Rehabilitation Nursing 1

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 Mutual understanding of level of spinal cord injury determined in 1983 and redone in 1992  American Spinal Cord Injury Association(ASIA)  Defined spinal cord injury as:  Lowest level where two things remain INTACT: Movement Sensation 3

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 #1 Factor:  Need to understand amount of functional ability client will gain or regain by knowing these terms:  Tetraplegia (means four)  Quadraplegia  Quadriparesis  Paraplegia  Paraparesis  Hemiplegia  Hemiparesis 5

 #2 Factor:  Higher up the spinal injury, the more devastating  Level of injury determines 2 things on severely affected side:  Amount of function remaining  Amount of function lost  The physiatrist must consider both to determine if rehab treatment is the client’s best option 6

 #3 Factor:  SCI classified by level of cord affected  Cord levels within spinal vertebrae in order  31 pairs of spinal nerves which affect muscles and areas of skin 7

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 Dermatome Chart:  Map showing the nerve roots/muscles the nerves affect and function  Nurses can assess the sensory areas through touch and pain 9

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 Ascending tracts: (blue)  up to the brain  Descending tracts: (red)  down to the spinal cord/peripheral nerves 11

 Injuries below L2 or lower, damage the tip of the spinal cord  Conus medullaris or cauda equina (L2-S5)  Spinal root damage  Different than cord damage  Central branch of sensory nerve is hurt: Tend to be weaker than peripheral nerves Easier to compress  Not peripheral damage  Spinal cord:  Widest cervical/lumbar areas  Increases risk for injury RT most flexible areas 12

Rehabilitation Nursing 13

 Approximately 45% of SCI are complete  Complete does not necessarily mean spinal cord is cut  It does mean:  All sensation and movement is LOST Below the level of injury  ASIA definition of Complete Injury:  Absence of all motor or sensory function in the anal and perineal region (S-4 to S-5)  Zone of Preservation  Partial Preservation 14

 Approximately 55% of SCI injuries  Evidence of sensation or movement still intact below the level of injury  RT some areas of the cord damaged and some not damaged permitting signals to continue getting through 15

 Similar to a brain concussion  Temporary shutting down of spinal accessory nerves  Affects:  All functional and natural reflexes below site of injury  Often seen when immediate injury occurs  Can be seen developing later  If no infection develops, the general course lasts 7-10 days  Signs: flaccidity of affected areas  Flaccid  Paralysis where muscles are soft and limp  Signs Spinal Shock is over 16

Spinal Cord Injured 17

 Due to advances in technology and care, SCI clients live longer  Eventually may develop overtime, other co- morbidities  SCIs affect nearly every body system  Result: Their lives will never be the same  Rehab nurses use FIM scoring to understand baseline:  Sensory function  Motor function 18

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 C1-C4- need Ventilator  C2-C5 most life-threatening  C4-C5 most common cervical injury  If requires respiratory assistance, use jaw thrust  C5-C8 and T1-T5  Weakened or paralyzed diaphragm/intercostal muscles  Decreasing chest expansion  Reduced inspiratory volume  Decreased expiratory efficiency  May require Quad cough assistance 20

 C1-T5-non-ambulatory  T6-T9- Limited ambulation with:  Braces  Lofstrand crutches  New Technology  T10 and below- Functional ambulation  May have some flaccidity below the lesion  May have some degree of spasticity below the lesion 21

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 Uncontrolled and involuntary muscle contractions and reflex tendons are exaggerated  Spasms may always be present  Managed by:  Performing daily ROM!!!  Gentle applied firm pressure  Massage to limb 25

 Serves as warning sign of pain or other developing problems  Signals: Infection Kidney stone Skin breakdown  Help maintain muscle size and bone strength  Helps decrease osteoporosis  Keeps blood circulating in lower limbs  Helps tighten lower limbs making it an easier transfer than when flaccid 26

 Because of positive benefits of spasms treatment is delayed until spasms interfere with:  Sleep  Limits client’s functioning ability  Medication treatment purpose:  Decrease muscle tone  Decrease frequency of spasms  Medications used:  Valium, Dantrium, Baclofen 27

 Interferes with diagnostics requiring client to lay still for procedure  Nursing may be required to assist during procedure to help with immobilizing spine positioning 28

 C1-C5- completely dependent  Special W/C  C6-C7- requires assistance  RT Gross motor control presence  T1-T5- requires assistance  Uses slide board  T5 or below  Should reach independence 29

 Over use syndrome  Chronic pain  Rotator cuff problems  Nerve entrapments  Wear and Tear on hands 30

 Bone changes increase in risk below the level of injury  Can change client’s ROM, which may interfere with ADLs and transfers  Bone Changes:  Osteoporosis  Heterotrophic Ossification  Fractures 31

 C5-T9- use hand controls  T10 and below driving possible 32

 FIM scoring used to assess level of functioning and offers guidelines to OT  C1-C4-dependent  C5-C7-needs assistance  T1 and below  Goal is independence  Ability to reach goal will vary 33

 C1-C7-dependent  T1-T9  May be independent with bladder  Requires assistance with bowel  T10-T12- expect to be independent  L1-L2- independent  L4-S5- has adequate independent control of both 34

 Reflex Bladder  Bladder empties only when full  Not RT:  Client relaxing to voluntarily urinate 35

 Non-Reflex Bladder  Bladder is flaccid- lacking tone  No reflex action present when stretches  May not feel fullness of bladder  Main problem:  Overfilling  Dribbling  Nursing Concern:  Need great teaching if managing bladder by intermittent catheterization  Obese clients require indwelling catheters 36

 Major cause of death with SCIs RT:  Poor technique  Poor care of equipment  Most clients develop colonized microbes in bladder  This does not indicate an active UTI  Normal adult signals of UTI  SCI signals of a UTI:  Increase in spasms  Foul smell to urine  Change in voiding habits  Fever  Possible autonomic dysreflexia episode 37

 #1 Kidney failure  #2 Hydronephrosis  #3 Increased risk for bladder CA RT intermittent catheterr use 38

 Men  Can change fertility/sexual function  Above level of conus medullaris may have reflexive erections, but few ejaculate(20%)  May require penile implants/vacuum pumps 39

 Women  Capable of sexual intercourse and conception  Capable of experiencing orgasm  Menses:  Disrupted after SCI injury for 3-6 months  Nurses watchful for return  Pregnancy:  Watch closely RT: Increased Low birth weights Increased premature births  Complications 40

 SCI clients can also develop peptic ulcers and gallstones  Three types of bowel problems:  #1 Reflex Neurogenic Bowel RT cervical/high thoracic injury  #2 Autonomous Reflex Neurogenic Bowel Lower injuries where anal tone/rectal reflex now absent  #3 Uninhibited Neurogenic Bowel From CNS trauma 41

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 Nurses use take advantage of the Gastrocolic Reflex:  Autonomic response occurring when food/fluids enter the stomach  Stimulating peristalsis  Client may experience urge to defecate within minutes of oral intake  Rectum  Stretches from fecal mass sending signals to brain  Brain returns with message to voluntarily control the anal sphincter  If relaxed sphincter, can push fecal mass out of body Gravity and contracting abdomen helps 43

 Spinal cord messages to brain may:  Work  Partially work  Not work at all  Location of injury/disease also plays a role 44

 Physical structures all present  Reflexes intact  Everything ready to go to work  Problem:  Body never gets the go ahead signal  Signal is lost never got to brain or there is a disruption RT damage  Major Problem:  Bowel maintenance and accidents  Nursing Interventions:  Bowel training  Time toileting 45

 Physical structures all present  Trouble with maintaining sphincter tone  Reflexes help involuntarily  Client unable to recognize:  Need to have BM(sensory)  Unable to hold BM even if wanted to(motor)  Major Problem: Bowel maintenance  Produces BMs at irregular times  Social issue  Nursing interventions:  Bowel training  Time toileting 46

 Physical structures all present  Neuro functions of motor and sensory + reflexes are lost  No tone, no rectal reflex  Client incapable of recognizing need to have BM  Incapable of holding BM  Nursing interventions:  Suppository insertion program  Time toileting schedule  Goal: Keep client cleaned out 47

 Diet  Fluids  Exercise 48

 Goal:  Retrain/gain control over bowels to prevent social issues  Individually adjusted  Suppositories, timing, massage of abdomen, etc  Once time of scheduled toileting is decided on it should not be changed:  Achieving bowel control takes up to 6 weeks  Requires consistency of staff/caregiver to be successful  Plan on accidents at first and eventually will rarely occur  Just don’t change the time!!!! 49

 Body gets used to certain times for things like sleeping and eating  Body can also be taught to go to the bathroom  Timed toileting takes advantage of Gastrocolic reflex occurring after eating  Client toileted 30 minutes after eating at their agreed time  Client is positioned on toilet with knees slightly higher or at rectum level  Leans forward and abdomen massaged  Can be offered warm fluids 50

 Requires physiatrist order  Administered while in Sims position  Use of Dulcolax(biscodyl) requires water  Use of glycerin requires water soluble lubricant  If routine timed toileting not working then can use suppository to help start the bowel program:  Must correctly insert the suppository and then wait 20 minutes before transferring to the toile  Can perform abdominal massage  If no BM, may digital stimulation  Get client off toilet within 30 minutes 51

 Works on the rectal reflex  Anal wink must be present  Stimulates reflex to relax and open  Enables BM to pass  Client sits over raised toilet seat:  Gloved nurse with lubricated index finger  Gentle insertion 1 inch and gently rotates for 30 seconds to 2 minutes until sphincter relaxes  OK to perform 2-3 times  If no BM, then manual removal required 52

 Perform until rectum empty  Avoid performing if cardiac issues 53

 S&S are not the same as a normal adult  Causes  If new SCI  May need to experiment with foods to find what contributed to this  Food diary recommended  Treatment  May need oral laxative  Call physiatrist  Prevention 54

 Causes  Diet changes or inadequate diet  Infection/illness  Stress!!  Stool softeners  Medications  Treatment  Must find cause  Can’t prevent until you know cause  Stop or decrease number of daily stool softeners  Must inform physiatrist!  Follow regular bowel program 55

 Symptoms  Pain on emptying bowel  Rectal itching  Rectal bleeding  Do assess/inspect for these  Causes  Straining with constipation  Frequent dig stimulation  Frequent diarrhea  Improper position on toilet seat  Treatment  Limit sitting time  Discourage dig stimulation  Use stool softeners or oil retention enemas to soften BM  Mild laxative for short time  Prevention  Follow bowel program 56

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