MS 2 Neuro Sci PDF

MS II: NEURO: CHAP 62 SPINAL CORD INJURY
Lecturer: Sir Ceddie

SPINAL CORD INJURY
•294,000 persons in the United States live with disability *MVA- a complication of this will be related now is your
from SCI respiratory failure -> although, Autonomic Dysreflexia
•Causes include MVAs, falls, violence (gunshot wounds), which is MEDICAL EMERGENCY.
and sports-related injuries AUTONOMIC DYSREFLEXIA- exaggerated activation of
•Males account for 78% of SCIs (bec of their your ANS, manifestation would be excited ANS function,
aggressiveness) meaning no’n mayroon tayong rapid increase BP,
•Average age of injury is 43 (we don’t limit SCI to this, any affecting VS.
age) .
•Risk factors include young age, male gender, alcohol PATHOPHYSIOLOGY OF SPINAL CORD INJURY
and drug use •The result of concussion, contusion, laceration, or
•Major causes of death are pneumonia, pulmonary compression of spinal cord
embolism (PE), and sepsis (bec if nagkaroon tayo ng •Primary injury is the result of the initial trauma and
access to motor function and accessory function there usually permanent (initial trauma is directed to your spinal
will be microorganism that will kill you) cord, more likely the effects would be permanent)
•Secondary injury resulting from SCI include edema and
NOTES: hemorrhage (some of the pharmacological management is
*most likely if we talk about SCI, this is now your traumatic trying to control your edema and hemorrhage)
injuries directed to your spinal cord, resulting in your direct or
•Major concern for critical care nurses (the goal of the
blunt trauma to your spinal column
nurse- IS TO PREVENT FURTHER DAMAGE, usually, in
*Blunt trauma- there’s no protruding or penetration outside
emergency case/scenario ang client natin is will be always
*Penetrating trauma-binaril, sinaksak sa likod
suspected for SCI, therefore, the nurse, in charge in certain
*two types of SCI: PARTIAL and COMPLETE SCI
procedure like, kinakailangan IMMOBILIZE ang pt)
*Complete SCI: total wreckage, total loss of motor and sensory
•Treatment is needed to prevent partial injury from
function below the level of injuries
*Partial SCI: there’s still attachment of Spinal column, hindi
developing into more extensive, permanent damage
siya buo. MOST FREQUENTLY INVOLVED VERTEBRAE
*and whenever you try to analyze your SCI, the affectation will •Cervical-C5, C6, and C7,
be below the level of injury, and it’s never the above. •Thoracic-T12
*the affectation will be from the cervical region, therefore ang •Lumbar-L1
affectation will be downward. *this type of injury might result to your tetraplegia and
*PARTIAL SCI: pwedeng may mga spinal fractures, katulad no’n paraplegia
sa breathing natin, integrated by your PHRENIC NERVE, pwede
*TETRAPLEGIA- paralysis of inability to move your upper
magkaroon ng loss of function sa may thoracic region but
breathing effort is still present.
and lower extremities; inability to move or execute of
voluntary movements in the upper and lower extremities
Trauma to the spinal cord causes partial or complete
disruption of the nerve tracts and neurons. *PARAPLEGIA – affectation is lower extremities; inability
SPINAL CORD INJURY to execute motor function voluntarily in the lower
•Loss of motor function, sensation, reflex activity, and extremities
bowel and bladder control may result.
*Remember: sa function ng bladder natin, pwede magkaroon SPINAL CORD PATHWAYS TRANSECTIONS
ng contraction but there’s no emptying of the bladder C1-C3- NO FUNCTION BELOW HEAD
*NEUROGENIC BLADDER- contraction of the bladder without C4-C5 -QUADRIPLEGIA: BREATHING SPARED (meaning
the expulsion of the urine. There’s no micturition. ng breathing spared- humihinga pa rin pt bec hindi pa
MICTURITION-a reflex expect the urine to the bladder affected ang phrenic nerve)
*may mga SCI na may contraction ang bladder pero hindi sila C6-C8 -LOSS OF LOWER LIMB FUNCTION: SOME UPPER
nakaka-ihi, na-apektuhan yong micturition reflex nila
LIMB FUNCTION INTACT
•The most common causes include motor vehicle T1-T9- PARAPLEGIA
accidents falls, sporting and industrial accidents, and
T10-L3- SOME LOWER LIMB FUNCTION INTACT
gunshot or stab wounds.
•Complications related to the injury include respiratory
failure, autonomic dysreflexia, spinal shock, further cord
damage, and death.
TRANSECTION OF THE CORD
Kate, Monette, Phia, Ella

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•COMPLETE TRANSECTION OF THE CORD -On the opposite side of the body (contralateral) from
The spinal cord is severed completely, with total loss of the lesion or cord damage, the sensations of pain,
sensation, movement, and reflex activity below the level temperature, and light touch are affected.
of injury.
*more likely, dalawa ang ating brown-sequard syndrome:
*Occurs resulting in permanent damage ipsilateral and contralateral
*COMPLETE-> gulay ang pt •CONUS MEDULLARIS SYNDROME
•PARTIAL TRANSECTION OF THE CORD -Conus medullaris syndrome follows damage to the
The spinal cord is damaged or severed partially. lumbar nerve roots and conus medullaris in the spinal
The symptoms depend on the extent and location of the cord.
damage. -Client experiences bowel and bladder areflexia and
•If the cord has not suffered irreparable damage, early flaccid lower extremities.
treatment is needed to prevent partial damage from -If damage is limited to the upper sacral segments of the
developing into total and permanent damage. spinal cord, bulbospongiosus penile (erection) and
micturition reflexes will remain.
*more likely, may attachment pa rin but severed partially
*need to prevent further damage.
*bladder, bowel, and intestine are affected
*some function or feeling below the injury
*directed to your lumbar roots and conus medullaris in
SPINAL CORD SYNDROMES IN INCOMPLETE INJURY spinal cord bandang baba
• CENTRAL CORD SYNDROME *erection and micturition reflex will remain
-Central cord syndrome occurs from a lesion in the
central portion of the spinal cord. •CAUDA EQUINA SYNDROME
-Loss of motor function is more pronounced in the -Cauda quina syndrome occurs from injury to the
upper extremities, and varying degrees and patterns lumbosacral. nerve roots below the conus medullaris.
of sensation remain intact.
*Affectation: central part -The client experiences areflexia of the bowel, bladder,
and lower reflexes.
•ANTERIOR CORD SYNDROME *affectation is lumbosacral nerve roots
-Anterior cord syndrome is caused by damage to the
anterior portion of the gray and white matter of the spinal
cord.
CERVICAL INJURIES
-Motor function, pain, and temperature sensation are
-Injury at C2 to C3 is usually fatal.
lost below the level of injury; however, the sensations of
position, vibration, and touch remain intact.
-C4 is the major innervation to the diaphragm by the
*sense of position is not lost
phrenic nerve. Involvement above C4 causes
•POSTERIOR CORD SYNDROME
respiratory difficulty and paralysis of all four
-Posterior cord syndrome Is caused by damage to the
extremities.
posterior portion of the gray and white matter of the
-Client may have movement in the shoulder if the injury
spinal cord.
is at C5 through C8 and may also have decreased
-Motor function remains intact, but the client
respiratory reserve.
experiences a loss of vibratory sense, crude touch, and
*usually cinocontrol natin ang cervical region bec diyan
position sensation.
ang pinaka-mabilis na makakamapatay sa pt, bec
•BROWN-SÉQUARD SYNDROME andiyan ang breathing.
-Brown-Séguard syndrome results from penetrating
THORACIC LEVEL INJURIES
injuries that cause hemisection of the spinal cord or
-Loss of movement of the 'chest, trunk, bowel, bladder,
injuries that affect half the cord.
and legs may occur, depending on the level of injury.
-Motor function, vibration, proprioception, and deep
-Leg paralysis (paraplegia) may occur.
touch sensations are lost on the same side of the body
-Autonomic dysreflexia with lesions or injuries above
(ipsilateral) as the lesion or cord damage. T6 and in cervical lesions may occur.

-Visceral distention from a noxious stimuli such as a
distended bladder or impacted rectum may cause INTERVENTIONS DURING HOSPITALIZATION
reactions such as sweating, bradycardia, RESPIRATORY SYSTEM
hypertension, nasal stuffiness, and goose flesh. -> * Assess respiratory status because paralysis of the
MANIFESTATION OF AUTONOMIC DYSREFLEXIA intercostal and abdominal muscles occurs with C4
injuries.
REMEMBER: ANO ANG LEVEL INJURIES TO GET * Monitor arterial blood gas levels and maintain
AUTONOMIC DYSREFLEXIA- > THORACIC mechanical ventilation if prescribed to prevent
*the moment the nurse anticipate that their client have respiratory arrest, especially with cervical injuries.
thoracic injuries, the pt is at risk for autonomic (client with respiratory depression represent with
dysreflexia RESPIRATORY ACIDOSIS)
LUMBAR AND SACRAL LEVEL INJURIES * Encourage deep breathing and the use of an incentive
-Loss of movement and sensation of the lower spirometer.
extremities may occur. * Monitor for signs of infection, particularly pneumonia
-S2 and S3 center on micturition; therefore, below this CARDIOVASCULAR SYSTEM
level, the bladder will contract but not empty * Monitor for cardiac dysrhythmias.
(neurogenic bladder). * Assess for signs of hemorrhage or bleeding around the
-Injury above S2 in males allows them to have an fracture site.
erection, but they are unable to ejaculate because of * Assess for signs of shock (hypotachytachy), such as
sympathetic nerve damage. hypotension, tachycardia, and a weak and thready pulse.
-Injury between S2 and S4 damages the sympathetic * Assess the lower extremities for deep vein thrombosis.
and parasympathetic response. preventing erection or (how do we prevent DVT? Stocking, and remove the stocking for
ejaculation. a while bec you have to assess the skin, if theres presence of
breakdown) (pwede ba i-massage ang pt with DVT? No, bec
pwede magdislodge)
EMERGENCY INTERVENTIONS
* Measure circumferences of the calf and thigh to
-Always suspect spinal cord injury when trauma occurs identify increases in size.
until this injury is ruled out. * Apply thigh-high anti embolism stockings as
-Immobilize the client on a spinal backboard with the prescribed.
head in a neutral position to prevent an incomplete * Remove antiembolism stockings daily to assess the
injury from becoming complete. skin.
EMERGENCY INTERVENTIONS * Monitor for orthostatic hypotension when repositioning
• Emergency management is critical because improper the client. (orthostatic hypotension- sudden drop of BP upon
movement can cause further damage and loss of rising)
neurological function. NEUROMUSCULAR SYSTEM
•Assess the respiratory pattern and maintain a patent * Assess neurological status.
airway. * Assess motor and sensory status to determine the
•Prevent head flexion, rotation, or extension. level of injury.
•During immobilization, maintain traction and alignment * Assess motor ability by testing the client's ability to
on the head by placing hands on both sides of the head squeeze hands, spread the fingers, move the toes, and
by the ears. turn the feet.
•Maintain an extended position. * Assess the absence of sensation, hyposensation, or
• Logroll the client. (turning the client as one unit) hypersensation by pinching the skin or pricking it with
•No part of the body should be twisted or turned, and the a pin, starting at the shoulders and working down the
client is not allowed to assume a sitting position. (it will extremities. (use the dull part of needle)
give pressure or flex to the lower part, supine position lang * Monitor for signs of autonomic dysreflexia and spinal
dapat )
shock.
•In the emergency department, a client who has
* Immobilize the client to promote healing and prevent
sustained a cervical fracture should be placed
further injury.
immediately in SKELETAL TRACTION via skull tongs or
halo traction to immobilize the cervical spine and * Assess pain.
reduce the fracture and dislocation * Initiate measures to reduce pain.

* Administer analgesics as prescribed. (the moment nagkaroon ng SCI ang pt, they will be at risk
* Monitor for complications of immobility. for spinal sock )
* Prepare the client for decompression laminectomy, * A sudden depression of reflex activity below the level
spinal fusion, or insertion of instrumentation or rods if of spinal injury
prescribed. * Muscular flaccidity, lack of sensation and reflexes
* Collaborate with the physical therapist and (manifestation)
occupational therapist to determine appropriate NEUROGENIC SHOCK
exercise techniques, assess the need for hand and wrist * Occurs most commonly in clients with injuries above
splints, and develop an appropriate plan to prevent T6 and usually is experienced soon after the injury.
footdrop. (mawala yong nerve sa foot) Massive vasodilation occurs, leading to pooling of the
blood in blood vessels, tissue hypoperfusion, and
GASTROINTESTINAL SYSTEM impaired cellular metabolism.
* Assess the abdomen for distention and hemorrhage. * Caused by the loss of function of the autonomic
* Monitor bowel sounds and assess for paralytic nervous system
ileus.(absence of peristalsis in intestinal area ) * Blood pressure, heart rate, and cardiac output
* Prevent bowel retention. decrease
* Initiate a bowel control program as appropriate. * Venous pooling occurs because of peripheral
* Maintain adequate nutrition and a high-fiber diet. (high vasodilation
residue diet) * Paralyzed portions of the body do not perspire
RENAL SYSTEM
* Prevent urinary retention. (they will differ based on the occurrence, neurogenic is
* Initiate a bladder control program as appropriate. more likely, to occur several years after)
* Maintain fluid and electrolyte balance. MANIFESTATIONS
* Maintain adequate fluid intake of 2000 mL/day. Neurogenic Shock
* Monitor for urinary tract infection and calculi. * Hypotension
UTI- color of urine dark tea color cola * Bradycardia
INTEGUMENTARY SYSTEM Spinal Shock
* Assess skin integrity. * Flaccid paralysis
* Turn the client every 2 hours. (Prevent pressure ulcer, * Loss of reflex activity below the level of the injury
how to measure pressure ulcer? Graded scales) * Bradycardia
PSYCHOSOCIAL INTEGRITY * Hypotension
* Assess psychosocial status. * Paralytic ileus
* Encourage the client to express feelings of anger and
depression. AUTONOMIC DYSREFLEXIA
* Discuss the sexual concerns of the client. Acute emergency!
* Promote rehabilitation with self-care measures, setting * Occurs after spinal shock has resolved and may occur
realistic goals based on the client's potential functional years after the injury
level. * Occurs in persons with SC lesions above T6
*Encourage contact with appropriate community * Autonomic nervous system responses are
resources. exaggerated
* Symptoms include severe pounding headache,
sudden increase in blood pressure, profuse
SPINAL AND NEUROGENIC SHOCK diaphoresis, nausea, nasal congestion, and
SPINAL SHOCK bradycardia
* A complete but temporary loss of motor, sensory, * Triggering stimull include distended bladder (most
reflex, and autonomic function that occurs immediately common cause), distention or contraction of visceral
after injury as the cord's response to the injury. It organs (e.g., constipation), or stimulation of the skin
usually lasts less than 48 hours but can continue for (AVOID THIS OCCURINGS)
several weeks
*biglang lalabas injury that will last 48 hours and temporary -exaggeration of your ANS

-at risk, bec akala ng pt is okay na sila, but soon after pwede sila COLLABORATIVE PROBLEMS AND POTENTIAL
magkaroon ng autonomic dysreflexia COMPLICATIONS OF THE PATIENT WITH SPINAL
-usually, occur after spinal sock resolve CORD INJURY
-spinal sock at risk for autonomic dysreflexia
* DVT
MANIFESTATIONS
* Orthostatic hypotension
* Sudden onset, severe throbbing headache * Autonomic dysreflexia
* Severe hypertension and bradycardia
* Flushing above the level of the injury
PLANNING AND GOALS FOR THE PATIENT WITH
* Pale extremities below the level of the injury
SPINAL CORD INJURY
* Nasal stuffiness
* Major goals may include:
* Nausea
* Improved breathing pattern and airway clearance
* Dilated pupils or blurred vision (pupil sensitivity and
* Improved mobility
reaction to light will manifest in neurologic deficit)
* Prevention of injury due to sensory impairment
* Piloerection (goose bumps)
* Maintenance of skin Integrity o Rellef of urinary
* Restlessness and a feeling of apprehension
retention
NURSING INTERVENTIONS FOR AUTONOMIC
* Improved bowel function
DYSREFLEXIA
* Decreasing pain
* Place patient in seated position to lower BP
* Recognition of autonomic dysreflexia and absence of
* Rapid assessment to identify and eliminate cause
(EMPTY THE BLADDER OR IRRIGATE IF PT HAVE CATHETER)
complications
o Empty the bladder using a urinary catheter or- * Promoting effective breathing and airway clearance
irrigate or change indwelling catheter * Monitor carefully to detect potential respiratory failure
o Examine rectum for fecal mass - Pulse oximetry and ABGs
o Examine skin - Lung sounds
o Examine for any other stimulus * Early and vigorous pulmonary care to prevent and
* Administer ganglionic blocking agent such as remove secretions
hydralazine hydrochloride (Apresoline) IV * Suctioning with caution (less than 10 secs, before you
suction the pt, hyperoxygenate)
* Label chart or medical record that patient is at risk for
* Breathing exercises
autonomic dysreflexia
* Assisted coughing (splinting/ if your client is trying to cough
* Instruct patient in prevention and management
put the pillow against the abdomen or CPT)
PRIORITY NURSING ACTIONS FOR CLIENTS WITH
* Humidification and hydration
Autonomic Dysreflexia
Improving mobility
* Raise the head of the bed.
* Maintain proper body alignment
* Loosen tight clothing on the client.
* If not on a specialized rotating bed, turn only if spine is
* Check for bladder distention (if nagkaroon ng distention
stable and as indicated by physician
lagyan ng catheter) or other noxious stimulus.
* Monitor blood pressure with position changes
* Administer an antihypertensive medication. (bec of
* PROM at least four times a day (PROM- passive range of
sudden rise of bp)
exercises)
* Document the occurrence, treatment, and response.
* Use neck brace or collar, as prescribed, when patient is
ASSESSMENT OF THE PATIENT WITH SPINAL CORD
mobilized
INJURY
* Move gradually to erect position
* Monitor respirations and breathing pattern * Strategies to compensate for sensory and perceptual
* Lung sounds and cough alterations
* Monitor for changes in motor or sensory function; * Measures to maintain skin integrity
report immediately * Temporary indwelling catheterization or intermittent
* Assess for spinal shock catheterization
* Monitor for bladder retention or distention, gastric *NG tube to alleviate gastric distention (confirm
dilation, and ileus placement: x-ray; confirm patency: pH meter) (never the
* Temperature; potential hyperthermia stethoscope bec it may induced flatulence)
* High-calorie, high-protein, high-fiber diet
* Bowel program and use of stool softeners
* Traction pin care
* Hygiene and skin care related to traction devices
ASSESSMENT OF THE PATIENT WITH TETRAPLEGIA OR

PARAPLEGIA
* Head-to-toe assessment ad review of systems
* Skin for redness or breakdown
* Bowel and bladder program
* Emotional and psychological responses
COLLABORATIVE PROBLEMS AND POTENTIAL
COMPLICATIONS
* Spasticity
* Infection and sepsis
PLANNING AND GOALS FOR THE PATIENT WITH
TETRAPLEGIA OR PARAPLEGIA
•Major goals may include:
* Attainment of some form of mobility
* Maintenance of healthy, intact, skin
* Achievement of bladder management without infection
* Achievement of bowel control
* Achievement of sexual expression
* Strengthening of coping mechanisms
* Knowledge of long-term management
* Absence of complications

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MS II: NEURO: CHAP 62 SPINAL CORD INJURY

Lecturer: Sir Ceddie

Kate, Monette, Phia, Ella

Kate, Monette, Phia, Ella

Kate, Monette, Phia, Ella

Kate, Monette, Phia, Ella

ASSESSMENT OF THE PATIENT WITH TETRAPLEGIA OR

Kate, Monette, Phia, Ella

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