Guidelines for Caregiving for Individuals with Paraplegia and Tetraplegia

Care for a patient with spinal cord injury

During the initial phase of paraplegia (paralysis of the lower extremities), preventing urinary tract damage is crucial. Because the bladder loses its reflex function and retains urine, the patient cannot feel when it's full. This can overstretch and damage the bladder's muscular wall (detrusor muscle). To prevent this, urologists perform bladder drainage, which helps prevent urinary tract infections. The most effective method is periodic bladder catheterization performed by trained healthcare professionals. Alternative methods, such as long-term catheterization with a closed system or suprapubic drainage, carry a higher risk of infection in paralyzed patients.

Patients with acute spinal cord injuries, especially those causing spinal shock, often require cardiovascular therapy to manage high (hypertension) or low (hypotension) blood pressure. They also need fluids to correct imbalances in their blood volume. Patients with complete spinal cord injuries are at risk of developing stress ulcers in the stomach and intestines. Cimetidine and ranitidine are effective treatments for these gastrointestinal ulcers.

High cervical spinal cord injuries can cause varying degrees of respiratory failure due to impaired function of the intercostal muscles and diaphragm. This respiratory failure may require mechanical ventilation and bronchopulmonary rehabilitation. For incomplete respiratory failure with a forced vital capacity of 10-20 ml/kg, respiratory therapy (inhalations) and chest massage are recommended.

A negative pressure corset can help prevent atelectasis and fatigue, particularly in patients with spinal cord injuries below the C5 level. In severe respiratory failure, tracheal intubation (using an endoscope if the spine is unstable) followed by tracheostomy ensures airway access for ventilation and secretion removal. Diaphragmatic nerve electrical stimulation is a promising new method for patients with injuries at the C5 level or above.

Once the patient's condition stabilizes, psychological support and rehabilitation planning are essential. Intensive rehabilitation programs often yield positive outcomes for young and middle-aged patients, enabling them to return home and resume their daily lives.

Patients with lower extremity paralysis can perform some self-care procedures with assistance.

Prolonged immobility increases the risk of pulmonary embolism due to:

• Skin breakdown over pressure points
• Urinary tract infections (sepsis)
• Autonomic instability

Patients should change positions every 3 hours, use emollients on their skin, and utilize soft bedding, including a pressure relieving mattress. These actions help to prevent skin breakdown.

Specially designed functional beds aid in repositioning and evenly distributing body weight, which reduces pressure on bony prominences.

If the sacral segments of the spinal cord are intact, patients may achieve automatic bladder emptying. Initially, patients may experience reflexive urination between catheterizations, and later they can learn techniques to trigger urination. If residual urine volume increases the risk of bladder infection, urological procedures or placement of an indwelling catheter may be necessary.

Most patients with paralysis need to monitor bowel function and ensure bowel movements at least twice weekly to prevent complications such as bowel obstruction.

Patients with cervical or upper thoracic spinal cord injuries may experience severe hypertension and bradycardia in response to stimuli such as skin irritation, bladder or bowel distension, or surgical procedures. This hypertension can be accompanied by severe flushing and excessive sweating above the level of the injury. The exact cause of these autonomic disorders is not fully understood. Antihypertensive medications are necessary, especially during surgery, but beta-blockers are generally avoided. Some patients may experience acute bradycardia during tracheal suctioning. This can be prevented by administering small doses of atropine.

A serious early complication is pulmonary embolism, which can occur due to immobility. Pulmonary embolism occurs in approximately 30% of patients with paralysis following acute spinal cord injury.

For detailed information on physiotherapy, rehabilitation, and orthopedic device usage for severe spinal cord conditions, consult the patient's physician (neurosurgeon, urologist, rehabilitation specialist, or therapist). Spinal orthopedic stabilization in spinal trauma is performed only when clinically necessary.