Shepherd Center: A Catastrophic Care Hospital. The Jane Woodruff Pavilion

Transcription

1 Shepherd Center: A Catastrophic Care Hospital The Jane Woodruff Pavilion

2 Acute Management of SCI & Prevention of Secondary Complications Joycelyn Craig, BSN, RN, CRRN SCI Nurse Education Manager

3 FACTS & STATISTICS Model SCI Care System Data, Archives of Physical and Medical Rehabilitation, January 2008 PREVALENCE in US 227, ,938 living with SCI 12,000 annually AGE 24% are between the ages of % are between the ages of % are older than 60 GENDER 77.8% are males

4 Model Systems National SCI database NSCI Statistical Center Independent and collaborative research Resources to individuals with SCI, family and caregivers, health care professionals and the general public

5 SPINAL CORD INJURY An injury to the spinal cord at any level between the foramen magnum and the cauda equina, from any cause.

6 CERVICAL: 7 Bones-8 Nerves

7 C1 C2 C3 C4 C5 C6 C7 C8 Neck Shoulder Shrug, Neck, Diaphragm Shoulder Muscles Front Arm Muscles Wrist Muscles, Shoulder Muscles Lower Arms, Fingers Cervical Nerves

8 THORACIC: 12 Bones-12 Nerves

9 Thoracic Nerves T1 Hand T2 thru T6 T7 thru T12 Middle part of the body (trunk), chest and stomach area Coughing and laughing muscles

10 LUMBAR: 5 Bones-5 Nerves

11 Lumbar L1 Hips L2 L3 Knees L4 L5 Top of Foot and Ankle

12 SACRAL: 1 Bone-5 Nerves

13 Sacral S1 S2 S3 Legs Feet S4 Bowel & Bladder S5 Sex Organs

14 CLASSIFICATION of SCI ASIA A E most widely accepted neurologic basis

15 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.

16 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.

17 INCOMPLETE SYNDROMES Brown-Sequard Central Cord Anterior Cord Posterior Cord Conus Medullaris Cauda Equina Mixed (combination of 2 of above)

18 INCOMPLETE SYNDROMES Brown Sequard: damage to one side of cord ipsilateral paralysis, loss proprioception contralateral loss of pain and temperature

19 INCOMPLETE SYNDROMES Central cord: damage to central part of cord greater weakness in arms verses legs sacral sensation

20 INCOMPLETE SYNDROMES POSTERIOR CORD Lesion within posterior 1/3 of cord Sensory and motor function intact Loss of proprioception ANTERIOR CORD Lesion within anterior 2/3 of cord Paralysis with loss of pain and temperature Proprioception intact

21 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.

22 Spinal Cord

23 Nursing Prevention of Secondary Injury Spinal stabilization Proactive Prevention of Medical Complications

24 FIRST ---Immobilize THEN-Assess & Test

25 High Dose Solumedrol Protocol Within 3 hours of the injury: Solumedrol 30 mg/kg IV as a bolus dose over minutes, then 5.4 mg/kg/hr for hours. Within 8 hours of the injury: Solumedrol 30 mg/kg IV as a bolus dose over minutes, then 5.4 mg/kg/hr for hours. Monitor blood glucose

26 Spinal Stabilization Goals: Prevent further damage to the spinal cord. Provide means for early mobilization.

27 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

28 Halo Vest A device that is used for unstable cervical injuries that are in alignment. Skin care. Patient safety.

29 Cervical Fusion and Wiring Anterior and/or Posterior Fusion Hard collar to be worn at all times post-op, for 6 weeks. Skin.

30 Harrington Rods For thoracic-lumbar injuries. Embedded in the neural arch to provide a distraction force. TLSO post operatively for 4-6 weeks. Skin.

31 Rehab Priorities 1st 72 Hours Spinal Shock Respiratory Intervention Skin Protection Bowel Function Bladder Health Early Mobilization

32 Spinal Shock Occurs 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.

33 Spinal Shock Bowel- Initiate suppository and manual evacuation within hours. Daily bowel program. Skin care. Bladder- Foley. Perineal skin care.

34 SKIN Bed Padding & Positioning Shearing Spasms Bony prominences Visualize new areas Head-to-toe assessments Pressure relief Turns Weight Shifts

35 EVERY Patient Deserves Their Turn! Evaluate to increase 30 min/week Skin checks at least twice per shift Keep pressure off affected areas

36 Padding and Positioning Protect the skin Prevent contractures Prevent painful shoulders Decrease respiratory complications

37 Autonomic Nervous System ANS Dysfunction ANS disruption makes the parasympathetic system dominant.

38 ANS Dysfunction Bradycardia Hypotension Pneumonia/ Atelactasis DVT Stress Ulcers/ GI Bleed Poikilothermism Autonomic Dysreflexia Bowel Bladder Skin

39 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

40 ANS Dysfunction Hypotension Parasympathetic dominance resulting in vasodilation. Vasoconstrictive therapy: Dopamine Neosynephrine Florinef Midodrine

41 Pneumonia/Atelectasis ANS Dysfunction 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

42 DVT/PE ANS Dysfunction Result of increased platelet aggregation and common post-op complication Intervention: Continuous Assessment Early Detection Prophylactic anticoagulants

43 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

44 Poikilothermism ANS Dysfunction 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.

45 Temperature control NO vasoconstriction, piloerection or heat loss through sweating below level of injury Do not over cool or over heat.

46 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.

47 ANS Dysfunction Autonomic Dysreflexia S & Sx Pounding headache BP > 15mm Hg over baseline Sweating Blotchy/skin redness above LOI Nasal congestion

48 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

49 ANS Dysfunction Autonomic Dysreflexia Monitor time Monitor BP Treat BP-procardia Notify MD Continue to search for cause Monitor BP

50 BOWEL ANS Dysfunction Stool continues to be produced; not evacuated. Suppository and rectal clearing. Monitor results. Consider contrast materials used. Skin at risk.

51 ANS Dysfunction BLADDER Neurogenic Bladder management Prevent overdistention, ureterovisical reflux. Skin at risk.

52 ANS Dysfunction SKIN Turns, no less than every 2 hours. Visualize new areas with every turn. Head-to-toe assessments.

53 Other Issues to Address 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

54 Family Involvement Directly related to degree of successful discharge and life planning. Teach family & caregivers all aspects of care.

55 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

56 Questions?