Nursing the spinal patient

Nursing spinal patients can be extremely challenging but very rewarding. There are a number of conditions, both surgical and non-surgical, that require special nursing skills. Nurses should understand the different types of spinal conditions and how to assess these patients to ensure the best possible care.

It is important that a physical examination is performed and comprehensive history taken on presentation. It should then be possible to confirm whether the condition is spinal in origin. Each patient should be checked to ensure no other conditions are present that might mimic spinal pain (for example, pancreatitis with abdominal pain).

It is also possible the patient is unable to stand due to another orthopaedic condition, such as bilateral cruciate disease. Patients may present with sudden-onset paraplegia, or with a more chronic onset of symptoms and slow progression of clinical signs. A number of conditions may be the cause; spinal patients don’t all present because of disc-related problems. Some conditions that we encounter include:

• intervertebral disc disease (Hansen type-1 disc extrusion and Hansen type-2 protrusion);
• vertebral fractures;
• neoplasia;
• FCE (fibrocartilagenous embolus);
• CDRM (chronic degenerative radiculomyelopathy);
• meningitis;
• discospondylitis; and
• congenital conditions (for example, atlanto-axial instability/ subluxation).

Some conditions require surgery and some are managed conservatively. The aim of any surgical procedure is to relieve pressure on the spinal cord, preventing further injury. Surgical conditions include:

• intervertebral disc disease (IVDD) with spinal cord compression (Hansen type-1 disc extrusion or Hansen type-2 disc protrusion);
• vertebral fractures or luxations that require stabilisation; and
• atlanto-axial stabilisation.

Non-surgical conditions include:

• FCE;
• CDRM;
• meningitis; and
• non-compressive disc extrusions.

In addition, some conditions are painful and some are not. Painful conditions will most likely include post-surgical patients, non-surgical (stable) fractures, neoplasia and non-surgical intervertebral disc extrusion (non-compressive).

Handle these patients with care, especially if the nature of the injury is unknown. Some are extremely susceptible to increased risk of spinal cord injury without careful handling and movement. Patients with unstabilised fractures or luxations should be handled with extreme care, ideally with two or more people to prevent any twisting, extension or flexion of the spinal column.

With larger patients a solid frame stretcher can be used to prevent movement of the spinal column. Blankets should be avoided as they do not provide adequate support. It is better for two people to carry the patient, holding it close to the body to provide support along the length of the spinal column.

At the initial examination, assess and record heart, pulse and respiratory rate and body temperature. Pulse quality, mucous membrane colour and capillary refill time should also be checked. Thoracic auscultation should be performed to ensure the chest is clear.

Following admission, start IV fluid therapy to maintain spinal cord perfusion. Patients on IV fluids should be checked more regularly – a minimum of every two hours – to continually observe for signs of over-infusion. These signs include restlessness, tachypnoea, possible serous nasal discharge, chemosis and subcutaneous or pulmonary oedema.

Neurology

As well as the basic physical examination, it is important for nurses to be competent in assessing a patient’s neurological status while hospitalised. This allows nursing staff to alert the surgeon to any sudden deterioration, or concerns regarding the patient’s progress.

Observation of the patient’s posture, movement and reflexes can help determine the progress of its condition. Does the patient have normal posture? Does the patient have normal muscle mass and tone? These observations will help achieve an accurate diagnosis and assessment. Looking at the patient’s movement is another important factor; for example, is movement voluntary or involuntary? If the patient is able to walk, gait assessment is also useful. Is the patient ataxic? Are the patient’s limb movements exaggerated (hypermetria) or smaller than normal (hypometria)? Can the patient move or wag it’s tail? All of this information is used to identify the location of the spinal cord injury. Distinguishing upper motor neuron (UMN) and lower motor neuron signs (LMN) will also help to locate the injury site (^{Table 1}). Local reflexes should be tested at least once, if not twice, daily to assess progress. These reflexes include: patellar reflex, perineal reflex, withdrawal reflex and panniculus.

Grading the condition

Using a grading system can help everyone involved with the case to see improvements or deteriorations in the patient’s condition. It quantifies the severity of the lesion and can help with predicting the prognosis.

• Grade 1 – pain only.
• Grade 2 – pain and paresis.
• Grade 3a – pain, paresis, and proprioceptive deficits.
• Grade 3b – pain, paresis, proprioceptive deficits, urinary continence, paraplegia.
• Grade 4 – paraplegia, urinary retention and overflow.
• Grade 5 – paraplegia, urinary retention and overflow with loss of deep pain sensation.

Pain perception assessment is important in the spinal patient – loss of deep pain sensation is serious and indicates a severe spinal cord injury. Prognosis for these patients is usually not good, and their chances of recovery are much reduced. Pressure is applied to the toe; light pressure initially to test superficial sensation and then firmer pressure to test for deep pain sensation. It is important to distinguish between conscious awareness of pain and unconscious withdrawal reflex.

Challenges

Nursing paraplegic and quadraplegic patients can be very challenging; they require frequent assessment, checking that they are clean and dry, that they are supported in a suitable position, and have adequate access to food and water. They must be comfortable and given adequate analgesia. Patients should be pain scored a minimum of twice daily to ensure they are pain-free and comfortable.

A number of different pain-scoring techniques are available in practice; it doesn’t matter which technique you use as long as all members of staff use the same one. A multimodal approach to the analgesia regime (combining an opioid with an NSAID) can be best for controlling pain in both conservative cases and post-surgical patients.

Padded mattresses should be provided to prevent decubitus ulcers and pressure sores from forming, especially in recumbent patients. Decubitus ulcers are caused by tissue damage and necrosis, due to reduced blood flow to the area.

This occurs if the patient is in one position for a long period and is usually found on bony prominences, for example, elbows, over the ilial wings of the pelvis and occasionally the sternum in thin dogs. Providing padded bedding and moving the patient frequently helps reduce the occurrence of pressure sores and ulcers.

Preventing hypostatic pneumonia is another important consideration. It is caused by prolonged unilateral recumbency. Quadraplegic patients may be more susceptible as they are often unable to maintain a sternal position or move themselves regularly. Move these patients regularly – a minimum of every four hours, but ideally every two hours. They should be moved from left lateral to sternal and then right lateral back to sternal.

Urine scalding can also be a complication sometimes encountered in spinal patients. If the patient is long haired it can be helpful to clip the hindquarters. This helps in keeping the patient clean and dry. If the patient does soil itself it is easier to clean if hair is clipped short, which also prevents urine from scalding the skin. Soiled skin and coat should be cleaned, bathed and thoroughly dried as soon as possible. Talcum powder can be useful to dry the coat and a barrier cream or spray can also be applied to protect the skin.

Bladder management

Bladder management is also important. The bladder should be checked at regular intervals to ensure it is not full. Bladder emptying is important in patients that have lost the ability to urinate voluntarily. Depending on the location of the spinal cord injury, the bladder may be affected in different ways. You may need to express the bladder manually, or catheterise it, to prevent it from becoming over full. A high tone (UMN) bladder may be difficult to express so medication may be helpful in relaxing the bladder sphincter.

Phenoxybenzamine and diazepam can be used to relax the internal and external urethral sphincter muscles, making it easier to express the bladder and encourage normal urination. Urinary tract infections may develop in patients with urinary retention so antibiotics should be administered to try to prevent this. Patients with an LMN bladder tend to continually dribble urine as the urethral sphincter becomes flaccid. LMN bladder patients will require more regular bathing to prevent urine scalding.

Assisted walking

Severely ataxic and paraplegic patients should be assisted when attempting to walk using a sling or towel under the abdomen. The patient should not be allowed to drag its hindlimbs on the ground, as it will cause damage to the skin on the tops of the feet. It is also helpful to provide non-slip floor coverings – rubber matting is ideal. A fall may reduce a patient’s confidence to mobilise unaided.

Physiotherapy and hydrotherapy can and should be used to aid post-surgery recovery and in conservatively managed patients. Physiotherapy is a specialised discipline. Patients should be assessed and an individual treatment plan should be devised. The aim of physiotherapy is to return the patient to normal function and gait re-education following spinal injury. Working alongside a chartered physiotherapist, VNs can help massively in the recovery of spinal patients and provide support to the owners of these patients.