Guideline Title: Management of the Acute Spinal Injured Patient

Transcription

1 bayside health Guideline Title: Campus: Alfred Control No.: AH0410 Category: Infection Control Related Policy No.: Responsibility for Review: Program Director, Rev.: 001 Cardiorespiratory and Intensive Care Date Approved: April 2010 Review Date: April 2013 GUIDELINES These guidelines should be read in conjunction with the Clinical care guidelines, and the following ICU guidelines. Management of ICU trauma patients, ICU bowel management, Sedation in ICU, Spinal clearance management and the ICU enteral nutrition. PURPOSE This guideline provides an outline of the nursing requirements of spinal injured patients in the intensive care unit (ICU). The guideline has been devised from a review of relevant literature and related guidelines. The guideline relates to the care of patients whilst in ICU and does not replace the spinal clearance guideline. The aim is to optimise nursing care using standardised practice for the care of patients with acute spinal injuries. The specific precautions necessary for spinal patients are explicitly stated. 1.0 Spinal immobilisation 1.1 Aim To reduce the risk of further injury to patients through effective communication of spinal precautions required for individual patients. To reduce the risk of pressure sore development. To promote safe work practice and reduce the risk of injury to staff. To prevent limb contractures as a result of reduced mobility. 1.2 Standard The specific spinal immobilisation precautions for patients with confirmed or suspected injury will be documented on the Spinal Assessment Chart MR R-69 by a relevant medical officer within 24 hours of admission to ICU. Patients will be positioned according to the instructions of the Spinal Clearance management protocol and as documented on the Spinal assessment chart. Page 1 of 9

2 1.3 Method The medical team responsible for the management of the patient s spinal injury (either neurosurgery or orthopaedics) is required to complete the Spinal Assessment Chart. The form should be filed with the patient s notes. The order should be reviewed by the relevant medical team and the ICU team during medical rounds and recharted at intervals not exceeding 5 days Until the form is completed patients with confirmed or suspected spinal injury must wear a Philadelphia or Aspen collar (the stiffneck collar should remain in situ for the shortest possible time) and be log rolled using a minimum of 4 persons in order to maintain spinal alignment. Patients require log rolling a minimum of every 3 hours for pressure area relief. There is no requirement to use the Jordan frame unless specified on the Spinal Assessment Chart or there is other significant injury that warrants its use e.g. unstable pelvic fractures Patients may be nursed on a regular ICU bed with clear signage stating NO BEND and with the knee bend/backrest mechanism locked and taped over where appropriate. Patients must be placed on a standard mattress until it is deemed safe to use a pressure relieving mattress and this is documented on the Spinal Assessment Chart. Patients should be cared for on a pressure relieving mattress whenever possible if there is no evidence of vertebral body injury or the injury has been surgically fixed During normal business hours ( ) the Orthotics Department (ext ) are available to fit Philadelphia and Aspen collars. The emergency Stiffneck collar should be replaced by a Philadelphia collar as soon as possible. Patients admitted after 1700 should have there Stiffneck collar replaced with a Philadelphia collar by a Registered Nurse accredited to fit collars as soon as possible. This should be assessed the following business day by an Orthotist Reposition and perform limb stretches according to the physiotherapy instructions for each individual patient. 2.0 Haemodynamic monitoring 2.1 Aim To monitor haemodynamic status in spinal injured patients. To prevent spinal cord ischemia by maintaining haemodynamic stability. To identify and treat hypotension that follows spinal cord injury due to loss of vascular tone and unopposed parasympathetic output (Greenberg, 2001). To reduce the risk of Autonomic Dysreflexia (AD). To detect signs of Autonomic Dysreflexia early. 2.2 Standard The mean arterial pressure (MAP) is maintained within the limits prescribed by the ICU team in consultation with the medical team treating the spine. Hypotension is avoided (AANS, 2002). Target MAP should be documented on the flow chart (MR E-10) by the ICU team. Page 2 of 9

3 Adequate hydration is maintained and the patient is carefully monitored for signs of pulmonary oedema (Greenberg, 2001). Bowel and Bladder care is provided according to this guideline. Sustained increases in blood pressure are reported to the ICU medical team. 2.3 Method Monitor the MAP via an arterial line for a minimum of 7 days (while in the ICU) following acute spinal cord injury. Notify the ICU medical officer if there is a deviation from acceptable MAP parameters so that appropriate treatment can be commenced. Provide bowel and bladder care according to the guidelines. Ensure creases in the bedclothes are removed and be vigilant about other possible sources of noxious stimuli (to prevent AD). Report sustained increases in blood pressure (that is > 30minutes) to the ICU medical team. Instigate treatment for autonomic dysreflexia using aggressive antihypertensive therapy. Other vital signs such as heart rate, central venous pressure and temperature should be monitored according to the patient s status as for any ICU patient. 3.0 Respiratory 3.1 Aim To maintain adequate gas exchange by ensuring optimal ventilation and oxygenation. To detect respiratory difficulty early To prevent and manage atelectasis 3.2 Standard Maintain optimal respiratory function and commence weaning from ventilator as early as possible. Maintain Sa0 2 95% (or patient s normal level) at all times\ 3.3 Method Measure the vital capacity for all non-ventilated patients using spirometry every 2 hours (Parsons et al, 2005). Notify the ICU medical team if measurement less than 10ml/kg or if there is a significant reduction of 500mls. Implement non-invasive ventilation modes if advised by the ICU medical team Page 3 of 9

4 4.0 Sedation and Analgesia 4.1 Aim To reduce pain and anxiety to levels acceptable to the patient. To monitor changes in haemodynamic status indicating pain, in the absence of sensation 4.2 Standard The patient s level of comfort is assessed on admission and every four hours during daylight hours during their stay in ICU Provide adequate and appropriate analgesia and sedation without delay Reduce likelihood of autonomic dysreflexia caused by untreated pain. 4.3 Method Refer to ICU sedation guideline Consult with ICU medical team regarding the requirement for antispasmodic medications. Monitor for increases in blood pressure and changes in heart rate which may be the only indicators of pain in patients who cannot feel pain but have intact nociception. Refer to the pain team early if pain is unrelieved. 5.0 Bowel care 5.1 Aim To empty the bowel at regular intervals in order to prevent incontinence and associated complications such as skin breakdown To maintain patient dignity To establish a bowel regime to prevent complications such as constipation and diarrhoea and minimise the use of laxatives and aperients that can irritate the bowel. 5.2 Standard Commence the bowel regime stipulated below on admission. The only exception to this rule is for patients with known previous spinal injury. Patients who have an existing spinal injury should continue on the regime they are familiar with. These patients should be questioned about their usual bowel regime. This should be documented and adhered to as long as it remains effective. Regular bowel action (at least every two days) of a formed stool is achieved. Constipation does not occur. Page 4 of 9

5 5.3 Method Fybogel 1tsp and lactulose 20mls BD are prescribed on the medication chart. NB. If the patient is not receiving adequate fluid input, Fybogel constipation very rapidly. will cause Daily bowel care consists of one Microlax enema, preferably administered with the patient on their left side, followed by a 20minute wait. The time for the enema to take effect can vary between patients. If no bowel motion occurs, gentle digital stimulation is performed by inserting a finger just inside the rectum. If there is still no bowel motion then the same procedure is repeated the next day. Ensure that the enemas or manual stimulation are performed with sufficient lubrication. The administration of aperients and bowel care at the same time each day aids the bowels ability to respond and empty more completely and avoids incontinence. If the patient does not have a bowel motion for 3 days it is important to review treatment to prevent impaction. Bowel routines take time to establish. It is recommended that a minimum of 5 days treatment be continued before a change to bowel medication is considered. Once a change is made it should also be continued for 5 days before further changes. Only one change to bowel medication should be made at a time, as multiple changes can lead to the bowel responding erratically and the carer will be unsure of which medication suits the patient. The simultaneous use of several medications is not recommended in acute spinal cord injury; it is best to adhere to the Fybogel and lactulose regime. Movicol one sachet may be added to treat constipation. Use of any aperients containing Senna is not recommended for spinal injured patients (SIU, 2001). A full abdominal examination should be performed to assist with determining underlying causes for absence in bowel movements and an abdominal X-ray should be considered. Bowel activity must be recorded on the patient s Bowel Chart Worksheet each day. 6.0 Bladder care 6.1 Aim Page 5 of 9

6 To prevent urinary tract infection (UTI) To detect UTI early 6.2 Standard UTI s will not occur Patients will not experience urinary tract discomfort and bladder distension 6.3 Method Ensure the urinary catheter tubing is strapped to the patient s leg and supported when ever the patient is repositioned. Report low ( 1ml/kg/hr) or high urine output states to the ICU medical team. Perform daily urine analysis Send a sterile sample of urine for microbiology analysis if protein or blood is detected. 7.0 Nutrition 7.1 Aim To provide adequate nutritional supplements as appropriate. Patients with spinal cord injury are susceptible to large nitrogen losses, losses of lean body mass, reduced protein synthesis, loss of gastrointestinal mucosal integrity and ultimately compromise of immune competence (AANS, 2002). 7.2 Standard Enteral feeding is started early according to ICU enteral nutritional guidelines. Adequate nutritional support is provided according to ICU enteral nutritional guidelines. 7.3 Method Refer to Nutrition Guidelines for ICU Refer to ICU Dieticians 8.0 Skin care 8.1 Aim To prevent pressure ulcers Page 6 of 9

7 To detect the signs of pressure ulcers early 8.2 Standard A pressure ulcer risk score (modified Sunderland score) is calculated and recorded on the ICU chart (MR E-10) every 24hours or when the patient s condition changes. A Spinal assessment chart (MR R-69) is completed within 24hours of admission and reviewed every 5 days thereafter. Pressure ulcers are recognised, documented and reported immediately 8.3 Method Follow the instructions in the Alfred Pressure ulcer prevention policy and Pressure ulcer prevention management guideline Wherever possible the patient should be nursed on a pressure relieving mattress. Refer to Spinal assessment chart (MR R-69) for restrictions. Ensure the legs are positioned on pillows lengthways with the heels elevated off the bed surface. When patients have a cervical collar in situ a skin check of the area under the collar should be performed at each pressure area care episode (at least every 3hours). Pressure relieving gel pads may be placed under the patients head in order to evenly distribute pressure from the collar. Contact orthotics department for fitting advice. 9.0 Psychosocial care 9.1 Aim To meet the specific psychosocial needs of the spinal injured patient and their family 9.2 Standard All patients with significant spinal cord injury and their families will be offered the services of social work and pastoral care. Patients will be offered counselling and assistance specific to their needs by the most suitably qualified person. Patients and their families will be encouraged to be involved in care 9.3 Method Offer to refer the patient/family to the ICU social worker Offer to refer the patient/family to the ICU Chaplain Page 7 of 9

8 Encourage family and friends to provide photographs and small keep sakes to personalise the bedside. Organise the provision of a TV and radio. When the patient is well enough ask the family to provide loose fitting clothes and easily fitted training shoes for comfort when sitting out in chair. RELATED DOCUMENTATION Sedation in ICU Guideline ICU Enteral Nutrition Guideline Spinal Clearance Management ICU Bowel Management Guideline Intranet Intranet Intranet Intranet ACKNOWLEDGEMENT Thank you to The Royal North Shore Hospital ICU for sharing their work with us. REFERENCES American Association of Neurosurgical Surgeons (AANS) Joint section on disorders of the spine and peripheral nerves of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons: Guidelines for the management of acute cervical spine and spinal cord injuries. Neurosurgery. 50 (Suppl). Coats-Bennett, U Use of support surfaces in the ICU, Critical Care Nursing Quarterly, 25(1): Greenberg, M Handbook of Neurosurgery, Fifth edition, Thieme, NY. Gutierrez, C.J., Harrow, J. and Haines, F Using an evidence-based protocol to guide rehabilitation and weaning of ventilator-dependant cervical spinal cord injury patients, Journal of Rehabilitation Research and Development, 40(5): , (Suppl 2). Larcher Caliri, M. H Spinal cord injury and pressure ulcers, Nursing Clinics of North America, 40: Nelson, A. (Ed.) 2001 Nursing practice related to spinal cord injury and disorders: a core curriculum, Eastern Paralysed Veterans Association, NY. Parsons, K. C. (Chair) et al 2005 Respiratory management following spinal cord injury. A clinical practice guideline for health-care professionals, The Journal of Spinal Cord Medicine, 28(3): Rowan, C.J., Gillanders, L.K., Paice, R.L. and Judson, J.A Is early enteral feeding safe in patients who have suffered spinal cord injury? International Journal of the Care of the Injured, 35: Page 8 of 9

9 Sidall, P.J. and Middleon, J.W A Proposed algorithm for the management of pain following spinal cord injury, Spinal Cord, 44: Spinal Injuries Unit (SIU) (ND/A) Management of Neurogenic Bowel: Clinical Practice Guidelines. RNSH. Spinal Injuries Unit (ND/B) Caring for the Neurogenic Bowel. RNSH. Spinal Injuries Unit (ND/C) Changes to Bowel Regimen. RNSH Winslow, C. and Rozovsky, J Effect of spinal cord injury on the respiratory system, American Journal of Physical Medical Rehabilitation, 82(100): Contact person: Jason Watterson Position: Clinical Nurse Educator (ICU) j.watterson@alfred.org.au Phone: Page 9 of 9