NURSING CARE AND REHAB FOR THE SPINAL CORD INJURY PATIENT By: Michele Cimino, MSN, RN
LEARNING OBJECTIVES Discuss the differences between a complete versus an incomplete SCI Injury Identify what physical components are associated with what level of injury Recognize the signs and symptoms of Autonomic Dysreflexia Prevention techniques for Autonomic Dysreflexia Treatment of Autonomic Dysreflexia Develop an appropriate plan of care for the SCI patient
CLASSIFICATION OF SCI A = Complete: No motor or sensory function is preserved in the S4-S5 sacral segments B = Incomplete: Sensory function but not motor function is preserved below the neurological level and includes the S4-S5 sacral segments C= Incomplete: Motor function is preserved below the neurological level, and more than half of key muscles below the neurological level have a muscle grade less than 3 D= Incomplete: Motor function is preserved below the neurological level, and at least half of key muscles below the neurological level have a muscle grade of 3 or more E= Normal: Motor and sensory function are normal
LEVELS OF SCI Quadriplegia
C1-C4 – Tetraplegia (High) C5-C7 – Tetraplegia Paraplegia T1-T12 – Thoracic Lumbar Paraplegia
C1 – C4 TETRAPLEGIA (QUADRIPLEGIA) C1 – C3 Most likely require mechanical ventilation Swallowing and phonation are preserved C1 – C4 Little or no movement of upper and lower extremity muscles Positive movement of head and neck Possible shoulder elevation (shrug) Will need assistance with all most all self-care needs & mobility
C5 TETRAPLEGIA
Functional use of elbow flexion Can assist with upper extremity dressing and bed mobility Can achieve independence with feeding and grooming Needs assistance with; transfers, lower extremity dressing, bathing, bowel and bladder
Nursing/Rehab: Important to prevent contractures of elbow flexion and forearm supination Power wheelchair with hand controls will mostly be required Manual wheel chair with hand grips for short-distance Driving with adaptations * Assistive technology
C7 & C8 TETRAPLEGIA C7 Ability to extend their elbow C8 Ability to functional finger flexion Independence with all self-care needs
LUMBAR PARAPLEGIA
C6 TETRAPLEGIA Added function of wrist extension Can grasp objects with assistive devices
Highest level for complete injury and still function independently Independent in feeding, grooming, bathing and bed mobility Can assist with bowl and bladder program More difficult for women Independent with phone, writing and typing Driving with adaptions
THORACIC PARAPLEGIA T1 – T12 Nerve sensation and function of all upper extremity muscles T2 – T9 Variable trunk control May stand by using bilateral knee-ankle-foot orthoses (KAFOs), along with crutches or walker
AUTONOMIC DYSREFLEXIA (HYPERREFLEXIA)
L2 – Hip flexion L3 – Knee extension (quadriceps) L4 – Ankle Dorsiflexion (tibialis anterior) L5 – Great toe extension (extensor hallucis longus)
Potentially dangerous complication of SCI Elevated BP to dangerous levels – if not treated may result in seizures, retinal hemorrhage, pulmonary edema, renal insufficiency, myocardial infarction, cerebral hemorrhage, and death
Can achieve functional independence for all mobility, self-care, and bladder and bowel skills.
SCI – T6 or higher at greater risk
SIGNS AND SYMPTOMS Hypertension (BP > 200/100) Bradycardia (HR < 60) Flushed face Nasal stuffiness Pounding headache Sweating above level of injury Red blotches on skin above level of injury Nausea Piloerection (goose bumps) below level of injury Cold, clammy skin below level of injury
CAUSES Bladder Bowel Skin – related disorders Sexual Activity Other
TREATMENT CONTINUED Evaluate for other causes Pressure area Post-operative irritation or pain Ingrown toe nail Burn Fracture Administer adequate analgesia
TREATMENT Check BP with manual sphygmomanometer Sit patient as upright as possible Remove all tight clothing including abdominal binders Monitor BP and pulse every 2 to 5 minutes Obtain assistance from other staff member Determine cause: Urinary: Check urinary catheter for kinks, folds, blockages Use lignocaine gel and wait 2 to 5 min if possible Be alert for sudden hypotension Bowl: Instill Lignocaine gel into the rectum If BP > 150 consider pharmacological management Fecal dis-impaction
PREVENTION TECHNIQUES Frequent pressure relief Avoidance of sun burn/scalds, protect skin Compliance with bowl and bladder program Proper maintenance of catheter
ACUTE VS SUB-ACUTE REHAB Acute
Patient Status
Significant functional and/or cognitive limitations; at least 2 therapy disciplines Medically stable with medical or surgical comorbidities manageable and not requiring acute medical attention Expected improvement from rehab inter vention within a reasonable and predictable period of time
ACUTE VS SUB-ACUTE REHAB Program Requirements
Acute
Sub-Acute
Requires care that is directly r e l a te d a n d r e a s o n a b l e f o r t h e presenting condition and/or illness ( i e . N u t ritio nal a n d r e s p irator y, v e nt ilato r m a n agem ent , f u nctio nal r e hab ilit ation, w o u nd c a re, i n f ectious d i s e as e m a nagement a n d p u l m onar y r e h ab) Medically stable with medical or surgical comorbidities manageable a n d n o t r e q u i r i n g a c u te m e d i c a l a t te n t i o n E x p e c te d i m p r o v e m e n t f r o m m e d i c a l a n d / o r r e h a b i n te r v e n t i o n (or end-stage disease) within a reasonable and predictable period of time
A t l e a s t 3 h o ur s p e r d ay o f s k i l l e d t h e r a p y ( m i n 5 d ay s a w e e k ) Medical assessment or oversight :≥ 3/week Preadmission screening assessment completed by a rehab professional Tr e a t m e n t p l a n d e v e l o p e d w i t h i n 2 d ay s o f admission I n t e r d i s c i p li na r y a n d g o a l - o r i e n t e d treatment by team Daily documentation of patient treatment i n t e r v e n t io n s Documentation of progress and m o d i f i c a t io n s o f t r e a t m e n t p l a n w e e k l y I n t e r d i s c i p li na r y t e a m m e e t i n g w e e k l y (must include discharge plans) Fa m i l y - c e n te r e d c a r e a v a i la bl e t h a t focuses on patient and family instruction for effective discharge M e d i c a l s p e c i a l t y, b e h a v i o r a l c o n s u l t a t i v e services and child life services or s p e c i a l i s t s a v a i l ab le Pharmacy and diagnostic services a v a i l ab le
REHAB Psychosocial – Emotional well being Impaired mobility: Depending on level of injury –
operating a wheel chair Positioning Pressure relief Safety principles
Impaired ADL’s – PT and OT to assist in establishing as much independence as possible
Sub-Acute
Skilled nursing at least 4 hours per day a n d / o r 2 - 3 h o u rs p e r d a y ( m i n 5 d a y a w e e k ) Medical assessment or oversight: ≥ 2/week Preadmission screening assessment completed by a rehab professional Treatment plan developed within 2 days of admission Interdisciplinary and goal-oriented treatment by team Daily documentation of patient treatment interventions Documentation of progress at least weekly Interdisciplinary team meeting weekly (must include discharge plans) Family-centered care available that focuses on patient and family instruction for effective discharge Medical specialty, behavioral consultative services and child life services or specialists available Pharmacy and diagnostic services available
REHAB CONTINUED Bladder Depending on level of injury Clean interment catherization Foley Will remain free of UTI and urinary leakage Mitrofanoff Procedure
Dressing Bathing Feeding
MITROFANOFF PROCEDURE Appendicovesicostomy Surgical procedure that creates a tube inside the body to drain the bladder. Appendix is detached from the large intestine and relocated to the bladder and skin. Allows the patient to catherize themselves through the stoma
MITROFANOFF PROCEDURE CONTINUED Prior to surger y:
Bowel prep Special diet NPO during Bowel prep After bowel prep clear liquids only
Surger y 1 to 3 hours May be performed laparoscopically (shorter hospital stay NG tube placement
Care af ter surger y Catheters
Secure Clean Irrigation Collection bags
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BOWL Bowl Pt. will be continent of bowel Maintain passage of soft formed stool every 1-3 days ACE (Antegrade Colonic Enema) Procedure Peristeen
ANTEGRADE COLONIC ENEMA (ACE) Allows patient to control bowel movement Small opening (ostomy) in the patients belly button or lower tummy. Continent ostomy – fluids only go in Initially flush with normal saline Then may advance to Tap water Desired bowel movement within 30 to 60 minutes
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PERISTEEN Anal Irrigation system Empties the bowel by introducing water into the bowel using a rectal catheter. It is performed while sitting on the toilet. The water stimulates the bowel and flushes out the stool, leaving the lower half of the bowel empty. Prevents fecal incontinence and constipation for up two days.
REHAB - CONTINUED Nutrition Healthy food choices Appropriate I/O to maintain Bowl and Bladder programs Skin and prevention of ulcers Weight within normal range for height and age May require tube feeds Megace to stimulate appetite
REHAB - CONTINUED Respiratory – Depending on level of injury Collapsed lungs Pneumonia Aspiration Ventilator – Weaning Tracheostomy Spirometer Abdominal Binder Frog Breathing Diaphragm or Breathing Pacemaker Cough Assist Vest
SEXUALITY AND SELF-IMAGE
PHYSICAL CHANGES There are two types of erections: Psychogenic – results from sexual thoughts, seeing or hearing something stimulating or arousing Reflex – direct contact with penis or other erotic area such as ear s, nipples or neck Reflex erection Involuntary and can occur without sexual or stimulating thoughts The nerves that control a man’s ability to have reflex erection are located in the sacral segments (S2-S4) of the spinal cord Most men with SCI are able to have reflex erections if S2-S4 pathways are not damaged
Erectile Dysfunction (ED) Erection using reflex erections may not be hard enough or last long enough for sexual activity; this is called erectile dysfunction (ED) There are various treatments available to treat ED A urologist can assist with this
OPTIONS Viagra ® (Sildenafil) Penile injection Injections must be used exactly as prescribed, or priapism (prolonged erection) can occur When this occurs, the blood fails to drain from the penis This can damage penile tissue and be extremely painful
Medicated Urethral System Erection (MUSE) MUSE is a medicated pellet placed in the urethra (opening to penis). It is absorbed into the surrounding tissue, causing the blood vessels to relax and allow blood to fill the penis Side effects include burning sensation, decreased blood pressure, fainting, and risk of infection
VACUUM PUMP
SURGICAL IMPLANT
The vacuum pump is a mechanical option The penis is placed in a vacuum cylinder and air is pumped out of the cylinder, causing blood to be drawn into the erectile tissue The erection is maintained by placing a constriction ring around the base of the penis This rings may also prevent urinary leakage It is important to remove the rings after sexual activity There are battery-operated devices available for those with limited hand function
Often the last option for ED, because it is permanent - penile prosthesis Involves a surgical procedure to insert an implant directly into the penile tissue to obtain an erection Three models are available: semi-rigid, fully inflatable, and self-contained Risks include mechanical breakdown, implant being pushed out through the skin, infection
FERTILITY The ability to father a child may be affected by your spinal cord injury This may be affected due to the inability to ejaculate The movement (motility) of the sperm decreases after SCI Another problem is called retrograde ejaculation, when sperms goes into the bladder instead of out of the penis Options for fertility Penile vibratory stimulation: This is used to produce erection and also ejaculation. Risks include swollen or inflamed skin, bruising, bleeding, or ulceration
Rectal Probe Electro-ejaculation: A physician inserts an electrical stimulation probe into the rectum which causes ejaculation
SELF-IMAGE E m otional c h anges M e n a r e o f te n c o n c e r n e d a b o u t t h e a b i l i t y to h a v e s e x u a l a c t i v i t y T h ey m ay b e c o n c e r n e d a b o u t h o w to m e e t a n d a t t r a c t p a r t n e r s Good communication is essential I f n e e d e d a c o u n s e l o r m ay h e l p to c o m m u n i c a te yo u r n e e d s a n d f e e l i n g s S a fe s e x T h e r i s k s o f s e x u a l l y t r a n s m i t te d d i s e a s e s ( S T D ) a r e t h e s a m e a s b e f o r e yo u r i n j u r y P r e c a u t i o n s m u s t b e t a k e n to p r e v e n t g e t t i n g S T D s , s u c h a s c o n d o m s R e m e m b e r to t r y to u s e l a te x - f r e e c o n d o m s B l a dder m a n agement L i m i t f l u i d i n t a k e i f yo u a r e p l a n n i n g a s e x u a l e n c o u n te r E m p t y yo u r b l a d d e r p r i o r to s e x u a l e n c o u n te r I f yo u h a v e a s u p r a p u b i c o r Fo l ey c a t h e te r, t a p e t h e t u b i n g to yo u r t h i g h o r a b d o m e n s o i t w o n ’ t k i n k , p o p - o u t , o r g e t i n t h e w ay B o wel m a n agement E s t a b l i s h a c o n s i s te n t b o w e l r e g i m e n Yo u m ay e m p t y yo u r b o w e l p r i o r to s e x u a l e n c o u n te r Av o i d m e a l s p r i o r to s e x u a l e n c o u n te r to r e d u c e t h e r i s k o f a b o w e l a c c i d e n t
WOMEN WITH SPINAL CORD INJURY:
Are desirable Have the opportunity to meet people, fall in love and marry Are sexual beings Have sexual desires Have the ability to give and receive pleasure Can and do enjoy active sex lives Can become pregnant and have children
ORGASMS
An orgasm is the intense physical pleasure at the height of sexual arousal Orgasms vary in type and intensity among all women Studies have shown that spinal cord injury female can still have orgasms, even though it might be different
FERTILITY
It is normal for you to miss your period for a brief time up to six months after initial injury However, you will still be ovulating, so you can get pregnant during this time After six months, there is usually no difference in menstrual cycle as compared to females without spinal cord injuries Protection is the most important issue
VAGINAL LUBRICATION
Vaginal lubrication can be limited due the spinal cord injury. Use of artificial water-based lubricants, such as KY Jelly, can aide in vaginal penetration and reduce vaginal tearing and/or pain. Do not use Vaseline.
AREAS OF SEXUAL AROUSAL
Mouth and lips Feet Neck and shoulder Ears Stomach Breasts Clitoris Buttocks
COMMON CONCERNS ABOUT SEXUAL ACTIVITY Urinary accidents Bowel accidents Not satisfying the partner Feeling sexually unattractive Others viewing yourself as sexually unattractive Not getting enough personal satisfaction Preparation too much trouble Hurting self Loss of interest Not liking methods for satisfaction
PREPARATION Bladder management Empty your bladder prior to sexual encounter If you have a suprapubic or Foley catheter, tape the tubing to your thigh or abdomen so it won’t kink, pop-out, or get in the way Bowel management Establish a consistent bowel regimen You may empty your bowel prior to sexual encounter Avoid meals prior to sexual encounter to reduce the risk of a bowel accident
REFERENCES BrainAndSpinalCord.org (2015). Levels of spinal cord injury. Retrieved from http://www.brainandspinalcord.org/content/levels_of_spinal_cord_injury Children's Hospitals and Clinics of Minnesota. (2016). Mitrofanoff. Patient family education. Retrieved from www.childrensmn.org/A-Z Cleveland Clinic (1995-2014). Understanding antegrade colonic enema (ACE) surgery. Retrieved from http://my.clevelandclinic.org/services/All/hic_understanding_antegrade_colonic_enema_a... Healthline. (2005-2015). All about autonomic dysreflexia (or hyperreflexia). Retrieved from http://www.healthline.com/health/autonomic-hyperreflexia Keck, W. M. Center for Collaborative Neurosciences (2002-2015). Spinal cord injury levels & classification. Rutgers University. Retrieved from http://www.sci-info-pages.com/levels.html Mayo Clinic Staff (2014). Disease and conditions: Spinal cord injury. Retrieved from http://www.mayoclinic.org/diseases-conditions/spinal-cord-injury/basics/complications/co... Middleton, J., Ramakrishnan, K., & Cameron, I. (2014). Treatment of autonomic dysreflexia for adults & adolescents with spinal cord injuries. Agency for Clinical Innovation ISBN: 978-174187-972-8 United Spinal Resource Center (n.d.). Autonomic dysreflexia. Retrieved from http://www.spinalcord.org/resource-center/askus/index.phy?pg=kb.page&id=248
HOW NURSES HELP? We are:
Compassionate Team players Motivational Stabilizers Treat Improve patient’s self-image Improve physical function and mobility Educate Assist patients to have independent lives
THANK YOU!
