Nursing Process: The Patient With Acute Spinal Cord Injury

NURSING PROCESS: THE PATIENT WITH ACUTE SPINAL CORD INJURY

Assessment

The breathing pattern is observed, the strength of the cough is as-sessed, and the lungs are auscultated, because paralysis of ab-dominal and respiratory muscles diminishes coughing and makes it difficult to clear bronchial and pharyngeal secretions. Reduced excursion of the chest also results.

The patient is monitored closely for any changes in motor or sensory function and for symptoms of progressive neurologic dam-age. It may be impossible in the early stages of SCI to determine whether the cord has been severed, because signs and symptoms of cord edema are indistinguishable from those of cord transection. Edema of the spinal cord may occur with any severe cord injury and may further compromise spinal cord function.

Motor and sensory functions are assessed through careful neu-rologic examination. These findings are recorded most often on a flow sheet so that changes in the baseline neurologic status can be closely monitored accurately. The American Spinal Injury Associ-ation (ASIA) classification is commonly used to describe level of function for SCI patients. Chart 63-7 also gives an example of nursing assessment of spinal cord function.

·      Motor ability is tested by asking the patient to spread the fingers, squeeze the examiner’s hand, and move the toes or turn the feet.

·      Sensation is evaluated by gently pinching the skin or touch-ing it lightly with a small object such as a tongue blade, starting at shoulder level and working down both sides of the extremities. The patient should have both eyes closed so that the examination reveals true findings, not what the pa-tient hopes to feel. The patient is asked where the sensation is felt.

·       Any decrease in neurologic function is reported immediately.

The patient is also assessed for spinal shock, a complete loss of all reflex, motor, sensory, and autonomic activity below the level of the lesion that causes bladder paralysis and distention. The lower abdomen is palpated for signs of urinary retention and overdistention of the bladder. Further assessment is made for gastric dilation and ileus due to an atonic bowel, a result of auto-nomic disruption.

Temperature is monitored because the patient may have peri-ods of hyperthermia as a result of alteration in temperature control due to autonomic disruption.

Diagnosis

NURSING DIAGNOSES

Based on the assessment data, the patient’s major nursing diag-noses may include the following:

·      Ineffective breathing patterns related to weakness or paral-ysis of abdominal and intercostal muscles and inability to clear secretions

·      Ineffective airway clearance related to weakness of inter-costal muscles

·      Impaired physical mobility related to motor and sensory impairment

·      Disturbed sensory perception related to motor and sensory impairment

·        Risk for impaired skin integrity related to immobility and sensory loss

·       Urinary retention related to inability to void spontaneously

·      Constipation related to presence of atonic bowel as a result of autonomic disruption

·      Acute pain and discomfort related to treatment and pro-longed immobility

COLLABORATIVE PROBLEMS/ POTENTIAL COMPLICATIONS

Based on the assessment data, potential complications that may develop include:

·      DVT

·       Orthostatic hypotension

·       Autonomic dysreflexia

Planning and Goals

The goals for the patient may include improved breathing pat-tern and airway clearance, improved mobility, improved sensory and perceptual awareness, maintenance of skin integrity, relief of urinary retention, improved bowel function, promotion of com-fort, and absence of complications.

Nursing Interventions

PROMOTING ADEQUATE BREATHING AND AIRWAY CLEARANCE

Possible impending respiratory failure is detected by observing the patient, measuring vital capacity, monitoring oxygen satura-tion through pulse oximetry, and monitoring arterial blood gas values. Early and vigorous attention to clearing bronchial and pharyngeal secretions can prevent retention of secretions and at-electasis. Suctioning may be indicated, but caution must be used during suctioning because this procedure can stimulate the vagus nerve, producing bradycardia, which can result in cardiac arrest.

If the patient cannot cough effectively because of decreased in-spiratory volume and inability to generate sufficient expiratory pressure, chest physical therapy and assisted coughing may be in-dicated. Specific breathing exercises are supervised by the nurse to increase the strength and endurance of the inspiratory muscles, particularly the diaphragm. Assisted coughing promotes clearing of secretions from the upper respiratory tract and is similar to using abdominal thrusts to clear an airway. It is important to ensure proper humidification and hydration to pre-vent secretions from becoming thick and difficult to remove even with coughing. The patient is assessed for signs of respiratory in-fection (cough, fever, dyspnea). Smoking is discouraged because it increases bronchial and pulmonary secretions and impairs ciliary action.

Ascending edema of the spinal cord in the acute phase may cause respiratory difficulty that requires immediate intervention. Therefore, the patient’s respiratory status must be monitored frequently.

IMPROVING MOBILITY

Proper body alignment is maintained at all times. The patient is repositioned frequently and is assisted out of bed as soon as the spinal column is stabilized. The feet are prone to footdrop; therefore, various types of splints are used to prevent footdrop. When used, the splints are removed and reapplied every 2 hours. Trochanter rolls, applied from the crest of the ilium to the midthigh of both legs, help prevent external rotation of the hip joints.

Patients with lesions above the midthoracic level have loss of sympathetic control of peripheral vasoconstrictor activity, lead-ing to hypotension. These patients may tolerate changes in posi-tion poorly and require monitoring of blood pressure when positions are changed. Usually the patient is turned every 2 hours. If not on a rotating bed, the patient should not be turned unless the spine is stable and the physician has indicated that it is safe to do so.

Contractures develop rapidly with immobility and muscle paralysis. A joint that is immobilized too long becomes fixed as a result of contractures of the tendon and joint capsule. Atrophy of the extremities results from disuse. Contractures and other com-plications may be prevented by range-of-motion exercises that help preserve joint motion and stimulate circulation. Passive range-of-motion exercises should be implemented as soon as possible after injury. Toes, metatarsals, ankles, knees, and hips should be put through a full range of motion at least four, and ideally five, times daily.

For most patients with a cervical fracture without neurologic deficit, reduction in traction followed by rigid immobilization for about 6 to 8 weeks restores skeletal integrity. These patients are allowed to move gradually to an erect position. A four-poster neck brace or molded collar is applied when the patient is mobi-lized after traction is removed (see Fig. 63-8).

PROMOTING ADAPTATION TO SENSORY AND PERCEPTUAL ALTERATIONS

The nurse assists the patient to compensate for sensory and per-ceptual alterations that occur with SCI. The intact senses above the level of the injury are stimulated through touch, aromas, flavorful food and beverages, conversation, and music. Additional strategies include the following:

·      Providing prism glasses to enable the patient to see from the supine position

·       Encouraging use of hearing aids, if indicated, to enable the patient to hear conversations and environmental sounds

·      Providing emotional support to the patient

·      Teaching the patient strategies to compensate for or cope with these deficits

MAINTAINING SKIN INTEGRITY

Because the patient with SCI is immobilized and has loss of sen-sation below the level of the lesion, there is an ever-present, life-threatening risk of pressure ulcers. In areas of local tissue ischemia, where there is continuous pressure and where the peripheral cir-culation is inadequate as a result of the spinal shock and recum-bent position, pressure ulcers have developed within 6 hours. Prolonged immobilization of the patient on a transfer board in-creases the risk of pressure ulcers. The most common sites are over the ischial tuberosity, the greater trochanter, and the sacrum. In addition, patients who wear cervical collars for prolonged pe-riods may develop breakdown from the pressure of the collar under the chin, on the shoulders, and at the occiput.

The patient’s position is changed at least every 2 hours. Turn-ing not only assists in the prevention of pressure ulcers but also pre-vents the pooling of blood and tissue fluid in the dependent areas.

Careful inspection of the skin is made each time the patient is turned. The skin over the pressure points is assessed for redness or breaks; the perineum is checked for soilage and the catheter is observed for adequate drainage. The patient’s general body align-ment and comfort are assessed. Special attention should be given to pressure areas in contact with the transfer board.

The patient’s skin should be kept clean by washing with a mild soap, rinsed well, and blotted dry. Pressure-sensitive areas should be kept well lubricated and soft with bland cream or lotion. The patient is informed about the danger of pressure ulcers to en-courage understanding of the reason for preventive measures.

MAINTAINING URINARY ELIMINATION

Immediately after SCI, the urinary bladder becomes atonic and cannot contract by reflex activity. Urinary retention is the imme-diate result. Because the patient has no sensation of bladder dis-tention, overstretching of the bladder and detrusor muscle may occur, delaying the return of bladder function.

Intermittent catheterization is carried out to avoid over-distention of the bladder and UTI. If this is not feasible, an in-dwelling catheter is inserted temporarily. At an early stage, family members are shown how to carry out intermittent catheterization and are encouraged to participate in this facet of care, because they will be involved in long-term follow-up and must be able to recognize complications so that treatment can be instituted.

The patient is taught to record fluid intake, voiding pattern, amounts of residual urine after catheterization, characteristics of urine, and any unusual sensations that may occur.

IMPROVING BOWEL FUNCTION

Immediately after SCI, a paralytic ileus usually develops due to neurogenic paralysis of the bowel; therefore, a nasogastric tube is often required to relieve distention and prevent aspiration.

Bowel activity usually returns within the first week. As soon as bowel sounds are heard on auscultation, the patient is given a high-calorie, high-protein, high-fiber diet, with the amount of food gradually increased. The nurse administers prescribed stool softeners to counteract the effects of immobility and pain med-ications. A bowel program is instituted as early as possible.

PROVIDING COMFORT MEASURES

After cervical injury, if pins, tongs, or calipers are in place, the skull is assessed for signs of infection, including drainage. The back of the head is checked periodically for signs of pressure, with care taken not to move the neck. The hair around the tongs usu-ally is shaved to facilitate inspection. Probing under encrusted areas is avoided.

The Patient in Halo Traction

Patients who have been placed in a halo device after cervical sta-bilization may have a slight headache or discomfort around the skull pins for several days after the pins are inserted. The patient initially may be bothered by the rather startling appearance of this apparatus but usually readily adapts to it because the device pro-vides comfort for the unstable neck. The patient may complain of being caged in and of noise created by any object coming in contact with the steel frame, but he or she can be reassured that adaptation to such annoyances will occur.

The areas around the pin sites are cleansed daily and observed for redness, drainage, and pain. The pins are observed for loos-ening, which may contribute to infection. If one of the pins be-comes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. A torque screw-driver should be readily available should the screws on the frame need tightening.

The skin under the halo vest is inspected for excessive perspi-ration, redness, and skin blistering, especially on the bony promi-nences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet, because dampness causes skin excoriation. Powder is not used inside the vest, because it may contribute to the development of pressure ul-cers. The liner should be changed periodically to promote hygiene and good skin care. If the patient is to be discharged with the vest, detailed instructions must be given to the family and time allowed for them to return demonstrate the necessary skills (Chart 63-9).

MONITORING AND MANAGING POTENTIAL COMPLICATIONS

Thrombophlebitis

Thrombophlebitis is a relatively common complication in patients after SCI. DVT occurs in a high percentage of SCI patients; thus, they are at risk for PE. The patient must be assessed for symptoms of thrombophlebitis and PE: chest pain, shortness of breath, and changes in arterial blood gas values must be reported promptly to the physician. The circumferences of the thighs and calves are measured and recorded daily; further diagnostic studies will be performed if a significant increase is noted. Patients remain at high risk for thrombophlebitis for several months after the ini-tial injury. Patients with paraplegia or quadriplegia are at in-creased risk for the rest of their lives. Immobilization and the associated venous stasis, as well as varying degrees of autonomic disruption, contribute to the high risk and susceptibility for DVT (Zafonte et al., 1999).

Anticoagulation is initiated once head and other systemic in-juries have been ruled out. Low-dose fractionated or unfraction-ated heparin may be followed by long-term oral anticoagulation (ie, warfarin) or subcutaneous fractionated heparin injections. Additional measures such as range-of-motion exercises, thigh-high elastic compression stockings, and adequate hydration are important preventive measures. Pneumatic compression devices may also be used to reduce venous pooling and promote venous return. It is also important to avoid external pressure on the lower extremities that may result from flexion of the knees while the patient is in bed.

Orthostatic Hypotension

For the first 2 weeks after SCI, the blood pressure tends to be un-stable and quite low. There is a gradual return to preinjury levels, but periodic episodes of severe orthostatic hypotension frequently interfere with efforts to mobilize the patient. Interruption in the reflex arcs that normally produce vasoconstriction in the upright position, coupled with vasodilation and pooling in abdominal and lower extremity vessels, can result in blood pressure readings of 40 mm Hg systolic and 0 mm Hg diastolic. Orthostatic hypo-tension is a particularly common problem for patients with lesions above T7. In some quadriplegic patients, even slight elevations of the head can result in dramatic changes in blood pressure.

A number of techniques can be used to reduce the frequency of hypotensive episodes. Close monitoring of vital signs before and during position changes is essential. Vasopressor medication can be used to treat the profound vasodilation. Thigh-high elastic compression stockings should be applied to improve venous re-turn from the lower extremities. Abdominal binders may also be used to encourage venous return and provide diaphragmatic sup-port when upright. Activity should be planned in advance and adequate time given for a slow progression of position changes from recumbent to sitting and upright. Tilt tables frequently are helpful in assisting patients to make this transition.

Autonomic Dysreflexia

Autonomic dysreflexia (autonomic hyperreflexia) is an acuteemergency that occurs as a result of exaggerated autonomic re-sponses to stimuli that are harmless in normal people. It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided. The sudden rise in blood pressure may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. A number of stimuli may trigger this reflex: distended bladder (the most common cause); distention or con-traction of the visceral organs, especially the bowel (from consti-pation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, pressure ulcer). Because this is an emergency situation, the objective is to remove the triggering stimulus and to avoid the possibly serious complications.

The following measures are carried out:

·      The patient is placed immediately in a sitting position to lower blood pressure.

·      Rapid assessment to identify and alleviate the cause is im-perative.

·      The bladder is emptied immediately via a urinary catheter. If an indwelling catheter is not patent, it is irrigated or re-placed with another catheter.

·      The rectum is examined for a fecal mass. If one is present, a topical anesthetic is inserted 10 to 15 minutes before the mass is removed, because visceral distention or contraction can cause autonomic dysreflexia.

·      The skin is examined for any areas of pressure, irritation, or broken skin.

·       Any other stimulus that can be the triggering event, such as an object on the skin or a draft of cold air, must be removed.

·      If these measures do not relieve the hypertension and ex-cruciating headache, a ganglionic blocking agent (hydralazine hydrochloride [Apresoline]) is prescribed and given slowly intravenously.

·       The medical record or chart should be labeled with a clearly visible note about the risk for autonomic dysreflexia.

·      The patient is instructed about prevention and manage-ment measures.

·      Any patient with a lesion above the T6 segment is informed that such an episode is possible and may even occur many years after the initial injury.

The rehabilitation of the patient with a SCI (ie, the quadri-plegic or paraplegic patient) is discussed below.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care

In most cases, SCI patients need long-term rehabilitation. The process begins during hospitalization as acute symptoms begin to subside or come under better control and the overall deficits and long-term effects of the injury become clear. The goals begin to shift from merely surviving the injury to learning strategies nec-essary to cope with the alterations that injury imposes on activi-ties of daily living. The emphasis shifts from ensuring that the patient is stable and free of complications to specific assessment and planning designed to meet the patient’s rehabilitation needs. Patient teaching may initially focus on the injury and its effects on mobility, dressing, and bowel, bladder, and sexual function. As the patient and family acknowledge the consequences of the injury, the focus of teaching may broaden to address issues nec-essary to carry out the tasks of daily living. Teaching begins in the acute phase and continues throughout rehabilitation and through-out the patient’s life as changes occur, the patient ages, and problems arise.

Caring for the SCI patient at home may at first seem a daunt-ing task to the family. They will require dedicated nursing sup-port to gradually assume full care of the patient (Craig et al., 1999).

Although maintaining function and preventing complications will remain important, goals regarding self-care and preparation for discharge will assist in a smooth transition to rehabilitation and eventually to the community.

Continuing Care

The ultimate goal of the rehabilitation process is independence. The nurse becomes a support to both the patient and the family,assisting them to assume responsibility for increasing aspects of patient care and management. Care for the SCI patient involves members of all the health care disciplines; these may include nurs-ing, medicine, rehabilitation, respiratory therapy, physical and occupational therapy, case management, social services, and so forth. The nurse often serves as coordinator of the management team and as a liaison with rehabilitation centers and home care agencies. The patient and family often require assistance in deal-ing with the psychological impact of the injury and its conse-quences; referral to a psychiatric clinical nurse specialist or other mental health care professional often is helpful.

The nurse should reassure female SCI patients that pregnancy is not contraindicated, but pregnant women with acute or chronic SCI pose unique management challenges. The normal physiologic changes of pregnancy may predispose women with SCI to many potentially life-threatening complications, includ-ing autonomic dysreflexia, pyelonephritis, respiratory insuffi-ciency, thrombophlebitis, PE, and unattended delivery (Atterbury & Groome, 1998).

As more patients survive acute SCI, they will face the changes associated with aging with a disability. Thus, teaching in the home and community focuses on health promotion and ad-dresses the need to minimize risk factors (eg, smoking, alcohol and drug abuse, obesity). Home care nurses and others who have contact with patients with SCI are in a position to teach patients about healthy lifestyles, remind them of the need for health screenings, and make referrals as appropriate. Assisting patients to identify accessible health care providers and imaging centers may increase the likelihood that they will participate in health screening (eg, gynecologic examinations, mammograms, etc.).

Evaluation

EXPECTED PATIENT OUTCOMES

Expected patient outcomes may include:

1)    Demonstrates improvement in gas exchange and clearance of secretions, as evidenced by normal breath sounds on auscultation

a)     Breathes easily without shortness of breath

b)    Performs hourly deep-breathing exercises, coughs effec-tively, and clears pulmonary secretions

c)     Is free of respiratory infection (ie, has normal tempera-ture, respiratory rate, and pulse, normal breath sounds, absence of purulent sputum)

2)    Moves within limits of the dysfunction and demonstrates completion of exercises within functional limitations

3)    Demonstrates adaptation to sensory and perceptual alter-ations

a)     Uses assistive devices (eg, prism glasses, hearing aids, computers) as indicated

b)    Describes sensory and perceptual alterations as a conse-quence of injury

4)    Demonstrates optimal skin integrity

a)     Exhibits normal skin turgor; skin is free of reddened areas or breaks

b)    Participates in skin care and monitoring procedures within functional limitations

5)    Regains urinary bladder function

a)     Exhibits no signs of UTI (ie, has normal temperature; voids clear, dilute urine)

b)    Has adequate fluid intake

c)     Participates in bladder training program within func-tional limitations

6)    Regains bowel function

a)     Reports regular pattern of bowel movement

b)    Consumes adequate dietary fiber and oral fluids

c)     Participates in bowel training program within func-tional limitations

7)    Reports absence of pain and discomfort

8)    Is free of complications

a)     Demonstrates no signs of thrombophlebitis, DVT, or PE

b)    Exhibits no manifestations of pulmonary embolism (eg, no chest pain or shortness of breath; arterial blood gas values are normal)

c)     Maintains blood pressure within normal limits

d)    Has no lightheadedness with position changes

e)     Exhibits no manifestations of autonomic dysreflexia (ie, no headache, diaphoresis, nasal congestion, brady-cardia, or diaphoresis)

Management of the Quadriplegic or Paraplegic Patient

Quadriplegia refers to the loss of movement and sensation in all four extremities and the trunk, associated with injury to the cer-vical spinal cord. Paraplegia refers to loss of motion and sensation in the lower extremities and all or part of the trunk as a result of damage to the thoracic or lumbar spinal cord or to the sacral root. Both conditions most frequently follow trauma such as falls, in-juries, and gunshot wounds, but they may also be the result of spinal cord lesions (intervertebral disk, tumor, vascular lesions), multiple sclerosis, infections and abscesses of the spinal cord, and congenital disorders.

The patient faces a lifetime of great disability, requiring on-going follow-up and care and the expertise of a number of health professionals, including physicians (specifically a physiatrist), re-habilitation nurses, occupational therapist, physical therapist, psychologist, social worker, rehabilitation engineer, and voca-tional counselor at different times as the need arises.

As the years go by, these patients also have the same medical problems as others in the aging population. In addition, they face the threat of complications associated with their disability. Usu-ally the patient is encouraged to attend a spinal clinic when com-plications and other issues arise. Lifetime care includes assessment of the urinary tract at prescribed intervals, because there is the likelihood of continuing alteration in detrusor and sphincter function and the patient is prone to UTI.

Long-term problems and complications of SCI include disuse syndrome, autonomic dysreflexia (discussed earlier), bladder and kidney infections, spasticity, and depression. Pressure ulcers with potential complications of sepsis, osteomyelitis, and fistulas occur in about 10% of patients. Flexor muscle spasms may be particu-larly disabling and occur in up to 25% of patients (Sullivan, 1999). Heterotopic ossification (overgrowth of bone) in the hips, knees, shoulders, and elbows occurs in up to 30% of SCI patients. This complication is painful and can produce a loss of range of motion (Mitcho & Yanko, 1999; Subbarao & Garrison, 1999). Management includes observing for and addressing any alter-ation in physiologic status and psychological outlook, and the prevention and treatment of long-term complications. The nurs-ing role involves emphasizing the need for vigilance in self-assessment and care.