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Spinal Cord Injuries: A Case Study

The purpose of this paper is to take an in depth look into current research and statistics related to Spinal Cord Injuries (SCI). It includes a description of the condition; with national and global statistics, predisposing factors, a description of signs and symptoms, and diagnostic testing. Treatment of SCI and nursing care including; medical or surgical treatments related to the care, any therapies, and most common medications prescribed to treat SCI. The complications of SCI and how they influence the individual’s prognosis. Also, a summary and conclusion of the findings, and how they will affect a newly graduated nurses practice.

Description of the Condition Spinal Cord Injuries (SCI) is described as, “the structures and functions of the spinal cord are damaged by trauma, inflammation, tumors or other causes, resulting in dysfunction of motion, feeling, sphincters and autonomic nerves below the damaged plane” (Yang, R. , Guo, L. , Wang, P. , Huang, L. , Tang, Y. , Wang, W. , … Shen, H. (2014)) Statistics Locally at the Northwest Regional Spinal Cord Injury System the statistics were compared to a national level in a 2003 study done through the University of Washington.

The study took a population from the National Spinal Cord Injury Database of 22,599 participants, 1,028 of those participant was from Washington state. When comparing the data nationally at that time the average age was 39. 7years old, whereas the Washington state participants average age was 37. 8. The leading cause of SCI among the members of this group was motor vehicle related. Nationally 47. 7% of these members cause of their SCI was due to motor vehicle crashes, the Washington states participants this was slightly lower at 43. 2%.

Similarly, to the national percentage of males with SCI at 81. %, Washington state participants were 78. 2% male. In Washington state the majority of their participants were non-Hispanic Caucasians making up 62. 8%. The study did state, “This partly reflects trends in the U. S. population, but there also have been changes in the race-specific rates of occurrence. ” (Tate D and Forchheimer M. 2002). Nationally this was similar at 63. 4% of the participants were non-Hispanic Caucasians. This study also compares length of acute care hospital length of stay and length of stay in a rehabilitation unit.

The National group had an average length of stay totally 18 days in an acute care hospital, and 46 days in a Rehabilitation center. This again was very similar in length to the group from Washington state with the average stay in an acute care hospital at 15 days, and 46 days in a Rehabilitation center. According to the University of Alabama – Birmingham’s National Spinal Cord Injury Statistic Center (NSCISC) as of 2016 there are approximately 282,000 people living in the United states with SCI; with about 17,000 new cases (54 cases per million) annually.

The 2016 data showed the average age of people with SCI to be 41 years old. Males make up 80% of this population, an 63. 5% are non-Hispanic Caucasians. The most popular cause of SCI is motor vehicle accident accounting for 38%, followed by falls at 30. 5%. The average length of hospital stay was 11 days following the trauma or inflammation causing SCI. Globally, each year approximately 275,000 suffer from SCI. The World Health Organization (WHO) estimates that as of 2013 there are about 40-80 cases per million people living with SCI. Of these affected the male to female ratio is 2:1.

WHO states that those who suffer from SCI are 2-5 times more likely to die a premature death than those without a SCI. Globally the leading cause of death in countries considered to be low income is infection from pressure ulcers. “Up to 90% of spinal cord injury cases are due to traumatic causes such as road traffic crashes, falls and violence. ” (Sminkey 2013). Predisposing Factors Spinal Cord Injury is usually the result of a trauma, and it can happen to anyone, however there are some predisposing factors that increase the likely hood that it could happen.

If one is male between the ages of 16 to 30 you are more likely to sustain a SCI. If a person engages in risky behavior such as skydiving, cliff diving, or driving a motor vehicle faster than posted speeds that person increases the chances that they will sustain a SCI. Bone and joint disorders such as osteoporosis is also a predisposing factor. Signs and symptoms Most signs and symptoms of SCI depend on severity and cause, and the severity will depend on which dermatome is affected by the injury or obstruction. The neurologic level of injury refers to the lowest part of the spinal cord that function normally following injury.

In some cases, following injury some motor and sensory nerves are still functioning either normally or slightly abnormal; this is called incomplete SCI. In other cases, there is a complete loss of motor function and an almost complete loss of sensory nerve function. If all four quadrants of the body are affected by paralysis, it is called quadriplegia or tetraplegia. Paraplegia is when the lower legs, and part of the trunk are affected by paralysis. Some symptoms may include numbness or tingling in the appendages, or loss of movement to parts of the body.

Loss of bladder or bowel control may also be a symptom. Other signs can be dyspnea or difficulty breathing, impaired breathing, or trouble clearing secretions. Burning sensation or intense pain sensation following an injury, or difficulty ambulating or with balance can also be a symptom of SCI. Diagnostic Testing Diagnostic testing for SCI includes a sensory function/neuro test, American Spinal Injury Association (ASIA) impairment scale, CT, MRI, Myelogram, Somatosensory evoked potential (SSEP), or an x-ray of the spine.

Which test used depends on the severity of the SCI and availability. In some countries an MRI or CT is unavailable and other options must be used to diagnose. After an injury some spinal cord injuries go undetected due to lack of symptoms, making it even more important to use diagnostic testing if a head, neck, or back injury occur. If a SCI is suspected immediately following an injury the victim should be kept as immobile as possible and transported with great care, keeping the head, neck and back aligned.

Once medical treatment is sought out, a provider will do a complete neurological examination and physical. Diagnostic testing will be performed, such as a CT, MRI or SSEP. A CT scan uses computer imaging to piece together cross-sections of the spine, this may show the severity of damage and location. An MRI or magnetic resonance imaging uses a strong magnetic field with radio waves, a computer can read this and produce an image which may show location and severity of injury. A myelogram is done with the use of dye that is injected into the spine and then an x-ray is taken.

SSEP or somatosensory evoked potential is a noninvasive test that uses electrical current to diagnose a pinch or damaged nerve or portion of the spine. The electrical current slows if there is damage and if done correctly can be up to 88. 24% with a 95% confidence interval. as stated by Thirumala et al. A spine x-ray specifically looks at the bones of the spine, if a fracture has occurred it can be noted using this diagnostic test. On the third day after the injury the provider may do an ASIA impairment scale.

The healthcare provider will use light touch and pinprick to 28 different sensory locations on each side of the body. After, the provider will check their motor skills, testing 10 muscles, 5 on the upper extremities and 5 on the lower extremities. A score of 0-5 is awarded, 0 being the worst or total paralysis, and 5 being full movement. Each muscle is awarded points for a total score of 100. During the ASIA they also diagnose complete or incomplete impairment, and key sensory points or dermatomes are tested for sensitivity.

The ASIA impairment scale defines the extent of the injury and can help determine the prognosis. Medical and Surgical Treatment and Nursing Care Medical and Surgical Treatment Including Pertinent Nursing Care Medical treatment of SCI progressively changes as the healing process commences. In the beginning immobilization and realigning the spine is key to the outcome. This can be done with the use of traction systems and braces or collars. The victim will be given high doses of steroids, such as methylprednisone to decrease inflammation, limiting the swelling and hopefully decreasing the damage to the spine.

Surgical treatment may be implemented to retrieve bone fragments, or repair herniations that are causing severe pain or “pinching” of the nerves. Additional surgeries may be performed after swelling has subsided to place permanent fixation to the spine. After the initial damage has mended, a baseline will be evaluated to plan the care of the victim and secondary injuries can be addressed. Raslan et al state “Secondary injury is defined a cascade of events initiated by trauma and involves vascular changes, electrolytes shifts, excitotoxic neurotransmitters accumulation, inflammation, and loss of energy metabolism”.

Secondary injuries include, but are not limited to, thrombus or blood clots, respiratory infections or aspiration, pressure ulcers or skin infection due to skin breakdown, deconditioning and atrophy, bowel and bladder complications, and muscle contracture, or a shortening of a joint or muscle resulting from prolonged hypertonic spasticity. At times during the prolonged care of SCI the secondary illness will take precedence over the damage of the spine, as most secondary illnesses are the cause of death. This will be discussed more in the complication section. Therapies

Many therapies are used to treat SCI, these include physical therapy (PT), occupational therapy (OT), speech therapy (ST), as well as rehabilitation, and psychological counseling. Physical therapist can help teach ambulation, as well as stretching to maintain muscle strength, they can also help fit braces, or other helpful equipment that may assist with physical mobility and ROM. Occupational therapist can work with a victim of SCI, to help them re-learn activities of daily living (ADLs) to regain lost independence. The occupational therapist can teach them to cook or brush teeth even with difficulties of motor function.

Speech therapist can work with troubles related to swallowing or speaking. Rehabilitation centers are a step down care facility from the hospital setting, there patients learn about the risk and care of pressure ulcers, bladder/bowel dysfunction, and other secondary deficits follow a SCI. Most rehabilitation centers have in-house therapist working throughout the day with patients, to help them build independence and strength. Psychological counseling helps with cognitive dysfunction, and emotional issues. Depression from loss of abilities is often a secondary problem following SCI.

Therapist from interdisciplinary specialties listed above work together as a team to allow the best outcome. Pharmacological Therapies Medications can help with some of the secondary effects of SCI, such as pain management, muscle spasms, bladder and bowel control, erectile dysfunction, and depression. Acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen and naproxen, can be used to treat pain either by itself or in combination with other medications. Other stronger forms of pain can be relieved by medications from the opioid family.

Narcotics, however, have unpleasant side effects for instance constipation, sedation, dependence, tolerance, and addiction. Muscle spasms can be limited with the help of muscle relaxants, like Baclofen, or clonidine. With the use of anticonvulsants muscle spasm and seizure may be helped. Anticonvulsants have 1st and 2nd generation, 1st generation include carbamazepine, phenytoin, and valproate. 2nd generations encompass gabapentin and pregabalin. Antidepressants can be prescribed for a number of reasons including depression, nerve pain, or relaxant.

In most cases tricyclic antidepressant (TCAs) or serotonin- norepinephrine reuptake inhibitors (SNRIs) are prescribed, examples of these are TCAs amitriptyline or nortriptyline or SNRIs Effexor. Anticholinergics, such as Ditropan assist with bladder control, they impede parasympathetic nerve impulses by blocking the neurotransmitter acetylcholine. “Several studies have shown that anticholinergic treatment increases bladder capacity, reduces bladder pressure, and improves compliance and quality of life (Taweel et. al. 2015).

Erectile dysfunction, a secondary effect of SCI, in some cases depending on dermatomes affected can be helped with Sildenafil. Complications and Prognosis Potential Complications Secondary complications to SCI include, but are not limited to, poor skin integrity, pressure ulcer, decreased circulation, loss of muscle tone and atrophy, sexual dysfunction, pain, depression or anxiety, loss of bladder or bowel control, and a decrease in respiratory system. “Complications are a frequent cause of morbidity and mortality and lead to increased rates of rehospitalization, loss of employability and decreased quality of life (Sezer, 2015)”.

Poor skin integrity and pressure ulcers leading to infection is the leading cause of death globally according to the World Health Organization (WHO). Sensation of skin below the affected dermatome is lost and numbness and tingling are a result, as well as burning or stinging sensation. Circulation is also affected by SCI, hypotension or low blood pressure, as well as edema or swelling of the extremities may be a persistent problem. Muscle spasticity or flaccidity result from loss of motor neurons below the affected area.

The lack of use of muscle systems cause the atrophy of affected areas leading to a sedentary lifestyle, regaining strength can be very difficult. Sexual dysfunction in males is also a result of a decrease in sensation. Depression can result from the loss of independence associated with the above secondary symptoms, and fear of being a burden on family or society are common. Loss of bladder or bowel control can lead to bladder distention or urinary tract infection. Renal failure is a leading cause of death and should be treated with greatest of importance.

Patients should be educated about bladder management immediately after SCI to avoid complications; however, less than 50% of SCI patients have good knowledge about bladder management and pressure ulcers after being discharged (Taweel et. al. 2015)” Loss of bladder control can affect skin integrity and psychologically. The respiratory system is affected in some SCI, if the diaphragm and other accessory respiratory muscles are effected; breathing, coughing, and clearing secretions becomes labored or difficult. A decrease in the respiratory system can lead to cyanosis, low oxygenation to appendages, aspiration, or possibly even death.

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