Nursing care of the patient with sci

A presentation I gave at Haydom Lutheran Hospital in Tanzania

1. Matthew Rollosson, RN
Haydom Lutheran Hospital
28 August 2014

2. Collaboration
Emergency personnel
Care begins at the place where the patient
was injured
Doctors
Nurses
Physiotherapists
The patient’s family

3. 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

4. Causes
Trauma
Interruption of blood supply
Diseases
Cancer
Infectious diseases
Bone degeneration
Congenital defects

5. Mechanisms of injury
Motor vehicle accidents
Falls
Violence
Sports injuries
Demographics
≥ 80% male
Young age
20 to 40 years of age

6. Brain injury
Chest trauma
Abdominal injuries
Limb fracture
Patient may not feel pain below level of
spinal cord injury

7. 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”

9. 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

10. 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

12. 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

14. Cardiovascular
Decreased cardiac output
Ineffective thermoregulation
Autonomic dysreflexia
Gastrointestinal
Risk for constipation
Bowel incontinence

15. Genitourinary
Risk for infection
Urinary incontinence
Musculoskeletal
Risk for injury
Disuse syndrome
Integument
Risk for impaired skin integrity

16. 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

17. 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

18. Nursing diagnosis:
Risk for ineffective cerebral tissue
perfusion

19. Nursing diagnosis:
Risk for ineffective cerebral central
nervous system tissue perfusion

20. 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

21. 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

22. 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

23. Unstable spine
Fracture
Dislocation

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

24. Log roll

Swartz, 2014

25. Nursing diagnoses
Ineffective airway clearance
Risk for infection
Risk for impaired skin integrity
Risk for constipation

26. Loss innervation of respiratory accessory
muscles, intracostal muscles, and abdominal
muscles
Quad coughing:
Atrice et al., 2013

27. Turn every 2 hours
Log roll
Douglas et al., 2013

28. 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

29. Encourage oral fluid intake
“At least 8 glasses per day”
≈ 2 liters

30. High fiber diet

31. 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

32. Life-threatening
Injuries above the 6
th
thoracic vertebra (T6)
Risk begins after the return of spinal reflexes
3 to 6 weeks after injury
Uncontrolled sympathetic discharge from the
spinal cord

33. 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

34. Complications:
Seizures (convulsions, fits)
Stroke
Retinal detachment (blindness)
Death

35. Cause
Painful stimulation, irritation below the
level of injury
Most commonly caused by
Distended bladder
Kinked, blocked catheter
Distended bowel
Constipation
Fecal impaction

36. 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

37. 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?

38. 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

39. 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

40. 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.

41. 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.