1 Back to School after a Spinal Cord InjuryChicago Pediatric Specialty Care Orthopaedics, Cleft Lip and Palate, Spinal Cord Injury Back to School after a Spinal Cord Injury Patricia Mucia, BSN, RN, CRRN West Virginia School Nurses November 4, 2016

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3 Objectives At the conclusion of this program the participant should be able to: Have a basic understanding of Spinal Cord Injuries Describe how a Spinal Cord Injury (SCI) changes normal bodily functions and activities of daily living Name three important things that challenge a student with a SCI Develop an understanding of Spinal Cord Injury and the role of the nurse in the school setting.

4 Central Nervous System & SpineBrain Spinal cord Made of a jello-like substance Comprised of nerve fibers which carry messages between the brain and the body Spine 33 bony structures Cervical C1-C7 Thoracic T1-T12 Lumbar L1-L5 Sacral S1-S5 Coccygeal fused

5 Spinal Nerves Spinal nerves exit from the spinal cord through the vertebrae. They branch out to supply and receive impulses to each area of the body. They are: Cervical C1-C8 Thoracic T1-T12 Lumbar L1-L5 Sacral S1-S5 Coccygeal

6 Levels of Impairment

7 Causes of Spinal Cord InjuriesDamage to the spinal cord may be caused by pressure or actual severing of the cord. Traumatic injury in children Motor vehicle crash Birth injuries Sports injuries Diving accidents Trampoline accidents Violence ( gun shot/stab wounds) Falls Non Traumatic Injuries Transverse Myelitis Guillien Barre Syndrome AVM (Arterio-Venous Malformation) Surgical Complication S.C.I.W.O.R.A.

8 SCI in the USA 276,000 Americans are spinal cord injured.12,500 new cases each year Annual incidence-approximately 40 cases per million in children- 1,455 per year 11.6% of total Spinal Cord Injuries per year In Children: % occur in the neck area 20% in the chest or upper back 5-20% in the low back

9 Acute Care A traumatic event that results in Spinal Cord Injury is devastating to the child and the family. Trauma surgery and Stabilization Spine Surgery Halo traction/vest Associated injuries Recovery from infectious illness Intensive care Respiratory Support Length of stay: 1970’s = 24 days since 2010= 11 days

10 Acute Care Contact with Shriners Hospital for Children-ChicagoPediatric Transfer of Care Contact with Shriners Hospital for Children-Chicago Philadelphia Nurse or Social Worker Sacramento Discharge planner Case Manger Care Coordinator Medical history Diagnostic tests Current condition Air Medical transport Cincinnati Shriners Transport

11 Rehabilitation Medical management Physical TherapyLength of stay: 1970’s = 98 days since 2010 = 36 days Medical management Physical Therapy Occupational Therapy Nursing Psychology Social Work Discharge planning Transition to home and community setting

12 Prevention of Pressure UlcersSkin Skin Care Prevention of Pressure Ulcers Occur in all age groups Occur in hospital, long term care facility and in the home Serious complication Medical complications Malnutrition Sepsis Osteomyelitis Cost Hospitalization Surgery Loss of time in school and/or work Loss of Skin integrity

13 Pressure Ulcer PreventionSkin Pressure Ulcer Prevention Pressure reliefs Seating evaluation, cushions, pressure mapping Skin inspection Education developmentally appropriate Repetitive Safety measures

14 Skin Skin Safety Burns Food Cooking Laptop computersRadiator or heat vents Hot pads, electric blankets Weather : sunburn or frostbite Positioning of extremities Clothing and shoes

15 BLADDER MANAGEMENT Diseases of the urinary system account for 3.5% of deaths among individuals with SCI. Diseases of the urinary system are contributing factors in another 5.2% of deaths of individuals with SCI. Individuals with SCI are 10.9% more likely to die of diseases of the urinary tract.

16 Management of Neurogenic BladderGOALS Preservation of renal function Prevention of complications Social continence

17 BLADDER MANAGEMENT The bladder is interlaced with smooth muscle, called detrusor. Two sphincters control the bladder outlet. Internal sphincter-smooth muscle, like the detrusor. External sphincter-striated muscle, like skeletal muscle.

19 BLADDER MANAGEMENT Normal Micturation (voiding) Bladder filling and emptying requires coordination between the bladder and the nervous system. Filling: (sympathetic)- increases tone at the base decreases tone at neck of the bladder decreases tone of detrusor muscle. Emptying: parasympathetic nerves release acetylcholine near bladder smooth muscle causing contraction of the detrusor. tone decreases at the base, relaxing the sphincter to release urine.

20 Detrusor Sphincter DysnergiaBLADDER MANAGEMENT Detrusor Sphincter Dysnergia Bladder filling stimulates the detrusor to contract. At the same time the sphincter is contracted and closed causing increased pressure and preventing the urine from leaving the bladder. Resulting in: intermittent voiding, leaking, incontinence urinary retention bladder distention reflux

21 BLADDER MANAGEMENT Neurogenic BladderVoluntary control of urination requires communication between the brain and the lower urinary tract (bladder). Without input from the brain, we have “neurogenic” or “neuropathic” bladder. Spinal Cord Injury Any lesion above the sacrum-detrusor areflexia: inability to contract causing urinary retention. Spinal Shock-lasts a few months-up to two years. When reflex returns-bladder is able to contract.

22 BLADDER MANAGEMENT Vesicoureteral refluxoccurs when the bladder is stiff, high pressure, low compliance the increased pressure creates a path for urine to flow back up to the kidneys (reflux) results in hydronephrosis

23 Management of Neurogenic BladderMedical Management Routine scheduled evaluations with a urologist Baseline studies: VCUG Urodynamics renal ultrasound Bladder Emptying Intermittent Catheterization Timed Voiding (based on urodynamics results) Surgical Procedures Bladder Augmentation Appendicovesicostomy Monti Urethral sling Medications Anticholinergics Antibiotics ( for treatment of UTI or prophylaxis)

24 Urodynamic Studies include:BLADDER MANAGEMENT Urodynamic Studies include: Uroflowmetry Cystometry Urethral pressure studies Voiding studies Sphincter EMG Video urodynamics Pharmacologic testing

25 BLADDER MANAGEMENT Renal UltrasoundSound waves create real time images of kidneys & bladder. Primary use is to show hydronephrosis. Also shows kidney/bladder stones, tumors or cysts. Non-invasive & painless. VCUG A real time study of bladder filling and emptying. A radio opaque solution is used to fill the bladder. A radiologist is present to assess the flow of the contrast solution. If possible, patient voids to empty their bladder at the end of the study.

26 BLADDER MANAGEMENT

27 BLADDER MANAGEMENT VCUG voiding cystourethragram showing reflux and hydronephrosis

29 Mitrofanoff PrincipleContinence mechanism based on flap valve Reservoir pressure is transmitted against wall of conduit

31 BLADDER MANAGEMENT Bladder Emptying Intermittent CatheterizationTimed Voiding (based on urodynamics results) Indwelling catheter Suprapubic catheter

33 Clean Intermittent CatheterizationBLADDER MANAGEMENT Clean Intermittent Catheterization prevents bladder overdistention prevents urethral irritation allows the bladder to fill and empty naturally exercises the muscles to prevent shrinkage and increased pressures.

34 BLADDER MANAGEMENT Suggested guidelinesClean intermittent catheterization- every 4 hours around the clock until no volumes exceed 500ml in the previous 48 hours. Then every 4-6 hours while awake. Overdistended bladder-remove no more than 1000ml at one time. Rapid changes in fluid balance can release pressure on the pelvic blood vessels, causing blood pressure and circulatory changes.

35 BLADDER MANAGEMENT Helpful Tips Size and type of catheter usually prescribed by a urologist. Infants- 4-5 french Older toddlers/preschoolers french School age french Adolescents french Adult french Bladder capacity in children Age in ounces +2 11y/o=11 ounces x 30ml=330ml +2x30ml=390ml

36 Management of Neurogenic BowelGOALS Complete and regular bowel movements Prevention of constipation or diarrhea Continence Independence

37 Neurologic ImpairmentUPPER MOTOR NEURON(REFLEXIC) (Cervical and thoracic level injuries above T12) Spinal cord and colon innervations remain intact. Reflex pathways continue to function. Loss of conscious sphincter control. Anal sphincter remains tight. Reflex peristalsis. Responds to digital stimulation and stimulant medications. Susceptible to Autonomic Dysreflexia.

38 Neurologic ImpairmentLOWER MOTOR NEURON (AREFLEXIC) (Lumbar and sacral injuries) Reduced reflex control of anal sphincter Flaccid bowel Require more frequent evacuation to remain continent. Decreased peristalsis Increase in transit time LMN bowel may not respond usual bowel intervention s: digital stimulation. Keep the stool well-formed and rectal vault clear to prevent embarrassing accidents.

39 BOWEL MANAGEMENT What is our poop telling us? Which type do you have?Which type is ideal?

40 Bowel Management CONSISTENCYBulky, soft, and formed stool is the goal. Easiest to evacuate More likely to be retained Affected by: Diet Fluid intake Medications Activity Supplements Stimulant laxatives

41 BOWEL MANAGEMENT REGULARITY Maintain child’s previous schedulePlan minutes after a meal (gastrocolic reflex) Same time every day or every other day Be loyal to the routine

42 BOWEL MANAGEMENT POSITIONING Sitting upright with trunk supported:Provides stability Pelvic floor relaxes Allows for more complete and timely emptying Assistance from gravity (physics) Adequate seat padding to prevent pressure

43 Management of Neurogenic BowelBowel program provides regular, predictable emptying of the bowel Initiated at approximately 2-4 years of age Necessities for success PATIENCE-takes time to establish Regularity frequency and time of day Privacy Position; sitting on toilet or commode Use of medications Laxatives Stool softeners Rapidly acting suppositories Magic Bullet (bisacodyl in water-soluble medium) Enemeez (docusate sodium) mini enema

44 BOWEL MANAGEMENT RECTAL STIMULATION Digital stimulation:stimulates the reflex relaxation of internal anal sphincter and contraction of the smooth muscle of the rectal vault. Use water-soluble lubricant on gloved finger(s) Use a circular motion following the contour of the rectal vault. Can be repeated every 5-10 minutes until evacuation is complete Complete evacuation is indicated if two consecutive digital stimulations yield no more stool. CAUTION: may cause autonomic dysreflexia

45 BOWEL MANAGEMENT

46 BOWEL MANAGEMENT MEDICATIONS: ORALOsmotic agents: attract fluid into the bowel and cause colonic distention and peristalsis. Polyethylene glycol-electrolyte solutions: MiraLax Lactulose products Milk of Magnesia Stimulant laxatives: alter the transport of electrolytes within intestinal mucosa, causing water retention and stimulates peristalsis. Senekot Dulcolax Lubricant laxative: lubricates stool for easy passage. Mineral oil

47 BOWEL MANAGEMENT MEDICATIONS: RECTALChemical agent to move stool into the rectum for evacuation Stimulate peristalsis. Provide more predictability Must be retained long enough to melt Inexpensive Glycerin Dulcolax Magic bullet Mini enemas Babylax, pedilax Enemeez

48 BOWEL MANAGEMENT vs

49 Autonomic DysreflexiaWhat Is It? Life threatening complication Over reaction of the nervous system in response to a noxious stimulus below the level of injury Most commonly occurs in patients with SCI level at T6 or above Hyper reflex causes vasoconstriction and hypertension Uncontrolled high blood pressure may cause STROKE, SEIZURES, and DEATH

50 Autonomic DysreflexiaCauses Bladder Infection, Foley catheter, plugged, kinked or overfilled Bowel Constipation, Impaction Skin Pressure ulcers, Burns, Open wounds, Tight or wrinkled clothing, Painful stimulation (cuts, bruises, pressure on body) Temperature changes Other Sexual activity, Menstruation, Ingrown toenail

51 Autonomic DysreflexiaClinical Manifestations Hypertension Bradycardia Sweating Anxiety Nausea Goose bumps Pounding headache Flushing above the level of injury Vasoconstriction below the level of injury Irritability, sleepiness in a young child

52 Autonomic DysreflexiaManagement of Autonomic Dysreflexia Remove the cause (empty the bladder, remove painful stimulus) Prevention (consistent bowel and bladder program) Education (family, community, teachers and aides) Carry medical alert information (card, bracelet)

53 Latex Allergy At risk population SCI MyelmeningoceleHealth care workers Prevention Education Avoidance of all latex containing devices/materials

54 School Age (6-12 years) Industry vs. InferiorityCharacteristics increasing independence thinking in more logical terms Peer approval becoming more important Experience lapses in their ability to perform self-care Concerned about privacy Development of self-concept

55 School Age (6-12 years) Industry vs. InferiorityInterventions: Social continence is very important for self esteem. Independence should be encouraged. Proficiency (or direction) with self-catheterization should be encouraged and achieved. Instructions should be written and visual. Care givers must provide reminders and encouragement. Privacy should be provided. Positive reinforcement and praise for adherence to schedule and proper technique. Learn about genitourinary system and dangers of reflux and UTI’s. Assist family in providing school with catheterization technique, schedule and patient’s level of independence. Parent should be taught to provide supplies for managing accidents at school. Reinforce education about Autonomic Dysreflexia. Clean change of clothes should be kept at school for accidents. Challenges: May want to do bladder care independently, but may need help Needs reminders to perform care and chores May become very embarrassed by incontinence Wants to please parents Peer pressure beginning

56 Adolescents (12-19 years) Identity vs. Role ConfusionCharacteristics Struggling with independence Concerned with body image and appearances Think “in the moment,” feel invincible, and may not consider future effects of current behavior May experiment with drugs, alcohol, and sex Acceptance from peers is a priority and may take precedence over self-care Privacy is extremely important

57 Adolescents (12-19 years) Identity vs. Role ConfusionInterventions: Social continence is essential Independence with bowel & bladder management (or direction) achieved Parents must gradually allow the adolescent to assume responsibility for bowel & bladder management Parents should monitor compliance Encourage a schedule for self care rather than “when I feel I need to…” Continue to reinforce education about Autonomic Dysreflexia. Reinforce teaching about Anatomy and Physiology of the genitourinary system, especially reflux and prevention of UTI’s. Discourage intentional constipation used to prevent accidents Challenges: Rebellion Body image very important Strong peer pressure. Does not want to be “different” from peers May not adhere to bowel & bladder management schedule

58 Adolescents (12-19 years) Identity vs. Role ConfusionConfidence and self-esteem are strongly impacted by the challenge of being incontinent in a continent world.

59 Coordination of Care Comunication IEP/504 Medications at schoolParents Hospital personnel (care manager) IEP/504 Medications at school Transportation Preparation and Prevention

60 Team Work

61 Enhance Knowledge of the Transition ProcessWhat happens while in the apartment Families prepare child for therapy Therapy and nursing assist families in working out kinks of home life Questions arise A routine begins Cooking group

63 Enhance Knowledge of the Transition ProcessWhat helps families related to discharge planning and transition Space restrictions Home schedule development Confidence in independence of care Smooth transition to the “real world” Community reintegration

64 Thank you West Virginia School NursesQuestions??????? Thank you West Virginia School Nurses

65 References Merenda, L.A. & Hickey, K.J. (2005). Key elements of bladder and bowel management for children with spinal cord injuries. SCI Nursing, (22)1, 8-14. Specialty of Rehabilitation: A Core Curriculum. Bristol stool chart via: