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spinal cord

Someone with a chronic spinal cord injury needs special care when hospitalized for any reason. Find out how you can modify nursing care to accommodate changes in his body and lifestyle.

THANKS TO ADVANCES in trauma care, many patients can now survive a severe spinal cord injury (SCI) and live for many more years. As a result, you're starting to see more aging patients living with an SCI who are entering the health care system. Besides their SCI, they may have various health problems associated with aging or disease. In this article, I'll discuss what you need to know about an SCI's farreaching effects on these patients and how to modify nursing care accordingly. For more on caring for a patient with an acute SCI, see Acute SCI Care: Brushing Up on the Current Guidelines.

On the level

BY KRISTY L. GIBSON, RN, CCM, CLCP, BSN

Caring for a patient who lives with a

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The degree of disability experienced by a patient with an SCI is determined by the level, severity, and mechanism of injury. Most SCIs affect the cervical and lumbar regions; the most common injury level is C5. (For details on spinal anatomy, see Back to Basics.) Cervical injury can result in partial or total paralysis of all four extremities (quadriplegia, also called tetraplegia). Injury to the thoracic or lumbar region leads to partial or total paralysis in the legs (paraplegia). Slightly more than 50% of all Americans with SCIs are tetraplegic; the rest are paraplegic. Spinal cord injuries are classified according to completeness of the injury and how the injury affects motor and sensory function. See How to Classify an SCI for a rundown of the Frankel classification system.

Far-reaching effects

Few other traumatic injuries have effects that are as far-reaching as an SCI. Because nearly every body system is innervated by the spinal cord, an SCI may directly or indirectly affect nearly every body system. 36

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Consider these examples. · Cardiovascular effects. Patients with SCIs are at increased risk for cardiovascular disease because of decreased physical activity, loss of skeletal muscle mass and bone, increased adipose tissue, reduced anabolic hormone levels, and changes in carbohydrate and lipid metabolism and blood vessel tone (the latter from sympathetic denervation). Patients with tetraplegia have chronically reduced cardiac output and stroke volume, the result of sympathetic nervous system damage. Orthostatic hypotension can also be a problem, especially in patients with injuries at T6 or above. Patients with high-level injuries (T6 or above) may develop bradyarrhythmias, which may be chronic. Paralysis of the legs and poor venous return also place patients at risk for deep vein thrombosis (DVT) after acute injury, when their normal exercise routine is interrupted. Patients with injuries at T6 or higher are at risk for developing autonomic dysreflexia, a lifethreatening response to a noxious stimulus (such as a full bladder) below the level of injury. Autonomic dysreflexia is characterized by a sudden severe headache, flushing of the skin above the level of injury, and diaphoresis, bradycardia, pallor, and coolness below the level of injury. The patient's blood pressure can rise quickly, possibly causing a stroke. (For more information, see "How Do I Respond to Autonomic Dysreflexia?" in Clinical Queries in the February issue of Nursing2003.) · Respiratory effects. Patients with complete C1 to C4 spinal injuries require a ventilator for respiration. Patients with lower cervical and high thoracic injuries (C5 to C8 and T1 to T5) have a weakness or paralysis of the diaphragmatic and intercostal muscles, decreasing chest expansion and 38

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reducing inspiratory volume. Paralysis of the abdominal and internal intercostal muscles also decreases expiratory efficiency, so the patient will have trouble coughing and clearing respiratory secretions. This is exacerbated if he has a coexisting respiratory problem or if he smokes. Treat the underlying problem and encourage smoking cessation, if appropriate. · Endocrine effects. Changes to the metabolic and endocrine systems associated with SCIs are under study and not yet entirely understood. One study has shown that patients with SCIs are four times more likely to develop diabetes because of difficulty metabolizing glucose. Patients with SCIs also should avoid temperature extremes because an SCI impairs the normal mechanisms of thermal regulation. · Gastrointestinal (GI) effects. Peptic ulcer disease and cholelithiasis are also more common among patients with SCIs. Possible factors contributing to these problems include changes in body composition (increased fat, decreased bone mineral content, and decreased body protein and body water relative to body weight), lack of exercise, poor diet, medications, and stress. Two types of neurogenic bowel conditions are associated with

SCIs; the extent of bowel dysfunction depends on the level of injury. Cervical or high thoracic injuries cause reflex bowel. The patient doesn't feel the urge to defecate, but the anorectal reflex remains intact. Injuries in the conus medullaris or cauda equina cause areflexic bowel, in which anal tone and the anorectal reflex are lost; the urge to defecate may or may not be lost. To manage either type of bowel dysfunction, the patient must learn and adhere to a bowel program, which may require medication, diet changes, a time commitment, and, for some patients, help from others. · Renal effects. Most patients with SCIs above the conus medullaris develop a reflex bladder, which contracts and empties in response to a filling pressure, rather than patient control. Individuals with an injury to the conus medullaris or cauda equina develop a nonreflex bladder, which is flaccid and lacks reflex action from the detrusor muscle. Depending on the type of SCI, the patient may not sense that the bladder is full, which can lead to overfilling and dribbling. Most patients manage their bladder by intermittent catheterization. Obese patients or those with highlevel SCIs may require an indwelling catheter and need help

How to classify an SCI

The Frankel classification system was developed by the American Spinal Injury Association to standardize the nomenclature for SCIs. Here's how it works: · Class A--complete injury. The patient has no motor or sensory function below the level of injury. · Class B--incomplete injury with preserved sensation only. The patient has no motor function below the level of injury, but sensory function is preserved. · Class C--incomplete injury with nonuseful motor function. The patient has some motor function and may or may not have sensory function below the level of injury. · Class D--incomplete injury with useful motor function. The patient has voluntary, useful motor function below the level of injury. · Class E--complete recovery. The patient's sensory and motor functions return, although he may still have abnormal reflexes or bowel, bladder, and sexual dysfunction.

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from an attendant. Urinary tract infections (UTIs) remain a major cause of complications and death in patients with SCIs because organisms are easily introduced into the urinary tract by intermittent catheterization, despite clean or sterile technique. Bacteria are often present in the urine of patients with SCIs, although this doesn't always indicate a UTI. A patient with an SCI probably won't be aware of common UTI signs and symptoms, such as dysuria, urgency, frequency, and back pain. Instead, he may experience worsening muscular spasticity, foul-smelling urine, a change in voiding habits, fever, or an episode of autonomic dysreflexia. Spinal cord injury can also trigger long-term renal complications. In fact, kidney failure was once the leading cause of death for patients with SCIs. Patients with SCIs are at risk for developing bladder and renal calculi, and those who require intermittent catheterization are susceptible to hydronephrosis. If the bladder isn't emptied adequately with catheterization, urine can back up into the ureters and kidneys. Emerging evidence indicates that patients with SCIs who use an indwelling catheter may be at a higher risk for developing bladder cancer, possibly because of chronic irritation of the bladder from repeated catheterizations, repeated UTIs, and bladder stones. · Reproductive effects. For men, an SCI can alter fertility and sexual function. Most men with SCIs above the level of the conus medullaris have reflex erections, but very few can ejaculate. Among men with injuries below the conus medullaris, only about 20% achieve erection, and about 20% of those achieve ejaculation. Refer the patient to a urologist for information on new erectile and fertility treatments for men with SCIs. Women with an SCI remain capable of sexual intercourse and

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Back to basics

C1

C7 T1

Cervical nerves (C1 to C8) The cervical nerves innervate the back of the head, neck, arms, and diaphragm. An injury between C1 and C5 paralyzes respiratory muscles and all extremities and is often fatal. An injury at C5 to C6 paralyzes the legs but leaves the arms with some motor function. An injury at C6 to C7 paralyzes the legs and lower arms; the patient can move his shoulders and elbows. An injury at C8 to T1 paralyzes the legs, trunk, and hands, but not the rest of the arm. Thoracic nerves (T1 to T12) The thoracic nerves innervate the chest, some of the back muscles, and some of the abdomen. Injury at T2 to T4 paralyzes the legs and trunk and causes loss of feeling below the nipples. An injury at T5 to T8 causes leg and lower trunk paralysis and loss of feeling below the rib cage. An injury at T9 to T11 causes leg paralysis and loss of feeling below the umbilicus. An injury at T12 to L1 causes paralysis and loss of feeling below the groin.

T12 L1

Lumbar nerves (L1 to L5) The lumbar nerves innervate the lower portion of the abdomen, the lower portion of the back, the buttocks, some of the external genitalia, and portions of the legs. The spinal cord tapers to form the conus medullaris. Injuries between L2 and L5 cause different patterns of leg weakness and numbness.

L5

Sacral nerves (S1 to S5) From the conus medullaris the sacral nerve roots extend through the spinal canal and are collectively termed the cauda equina. The sacral nerves innervate the remainder of the genitalia, the anus, the thighs, the lower legs, and the feet. Injuries between S1 and S2 cause different patterns of leg weakness and numbness. Injuries between S3 and S5 cause loss of bladder and bowel control and perineal numbness (cauda equina syndrome).

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conception, and between 50% and 75% are able to have an orgasm. Menses may be disrupted initially, but generally resume normally 3 to 6 months after injury. Pregnant women with SCIs must be closely monitored because they tend to have a higher rate of premature and

small-birth-weight infants. Because a woman with an SCI is at higher risk for DVT, hormonal contraceptives aren't recommended. · Integumentary effects. Patients with SCIs are particularly vulnerable to pressure ulcer development because of impaired circulation

Acute SCI care: Brushing up on the current guidelines

Each year, 14,000 people in North America suffer an SCI. The American Association of Neurological Surgeons and the Congress of Neurological Surgeons recently released guidelines for managing acute cervical spine injuries and SCIs, from prehospital care through the acute phase of hospitalization. Here are the highlights: · Cervical spine immobilization should be done at the scene and maintained during transport to the hospital for all patients with a potential SCI. The recommended method of immobilizing a patient is to place him on a backboard with straps, a rigid cervical collar, and supportive blocks. He should be transported to a trauma center as quickly as possible for emergency care. · Cervical spine X-rays are no longer routine for ruling out a cervical SCI in every patient with a potential neck injury. If the patient is awake, alert, and not intoxicated; has no neck pain or tenderness; and has no significant injuries that would raise the suspicion of an SCI, X-rays may not be indicated. However, if he's symptomatic following a traumatic injury, as defined by the Frankel classification system, obtain anteroposterior, lateral, and odontoid views. Prepare the patient for computed tomography if some areas aren't well visualized or look suspicious on X-ray. · Use of steroids following an acute SCI has long been the standard of practice. However, evidence doesn't support this practice. Although the current guidelines suggest methylprednisolone for 24 or 48 hours as an option, they warn that potential adverse reactions (such as gastric ulceration, electrolyte imbalances, and delayed wound healing) may override the treatment's clinical benefit. · Initial assessment is guided by the American Spinal Injury Association's standards for classifying an SCI. Use the Functional Independence Measure, which rates levels of assistance needed with self-care, to assess the degree of recovery following an SCI. · Admission to the ICU is still recommended following an acute SCI. The patient's cardiac, respiratory, and hemodynamic status should be closely monitored and treated promptly. · Hypotension secondary to loss of sympathetic tone should be corrected if the patient's BP falls below 90 mm Hg systolic. Hypoperfusion of the spinal cord could worsen the patient's condition and compromise recovery. Maintain mean arterial pressure between 85 and 90 mm Hg for the first 7 days following the injury. · Preventive measures against deep vein thrombosis (DVT) are indicated because immobility after an SCI raises the patient's risk of DVT. The guidelines recommend a combination of prophylactic low-molecular-weight heparin, rotational beds, or adjusted-dose unfractionated heparin. Low-dose heparin with pneumatic compression stockings also is an option. · Hypermetabolism secondary to an SCI should be treated by nutritional support. The patient's energy expenditure can be determined by indirect calorimetry so he can receive the correct level of nutritional support.

SELECTED REFERENCE "Guides for Management of Acute Cervical Spinal Injury," Neurosurgery. 50(3, Suppl.):S1­S84, March 2002.

By Debbie Fischer, RN, CCRN, MSN

from muscular disuse and possible sensory dysfunction, depending on the level of injury. Most of these patients have had, or will have, a pressure ulcer in their lifetime. Pressure ulcer prevention is key and includes weight shifts, good nutrition, adequate hydration, and exercise. · Musculoskeletal effects. Patients with SCIs will have some degree of flaccidity below the lesion, and most patients also have some degree of spasticity--uncontrolled, involuntary muscle contractions and exaggerated tendon reflexes. Spasticity can be controlled by daily range-of-motion exercises and medication. Although spasticity can be severe, some spasticity improves circulation and can be useful in transfers. (For example, a patient with minimal leg spasticity may learn to trigger spasticity to help with dressing or transfers.) For the stable patient with an SCI, however, increasing amounts of spasticity can signal other problems, such as infection, kidney stones, skin breakdown, and even syringomyelia (a degenerative condition of the spinal cord associated with fluid-filled spinal cavities, changes in sensation, and muscle weakness). Bony changes secondary to an SCI include the development of osteoporosis and heterotopic ossification from reduced weight bearing and immobility. Osteoporosis places the patient at high risk for fractures below the level of the SCI. The use of a standing frame, which forces the legs to bear weight, may help prevent osteoporosis. Heterotopic ossification, which occurs in 15% to 20% of all patients with SCIs, is a deposit of bone in areas where bone doesn't normally occur, such as soft tissue surrounding a joint. Ectopic bone can limit a joint's range of motion, further impairing transfers and the patient's ability to participate in daily activities. The cause of hetwww.nursingcenter.com

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erotopic ossification isn't known. Because most patients with SCIs use their arms to propel a wheelchair and to transfer, they place unusual stress on upper extremity joints and are susceptible to overuse syndrome, chronic pain, rotator cuff problems, and nerve entrapments.

Implications for acute care

After suffering an SCI, most patients get to know their bodies extremely well. By listening closely to your patient, you can find out not only his current symptoms, but also what's normal for him. Patients with SCIs often develop a set routine; for example, the time when they perform range-ofmotion exercises or their bowel program. Schedule your interventions around the patient's routine as much as possible. When you administer prescribed medications, keep in mind how they can influence your patient's bowel function. For example, anticholinergics, vitamins, iron supplements, opioids, and anesthetics can

further slow GI motility, which may lead to constipation, ileus, or impaction. Antibiotics, on the other hand, can cause diarrhea. Alterations in the patient's body composition and metabolism may mean he needs high dosages of some medications for them to be effective; patients with SCIs have expanded extracellular volume and may need larger dosages of drugs such as aminoglycosides, which are distributed in extracellular fluid. But higher drug dosages can increase the risk of complications, especially those affecting the bowel. Talk with the patient to help identify possible complications and treat them early. Meeting the patient's emotional and educational needs means becoming as familiar as possible with how the SCI has affected his life. Don't assume, for example, that the patient doesn't feel pain or isn't sexually active. Identify his problems and set educational goals that are meaningful to him. By developing a better understanding of how an SCI alters

your patient's health, you can help him get on with a productive and healthy life.

SELECTED REFERENCES Blackwell, T., et al.: Spinal Cord Injury Desk Reference: Guidelines for Life Care Planning and Case Management. New York, N.Y., Demos Medical Publishing, 2001. Kemp, B., and Thompson, L.: "Aging and Spinal Cord Injury: Medical, Functional, and Psychosocial Changes," SCI Nursing. 19(2):5159, Summer 2002. Miranda, A., and Hassouna, H.: "Mechanisms of Thrombosis in Spinal Cord Injury," Hematology/Oncology Clinics of North America. 14(2):401-416, April 2000. Spinal Cord Injury Information Network: Spinal Cord Injury: Facts and Figures at a Glance. University of Alabama at Birmingham, May 2001, http://www.spinalcord.uab.edu. Winkler, T.: "Spinal Cord Injury and Life Care Planning," in A Guide to Rehabilitation, P. Deutsch and H. Sawyer, New York, N.Y., Ahab Press, Inc., 1999.

Kristy L. Gibson is an independent nurse-consultant in Blair, Neb. Debbie Fischer, author of Acute SCI Care: Brushing Up on the Current Guidelines, is critical care clinical nurse-educator at Delaware County Memorial Hospital in Drexel Hill, Pa.

S E L EC T E D W E B S I T E Craig Hospital, Englewood, Colo.: Bladder Cancer (in SCI patients) http://www.craighospital.org/sci/mets/ bladdercancer.asp Last accessed on June 2, 2003.

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Caring for a patient who lives with a spinal cord injury

Instructions: · Read the article beginning on page 36. · Take the test, recording your answers in the test answers section (Section B) of the CE enrollment form. Each question has only one correct answer. · Complete registration information (Section A) and course evaluation (Section C). · Mail completed test with registration fee to: Lippincott Williams & Wilkins, CE Dept., 16th Floor, 345 Hudson St., New York, NY 10014. · Within 3 to 4 weeks after your CE enrollment form is received, you will be notified of your test results. · If you pass, you will receive a certificate of earned contact hours and an answer key. If you fail, you have the option of taking the test again at no additional cost. · A passing score for this test is 12 correct answers. · Need CE STAT? Visit http://www.nursingcenter.com for immediate results, other CE activities, and your personalized CE planner tool. · No Internet access? Call 1-800-933-6525, ext. 331 or ext. 332, for other rush service options. · Questions? Contact Lippincott Williams & Wilkins: 212886-1331 or 212-886-1332. Registration Deadline: July 31, 2005 Provider Accreditation: This Continuing Nursing Education (CNE) activity for 2.0 contact hours and 0.5 pharmacology contact hour is provided by Lippincott Williams & Wilkins, which is accredited as a provider of continuing education in nursing by the American Nurses Credentialing Center's Commission on Accreditation and by the American Association of Critical-Care Nurses (AACN 9722, CERP Category A). This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.0 contact hours and 0.5 pharmacology contact hour. LWW is also an approved provider of CNE in Alabama, Florida, and Iowa and holds the following provider numbers: AL #ABNP0114, FL #FBN2454, IA #75. All of its home study activities are classified for Texas nursing continuing education requirements as Type I. Your certificate is valid in all states. This means that your certificate of earned contact hours is valid no matter where you live. Payment and Discounts: · The registration fee for this test is $13.95. · If you take two or more tests in any nursing journal published by LWW and send in your CE enrollment forms together, you may deduct $0.75 from the price of each test. · We offer special discounts for as few as six tests and institutional bulk discounts for multiple tests. Call 1-800-933-6525, ext. 332, for more information.

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C E

Caring for a patient who lives with a spinal cord injury

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GENERAL PURPOSE To provide professional nurses with an understanding of how to care for a patient who lives with an SCI and new guidelines for managing acute SCI. LEARNING OBJECTIVES After reading the preceding article and taking this test, you should be able to: 1. Identify the level of injury and how to classify SCI. 2. Identify management guidelines for acute SCI. 3. Identify health problems associated with chronic SCI and their implications for patient care. 1. An injury at T12 to L1 causes a. paralysis of respiratory muscles. b. paralysis and loss of feeling below the groin. c. loss of feeling below the nipples. d. paralysis of all extremities. 2. Which nerves innervate the back of the head, neck, arms, and diaphragm? a. sacral b. lumbar c. thoracic d. cervical 3. The classification system developed to standardize nomenclature for SCIs is known as the a. Gibson system. b. Fischer system. c. Frankel system. d. cauda equina system. 4. A patient who has no motor or sensory function below the level of injury has what class of injury? a. Class A b. Class B c. Class C d. Class D 5. A patient whose sensory and motor function return after an injury would be classified as a a. Class B. b. Class C. c. Class D. d. Class E. 6. If you suspect that a patient has an SCI, what should you do immediately at the scene and during transport to the hospital? a. Administer steroids. b. Immobilize his cervical spine. c. Institute DVT prevention. d. Provide nutritional support. 7. A motor-vehicle-accident victim has only sensory function below C4, and the odontoid view of the cervical spine X-ray looks suspicious. Prepare the patient for a. a new set of X-rays. b. a computed tomography scan. c. surgery. d. a blood glucose level drawn. 8. Which isn't an adverse reaction to steroids? a. gastric ulceration b. DVT c. electrolyte imbalance d. delayed wound healing 9. A patient's mean arterial BP should be maintained for the first 7 days post-SCI at a. 24 to 48 mm Hg. b. 50 to 75 mm Hg. c. 85 to 90 mm Hg. d. greater than 90 mm Hg. 10. Paralysis of all extremities is called a. paraplegia. b. tetraplegia. c. spasticity. d. dysreflexia. 11. Which statement about SCIs is correct? a. Many patients survive their injuries and live many years. b. Only older patients have health care problems associated with the SCI. c. Most SCIs affect the thoracic and sacral areas. d. An SCI to the lumbar region can result in partial or total paralysis of all extremities. 12. Patients with SCIs are at increased risk for cardiovascular disease because of a. decreased physical activity. b. gain in skeletal muscle mass and bone. c. decreased adipose tissue. d. increased anabolic hormone levels. 13. Autonomic dysreflexia is a risk for patients with injuries at levels a. L1 to L2. b. L3 to L5. c. S1 to S5. d. T6 or higher. 14. Which statement about autonomic dysreflexia is correct? a. The patient's BP can drop quickly. b. It's a life-threatening response to a noxious stimulus. c. It causes tachycardia and peptic ulcer disease. d. It causes bony changes such as osteoporosis and heterotopic ossification. 15. Injuries in the conus medullaris or cauda equina cause loss of anal tone and anorectal reflex because of a. reflex bowel. b. areflexic bowel. c. infection. d. hypometabolism. 16. Which medication causes diarrhea in an SCI patient? a. vitamins b. opioids c. antibiotics d. anesthetics 17. Because of expanded extracellular volume, patients with SCIs need larger doses of a. hormonal contraceptives. b. aminoglycosides. c. steroids. d. tobacco.

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Nursing2003, July, Caring for a patient who lives with a spinal cord injury

A. Registration Information: Last name ____________________________ First name ________________________ MI ____ _ Address ______________________________________________________________________________ _ City _______________________________________ State _________________ ZIP ___________ ___ Telephone ____________________ Fax ____________________ E-mail ____________________ Registration Deadline: July 31, 2005 Contact hours: 2.0 Pharmacology hours: 0.5 Fee: $13.95

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