Respiratory Complications – Nursing Interventions for Acute Spinal Cord Injury

by Rhonda Lawes, PhD, RN

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    00:00 Okay. So there is the neurological complications. We've done the cardiovascular complications.

    00:05 Now we're looking at the respiratory complications.

    00:09 So injuries above C4, the fourth cervical vertebra and the higher.

    00:14 Now you have total loss of respiratory muscle function.

    00:18 Injuries below C4, the patient might be able to do some diaphragmatic breathing if the phrenic nerve is still okay.

    00:26 Now, if edema and hemorrhage have impaired the phrenic nerve, then they're not gonna be able to have that diaphragmatic breathing.

    00:33 But this is really pivotal, every nurse should know, injuries above C4, we're gonna have a total loss of respiratory muscle function.

    00:42 We're gonna have to provide breathing for them and support.

    00:45 Below C4, we might have a chance, right? They might have some diaphragmatic breathing if that phrenic nerve is still functional.

    00:53 Now let's talk about the phrenic nerve in case you're kinda new to that.

    00:57 See, the phrenic nerve originates from the cervical nerves in the neck.

    01:01 It goes all the way through the thorax on the right and the left and it innervates the diaphragm that's what makes the diaphragm function.

    01:09 Now, it's the only source of muscle innervation to the diaphragm.

    01:13 That way, if something happens to the phrenic nerve, it plays such a crucial role in breathing that patient's not gonna be able to use their diaphragm to assist them in breathing.

    01:23 So that's why a lot of times cervical injuries are the most likely patients to require to have to be intubated because the impact on the patient's ability to breathe.

    01:32 So high thoracic injuries might need to be intubated. But the high cervical injuries, definitely will need to be intubated.

    01:39 So what's my role when the patients intubated on mechanical ventilation? Well, you're gonna be working with the respiratory therapists, collaborating with the healthcare provider for special orders and settings for the ventilator.

    01:50 You're gonna be watching them closely for signs of hypoventilation and the need to intubate initially.

    01:56 Also, you're gonna look for, how do I know when a patient is wearing out? Well, we always have in the back of our mind that a spinal cord injury patient, especially a high cervical one is going to possibly need intubation and mechanical ventilation, right? So we're watching and seeing how that patient is doing.

    02:14 If the injury was severe enough, you, the patient may be intubated before they ever get to you.

    02:19 But if they weren't, your job is to assess for the need for the patient to be intubated.

    02:23 So you're gonna watch and see how they're working. What's their respiratory rate? Does it seem like it's taking a whole lot of effort for them to try to breathe? Notice that the forced vital capacity. Is that number going down? That's something we measure in the patient. Look at their ABGs.

    02:39 What do you see for their CO2 or their pO2 levels? What are those values coming back? So that's my role as a nurse and being on the lookout if the patient hasn't been intubated yet, watching for signs that they may need to be intubated.

    02:53 Now if a patient is intubated; that's a tube that's put in their mouth into their trachea connected to a ventilator.

    03:01 If the patient's gonna have to be on a ventilator for an extended period of time, then they're gonna usually put in a tracheostomy.

    03:08 Now the words tracheostomy and tracheotomy are often used interchangeably.

    03:14 Ostomy is the opening. Otomy is the slicing, the incision.

    03:17 But we tend to use those terms interchangeably.

    03:21 Tracheostomy/tracheotomy, essentially what that means is you're gonna make an incision, the physician's gonna make an incision; those are surgical procedure.

    03:29 And instead of inserting that tube into the mouth and down into the trachea, they're gonna make an incision right through the trachea and insert the tube.

    03:38 Now, these are for people that are gonna be on the ventilator like more than a week or so.

    03:42 We think it's gonna be a long time before we can get them off, then a trache is always considered.

    03:48 If they're on a week but we think they're gonna come off really soon, we probably wouldn't go through that procedure.

    03:53 But that's why a trache is a longer-term appropriate use for airway management than having somebody orally intubated.

    04:01 So, people with more severe cervical cord injuries are particularly likely to end up needing a tracheostomy because they're gonna need that ventilator support long-term.

    04:10 So what's my job? Well, nursing interventions are -- I take care of the trach.

    04:15 When someone first has a trache, you can expect a lot of pink drainage coming out from them cuz you're gonna see some bleeding because they've had a surgical procedure.

    04:24 I'm responsible for changing the dressings and cleaning the site and changing out the tubes if they're disposable or taking the innertube out and cleaning it and replacing it.

    04:35 So my job as a nurse is to manage that trache, care for the wound and keep the airway clean and open.

    04:41 Now some other respiratory complications for people with spinal cord injury, now think about what they have going on there.

    04:49 In order for me to breathe well, I have to have a diaphragm that's functioning well.

    04:54 I need to have intercostal muscles.

    04:55 As that diaphragm pulls down, and creates negative pressure and the intercostal muscles are what help pick my ribcage up and help it expand.

    05:03 I need to have strong abdominal muscles to really breathe and cough well.

    05:08 All three of those can take a hit in a spinal cord injury.

    05:12 So, I'm gonna have a decreased vital capacity and tidal volume.

    05:16 Just meaning, I won't be able to take a really good breath when I need it.

    05:23 If my diaphragm, intercostal and abdominal muscles are not strong or able to function like they normally did before my spinal cord injury.

    05:32 So anytime the diaphragm is weak and the chest muscles are weak, you're gonna end up with the inability to get rid of secretions.

    05:41 You have a weak cough and you have an increased risk for atelectasis.

    05:46 Now, atelectasis means it is kind of an area where we talk about a lung being flat or they drop a lung.

    05:53 Atelectasis is an area where there's not the a -- O2/CO2 exchange happening.

    05:59 So know that we've got some chance for some really severe respiratory complications besides needing extra ventilator support, we're at risk for these problems too.

    06:08 They can't get rid of their secretions, they don't have a good cough and we're at risk for atelectasis.

    06:13 So you're gonna watch for signs of respiratory failure, watch for signs of pulmonary edema.

    06:18 That would be a sign of fluid volume overload. You know with extra fluid in the alveoli, because there's too much volume on board for that patient's body to handle.

    06:28 That might be because the heart's having a hard time, they're in shock, whatever reason, we're really on top of watching for a pulmonary edema.

    06:36 Now you can figure that out with your stethoscope.

    06:38 You'll see it on chest x-ray, but you can also hear it with your stethoscope.

    06:43 Pulmonary edema first starts in the back and in the bases.

    06:46 So excellent nursing care involves careful assessment of lung sounds in the front and in the back.

    06:53 So we're watching for respiratory failure.

    06:55 That means they're just wearing out, not able to keep breathing well enough.

    07:00 Pulmonary edema, the alveoli filling up with fluid.

    07:04 That's a sign that there's more volume on board than the body can handle.

    07:07 Pneumonia, now that's -- depending on what the patient was exposed to with a spinal cord injury, then we end up with an infection like pneumonia or a pulmonary embolism.

    07:18 Now this is really serious.

    07:20 A pulmonary embolism is when a clot ends up in the pulmonary vasculature.

    07:24 Sometimes this can be fatal and quick. Other times we can catch it and maybe did work with the patient.

    07:30 But a pulmonary embolism has a potential to be fatal.

    07:35 So, in managing a patient's airway, you're gonna be careful particularly in patients with a cervical spine injury because they're not -- we can't move them very much, right? So they're more at risk to develop those pneumonias and those type of things.

    07:48 We don't know what they kind of -- and other injuries they have.

    07:50 So it's not as straightforward as someone who doesn't have all this going on up here.

    07:55 So know that we know they're at risk for respiratory complications.

    07:59 We know that it might be complicated to help fend those off because of their injuries and having to keep them immobile until we can take care of those others spinal cord injuries.

    08:09 So respiratory complications are something that we play a key role in assessing for.

    08:14 You wanna do a very thorough assessment and regularly.

    08:18 See, with spinal cord injuries, because things can change quickly and they can progress and get worse, our job is to catch it as early as possible.

    08:29 So you wanna look at your patient and see, how are they breathing? Are they breathing enough for them? Do I see any signs of a neurogenic pulmonary edema? If a cervical or a thoracic injury, I'm watching for those abdominal muscles.

    08:42 How are they working? How are the intercostal muscles working? And are these -- is this patient at an increased risk of aspiration? Oh, absolutely. Spinal cord injuries are definitely at an increased risk of aspiration, atelectasis and pneumonia.

    08:56 So those lines can get filled up and gunked up.

    08:59 So we know we always wanna be on top of that and watching how the patient is progressing.

    09:04 Now I've got a picture there that shows you anteriorly the spots you had moved your stethoscope to listen to the patient's lungs.

    09:10 And on the back, you got the same diagram, similar diagram that will show you the spots where you place your stethoscope.

    09:18 I really can't stress enough, this is not a place to cut corners.

    09:22 Your assessment is what can prevent your patient from getting into really difficult situations to come back from.

    09:29 So, no matter what you've seen, role modeled, practice differently.

    09:35 Practice in a way that you know you gave the best possible care to that patient.

    09:40 The kind of care you would give to somebody that you knew personally and really, really cared for.

    09:45 It doesn't take that much extra time to do a good assessment.

    09:50 But you could really make a difference in that patient's quality of life.

    About the Lecture

    The lecture Respiratory Complications – Nursing Interventions for Acute Spinal Cord Injury by Rhonda Lawes, PhD, RN is from the course Spinal Cord Injuries and Syndromes (Nursing) .

    Included Quiz Questions

    1. C4
    2. T4
    3. C5
    4. T5
    1. Phrenic nerve
    2. Intercostal nerve
    3. Saphenous nerve
    4. Subcostal nerve
    1. When ventilator support is anticipated past 7–10 days
    2. If the injury is below T4
    3. After the client is able to support their respirations independent from ventilatory support
    4. Immediately after the client goes into respiratory failure
    1. Decreased capacity and tidal volume
    2. Impaired ability to clear secretions
    3. Atelectasis
    4. Hyperinflation of the lungs
    5. Stable and appropriate exchange of O2 and CO2
    1. Thorough and regular assessment of the client's lungs
    2. Mobilization of the client
    3. Titration of oxygen to maintain SpO2 greater than 95%
    4. Performance of chest physiotherapy

    Author of lecture Respiratory Complications – Nursing Interventions for Acute Spinal Cord Injury

     Rhonda Lawes, PhD, RN

    Rhonda Lawes, PhD, RN

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