Nursing for people with spinal cord lesion

The main nursing objectives in providing care for people who have sustained a spinal cord lesion are to: identify problems and prevent deterioration; prevent secondary complications; facilitate maximal functional recovery; support patients and significant others in learning to adjust to the patients’ changed physical status; be aware of the effect of the injury on the patients’ perception of self worth; give high priority to empowering patients, enabling them to take control of their life through formal and informal education.

Nurses need to recognise that patients will spend a long time in hospital, probably between four and nine months. Most patients are male (4 : 1 men to women) aged between 15 and 40 years, but an increasing number of older people are sustaining injuries. Patients will initially be very dependent on others, and those with high lesions or from the older age group may continue to be dependent and have a disappointing level of neurological recovery and functional outcome.

Nursing aims:

• Identify problems and prevent deterioration
• Prevent secondary complications
• Maximise functional recovery
• Support patients and relatives
• Empower patients
• Educate patients to take control of their lives

Factors which contribute to establishing close and supportive relationships between staff and patients often blur boundaries between professional and personal roles. This, with the psychological support required by patients, and the increased need for physical input, offers many challenges, yet many rewards to the nurse involved in care.

Psychological trauma:

• Fear and anxiety
• Sensory deprivation
• Wide variety of moods
• Behaviour similar to the grieving process

The psychological trauma of spinal cord injury is profound and prolonged. The impact on the injured person and his or her family is highly individual and varies from patient to patient throughout the course of their care. Fear and anxiety, worsened by sensory deprivation, may initially be considerable and continue in some degree for many months. During the acute phase, particularly when patients are confined to bed, they may experience a wide variety of mood swings including anger, depression, and euphoria. They may exhibit behaviour identifiable with a normal grieving process — guilt, denial or other coping mechanisms such as regression. They may suffer from a sense of frustration, be verbally demanding, or sometimes withdrawn.

Relatives often progress to adjustment much more quickly than the patients themselves, and this may complicate planning for the future. Intervention must take into consideration the coping mechanisms used by the patients and their families. Long-term decisions must not be taken before patients are willing and able to participate.

Stressful rehabilitation landmarks:

• Any occasion experienced for the first time
• Visits home to family and friends
• Discharge

Certain landmarks in rehabilitation are especially stressful for the patient. Any occasion experienced for the first time after injury is likely to be psychologically demanding. Being mobilised from bed to wheelchair is one example, with its combination of blood pressure instability, physical exhaustion, and the shock of coming to terms with altered body sensation and image. For many, visits to home and friends are other physical and psychological hurdles that must be crossed. Most spinal injuries units have an "aid to daily living" (ADL) flat, where patients and their carer can stay prior to their first weekend at home, with staff close at hand if problems arise.

These events need careful preparation, with discussion taking place before and afterwards, initially with staff from the unit, and later with family and friends. Discharge from hospital is a considerable challenge, with patients and their families often having to cope with lack of stamina; loneliness; social isolation, and the changed relationship caused by injury. Continuing support will be needed for at least two to three years while the patient adjusts to his or her new lifestyle.

 

Nursing management

In the emergency department

Many patients arrive in the emergency department from the scene of an accident on a spinal board, which enables the paramedics to immobilise the back or neck, and maintain spinal alignment. If a cervical spine injury is suspected, and no collar has been applied, the neck should be immobilised by using a semirigid collar supplemented with sandbags or bolsters taped to the forehead and collar, except in the case of the physically uncooperative or thrashing patient (see chapter 2). In an ideal situation, the collar must remain in place until completion of the initial assessment, resuscitation, and diagnostic x rays. The decision to remove the collar must be made by a competent member of the medical team.

Emergency management:

• Immobilisation of the neck
• Co-ordinated team
• Remove from spinal board
• Remove clothing
• Examine skin for marking and damage
• Pressure relief

The non-conforming nature of the spinal board means that potential pressure points are exposed to high interface pressures. This necessitates removal of the spinal board as soon as is appropriate by a coordinated trained team. With the neck held, and with the use of a log roll, the patient should be transferred using a sliding board on to a well-padded trauma trolley with a firm base, in case resuscitation is needed. If resuscitation or the insertion of an airway is necessary, the chin lift or jaw thrust manoeuvre and not a head tilt is used for unconscious patients and those with suspected cervical spine lesions.

Hypothermia. High lesion patients are poikilothermic, therefore risk of hypothermia, with:

• Confusion
• Bradycardia → cardiac arrhythmias
• Hypoventilation
• Hypotension

All clothing should be removed to facilitate full examination and inspection for skin damage. Care should be taken not to raise both of the arms above head level, to reduce the risk of cord lesion extension. Upper thoracic and cervical cord lesion patients may become poikilothermic (taking on the surrounding environmental temperature), with a tendency towards hypothermia. During the assessment phase, and their time in the emergency department, care must be taken to maintain the patient’s temperature within acceptable levels.

Attention! Patient centred interdisciplinary approach - Essential throughout all stages of rehabilitation.

Once a spinal cord injury has been diagnosed, care of pressure areas is extremely important. If delay in admission to the ward, where the patient will be nursed on a pressure-relieving mattress, is expected, the patient must be log rolled into the lateral position for one minute every hour. A firm mattress is more supportive to the spine, and far more comfortable.

 

In the acute and rehabilitation care setting

A patient-centred approach is essential to meet the various problems with which a patient may present. In the initial acute phase, nursing care will be implemented to meet the patient’s own inability to maintain his or her own activities of daily living. As the patient progresses through the rehabilitation phase, the nurse’s role becomes more supportive and educative, with the patient taking responsibility through self-care or by directing carers.

 

Choice of bed

The standard King’s Fund bed, or profiling bed, with a stable mattress consisting of layers of varying density foam, is suitable for most patients, with the addition of a Balkan beam and spreader bar. It is probably the best bed for tetraplegics requiring skull traction, facilitating good positioning of the shoulders and arms. An electrically powered turning and tilting bed is particularly suitable for heavy patients, and those with multiple injuries. It facilitates postural drainage in chest injuries. It permits easier nursing as far as numbers are concerned, but still requires a full team of five or four nurses for inspection of pressure points, especially the natal cleft, for hygiene requirements, and bowel management.

 

Positioning

Regular position changing is every two to three hours initially to relieve pressure. Skin inspection for red marks, spinal alignment and positioning of limbs is essential for a patient with spinal cord injury. The aims are simple: to support the injured spine in a good healing position; to maintain limbs and joints in a functional position, thus avoiding deformity and contractures, and to reduce the incidence of spasticity. There are several ways of achieving these aims, so the methods chosen should follow discussion with the interdisciplinary team, and suit the patient, level of injury, and the availability, knowledge and skill of the nursing staff.

Acute phase:

• Support injured spine in alignment
• Maintain limbs and joints in functional position
• Passive movements

 

Spinal alignment

Before undertaking a turn or preparing to move/transfer a patient, spinal alignment should be maintained by checking (when the patient is supine) that the nose, sternum and symphysis pubis are in alignment and that the shoulders and hips are level. A shoulder hold provides countertraction by applying pressure onto the shoulders to prevent an upward movement.

 

Handling and turning

Patient handling techniques need to be considered in relation to the Manual Handling Operations Regulations 1992. Patients with spinal cord injury are unable to help, and care must be taken to maintain alignment and stability of the neck and back at all times throughout the handling technique. This may pose problems for the staff when considering the method of transfer and movement of a patient, hence the need for rigorous assessment with the application of ergonomic principles.

Manual hoisting aids with stretcher attachments, and side to side, and up and down transfer products are available in the United Kingdom. Outside the European Community, and especially in developing countries, handling equipment may not be available, and there may be no alternatives following risk assessment but to handle the patient manually.

When transferring or moving a patient with an acute cervical injury, to maintain neck alignment and stability, the "lead" nurse holds the neck and head with both hands under the neck, and both wrists supporting the patient’s head behind the ears. The nurse at the patient’s head takes control and coordinates the turn after checking her team is ready.

Countertraction, starting at the top of the patient, may also be used to prevent movement of the spine when inserting hands or equipment under the patient, or starting at the foot end first when hands are being withdrawn.

A log roll is needed for carrying out nursing care, such as bowel management, skin hygiene, and for lateral positioning of both paraplegic and tetraplegic patients. Figure shows how the paraplegic patient should be held when preparing to turn. Note the injury site is well supported. When the log roll is complete, the patient remains supported by pillows. Note the alignment of the shoulders, hip, iliac crest, and upper leg in figure. A tetraplegic patient will require a head hold to complete this move. The nurse performing the head hold coordinates the manoeuvre. End positioning of the head will be determined by the mechanism of injury and the head and neck will be maintained in a neutral, extended, or flexed position, using a "water bag", neck roll, sand bag, or pillows.

 

The pelvic twist

The pelvic twist is a simple turn needing only three nurses to perform and suitable for many tetraplegic patients. It must not be used for patients with thoracolumbar lesions. The nurse at the patient’s head holds the shoulders securely to the bed; the second nurse (standing on the side to which the patient is being turned), applies countertraction and gets ready to support the back and legs on completion of the twist, before inserting the pillows. The third nurse proceeds with the twist by placing her or his upper arm under the patient’s back (using countertraction), and her or his lower arm under the patient’s nearest thigh, and over the furthest thigh to support and move the hip. The movement is a gentle lift and turn of the near hip joint, enough to free the sacrum of any pressure. On completion of the turn, a pillow is folded in half into the lumbar region to support the back and pelvis, and two pillows are placed under the upper leg.

In all turns involving tetraplegic patients, the nurse holding the head is in charge of the timing and coordination of the team. The frequency of turns in the acute stage of management is determined by the patient’s tolerance, but length between turns should not be greater than three hours.

Once the patient has progressed into the rehabilitation phase of care, the interval between turns can be increased, as long as there is no skin marking. The number of pillows used to support the body and limbs may be decreased.

 

Legs

When patients are supine, avoid hyperextension of the knees. Keep the feet in line with the hips and hold the feet at 90° using a foot board and pillows. Avoid pressure on the heels.

When patients are on their side, the lower leg should be extended, with the upper leg slightly flexed and resting on pillows, and not over the lower leg.

 

Arms

When tetraplegic patients are supine, between turns, their joints need to be placed gently through a full range of positions to prevent stiffness and contractures. Hands and arms must always be supported through the movement. If remaining in the supine position, arms and hands need to be supported down by the patient’s side.

When positioning the patient in a left or right pelvic twist, the arm facing the same direction as the twist can either be extended straight out (a), or the forearm placed pointing towards the head or downwards towards the feet (b). The forearm on the side away from the twist should point to the head or feet, but should not be in a similar position to the other arm (b).

In log rolls the lower arm is extended (a), with the upper arm placed at the patient’s side, or flexed across the chest (b).

The shoulders and arms should always be protected from pressure — by gentle handling and good support with pillows.