cord Penetrating trauma → tearing and transection Etiology and Pathophysiology Primary Injury Copyright © 2017, Elsevier Inc. All Rights Reserved.

8. Ongoing, progressive damage that occurs after initial injury Several theories exist on what causes ongoing damage Etiology and Pathophysiology Secondary Injury Copyright © 2017, Elsevier Inc. All Rights Reserved.

9. Several theories on what causes ongoing damage at molecular and cellular levels Vascular changes Free radical formation Lipid peroxidation Release of glutamate Uncontrolled calcium influx Etiology and Pathophysiology Secondary Injury Copyright © 2017, Elsevier Inc. All Rights Reserved.

10. Apoptosis (programmed cell death) for weeks after injury Lead to scar tissue formation, irreversible nerve damage, and permanent neurologic deficit Etiology and Pathophysiology Secondary Injury Copyright © 2017, Elsevier Inc. All Rights Reserved.

11. Events Leading to Second Injury (Modified from Marciano FF, Greene KA, Apostolides PJ, et al: Pharmacologic management of spinal cord injury: review of the literature , BNI Q 11[2]:11, 1995. In McCance KL, Huether SE, editors: Pathophysiology: the biologic basis for disease in adults and children , ed 5, St Louis, 2006, Mosby.) Copyright © 2017, Elsevier Inc. All Rights Reserved.

12. Within 24 hours, permanent damage may occur because of edema Extent of damage and prognosis for recovery most accurately determined 72 hours or more after injury Greatest improvement occurs in first 3 to 6 months following injury Etiology and Pathophysiology Secondary Injury Copyright © 2017, Elsevier Inc. All Rights Reserved.

13. J.N.’s cervical spine x-rays and CT reveal fractured C7-8 vertebrae. Physical exam demonstrates total loss of reflexes, sensation, and movement below the level of injury. Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

14. You recognize these symptoms as being caused by spinal shock. What is spinal shock and how does it differ from neurogenic shock? Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

15. Characterized by ↓ Reflexes Loss of sensation Absent thermoregulation Flaccid paralysis below level of injury Lasts days to weeks Spinal Shock Copyright © 2017, Elsevier Inc. All Rights Reserved.

16. Characterized by Hypotension Bradycardia Loss of SNS innervation Peripheral vasodilation Venous pooling ↓ C ard iac output T6 or higher injury Neurogenic Shock Copyright © 2017, Elsevier Inc. All Rights Reserved.

17. SCI is classified by Mechanism of injury Level of injury Degree of injury Classification of SCI Copyright © 2017, Elsevier Inc. All Rights Reserved.

18. Major mechanisms of injury are Flexion Hyperextension Flexion-rotation Extension-rotation Compression Classification of SCI Copyright © 2017, Elsevier Inc. All Rights Reserved.

19. Mechanisms of Injury Copyright © 2017, Elsevier Inc. All Rights Reserved.

20. Skeletal vs. neurologic level Level of injury may be Cervical Thoracic Lumbar Sacral Tetraplegia ( quadraplegia ) Paraplegia Level of Injury Copyright © 2017, Elsevier Inc. All Rights Reserved.

21. Complete Total loss of sensory and motor function below level of injury Incomplete (partial) Mixed loss of voluntary motor activity and sensation Some tracts intact Degree of Injury Copyright © 2017, Elsevier Inc. All Rights Reserved.

22. Syndromes Associated with Incomplete SCI Copyright © 2017, Elsevier Inc. All Rights Reserved.

23. Damage to central spinal cord Most commonly cervical region More common in older adults Motor weakness and sensory loss Lower extremities are not usually affected Dysesthetic burning pain in upper extremities Incomplete SCI Central Cord Syndrome Copyright © 2017, Elsevier Inc. All Rights Reserved.

24. Damage to anterior spinal artery → compromised blood flow Typically results from flexion injury Motor paralysis and loss of pain and temperature sensation below level of injury Incomplete SCI Anterior Cord Syndrome Copyright © 2017, Elsevier Inc. All Rights Reserved.

25. Damage to one-half of cord Typically results from penetrating injury Ipsilateral loss of motor function and pressure, position, and vibration sense Contralateral loss of light touch, pain, and temperature sensation Incomplete SCI Brown- Séquard Syndrome Copyright © 2017, Elsevier Inc. All Rights Reserved.

26. Result from damage to conus medullaris (lowest portion of spinal cord) Motor function in legs may be preserved, weak, or flaccid Decrease in or loss of sensation in perianal area Areflexic bladder and bowel Impotence Degree of Injury Conus Medullaris Syndrome Copyright © 2017, Elsevier Inc. All Rights Reserved.

27. Result from damage to cauda equine (lumbar and sacral nerve roots) Asymmetrical distal weakness Flaccid paralysis of lower extremities Complete loss of sensation in saddle area Areflexic (flaccid) bladder and bowel Severe, radicular, asymmetric pain Cauda Equina Syndrome Copyright © 2017, Elsevier Inc. All Rights Reserved.

28. Related to level and degree of injury Incomplete → variable Sequelae more serious with higher injury Clinical Manifestations Copyright © 2017, Elsevier Inc. All Rights Reserved.

29. Manifestations depend on level of spinal injury Copyright © 2017, Elsevier Inc. All Rights Reserved.

30. ASIA Impairment Scale (From American Spinal Injury Association.) Copyright © 2017, Elsevier Inc. All Rights Reserved.

31. Closely correspond to level of injury Above level of C4 Total loss of respiratory muscle function Below level of C4 Diaphragmatic breathing → respiratory insufficiency Clinical Manifestations Respiratory System Copyright © 2017, Elsevier Inc. All Rights Reserved.

32. Cervical and thoracic injuries Paralysis of abdominal and intercostal muscles → ineffective cough → risk for aspiration, atelectasis, pneumonia Risk for neurogenic pulmonary edema Clinical Manifestations Respiratory System Copyright © 2017, Elsevier Inc. All Rights Reserved.

33. Injury above T6 leads to dysfunction of sympathetic nervous system Leads to neurogenic shock Bradycardia Peripheral vasodilation Hypotension Relative hypovolemia because of ↑ in capacity of dilated veins Reduced venous return decreasing cardiac output Clinical Manifestations Cardiovascular System Copyright © 2017, Elsevier Inc. All Rights Reserved.

34. Neurogenic bladder Bladder dysfunction related to abnormal or absent bladder innervation No reflex detrusor contractions (flaccid, hypotonic) Hyperactive reflex detrusor contractions (spastic) Lack of coordination between detrusor contraction and urethral relaxation ( dyssynergia ) Clinical Manifestations Urinary System Copyright © 2017, Elsevier Inc. All Rights Reserved.

35. Acute phase Urinary retention Bladder atonic, overdistended , fails to empty Indwelling catheter Postacute phase Bladder may become hyperirritable Loss of inhibition from brain Reflex emptying and failure to store urine Clinical Manifestations Urinary System Copyright © 2017, Elsevier Inc. All Rights Reserved.

36. Decreased GI motor activity Gastric distention Development of paralytic ileus Gastric emptying may be delayed Excessive release of HCl may cause stress ulcers Dysphagia may be present Intraabdominal bleeding may be difficult to diagnose Clinical Manifestations Gastrointestinal System Copyright © 2017, Elsevier Inc. All Rights Reserved.

37. Potential for skin breakdown Poikilothermism Interruption of SNS ↓ A b ility to sweat or shiver below the level of injury More common with high cervical injury Clinical Manifestations Integumentary System Copyright © 2017, Elsevier Inc. All Rights Reserved.

38. NG suctioning → metabolic alkalosis Monitor electrolytes, especially sodium and potassium ↑ Nutritional needs Nutritional support to focus on caloric and nitrogen needs Prevent skin breakdown, reduce infection, decrease muscle atrophy Clinical Manifestations Metabolic Needs Copyright © 2017, Elsevier Inc. All Rights Reserved.

39. Venous thromboembolism (VTE) Deep vein thrombosis (DVT) may be difficult to detect Pulmonary embolism Leading cause of death Clinical Manifestations Peripheral Vascular Problems Copyright © 2017, Elsevier Inc. All Rights Reserved.

40. Nociceptive Pain Musculoskeletal pain dull or aching, worsens with movement Visceral pain in thorax, abdomen, pelvis - dull, tender, or cramping Neuropathic Pain Located at or below level of injury Hot, burning, tingling, pins and needles, cold, shooting May be extremely sensitive to stimuli Clinical Manifestations Pain Copyright © 2017, Elsevier Inc. All Rights Reserved.

41. CT scan Cervical x-rays MRI Comprehensive neurologic examination CT angiogram Diagnostic Studies Copyright © 2017, Elsevier Inc. All Rights Reserved.

42. Immediate goals Patent airway Adequate ventilation/breathing Adequate circulating blood volume Prevent extension of spinal cord damage Interprofessional Care Prehospital Copyright © 2017, Elsevier Inc. All Rights Reserved.

43. Immobilization Rigid cervical collar Backboard with straps Spinal immobilization with penetrating trauma not recommended Maintain systolic BP >90mm Hg Interprofessional Care Prehospital Copyright © 2017, Elsevier Inc. All Rights Reserved.

44. Initial care Cervical injury requires more intense support Obtain history, emphasizing incident Assess extent of injury Initial assessment Managing ABCs and vital signs Medical interventions and diagnostics Complete neurologic assessment using ASIA tool Interprofessional Care Acute Care Copyright © 2017, Elsevier Inc. All Rights Reserved.

45. Additional assessment Brain injury and/or vertebral artery injury History of unconsciousness Signs of concussion Increased intracranial pressure Musculoskeletal injuries Trauma to internal organs Interprofessional Care Acute Care Copyright © 2017, Elsevier Inc. All Rights Reserved.

46. Move the patient in alignment as a unit (logroll) Monitor respiratory, cardiac, urinary, GI functions Interprofessional Care Acute Care Copyright © 2017, Elsevier Inc. All Rights Reserved.

47. Stabilization of injured spinal segment Eliminates damaging motion Prevent secondary damage Decompression Traction or realignment Early realignment Closed reduction Craniocervical traction Interprofessional Care Nonoperative Stabilization Copyright © 2017, Elsevier Inc. All Rights Reserved.

48. Used following acute SCI to fix instability and decompress the spinal cord Surgery within first 24 hours associated with improved neurologic outcome Posterior approach Anterior approach Fusion Interprofessional Care Surgical Therapy Copyright © 2017, Elsevier Inc. All Rights Reserved.

49. J.N.’s cervical spine is immobilized. A neurosurgeon is consulted. Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

50. Low-molecular-weight heparin Prevent VTE Vasopressor agents Maintain mean arterial pressure >85-90 mm Hg Significant risk of complications Altered drug metabolism → ↑ risk for interactions Interprofessional Care Drug Therapy Copyright © 2017, Elsevier Inc. All Rights Reserved.

51. Subjective Data Health history Functional health patterns Health perception–health management Activity-exercise Cognitive-perceptual Coping–stress tolerance Nursing Assessment: SCI Copyright © 2017, Elsevier Inc. All Rights Reserved.

52. Objective Data Poikilothermism Warm, dry skin (neurogenic shock) Respiratory difficulties Bradycardia, hypotension Decreased or absent bowel sounds Abdominal distention Constipation, incontinence, impaction Nursing Assessment Copyright © 2017, Elsevier Inc. All Rights Reserved.

53. Objective Data Urinary retention Flaccid or spastic bladder Priapism Loss of sexual function Paralysis Hyperactive deep tendon reflexes Muscle atony, contractures Nursing Assessment Copyright © 2017, Elsevier Inc. All Rights Reserved.

54. Ineffective breathing pattern Imbalanced nutrition: less than body requirements Ineffective peripheral tissue perfusion Impaired skin integrity Impaired urinary elimination Constipation Risk for autonomic hyperreflexia ( dysreflexia ) Nursing Diagnoses Copyright © 2017, Elsevier Inc. All Rights Reserved.

55. Overall Goals Optimal level of neurologic functioning Minimal to no complications of immobility Learn skills, gain new knowledge, and acquire new behaviors to care for self Return to home at optimum level of functioning Planning Copyright © 2017, Elsevier Inc. All Rights Reserved.

56. Health Promotion Identify High-risk populations Counseling Teaching Support legislation to Prohibit texting while driving, Mandate use of seat belts in cars, Mandate helmets- motorcyclists/ bicyclists Mandate child safety seats Recommend tougher penalties for drunk-driving Nursing Implementation Copyright © 2017, Elsevier Inc. All Rights Reserved.

57. Health Promotion Teaching and counseling Referring to programs Performing routine physical exams Facilitate wheelchair-accessible health care screening, exam rooms, etc. Nursing Implementation Copyright © 2017, Elsevier Inc. All Rights Reserved.

58. Immobilization Maintain neutral position Stabilize to prevent lateral rotation Hard cervical collar Backboard Keep body in correct alignment Turn as a unit (logrolling) Acute Care Copyright © 2017, Elsevier Inc. All Rights Reserved.

59. J.N. is sent to the OR for surgical stabilization of her spine. Her family tells you they had a friend with a cervical fracture who was treated with traction. They ask you to explain the difference in treatment. What is cervical traction? Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

60. Skeletal traction Realignment or reduction of injury Crutchfield, Gardner-Wells, or halo Rope, pulley, and weights Traction maintained at all times If displacement occurs, hold head in neutral position and get help Immobilization Copyright © 2017, Elsevier Inc. All Rights Reserved.

61. Immobilization Copyright © 2017, Elsevier Inc. All Rights Reserved.

62. SOMI Brace Copyright © 2017, Elsevier Inc. All Rights Reserved.

63. Halo Vest Copyright © 2017, Elsevier Inc. All Rights Reserved.

64. Potential for infection at sites of tongs or halo pin insertion Preventive care based on hospital protocol Common protocol involves: Cleansing with ½ strength peroxide and normal saline twice a day Applying antibiotic ointment Pin Site Care Copyright © 2017, Elsevier Inc. All Rights Reserved.

65. Kinetic therapy Continual side-to-side rotation Prevent pulmonary complications Prevent pressure ulcers Immobilization Copyright © 2017, Elsevier Inc. All Rights Reserved.

66. RotoRest Copyright © 2017, Elsevier Inc. All Rights Reserved.

67. Stable thoracic or lumbar spine injuries Custom thoracolumbar orthosis (TLSO or body jacket) Jewett brace Profound effects of immobility Meticulous skin care critical Fit immobilizers properly Immobilization Copyright © 2017, Elsevier Inc. All Rights Reserved.

68. What would be your priority assessment of J.N. ’s condition upon her return from surgery? Explain your answer. Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

69. Spinal cord edema may increase during first 48 hours May need intubation and mechanical ventilation ↑ R i sk for pneumonia and atelectasis Respiratory Dysfunction Copyright © 2017, Elsevier Inc. All Rights Reserved.

70. Regular assessment Intervene to maintain ventilation Administer oxygen Provide ventilator support Chest physiotherapy Assisted (augmented) coughing Tracheal suctioning Incentive spirometry Appropriate pain management Respiratory Dysfunction Copyright © 2017, Elsevier Inc. All Rights Reserved.

71. Risk for bradycardia and cardiac arrest Chronic low blood pressure with postural hypotension ↑ R isk for DVT Dysrhythmias may occur Cardiovascular Instability Copyright © 2017, Elsevier Inc. All Rights Reserved.

72. Frequently assess vital signs Anticholinergic drug/pacemaker Fluid replacement, vasopressor agent If blood loss occurred Monitor hemoglobin and hematocrit Possible blood administration Assess orthostatic BP Abdominal binders/compression stockings Drug therapy Cardiovascular Instability Copyright © 2017, Elsevier Inc. All Rights Reserved.

73. Assess for signs of DVT Prophylactic low-molecular-weight heparin or low-dose heparin Sequential compression devices and/or gradient stockings Assess thighs and calves every shift Range-of-motion exercises and stretching Cardiovascular Instability Copyright © 2017, Elsevier Inc. All Rights Reserved.

74. Paralytic ileus may occur, requiring NG tube Monitor fluid and electrolytes Nutrition should be started within 72 hours Individualized solutions/additives High-protein, high-calorie diet Possible parenteral nutrition Fluid and Nutritional Maintenance 74 Copyright © 2017, Elsevier Inc. All Rights Reserved.

75. Inadequate nutritional intake Assess for cause Contract with patient General measures Pleasant eating environment Adequate time Calorie count Dietary supplements Increased dietary fiber Fluid and Nutritional Maintenance Copyright © 2017, Elsevier Inc. All Rights Reserved.

76. J.N. is concerned about how she will be able to control her bladder and bowel with her current status. How will you respond to J.N.? Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

77. Neurogenic bladder initially Indwelling urinary catheter Strict aseptic technique ↑ Fluid intake Intermittent catheterization program Every 4-6 times daily Monitor for signs and symptoms of urinary tract infections Bladder Management Copyright © 2017, Elsevier Inc. All Rights Reserved.

78. Neurogenic bowel initially Bowel program started during acute care Daily rectal stimulant Suppository or small-volume enema Digital stimulation or manual evacuation Adequate fluid and fiber intake Increased activity and exercise Bowel Management Copyright © 2017, Elsevier Inc. All Rights Reserved.

79. No vasoconstriction, piloerection, or heat loss through perspiration below level of injury Temperature control is external Monitor environment and body temperature Do not use excessive covers or unduly expose patient Temperature Control Copyright © 2017, Elsevier Inc. All Rights Reserved.

80. ↑ R is k secondary to severe trauma and physiologic stress Monitor stool, gastric contents, and hematocrit Prophylactic medications Stress Ulcers Copyright © 2017, Elsevier Inc. All Rights Reserved.

81. Secondary to absent sensations Stimulate patient above level of injury Conversation, music, and interesting foods Prism glasses to read and watch TV Help patient avoid withdrawing from the environment Sensory Deprivation Copyright © 2017, Elsevier Inc. All Rights Reserved.

82. Musculoskeletal nociceptive pain Antiinflammatory drugs Opioids Visceral nociceptive pain Diagnostic imaging to evaluate cause Neuropathic pain Gabapentin (Neurontin) or pregabalin (Lyrica) Teach about pain triggers and relaxation therapy Pain Management Copyright © 2017, Elsevier Inc. All Rights Reserved.

83. Comprehensive visual and tactile examination Careful positioning and repositioning every 2 hours Specialty mattresses, pressure-relieving cushions Assess nutritional status Skin Care Copyright © 2017, Elsevier Inc. All Rights Reserved.

84. Return of reflexes may complicate rehabilitation Hyperactive Exaggerated responses Penile erections Spasms Patient teaching Antispasmodic drugs Reflexes Copyright © 2017, Elsevier Inc. All Rights Reserved.

85. Some of J.N.’s reflexes have returned. You walk into her room one morning to find her pale and diaphoretic. She is complaining of a pounding headache. You assess her vital signs and find her BP is 206/100 mm Hg and her heart rate is 56 bpm. Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

86. What do you suspect is going on with J.N.? Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

87. Massive uncompensated cardiovascular reaction mediated by sympathetic nervous system SNS responds to stimulation of sensory receptors – parasympathetic nervous system unable to counteract these responses. Hypertension and bradycardia Autonomic Dysreflexia Copyright © 2017, Elsevier Inc. All Rights Reserved.

88. What would be the most likely cause of autonomic dysreflexia in J.N.? Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

89. Most common precipitating factor is distended bladder or rectum Manifestations Hypertension (up to 300 mm Hg systolic) Throbbing headache Marked diaphoresis above level of injury Bradycardia (30 to 40 beats/minute) Autonomic Dysreflexia Copyright © 2017, Elsevier Inc. All Rights Reserved.

90. For what other clinical manifestations of autonomic dysreflexia will you assess J.N.? Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

91. Manifestations Piloerection Flushing of skin above level of injury Blurred vision or spots in visual field Nasal congestion Anxiety Nausea Autonomic Dysreflexia Copyright © 2017, Elsevier Inc. All Rights Reserved.

92. What are appropriate nursing interventions for J.N. at this point? Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

93. Nursing interventions Elevate head, sit upright Notify HCP Assess for and remove cause Immediate catheterization Remove stool impaction if cause Remove constrictive clothing/tight shoes Monitor and treat BP Patient and caregiver teaching Autonomic Dysreflexia Copyright © 2017, Elsevier Inc. All Rights Reserved.

94. Complex Goal to function at highest level of wellness Retraining focus Interprofessional team effort Rehabilitation and Home Care Copyright © 2017, Elsevier Inc. All Rights Reserved.

95. Organized around patient’s goals and needs Patient expected To be involved in therapies To learn self-care Can be very stressful Frequent encouragement Rehabilitation and Home Care Copyright © 2017, Elsevier Inc. All Rights Reserved.

96. Rehabilitation and Home Care Copyright © 2017, Elsevier Inc. All Rights Reserved.

97. Respiratory Rehabilitation Mechanical ventilation for injury above C3 Round-the-clock caregiver Respiratory hygiene Tracheostomy care Phrenic nerve stimulator Diaphragmatic pacemaker Mobile ventilators Patient teaching Copyright © 2017, Elsevier Inc. All Rights Reserved.

98. Areflexic (flaccid), hyperreflexic (spastic), or dyssynergia Common problems Urgency, frequency, incontinence, inability to void, and high bladder pressures resulting in reflux of urine into kidneys Neurogenic Bladder Copyright © 2017, Elsevier Inc. All Rights Reserved.

99. Drug therapy Anticholinergic drugs α- Adrenergic blockers Antispasmodic drugs Drainage methods Bladder reflex training Indwelling, intermittent, external catheterization Urinary diversion surgery Patient teaching Neurogenic Bladder Copyright © 2017, Elsevier Inc. All Rights Reserved.

100. Voluntary control may be lost High-fiber diet Adequate fluid intake Suppositories Small-volume enemas Digital stimulation Mandatory for upper motor neuron injury Neurogenic Bowel Copyright © 2017, Elsevier Inc. All Rights Reserved.

101. Stool softener Oral stimulant laxatives Valsalva maneuver with manual stimulation Use of gastrocolic reflex Timing to not interrupt therapy Neurogenic Bowel Copyright © 2017, Elsevier Inc. All Rights Reserved.

102. Can be both beneficial and undesirable Ashworth and modified Ashworth scales Treatment ROM exercises Antispasmodic drugs Botulinum toxin injections Spasticity Copyright © 2017, Elsevier Inc. All Rights Reserved.

103. Prevention essential Patient teaching Comprehensive daily exam Teach to reposition At least every 2 hours while in bed Every 15 to 20 minutes when in a chair Pressure-relieving cushion or mattress Adequate nutrition Protect from thermal injury Neurogenic Skin Copyright © 2017, Elsevier Inc. All Rights Reserved.

104. Acute pain Assess, evaluate, and treat routinely Analgesics Massage and repositioning Chronic pain May be result of overuse of muscles Sleep may be disrupted May refer to pain management specialist Pain Management Copyright © 2017, Elsevier Inc. All Rights Reserved.

105. J.N. is worried how this SCI will affect her sexual abilities. What will you teach her? Case Study (©Comstock/Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

106. Important issue regardless of patient’s age or gender Nurse must Have an awareness and an acceptance of personal sexuality Have knowledge of human sexual responses Use medical terminology Sexuality Copyright © 2017, Elsevier Inc. All Rights Reserved.

107. Injury level and completeness of injury impacts function Psychogenic versus reflex erection Treatments for erectile dysfunction Drugs Vacuum devices Surgical procedures Fertility issues Sexuality Copyright © 2017, Elsevier Inc. All Rights Reserved.

108. Fertility not usually affected Pregnancy complicated Risk for precipitous delivery Female sexual activity Urinary catheterization Planning for bowel evacuation prior Incontinence Lubrication Sexuality Copyright © 2017, Elsevier Inc. All Rights Reserved.

109. SCI Has Major Effect on Person and Family (© JackF / iStock /Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

110. Depression is common Overwhelming sense of loss Loss of control Adjustment more than acceptance Wide fluctuation in emotions Allow mourning while encouraging hope Grief and Depression Copyright © 2017, Elsevier Inc. All Rights Reserved.

111. Sympathy not helpful Encourage patient participation Consistency of care Psychiatric consult if needed Caregiver and family counseling Support group Grief and Depression Copyright © 2017, Elsevier Inc. All Rights Reserved.

112. Adequate ventilation Adequate circulation and BP Intact skin Adequate nutrition Bowel management Bladder management No autonomic hyperreflexia Evaluation Copyright © 2017, Elsevier Inc. All Rights Reserved.

113. Older Adult with SCI An increasing number of older adults are living with a chronic spinal cord injury. (© WavebreakmediaLtd / WavebreakMedia /Thinkstock) Copyright © 2017, Elsevier Inc. All Rights Reserved.

114. Increased incidence Increased complications Hospitalized linger Increased mortality rates Health promotion and screening Rehabilitation lengthened Gerontologic Considerations Copyright © 2017, Elsevier Inc. All Rights Reserved.

115. A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for return of reflexes. bradycardia with hypoxemia. effects of sensory deprivation. fluctuations in body temperature. Audience Response Question Copyright © 2017, Elsevier Inc. All Rights Reserved.

116. A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to breathe with respiratory support. drive a vehicle with hand controls. ambulate with long-leg braces and crutches. use a powered device to handle eating utensils. Audience Response Question Copyright © 2017, Elsevier Inc. All Rights Reserved.

117. During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which finding would concern the nurse the most ? A heart rate of 92 A reddened area over the patient’s coccyx Marked perspiration on the patient’s face and arms A light inspiratory wheeze on auscultation of the lungs Audience Response Question Copyright © 2017, Elsevier Inc. All Rights Reserved.