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Spinal cord injuries


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lesson plan on spinal cord injury and its management

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Spinal cord injuries

  1. 1. TIME SPECIFIC OBJECTIVE CONTENT MATTER 30secs TEACHING LEARNING ACTIVITIES EVALUATION INTRODUCTION Spinal cord injury is a major health problem. It occurs almost four times more often in males than in females. Young people aged 16-30 suffer more than half of new spinal cord injuries each year. 30secs Define spinal cord injury Definition The student teacher What do you Any injury to the spinal cord is known as defines spinal cord injury understand by spinal cord injury and is characterized using power point spinal cord injury? by decrease or loss of sensory and motor function below the level of injury. 1min Causes  Motor vehicle crashes  Violence  Falls  Sports Other causes can be  Hyperflexion  Hyperextension  Compression Enlist the causes of spinal cord injuries 30secs Enumerate the risk factors of spinal cord injuries Risk factors  Age  Gender The student teacher enlists the causes by flannel chart What are the causes of spinal cord injuries? The student teacher Enumerates the risk What are the risk factors of SCI?
  2. 2.  Alcohol  Drug use 2mins 3mins Describe the pathophysiology of spinal cord injury Pathophysiology : Classify the spinal cord injuries Types: The spinal cord injuries may be classified by location or by degree of damage to the cord. Spinal cord injuries can be separated into two categories: a) Primary injuries or complete transaction of the cord The spinal cord is made up of nerve fibers that allow communication between the brain and the rest of the body. Damage to the spinal cord ranges from transient concussion to contusion, laceration and compression of the cord substance to complete transaction of the cord and results in interference with the communication process. Damage may be caused by bruising , cutting, or bleeding into the cord, external forces or by fragments of fractured bone. The most frequently involved vertebrae are: 1. Cervical 5,6 and 7 2. Thoracic 12 3. Lumber 1 factors using power point. The student teacher describes pathophysiology by showing power point What is the pathophysiology of spinal cord injuries? The student teacher explains types of SCI by using flannel chart. What are types of spinal cord injuries?
  3. 3. b) Secondary injuries or incomplete transaction of the cord Primary injuries are the result of the initial trauma and are usually permanent. Secondary injuries are usually result of a contusion or tear injury in which nerve fibres begin to swell and disintegrate. A secondary chain of events produces ischemia, hypoxia, edema, and hemorrhagic lesions which in turn result in destruction of myelin and axons. These secondary reactions , believed to be the principal causes of spinal cord degeneration at the level of injury and thought reversible after 4 -6 hours after injury. Therefore if the cord has not suffered irreparable damage , some kind of early treatment is needed to prevent partial damage from developing into total and permanent damage. 4mins Discuss the clinical manifestations of spinal cord injuries Clinical manifestations: Cervical injuries: Cervical cord injuries can affect all four extremities, causing paralysis and parasthesias, impaired respiration and loss of bowel and bladder control. Paralysis of all the four extremities is called quadriplegia; weakness of all the extremities is called quadriparesis. If The student teacher discusses the clinical manifestations using flash cards What are the clinical manifestations of SCI?
  4. 4. the injury is at C3 or above, the injury is usually fatal because muscles used for breathing are paralysed. An injury at the fourth or fifth cervical vertebrae will affect breathing and may necessitate some type of ventilator support. These clients typically need long term assistance with activities of daily living. Thoracic/lumber injuries Thoracic and lumber injuries affect the legs, bowel and bladder. Paralysis of the legs is called paraplegia; weakness of the legs is called paraparesis. Sacral injuries affect the bowel and bladder continence and may affect foot function. Individuals with thoracic, lumbar and sacral injuries can usually learn to perform activities of daily living independently. Spinal shock Spinal cord injury has profound effect on the autonomic nervous system. Immediately following injury the cord below the injury stops functioning completely. This causes a disruption of the sympathetic nervous system, resulting in vasodilation, hypotension, and bradycardia. Dilation of the blood vessels allow more blood flow just beneath the
  5. 5. skin. This blood cools and is circulated throughout the body, causing hypothermia. Keep the client covered as much as possible but avoid overheating. This may last from a week to many weeks in some clients. 3mins Explain the effects of spinal cord injuries Effects of spinal cord injuries 1. Central cord syndrome Characteristics: motor deficits (in the upper extremeties compared to the lower extremities; sensory loss varies but more pronounced in the upper extremities); bowel/bladder dysfunction is variable or function may be completely preserved. Cause: injury or edema of the central cord usually of the cervical area. 2. Anterior cord syndrome Characteristics: loss of pain, temperature and motor function is noted below the level of lesion; light touch, position, and vibration, sensation remain intact Cause: the syndrome may be caused by acute disk herniation or hyperflexion injuries associated with fracture- dislocation of vertebrae. It may also occur as a result of injury to the anterior The student teacher explains the effects by showing Chart and power point slides What are the various effects of SCI?
  6. 6. spinal artery, which supplies the anterior two thirds of the spinal cord 3. Brown- sequard syndrome (lateral cord syndrome) Characteristics: ipsilateral paralysis or paresis is noted, together with ipsilateral loss of touch, pressure and vibration and contralateral loss of pain and temperature Cause: the lesion is caused by a transverse hemisection of the cord usually as a result of a knife or missile injury, fracturedislocation of a unilateral articular process or possibly an acute ruptured disk. 4. Conus medullaris syndrome It follows damage to the lumber nerve roots and conus medullaris in spinal cord Client experiences bowel and bladder arefelxia and flaccid lower extremities 5. Cauda equine syndrome It occurs from injury to the lumbosacral nerve roots below the conus medullaris The patient experiences areflexia of the bowel, bladder and lower
  7. 7. 4mins Enumerate the complications of spinal cord injuries reflexes. Complications 1. Infection Impared respiratory effort, decreased cough, mechanical ventilation and immobility all predispose the cervical cord injured client to pneumonia. Catheterization whether indwelling or intermittent places the client at risk for urinary tract infection. 2. Deep vein thrombosis Lack of movement in the legs inhibits normal blood circulation. Compression stockings, sequential compression devices and subcutaneous heparin may be used separately or together to reduce the risk of deep vein thrombosis 3. Orthostatic hypotension Spinal cord injured clients no longer have muscular function in their legs to promote venous return to the heart. They also have impaired vasoconstriction. This leads to the pooling of the blood in the legs when the client moves from supine to a sitting position. If the movement is sudden the client may faint. Gradual elevation of the The student teacher enumerate the complications by using chart What are the complications of spinal cord injuries?
  8. 8. head, use of elastic stockings and a reclining wheelchair help lessons this response. 4. Skin breakdown Clients or their caregivers must be diligent about relieving pressure on the skin by position changes and cushioning of the body prominences. Development of the pressure ulcers can lead to infection and loss of skin, muscle or bone. Treatment of pressure ulcers is time consuming and expensive and may interfere with work . 5. Renal complications Urinary tract infections are an ongoing concern to spinal cord injured clients. Both urinary reflex and untreated urinary tract infections can cause permanent damage to the kidneys 6. Depression and substance abuse Clients with spinal cord injury have a higher than average incidence of depression and substance abuse. Both of these factors can interfere with the client’s ability to care for himself or herself. Individual or family counseling may be helpful. Some
  9. 9. rehabilitation centers have support groups for spinal cord injured clients 7. Autonomic dysreflexia This life threatening complication occurs in clients with injuries above the T6 level. The spinal cord injury impairs the normal equilibrium between the sympathetic and parasympathetic autonomic nervous system Stimulation of the sympathetic nervous system results in cool. Pale skin, gooseflesh and vasoconstriction seen below the level of injury. The blood pressure may rise to 300mmHg systolic. The parasympathetic response results in vasodilation, causing flushing and diaphoresis above lesion and bradycardia as low as 30 beats per minutes. The client complaints of a pounding headache and nasal congestion secondary to the dilated blood vessels. 1min Discuss the diagnostic tests used to diagnose spinal cord injuries Diagnostic tests A detailed neurological examination is performed. Diagnostic X-rays and CT scanning are usually performed initially. An MRI scan may be ordered as a further The student teacher discusses the diagnostic tests by using power point How can we diagnose the spinal cord injuries?
  10. 10. workup if a ligamentous injury is suspected. Continuous electrocardiographic monitoring may be indicated if a cord injury is suspected since bradycardia and asystole are common in acute spinal cord injuries. 2mins Explain the emergency management of the client with spinal cord injury Emergency management The immediate management of the patient at the scene of injury is critical, because improper handling can cause further damage and loss of neurologic function.  Initial care must include a rapid assessment, immobilization, stabilization or control of life threatening injuries and transportation to the most appropriate medical facility  One member of the team must assume control of the patient’s head to prevent flexion , rotation or extension. This is done by placing the hands on both sides of the patient’s head at about ear to limit the movement and maintain alignment while spinal board or immobilizing device is applied  Any twisting movement may irreversibly damage the spinal cord by causing a bony fragment The student teacher explains the emergency management by showing transparency What is the emergency management of the patient with SCI?
  11. 11. of the vertebrae to cut into, crush and sever the cord completely  The patient must always be maintained in extended position and no part of the body should be twisted or turned nor the patient should be allowed to sit  Once the extent of the injury is determined the patient may be placed on the rotating bed(roto rest) or in a cervical collar 5mins Describe the medical management . Medical management The goals of the medical management is to prevent further SCI and to serve for the symptoms of progressive neurologic deficits.  The patient is resuscitated as necessary and oxygenation and cardiovascular stability is maintained  Regeneration therapy can also be given which involves the transplantation of the fetal tissue into the injured spinal cord in the hopes of regenerating the damaged tissue Pharmacological therapy  The administration of high dose The student teacher describes the medical management by using power point slides and chart What is the medical management of the patient with SCI?
  12. 12. corticosteroids specifically methylprednisolone has been found to improve motor and sensory outcomes at 6 weeks, 6 months, and 1 year if given within 8 hours of the injury.  Use of high dose methylprednisolone is accepted as standard therapy in many countries and remains an established clinical practice in most institutions. Respiratory therapy  Oxygen is administered to maintain a high arterial PO2 because hypoxemia can create or worsen a neurologic deficit of the spinal cord.  If endotracheal intubation is necessary extreme care is to taken to avoid flexing or extending the patient’s neck which can result in an extension of a cervical injury  In high cervical spine injuries, spinal cord innervations to the phrenic nerve which stimulates the diaphragm is lost. Diaphragmatic pacing attempts to stimulate the diaphragm to help the client breathe
  13. 13. Skeletal fracture reduction and traction Management of SCI requires immobilization and reduction of dislocations and stabilization of the vertebral column.  Cervical fractures are reduced and cervical spine is aligned with some form of skeletal traction such as skeletal tongs or calipers or halo device. a) Skull or skeletal tongs - Skull tongs are inserted into the outer aspect of the client’s skull and traction is applied - Weights are attached to the tongs and the client is used as countertraction - Monitor neurological status of the client - Determine the amount of weight prescribed to be added to the traction - Ensure that the weights hang freely at all times - Ensure that the ropes for the traction remain within the pulley - Turn the client every 2 hours - Provide sterile pin site care
  14. 14. as prescribed b) Halo traction - Halo traction is a static traction device that consists of a headpiece with four pins, two anterior, inserted into client’s skull - The metal ring may be attached to a vest or cast when the spine is stable allowing increased client mobility - Monitor the client’s neurological status and never move or turn the client by holding or pulling on the halo traction device - Assess the skin integrity to ensure that the jacket or cast not causing pressure 2mins Describe the surgical management Surgical management Surgery is indicated in any of the following instances  Compression of the cord is evident  The injury results in a fragmented or unstable vertebral body  The injury involves a wound that penetrates the cord  There are bony fragments in the spinal cord  The patient’s neurologic status is The student teacher discusses the surgical management by using chart What is the surgical management of the patient with SCI?
  15. 15. deteriorating Surgery is performed to reduce the spinal fracture or dislocation or to decompress the cord. A laminectomy(excision of the posterior arches and spinal processes oof a vertebrae) may be indicated in the presence of progressive neurologic deficit, suspected epidural hematoma, bony fragments or penetrating injuries. 4mins Explain the nursing management Nursing management Assessment  Obtain the information about the injury  Perform neurologic assessment  Assess vital signs with a focus to respiratory status  Ongoing monitoring: neurologic, motor, sensory abilities, bowel and bladder pattern and signs of respiratory distress and spinal shock Nursing diagnosis      Ineffective breathing pattern Ineffective airway clearance Risk for impaired gas exchange Pain Impaired physical mobility The student teacher explains the nursing management with the help of power point and chart. What is the nursing management of the patient with SCI?
  16. 16.  Risk for impaired skin integrity  Altered elimination  Imbalanced nutrition Respiratory support  Mechanical ventilator  Chest physical therapy  Suctioning  Kinetic bed  Tracheostomy  Abdominal binder to facilitate abdominal breathing  Incentive spirometry Thermoregulation  Rectal and core temperature monitoring  Environmental control  Prevention of cool draught  Top linen to protect warmth  Hypothermia blanket Maintaining urinary elimination  Intermittent catheterization is carried out to avoid the distention of the bladder and UTI  If latter is not feasible then indwelling catheter is inserted temporarily.  Intake output chart is maintained. Physical mobility  Position to avoid contractures and
  17. 17. foot drop  Maintain skin integrity by 2 hourly position, massaging bony prominences , keep the skin clean and dry and use pressure relieving devices  Assist to perform isometric, active and passive exercises Psychological support  Provide psychological support or psychotherapy to the patient  Provide opportunity to ventilate the feelings  Assist the individual to adjust to the impairment if permanent injury is there Spinal rehabilitation The spinal rehabilitation begins on admission. During acute stage the care should focus on prevention of infection, pressure sores, contractures facilitates rehabilitation and reduce sufferings and limits disability. Establish functional goals and motivate client and family amd involve them in the care. Goals of rehabilitation  Promote mobility  Reduce spasticity
  18. 18.  Improve bowel and bladder control  Prevent pressure sores  Reduce respiratory dysfunction  Control pain  Nutritional management  Effective health management 1min Summarization Today we discussed about:  Definition  Causes of SCI  Risk factors  Pathophysiology  Clinical manifestations  Effects of spinal cord injuries  Diagnostic measures  Emergency management  Medical management  Surgical management  Nursing management
  19. 19. 30secs Conclusion From above discussion we can say that Spinal cord injuries are major health problems. So the nurses must be efficient enough to provide care to these clients in order to minimize disability and highest possible level of functioning. www.en.wikipedia.orge www. Books:1)Black M. Joyce ; Medical surgical nursing ; 5th edition ; W.B Saunders Company ; Singapore 2008 ; pg no. 1948-1960.
  20. 20. 2)William S. Linda; understanding medical surgical nursing; 1st edition; F.A davis company; Philadelphia 1999; pg .no. 937-940 3)Suddarth’s and brunner; Textbook of medical surgical nursing; 11th edition; Lippincott Williams and Wilkins ; United states of America 2009; pg. No. 1926-1933 4) Silvistri Anne Linda; Saunders comprehensive review for the NCLEX –RN examination;5th edition; Elsevier; St. Louis; pg. no.947-942 General Information: Subject: Educational methods and media. Topic: Nursing management of a patient with spinal cord injury Group: B.Sc Nursing 4TH year students Size of the group: 9 students Venue: Room No. 12 Time: 12.10-12.50pm Duration: 40 mins (30 mins : teaching, 10 mins: discussion) Roll no. of Student Teacher: 1917 Supervisor: Examiner Method of Teaching: lecture cum discussion.
  21. 21. A.V Aids: power point slides, chart, flannel charts, flash cards, chalk board and handouts. Previous knowledge: Students have general idea about levels of disease prevention. General objectives: At the end of teaching group of students will be able to  Explain the spinal cord injuries in detail.  Apply this knowledge in practical field.