Shepherd Center: A Catastrophic Care Hospital

Shepherd Center:
A Catastrophic Care Hospital
The Jane Woodruff Pavilion
Acute Management of SCI
&
Prevention of Secondary Complications
Joycelyn Craig, BSN, RN, CRRN
SCI Nurse Education Manager
FACTS & STATISTICS
Model SCI Care System Data, Archives of Physical and Medical Rehabilitation, January 2008
PREVALENCE in US
• 227,080 - 300,938 living with SCI
• 12,000 annually
AGE
• 24% are between the ages of 16-30
• 55% are between the ages of 31-45
• 11.5% are older than 60
GENDER
• 77.8% are males
Model Systems
• National SCI database
– NSCI Statistical Center
– www.spinalcord.uab.edu
• Independent and collaborative research
• Resources to individuals with SCI, family and
caregivers, health care professionals and the
general public
– www.shepherd.org
– www.pva.org
SPINAL CORD INJURY
An injury to the
spinal cord at any
level between the
foramen magnum
and the cauda
equina, from any
cause.
CERVICAL:
7 Bones-8 Nerves
Cervical Nerves
C1
C2
Neck
C3
C4
Shoulder Shrug,
Neck, Diaphragm
C5
Shoulder Muscles
Front Arm Muscles
C6
Wrist Muscles,
Shoulder Muscles
C7
C8
Lower Arms, Fingers
THORACIC: 12 Bones-12 Nerves
Thoracic Nerves
T1
Hand
T2 thru T6
Middle part of the
body (trunk), chest
and stomach area
T7 thru T12
Coughing and
laughing muscles
LUMBAR:
5 Bones-5 Nerves
Lumbar
L1
Hips
L2
L3
Knees
L4
Top of Foot and
Ankle
L5
SACRAL: 1 Bone-5 Nerves
Sacral
S1
Legs
S2
Feet
S3
S4
Bowel & Bladder
S5
Sex Organs
CLASSIFICATION of SCI
ASIA
• A–E
• most widely accepted
• “neurologic” basis
ASIA CLASSIFICATIONS
ASIA A = no motor or sensory function is preserved in the sacral
segments S4-S5.
ASIA B = sensory but not motor function is preserved below the
neurological level and includes the sacral segments S4-S5
ASIA C = motor is preserved below the neurological level, and
most of the key muscles below the neuro level have a muscle
grade < 3.
ASIA D = motor function is preserved below the neurological
level, and at least half of key muscles below the neurological
level have a muscle grade =or > 3.
ASIA E = NORMAL motor and sensory testing.
CLASSIFICATION of SCI
• Complete SCI = no motor or sensory
function below the LOI.
• Incomplete SCI = any sensation present
and/or any motor function below the LOI.
INCOMPLETE SYNDROMES
•
•
•
•
•
•
•
Brown-Sequard
Central Cord
Anterior Cord
Posterior Cord
Conus Medullaris
Cauda Equina
Mixed (combination of 2 of above)
INCOMPLETE SYNDROMES
Brown Sequard:
damage to one
side of cord
– ipsilateral
paralysis, loss
proprioception
– contralateral loss
of pain and
temperature
INCOMPLETE SYNDROMES
Central cord:
damage to central
part of cord
– greater weakness
in arms verses legs
– sacral sensation
INCOMPLETE SYNDROMES
POSTERIOR
CORD
ANTERIOR
CORD
Lesion within
posterior 1/3 of
cord
Sensory and
motor function
intact
Loss of
proprioception
Lesion within
anterior 2/3 of
cord
Paralysis with loss of
pain and
temperature
Proprioception
intact
MECHANISM OF INJURY
The CNS, of which the spinal cord is a part, is
extremely fragile.
Even slight pressure on the spinal cord from
the primary injury or from the secondary
injury in the form of swelling or infection or
bruising, can result in permanent and severe
neurologic injury.
Spinal Cord
Nursing
• Prevention of
Secondary Injury
• Spinal stabilization
• Proactive Prevention of
Medical Complications
FIRST ---Immobilize
THEN-Assess & Test
High Dose Solumedrol Protocol
Within 3 hours of the injury:
• Solumedrol 30 mg/kg IV as a bolus dose
• over 15-60 minutes, then 5.4 mg/kg/hr for 23-24
hours.
Within 8 hours of the injury:
• Solumedrol 30 mg/kg IV as a bolus dose over 15-60
minutes, then 5.4 mg/kg/hr for 47-48 hours.
• Monitor blood glucose
Spinal Stabilization
Goals:
• Prevent further damage to the spinal cord.
• Provide means for early mobilization.
Cervical Traction: Gardner-Wells Tongs
• Proper alignment until surgery.
• Constant traction force at all times. Ensure that weights
hang freely.
• Pin-site care with soap and water every shift.
• Log rolls
Halo Vest
• A device that is
used for unstable
cervical injuries
that are in
alignment.
• Skin care.
• Patient safety.
Cervical Fusion and Wiring
•
•
•
•
Anterior and/or Posterior Fusion
Hard collar to be worn at all times
post-op, for 6 weeks.
Skin.
Harrington Rods
• For thoracic-lumbar injuries.
• Embedded in the neural arch to provide a
distraction force.
• TLSO post operatively for 4-6 weeks.
• Skin.
Rehab Priorities 1st 72 Hours
•
•
•
•
•
•
Spinal Shock
Respiratory Intervention
Skin Protection
Bowel Function
Bladder Health
Early Mobilization
Spinal Shock
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•
•
•
Occurs 30-60 minutes post traumatic SCI
Can last a few hours to several weeks
Flaccid paralysis
Absence of all spinal reflexes below the level of
injury.
• Loss of pain, touch, temperature, and pressure.
• Loss of bowel & bladder function.
Spinal Shock
• Bowel– Initiate suppository and manual evacuation within
24-48 hours.
– Daily bowel program.
– Skin care.
• Bladder– Foley.
– Perineal skin care.
SKIN
•
•
•
•
•
•
•
Bed
Padding & Positioning
Shearing
Spasms
Bony prominences
Visualize new areas
Head-to-toe
assessments
• Pressure relief
• Turns
• Weight Shifts
EVERY Patient
Deserves Their Turn!
• Evaluate to increase 30
min/week
• Skin checks at least twice
per shift
• Keep pressure off affected
areas
Padding and Positioning
•
•
•
•
Protect the skin
Prevent contractures
Prevent painful shoulders
Decrease respiratory complications
Autonomic Nervous System
• ANS Dysfunction
• ANS disruption makes the parasympathetic
system dominant.
ANS Dysfunction
•
•
•
•
•
Bradycardia
Hypotension
Pneumonia/ Atelactasis
DVT
Stress Ulcers/ GI Bleed
•
•
•
•
•
Poikilothermism
Autonomic Dysreflexia
Bowel
Bladder
Skin
ANS Dysfunction
Bradycardia
• Already decreased due to parasympathetic
dominance--the absence of the inhibiting effects of
the sympathetic system
• Often due to vagus nerve stimulation
• Can be extreme:
– Pre-medicate prior to suctioning
– Pacemaker
ANS Dysfunction
Hypotension
• Parasympathetic dominance resulting in
vasodilation.
• Vasoconstrictive therapy:
– Dopamine
– Neosynephrine
– Florinef
– Midodrine
ANS Dysfunction
Pneumonia/Atelectasis
• Leading cause of death in SCI population.
• PS—mucus production increases; bronchial
constriction
• Result of immobilization, artificial ventilation, and
general anesthesia.
• Interventions:
– Aggressive pulmonary toiletry
– Bronchodilator therapy
ANS Dysfunction
DVT/PE
• Result of increased platelet aggregation and
common post-op complication
• Intervention:
– Continuous Assessment
– Early Detection
– Prophylactic anticoagulants
ANS Dysfunction
GI
• PS-increased gastric secretions, motility,
digestion
• Gastroduodenal ulcers; GI bleeding
• Disruption of CNS, stress response, abdominal
trauma
• Interventions:
– Initiate proper delivery of nutrition
– Prophylactic meds
ANS Dysfunction
Poikilothermism
• Interruption of sympathetic pathways to
hypothalamus.
• Loss of sympathetic response below level of
injury resulting in the inability to shiver or
perspire.
• Warming or cooling blankets.
Temperature control
• NO vasoconstriction, piloerection or heat loss
through sweating below level of injury
• Do not over cool or over heat.
ANS Dysfunction
Autonomic Dysreflexia
• Life-threatening.
• Inappropriate reflex action, occurring with
injury levels T6 and above.
• Noxious stimuli: distended bladder, full rectal
vault, skin issue, infection, ingrown toenail.
ANS Dysfunction
Autonomic Dysreflexia
• S & Sx
– Pounding headache
– BP > 15mm Hg over baseline
– Sweating
– Blotchy/skin redness above LOI
– Nasal congestion
ANS Dysfunction
Autonomic Dysreflexia
• Interventions:
– Elevate HOB to 90 degrees
– Remove constrictions: binder, TED hose, etc.
– Assess foley for drainage problems
– Bowel program with nupercaine
– Skin issues
ANS Dysfunction
Autonomic Dysreflexia
• Monitor time
• Monitor BP
• Treat BP-procardia
• Notify MD
• Continue to search for cause
• Monitor BP
ANS Dysfunction
BOWEL
• Stool continues to be produced; not
evacuated.
• Suppository and rectal clearing.
• Monitor results.
• Consider contrast materials used.
• Skin at risk.
ANS Dysfunction
BLADDER
• Neurogenic Bladder management
• Prevent overdistention, ureterovisical reflux.
• Skin at risk.
ANS Dysfunction
SKIN
• Turns, no less than every 2 hours.
• Visualize new areas with every turn.
• Head-to-toe assessments.
Other Issues to Address
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Impaired physical mobility
Altered nutrition
Sexual dysfunction
Risk or injury r/t sensory deficits
Altered family processes
Risk for ineffective individual coping
Body image disturbance
Grief, guilt, depression
Family Involvement
Directly related to degree of successful discharge
and life planning.
Teach family & caregivers all aspects of care.
Help me be ready for rehab
• Prevent skin issues
• Prevent respiratory
complications
• Reduce secondary
complications
• Anticipate discharge
• Involve the family
• Educate & Explain
• Establish B & B regime
Questions?