Breaking The Silence: - Texas Occupational Therapy Association
Contents
1. Breaking The Silence Everything You Wanted To Know But Couldn t Ask About Spinal Cord Injury TTUHSC MOT Presented By Audrey Attard Micah Dawson Kayla Gaitan Laura Johnson Morgan Ketchersid Alexa Lozada Pelczynski Lauren Ray Kristen Shideler Heather Siewert Dawndra Sechrist Table of Contents Bowel and Bladder Bladder Program Bowel Program Adaptive Equipment Resources Puberty Female Sexuality Male Concerns Spinal Levels Female Concerns Sex Adaptations and Strategies Male Assisted Reproductive Technology Resources Psychosocial Adjustments Normal Reaction Relationships Work amp Education Finances Coping Strategies Spinal Cord Injury Care Education Monitoring Tool Resources amp Credible Organizations BREAKING THE SILENCE TTUHSC BLADDER PROGRAM What does a typical bladder program procedure look like Assemble Equipment e Gloves e Sterile catheter e Lubricant e Mirror for women to locate opening of urethra e Soap water and washcloth e Plastic bag to throw away waste e Preferably a firm surface to sit on General Instructions e Gather necessary equipment e Arrange clothing so it is not in the way e Attempt to urinate on your own e Wash your hands with soap and water Wash your perineal area from front to back If away from home antiseptic wipes may be used Refrain from using these wipes for daily perineal care e Open catheter packaging e Open lubricant tube2. S dOTIPT Swallow CSP a Followup care recommended Home Mobility Safety Home Eval OT PT SecondaryFaciltes __ Driving Academic Vocational ____ OT SLP OutPatent Cd SocialSevices SW _ HomeHealn VJ I Irunding sources Sw f inusng _ _ O O i yi Ff Wc mop PT Physical Therapy SY rT rams __ PT_ Occupational Therapy CS O f sas Pr Speech and Language Pathology O f f cubs PT I Therapeutic Recreation Cd cartansers PT _ LI KOROM OTT Home Program OT Occupational Therap PT Physical Therap LP Speech Therapy R Recreation Therap W Social Work N LVN Nursing Attend a family caregiver conference Date Location Must attend training as clinically needed Signatures initial and discipline Family Caregiver 27 BREAKING THE SILENCE TTUHSC RESOURCES amp CREDIBLE ORGANIZATIONS Christopher amp Dana Reeve Paralysis Resource Center o www paralysis org 800 539 7309 Disabled Sports USA o www dsusa org chapter html Family Voices o www familyvoices org states 888 835 5669 Help Hope Live formally NTAF o www helphopelive org 800 642 8399 National Spinal Cord Injury Association o www spinalcord org 800 962 9629 Office of Disability Employment Policy o www dol gov odep 866 487 2365 Spinal Cord Injury Information Network o www spinalcord uab edu 205 934 3450 The America
3. IL Beyondmedia Education 35 minutes Molly and Jeramy Relationships Sexuality and Spinal Cord Injury Sherborn MA Aquarius Healthcare Videos 2004 25 minutes DVD and VHS Reproductive Health for Women with Spinal Cord Injury Part 1 The Gynecological Examination Birmingham AL RRRTC on Secondary Conditions of SCI 1997 30 minutes Reproductive Health for Women with Spinal Cord Injury Part 2 Pregnancy amp Delivery Birmingham AL RRRTC on Secondary Conditions of SCI 1997 32 minutes Toward Intimacy Women with Disabilities New York NY Filmmakers Library 1992 60 minutes University of Alabama at Birmingham s streaming video on Sexuality and Sexual Function 59 minutes Untold Desires New York Filmmakers Library 1995 Women s Sexuality after SCI Miami FL University of Miami School of Medicine 2003 18 minutes 23 BREAKING THE SILENCE TTUHSC PSYCHOSOCIAL ADJUSTMENTS A spinal cord injury is among the most devastating injuries one can experience There is no universal response to adjustment but a lifelong process of adaptation This involves transitioning from an independent life to a more dependent state and experiencing an overwhelming new reality There is hope Most persons with SCI 75 were found to have a high quality of life even with a severe disability Therapeutic approach plays an important role in the recovery process ALL interactions should be based on respect equa
4. http professional medtronic com pt uro snm edu about index htm USF7XKV8zFJ Bladder and Bowel Wheelchair LIFE Retrieved from http www wheelchairlife net Bladder_Maintenance_Bowel_Maintenance_For_Parapleg ics_Quadriplegics_In_Wheelchairs html Bladder Care Shepherd Center Learning Connections Retrieved from http www myvitalconnections org webmanuals nsf 3478d43e5c5c8dcb85256ae60061f8 97 CF2B89D36786EF1F852571C50063D00F Sample Policy and Procedure Insertion Removal and Care of an Indwelling Foley Catheter Retrieved from http www ucdenver edu academics colleges medicalschool departments medicine hcpr cauti documents Sample 20Policy 20and 20Procedures pdf Suprapubic Catheter Catheterout org Retrieved from http www catheterout org q content suprapubic catheter Urinary Catheters Medline Plus Retrieved from http www nlm nih gov medlineplus ency article 003981 htm USA JEANS The Leader in Sitting Pants Retrieved from http www wheelchairjeans com What happens to the bladder bowel and sexual function Spinal Cord Injury Zone Retrieved from http www spinalcordinjuryzone com answers 1552 what happens to the bladder bowel and sexual function Woodward S The Men s Liberty Blog Men s Liberty Retrieved from http blog mensliberty com blog BBP 13 BREAKING THE SILENCE TTUHSC RESOURCES BOWEL Bowel Management Program after Spinal Cord Injury Care Guide Drugs com Retrieved from http www drugs
5. http www intimaterider com LG 19 BREAKING THE SILENCE TTUHSC Females e Sex Wedges o This device allows you to achieve an optimal position in a comfortable manner to allow more energy to be expended during sex It comes in all shapes sizes and colors designs are available Sy o Price ranges from 70 to 300 depending on style o For more information visit http www liberator com wedge ramp combo html e Sex Swings o This device allows couples to achieve difficult positions more easily therefore enhancing sexual performance Many styles are available that have customizable options nI o Price ranges from 90 to 600 o For more information visit http sexswings com e Sex Stool o This device allows a person to enjoy sex in a seated comfortable position without having to put weight or strain on the lower extremities This device comes in different dimensions styles and materials is o Price ranges from 50 to 200 o For more information visit http www adameve com sex y extras sex furniture props sp sex stool 12963 aspx 20 BREAKING THE SILENCE TTUHSC MALE ASSISTED REPRODUCTIVE TECHNOLOGY Penile Vibratory Stimulation PVS e Most effective for those with an injury at level T10 or above 88 success rate e Cost is low and it can be utilized at home once evaluated in a clinic e Devices available over the counter such as Ferti Care for 850 http medic
6. long 10 BREAKING THE SILENCE TTUHSC Royal Grip Suppository Inserter Digital Bowel Stimulator Suppository Inserter 101 00 Spring loaded tip on inserter prevents suppository from being expelled prematurely Adjusts for left or right hand use Digital Bowel Stimulator 88 90 Provides stimulation to improve independence with bowel program Adjusts for left or right hand use Our Popular Bottom Buddy Bottom Buddy 80 80 Flexible head grips tissue or moistened wipe and releases the paper F with a push of a button Sure Grip Suppository Inserter Digital Bowel Stimulator Suppository Inserter 77 80 Used to insert suppository Inserter rotates 360 Plastic u cuff that can loop over either hand Digital Bowel Stimulator 70 70 Provides stimulation to improve independence with bowel program and plastic u cuff that can loop over either hand 11 BREAKING THE SILENCE TTUHSC Rehab Shower Commode Chair 24 Wheels Shower Commode Chair 1 299 00 Rolling shower chair commode with special features includes side cut out for improved access for bowel program and perennial hygiene Swing back and removable arm and leg rests Can choose between rigid or folding frame Recommend further research with medical equipment companies for competitive pricing 12 BREAKING THE SILENCE TTUHSC RESOURCES BLADDER About Sacral Neuromodulation Medtronic for Healthcare Professionals Retrieved from
7. stimulation This will also decrease the risk of losing balance when laterally bending to the side Massage the abdomen in a clock wise motion to help stimulate peristalsis of the intestines e Put on gloves lubricate your index finger or Dil stick and begin digital stimulation to remove any stool in rectum BREAKING THE SILENCE TTUHSC When ALL the stool in the rectum is removed insert 2 suppositories as far into the rectum as you can along the bowel wall e Wait in bed on your left side 15 45 minutes Time varies for each individual e Sit for 15 20 minutes doing digital stimulation 2 or 3 times if necessary Be careful not to be too aggressive with digital stimulation because the rectal tissues are very sensitive e Note size consistency and color of stool Clean yourself with baby wipes or wash cloth How do you help someone perform digital stimulation Purpose To stimulate peristalsis and aid in defecation for the individual with a neurogenic bowel 1 First start by massaging the abdomen for several minutes and as often as the client deems necessary to help prepare the individual for a bowel movement 2 Instruct the client to laterally bend to side and feel for anus with finger or Dil stick 3 Patient can use mirror to assist them in locating the correct placement Tricks Of The Trade Establish a routine Daily or every other day e Use a suppository every other day morning or evening but most important
8. EL PROGRAM What does a typical bowel program procedure look like Assemble Equipment e Gloves e Dil Stick if preferred e Lubricant e Soap water and washcloth e Toilet paper under pads if done in bed e Plastic bag to throw away waste e Raised toilet seat commode chair or shower chair depending on location General Instructions STARTING IN BED Position on side of the bed with right leg crossed over the left for easier access to rectum It is best to place the person on their left side due to the anatomy of the intestines Place 2 blue pads behind buttocks e Put on gloves lubricate your index finger or Dil stick and begin digital stimulation to remove any stool in rectum When ALL the stool in the rectum is removed insert 2 suppositories as far into the rectum as you can along the bowel wall e Wait in bed on your left side 15 45 minutes Time varies for each individual Transfer to bedside commode or toilet via w c e Sit for 15 20 minutes doing digital stimulation 2 or 3 times if necessary Be careful not to be too aggressive with digital stimulation because the rectal tissues are very sensitive e Note size consistency and color of stool Clean yourself with baby wipes or wash cloth STARTING IN BATHROOM e Itis easiest to use a raised toilet seat with a cut out like the Activaid Make sure that the Activaid seat is positioned to where the opening is to the side to ease access for
9. RTY Adhere to parental permission regulations Adolescents will learn about puberty through school or parents and timing of puberty varies between individuals e Use appropriate developmental education for children or adolescents with SCI e Explain normal body changes such as body hair voice changing growth spurts body odor acne erections and ejaculations e Address sexual activity issues as some adolescents become worried after their first ejaculation e Prepare parents and patients as there is a possibility of an early onset of puberty e As evidenced by female puberty as well high levels of prolactin released in body from shock of injury can cause impotence and decreased sexuality in males in first 6 months 16 BREAKING THE SILENCE TTUHSC SEXUALITY MALE CONCERNS e Masculinity amp gender roles are heavily linked to sexual function e Difficulties amp concerns o Erectile difficulties o Loss of sensation o Change in social roles o Altered body image ERECTION AND EJACULATION AS AFFECTED BY SPINAL CORD LEVEL e Erection The severity and level of an injury can give an indication of how likely a man is able to have erections Erection BEFORE SCI Erection AFTER SCI e Psychogenic This type of erection means imagining something you find sexy or attractive The erection may come from sights sounds or thoughts that are arousing Not likely possible for men with complete upper motor neuron T11 a
10. This is an even more complex process than erection Men with complete upper motor neuron Men with complete lower motor neuron T11 amp above T12 amp lower The ability to ejaculate is rare and less than The ability to ejaculate is usually not 10 are able to have normal ejaculations possible especially if the sacral nerves are involved e Sometimes the spinal cord injury prevents the bladder neck from closing and seminal fluid semen will be ejaculated into the bladder instead of out the penis This is called retrograde ejaculation FEMALE CONCERNS e Loss of bowel and bladder function e Inability to maintain optimal feminine hygiene e Vaginal lubrication can be an issue o After a spinal cord injury your vagina may lubricate less and some women find it takes longer for lubrication to occur e Orgasm IS possible if there is some residual pelvic innervations e More predominant is a phantom orgasm which is a pleasurable fantasized orgasm that mentally intensifies an existing sensation e Female s ability to engage in sexual activity is less likely affected by SCI compared to males due to the way the female body is constructed 18 BREAKING THE SILENCE TTUHSC SEX ADAPTATIONS AND STRATEGIES Males e Vacuum Induced Erections o This device allows males to achieve an erection by placing a tube over the penis where the air is sucked out and the blood can inflate the penis o Price rang
11. a Society Christopher amp Dana Reeve Foundation e Seeking help from religious beliefs e Trying for Independence o Trying for movement o Receiving education from professional healthcare providers and peers o Employment o Searching for information o Setting goals for self care and independence e Hope for o Healing o Successful surgical operation o Divine Intervention o Progresses in medicine 26 BREAKING THE SILENCE TTUHSC dy Pe Patient A e SPINAL CORD INJURY CARE EDUCATION MONITORING TOOL T Koj s o E 5 S a E Ee Q z 2 8l lt O a Q iz EDUCATION 7 DME Durable Medical Equipment i 2 o lOvewowse ss fore IEI I o o CathTraining Ss INSG Wheelchair Cid C _ PainManagement NSG _ DropArm Bedside Commode i C Medication NSG_ _ Shower Chair Extended Tub Bench __ C a s r C _ Nutrition Nse _ SidngBoard BoweBladderProgam_ Nse _ _ Wheelchairramp Skininspecion gt gt OTPT Cathing Supplies Cd Autonomic Dysreflexa Ss OT PT _ Handheld mirror ss Cd PressureRelief__________ OT PT_ Braces Supports TransferTechnique _ OTPT_ _ Home Modification sss ss AbdominatBinder_________ OTIPT Other S y 4 isojesica fOnPT gg to Depression _ OTPT pT Jsexualty __ S
12. alvibrator com products page Electroejaculation EEJ e Performed by specially trained physician and is 95 effective e Recommended for those who do not respond to PVS e This was the most common method used but due to its evasive procedure is not preferred by men Prostate Massage e Physician assisted and no indications are required for this method e Usually recommended by physicians if there is no PVS or EEJ equipment available Surgical Sperm Retrieval e Physician assisted e Controversial method because due to a low yield of total motile sperm couples may have to use IVH insemination procedures IVH is the most expensive insemination procedure 21 BREAKING THE SILENCE TTUHSC MALE RESOURCES BOOKS Amador M J Charles M L amp Nancy L B A Guide and Resource Directory to Male Fertility Following Spinal Cord Injury Dysfunction Miami FL Miami Project to Cure Paralysis 2000 To order call the Miami Project at 1 305 243 7108 Baer R W Is Fred Dead A Manual on Sexuality for Men with Spinal Cord Injuries Pittsburgh PA Dorrance Publishing 2003 Retrieved from www dorrancepublishing com Blackburn M Sexuality amp Disability Oxford UK Butterworth Heinemann 2002 This book is specific to those with spina bifida and hydrocephalus Karp Gary Disability amp The Art of Kissing Questions and Answers on the True Nature of Disability Life on Wheels Press 2006 2 Sexuality and Reproduc
13. and apply a generous amount of lubricant to the first few inches of the catheter Lubricant must be water soluble Note Some catheters come with lubrication already on them e Sit on toilet or firm surface and lean back Intermittent Catheterization For Women e Slightly spread legs apart Using the hand you won t be using to hold the catheter spread your vaginal lips labia apart both outer and inner parts e Identify your clitoris urinary opening and vaginal opening using a mirror or simply by feeling the area e Pick up the lubricated catheter with the other hand Hold it like a pencil about 2 3 from its tip and insert tip straight or upward into urinary opening Allow the other end to hang down between your legs into a basin or toilet unless a drainage bag is attached to the catheter e Gently thread the catheter up into your urethra until urine starts to flow Do not force the catheter BREAKING THE SILENCE TTUHSC Intermittent Catheterization For Women Continued e If the catheter enters the vagina instead of the urinary opening remove the catheter wash it with soap and water vigorously rinse the catheter lumen tube with tap water dry it and start again e When the urine stops flowing remove the catheter Pinch the end closed to avoid getting wet e Note color and amount of urine output e Clean yourself with antiseptic wipes or wash cloth Intermittent Catheterization For Men e Move back the foresk
14. ated activities DWI drug related violence etc e Increased problems with pressure sores ruined internal catheterization programs distended bladder etc e Chronic pain burning stinging pain is more common than pulling pressing cramping stabbing and tingling numbness e PTSD symptoms MARITAL STATUS RELATIONSHIP ROLE CHANGES Couples who separate within the 1 year post injury are very likely to divorce e New marriages occurring post injury have a very high success rate e The key is intervention within the 1 year including spouses and loved ones It is a misconception that SCI patients cannot marry continue a successful marriage or find love again WORK AND EDUCATION e Paraplegics have a higher rate of return to work than tetraplegics e SCIat younger age more likely to become reemployed e More education prior to injury correlates to a higher employment rate post injury e Completion of vocational rehabilitation program makes employment more likely e Research shows that most who were in school prior to injury will return e Online programs and political push for inclusion of disabilities has helped with accessibility and equal opportunities for individuals with SCI FINANCIAL RESPONSIBILITIES TO EXPECT e Re hospitalization Initially following injury SCI patients are re hospitalized on average once every 2 years These re hospitalizations become less frequent post injury Average length of stay during re hosp
15. com cg bowel management program after spinal cord injury html Bowel Program in SCI Rehab Team Site Retrieved from http calder med miami edu pointis bowel html Christopher Reeve Spinal Cord Injury and Paralysis Foundation Retrieved from http www christopherreeve org site c ddJ FKRNoFiG b 4048063 k CS5D5 Christopher_R eeve_Spinal_Cord_Injury_and_Paralysis_Foundation htm Digital Stimulation Shepherd Center Learning Connections Retrieved from http www myvitalconnections org webmanuals nsf ae05066a27d4960485256afb0069d0 63 fca24e0693d98e9485257 166007 1b215 OpenDocument Helpful Stuff Wheelchair LIFE Home Retrieved from http www wheelchairlife net index html When Spinal Cord Injury Affects the Bowel Spinal Cord Injury Zone Retrieved from http www spinalcordinjuryzone com info 747 1 when spinal cord injury affects the bowel RESOURCES ADAPTIVE EQUIPMENT Experts in Motion Spinlife Retrieved from http www spinlife com Patterson Medical Retrieved from http www pattersonmedical com Wheelchairs for Sports and Everyday Sportaid Retrieved from http www sportaid com Interesting Information Spinal Cord Injury Grants amp Research Travis Roy Foundation Retrieved from http www travisroyfoundation org Provides grants to SCI survivors for modifications adaptations 14 BREAKING THE SILENCE TTUHSC FEMALE PUBERTY After injury your body may react in different ways e Amenorrhea Loss of menstrual c
16. ctice toileting steps for dynamic balance and digital stimulation o Use a mirror and Dil Stick to locate proper placement of stick o Perform the bowel program so that the client becomes more comfortable with the procedure According to many online blogs bowel programs for SCI patients are the worst part of their day If we as OT s can make this process easier on them especially initially and help them figure out strategies that work they will be more likely to follow their bowel program and accept it as a new routine they must perform on a regular basis BREAKING THE SILENCE TTUHSC ADAPTIVE EQUIPMENT BOWEL BLADDER MANAGEMENT Catheter Inserter Catheter Inserter with U Cuff 50 50 Pressure is applied to both handles to open spring clip Pressure is released to securely pinch catheterization tubing for easy insertion Handle bends to adjust to various hand sizes Knee Spreader with Mirror d AN Knee Spreader with Mirror 92 90 Designed to assist with self catheterization Rigid 6 x4 knee separator provides 9 of abduction Lumex Open Padded Raised Toilet Seat ri Raised Toilet Seat 89 00 Side cut out allows for improved access for bowel programs and perennial cleaning Can be front side or rear mounted Flexible Para Inspection Mirror Flexible Mirror 30 30 10 aluminum shaft Hand loop adjusts and shaft maintains desired angle Mirror measures 5 1 2 square Handle is 5 1 2
17. er This is a catheter surgically implanted into the bladder Consult your physician for more information and to see if this is right for you BREAKING THE SILENCE TTUHSC Tricks Of The Trade Establish a routine Daily or every other day e Vitamins cranberry capsule and no carbonation or alcohol will decrease risk of UTI Wash your hands Wash your hands Wash your hands Many UTI s can be prevented Purchase cushion for toilet commode seat to prevent skin breakdown Utilize positioning techniques for comfortable transfers to toilet Have all supplies available and within easy reach Use a bungee cord to hold pants out of the way to free up both hands to self catheterize e Providine Benadine can be applied to a female to help locate the urethral meatus A little puddle will form at the base of the urethral meatus to help identify where to cath Leave the Providine Benadine on to catheterize e Slightly loosen the cap on the collection tube If it is not slightly loosened it may create a vacuum and will not drain by gravity e Wheelchair Jeans www wheelchairjeans com VERY IMPORTANT INFORMATION TO RELAY TO YOUR CLIENTS e Every client must be educated on the signs and symptoms of autonomic dysreflexia Patients can experience these symptoms when their catheter bags are too full and when they haven t had a regular bowel movement o Patients with spinal cord injuries at T6 and above are at the highest risk for experienc
18. es from 200 to 500 o For more information visit http www edguidance com treatment mechanical treatment html e Injected Vaso Active Drug o A prescribed amount of dosage injected by a very fine needle at the base of the tip The needle is extra fine to prevent discomfort or pain as much as possible The drug enlarges the blood vessels in the penis causing an erection that can last from 15 minutes to an hour depending on the dosage level o Price ranges from 10 to 20 per injection depending on medications used o For more information visit http www urologicalcare com other ed treatments penile injection therapy http www sexhealthmatters org erectile dysfunction self injection erectile dysfunction e Penile Implants or Penile Prostheses o Arod or an inflatable tube is surgically inserted into the penis Inflatable tubes consisting of several chambers are filled with fluid to produce an erection The fluid is emptied after intercourse Penile implants are found to typically last 8 15 years on average o Price ranges from 10 000 to 20 000 o For more information visit http www urologicalcare com advanced ed treatments types penile implants e Intimate Rider o A small swing chair device that is designed to offer a natural gliding motion that will improve sexual mobility The movement of the upper torso is enough momentum to use this product o Price is 365 00 o For more information visit
19. in of your penis if uncircumcised e Wash the tip of your penis with Betadine antiseptic cleaner an antiseptic wipe or soap and water e Ina seated position hold your penis horizontally from your body with one hand e With the other hand gently thread the catheter through the urethral opening until urine starts to flow Do not force it After the urine begins to flow thread it an additional 1 2 until a good steady flow is obtained e Allow the other end of the catheter to hang down between your legs into a basin or toilet unless a drainage bag is attached to the catheter e When the urine flow stops gently remove the catheter and pinch the end closed to avoid getting wet e Note color and amount of urine output e Clean yourself with antiseptic wipes or wash cloth External Catheter Some men utilize a condom catheter to manage a leaking bladder These catheters are ordered based on the circumference of the penis and are ordered by health care professionals They are available in circumcised or uncircumcised designs Care must be taken to prevent skin breakdown of the penile shaft Use of a skin barrier is important should skin become irritated Indwelling Catheter A physician must write the order for the placement of an indwelling foley catheter A health professional trained and competent in indwelling catheters is responsible for placing the indwelling foley urinary catheter Suprapubic Cathet
20. ing complications with autonomic dysreflexia e Common causes of autonomic dysreflexia related to the bladder o Kink in the catheter tubing o Urinary tract infection o Anything that would be painful if sensation were present e What do you watch for o Headache o Increased blood pressure o Sweating above level of injury o Nausea o Blotchy skin e What do you do if you are experiencing any of these symptoms o Sit up if not already doing so o Check for a kink in the tubing If dysreflexia goes away the patient can continue their bladder program as planned but if it persists or gets worse contact healthcare provider immediately BREAKING THE SILENCE TTUHSC Intervention Ideas e EDUCATION EDUCATION EDUCATION o Patient o Family o Caregivers The more everyone knows who will be involved with the patient s bladder program the more likely they are going to be compliant with the program o Don t assume that they have been told anything o Gather and open supplies needed for bladder program o Transfers to toilet e Bed to w c e W c to toilet e W c to floor to toilet e W c to bedside commode e W c to raised toilet seat Practice FM tasks such as playing game Kerplunk lacing beads etc Cath a banana Show how to use a mirror Practice correct positioning and dynamic sitting balance Actually perform the bladder program so that the client becomes more comfortable with the procedure Oooo 0 BOW
21. italization is 17 days Costs associated with these stays can add to the stressors leading to depression e Outpatient Services amp Physician Fees Average cost of outpatient services during the first year post injury averaged 3000 in 1995 Costs have increased since then e Durable Equipment Hospital equipment mattresses cushion covers crutches braces splints orthoses ventilators etc 25 BREAKING THE SILENCE TTUHSC e Environmental Modifications New car van modifications to vehicle home modifications e Medications and Supplies Prescription or non prescription typically involve muscle relaxers urine acidifiers antacids laxatives analgesics and antibiotics Supplies include catheters tubing leg and bed bags bed pans bandages diapers etc e Attendant Care Household Assistance Payment to unskilled cleaning cooking laundry shopping and yard work and skilled services nursing or home health rehabilitation services This is the highest cost associated with injury e Vocational Rehabilitation Self pay or third party source when available HOW TO COPE e Empower the patient with knowledge e Take advantage of all therapeutic opportunities e Meet with other people and families for both old and new SCI e Be careful of random internet surfing on SCI topics e Rely on reputable organizations e Check out local and state support groups o National Spinal Cord Injury Association The American Traum
22. lity and support Whether the patient grows from the experience or succumbs to the disability is directly influenced by the support received in rehabilitation Normal Reaction v Major Depressive Disorder Normal and expected reaction to SCI Denial and disbelief Sadness anger and bargaining Acceptance E colle a Formulating a new identity During these stages patients may have considered suicide though few attempt it Many will go through periods of self neglect Depressive reactions and posttraumatic distress may commonly occur after spinal injuries but will usually improve over time The key is follow up contacts post discharge to identify patients who are at risk of developing chronic psychopathology Major Depressive Disorder According to the DSM IV a person who suffers from major depressive disorder must have depression symptoms depressed mood or a loss of interest pleasure in daily activities consistently for at least a two week period This mood must represent a change from the person s normal mood Social occupational educational or other important functioning must also be negatively impaired by the change in mood 2012 Study of 102 1 Year Post 4 Years Post SCI Patients Injury Injury Depressive Symptoms 46 12 PTSD Symptoms 9 2 24 BREAKING THE SILENCE TTUHSC Screen for Comorbidity Population at risk for comorbid conditions e Individuals who became injured as a result of substance rel
23. ly at the same time It is best 1 2 hours after eating e Choose foods high in fiber roughage such as fresh fruits vegetables and whole grain foods e Drink enough liquids to keep the stool a soft formed consistency and or use a stool softener Prune juice is a great natural laxative e Fat yogurt and probiotics acidophilus to promote healthy intestinal flora e Avoid foods which cause constipation or very hard stools such as meats and dairy products which are low in fiber or roughage e Avoid foods which cause diarrhea or very loose stools such as spicy foods greasy foods onions etc Be as active as you can The lack of activity can cause constipation Drink a cup of hot fluid tea coffee etc to help initiate bowel movement Use a commode chair or toilet but be aware of potential skin breakdown Purchase a cushion for toilet commode seat to prevent skin breakdown Practice positioning techniques for comfortable transfers to toilet Have all supplies available and within easy reach BREAKING THE SILENCE TTUHSC VERY IMPORTANT INFORMATION TO RELAY TO YOUR CLIENT e Every client must be educated on the signs and symptoms of autonomic dysreflexia Patients can experience these symptoms when their catheter bags are too full when they haven t had a regular bowel movement and also when they are too aggressive with their bowel program o Particularly when using a Dil stick clients are too aggressive for the sensitive
24. mp above injuries e Reflexogenic This type of erection is a direct result of physical touch or stimulation to the penis The ability to get a reflexogenic erection or spontaneous erection is controlled by nerves found in the lowest part of the spinal cord segments S2 4 Reflexogenic erections are possible for men with complete upper motor neuron T11 amp above injuries e Spontaneous If you have ever awakened with an erection because your bladder is full you ve had a spontaneous erection This is from internal stimulation Psychogenic For many men after SCI having an erection by just thinking about something sexual may not work so well This is because the area of the spinal cord responsible for erections is located between T11 and L2 Therefore if your level of SCI is above this the message from your brain cannot get through the damaged part of the spinal cord Reflexogenic Some men with SCI may still get an erection when the catheter is being changed when penis is being cleaned or wiped or even by just pulling clothing or blankets over the body This stimulation to the penis may actually produce an erection even if you really didn t want that to happen e g Reflex erections can be controlled by more apparent stimulation such as pulling the pubic hairs Spontaneous Some men after SCI may still get an erection when their bladder is full 17 BREAKING THE SILENCE TTUHSC e Ejaculation
25. n Trauma Society o Wwww amtrauma org 800 556 7890 28
26. tissues of the anus and the rectum o Patients with spinal cord injuries at T6 and above are at the highest risk for experiencing complications with autonomic dysreflexia e Common causes of autonomic dysreflexia related to the bowels o Constipation impaction o Distention during bowel program digital stimulation o Hemorrhoids or anal fissures o Infection or irritation appendicitis colitis etc o Anything that would be painful if sensation was present e What do you watch for o Headache o Increased blood pressure o Sweating above level of injury o Nausea o Blotchy skin e What do you do if you are experiencing any of these symptoms o Stop stimulation immediately o Sit up if not already doing so o Insert a local numbing agent like Nupercainal Ointment into rectum TF dysreflexia goes away the patient can continue their bowel program as planned but if it persists or gets worse contact your healthcare provider immediately Intervention Ideas e EDUCATION EDUCATION EDUCATION o Patient o Family o Caregivers The more everyone knows who will be involved with the patient s bowel program the more likely they are going to be compliant with the program o Gather and open supplies needed for bowel program BREAKING THE SILENCE TTUHSC o Transfers to toilet e Bed to w c e W c to toilet e W c to floor to toilet e W c to bedside commode e W c to raised toilet seat o Perform Shaving Cream Exercise to help pra
27. tive Health in Adults with Spinal Cord Injury A Clinical Practice Guideline for Health Care Professionals Washington DC Paralyzed Veterans of America 2010 VIDEOS http www spinalcord uab edu show asp durki 97417 o University of Alabama at Birmingham s streaming video on Sexuality and Sexual Function 59 minutes Portraits in Human Sexuality Medical Issues Princeton NJ Films for the Humanities and Sciences 2006 DVD o Includes a segment on a man with a spinal cord injury 36 minutes Untold Desires New York Filmmakers Library 1995 o Both men and women with disabilities discuss their quest to be recognized as sexual beings and their right to become parents 22 BREAKING THE SILENCE TTUHSC FEMALE RESOURCES BOOKS Karp G Disability amp the Art of Kissing Questions and Answers on the True Nature of Disability Life on Wheels Press 2006 2 Kuttai H Maternity Rolls Pregnancy Childbirth and Disability Halifax Canada Fernwood Publishing 2010 Rogers J The Disabled Woman s Guide to Pregnancy and Birth New York NY Demos Medical Publishing 2006 Sexuality and Reproductive Health in Adults with Spinal Cord Injury A Clinical Practice Guideline for Health Care Professionals Washington DC Paralyzed Veterans of America 2010 VIDEOS Disability and Motherhood Princeton NJ Films for the Humanities amp Sciences 1995 25 minutes Doin It Sex Disability and Videotape Chicago
28. ycle lasting usually only around 3 6 months o If periods have not resumed after 4 6 months post injury consult a physician about possible hormone therapy to stimulate ovulation e Autonomic Dysreflexia Over activity of the Autonomic Nervous System ANS which controls the unconscious functions of the body An irritating stimulus sends nerve impulses up the spinal cord until blocked by the lesion at level of injury which due to this disconnect of messages to the brain involves spasms increased blood pressure and narrowing of blood vessels e Decreased dysmenorrhea Less menstrual cramping than before injury o However it is shown that there could also be increased pain at separate portions of menstrual cycle due to spasticity exacerbations and bladder spasms e Increased PMS symptoms Extreme irritability and emotional lability e Exacerbations of autonomic symptoms Sweating headaches flushing or goose flush e UTI yeast infections Chronic antibiotic use and wheelchair users who remain in seated position have increased incidents of these vaginal infections e Immediate cessation menopause after injury Menstrual cycle bleeding stops immediately after injury which allows for menopause and menopausal symptoms to begin o Menopausal symptoms can include spasticity bladder spasms increased bone fractures and dysautonomia malfunction of ANS that controls all unconscious functions of body e Longer menstrual c
29. ycles e Increased bloating and lower extremity swelling 15 BREAKING THE SILENCE TTUHSC Tampon Use Many prefer over pads as there is no skin irritation and better protection during transfers e Be cautious of lack of sensation as you may not be able to feel where tampon is positioned e Familiarize yourself with your vaginal shape because everyone is different e Use mirror to look at vagina lying on bed like when learning to self catheterize e You can use a lubricated tampon with gel especially if you have limited hand function or trouble inserting it e Change 3 4x day or every 4 hours to avoid Toxic Shock Syndrome which can include fever low blood pressure blanching vomiting diarrhea or can be potentially fatal e Remove before catheterizing and use gel on catheter as well as tampon if necessary due to dryness after tampon use Sanitary Napkin Use e Position pad more posteriorly toward anus flat and even as to not cause pressure and to lessen chance of leakage e Wear firm fitting underpants to lessen movement of pad e Check regularly for signs of skin irritation and pressure between legs e For wear with self catheters o Make sure pad sticks well to underpants and is positioned correctly Wipe away blood in downward fashion to avoid any fecal contamination Add gel if experience dryness Be as clean as possible Wash hands before and after Cut down middle of pad to fit catheter tube O O O o MALE PUBE
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