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October 2001


Privacy Please

By Lisa A. Merenda, MSN, RN, CRRN, and Michele Bakun, RN


Approximately 20% of all spinal cord injuries (SCIs) that occur in the United States affect children and adolescents.1 It is easy to treat the pediatric patient with SCI as if he were a small adult; however, treatment of children with SCI requires a unique approach to address children's ever-changing physical, medical, developmental, psychosocial, and sexual needs. Plans of care must be individually tailored to each child's developmental level and they must involve both the child and family. Health care professionals should encourage participation in self-care activities as soon as the child shows interest.

Bathing
Upon admission, the frequency of bathing should be established according to need by considering general skin type, age, and exercise. Once specific activity orders have been outlined by the physician (transfers, head elevation), close collaboration with therapy should occur to outline and plan self-care activities. The nurse must integrate the skills learned by the patient into daily care, reinforce the lessons of the therapist, monitor patient response, and communicate any problems to the therapist. Occupational therapy can work with the patient to assess physical function/potential, establish realistic goals, advise on positioning that allows the patient the greatest ease, and select appropriate aids. Areas of functional assessment should include ability to learn, ability to direct others, proprioception, sitting balance, upper extremity strength, hand/arm function, and transfer skills.2 Bathing facilities/equipment should also be assessed at home to determine if adaptations are needed to make the home more accessible before discharge. The bathroom is often the least accessible room in a home.

Patients with tetraplegia often experience profuse sweating above the level of injury, which may necessitate more frequent bathing. The patient should be educated about the temperature of the water. Excessively hot water can cause burns to insensate skin. Water temperature should be tested beforehand. A temperature control unit on a shower device is very useful to avoid any injury.

Bathing is an excellent time for thorough skin inspection. The use of a mirror for skin inspection during bathing is very helpful. The patient should be taught to check the lower limbs where skin tends to become dry due to autonomic nervous system dysfunction and lack of sweat production.3 Moisture softens the skin so wet skin is more susceptible to breakdown. The patient should always be thoroughly dried especially between the toes, under the breasts, and in the groin area. Portable shower stretchers may be utilized for those patients who are unable to tolerate an upright position or have restrictions on mobility.

Independent skills for washing can be introduced very early. Upper extremity washing can begin while on bed rest for the patient with a thoracic or lumbar injury as soon as the patient is physically stable. Lower extremity washing can be introduced when the patient is allowed to sit at a 45-to-60 degree angle in bed.3

As wheelchair sitting tolerance increases, the patient should be taught to transfer to a shower chair. Portable shower chairs/bath benches are convenient for those patients who are permitted to transfer and be upright. Additionally, weight and height can also affect the level of independence during bathing activities. Patient safety must always be considered as the presence of spasticity or balance deficits can contribute to an increased risk for falls when bathing in a seated position. Upper extremity washing can be introduced to the patient with a cervical injury when the patient is comfortable sitting at a 45-degree angle in bed.3 Consulting with occupational therapy on adaptive aids and positioning is also a must when working with patients with tetraplegia. Adaptive aids such as shower chairs, long-handled sponges, and washing mitts can enhance function and independence.4 Lower extremity washing may be possible when the patient is able to balance well in long sitting. Sometimes bathing activities can be performed only with the added protection of a brace. When leather portions of the brace get wet, they cannot be worn for the remainder of the day. The most ideal solution is to have separate braces for bathing activities. When a cervical collar is necessary for spinal stability, one portion of the collar may be removed at a time for bathing/skin inspection to prevent undue movement and maintain stability. Specific physician orders should be noted before removing any orthoses placed for stability.

Patients requiring spinal orthoses such as a thoraco-lumbar-sacral orthosis (TLSO) also need frequent skin checks and removal of the orthosis for bathing. Patients wearing these devices often have increased sweating, and the moisture produced underneath can potentially lead to skin breakdown. The skin should be washed and thoroughly dried before reapplying the brace.

Lastly, the activity of bathing should be kept as private as possible. It is all too often that health care providers may forget the personal, private nature of this activity.

Toileting
Management of bowel and bladder issues is one of the most significant challenges facing individuals with SCI. Bowel and bladder dysfunction can leave any person with a sense of embarrassment and affect his or her perception of personal well-being. Failure to establish effective elimination programs can result in depression, anger, frustration, and poor self-image, and prevent those with an SCI from reaching their full level of functional potential.5

Establishment of effective bowel and bladder control is a key factor in the developmental, emotional, psychosocial, and physical stability of not only pediatric SCI patients but also their caregivers.4 Development of a successful regime should be an interdisciplinary effort. Caregivers, patients, and health care providers should work in collaboration to develop an appropriate program that allows an optimal level of patient independence.

Health care providers need to be aware of various factors when caring for a pediatric patient with SCI. Addressing growth and development, emotional capabilities/limitations, and psychosocial needs are just as important as the obvious physical needs. Privacy and patient preferences should also be preserved especially during care activities such as bowel and bladder management. Care should be taken to develop a schedule that does not interrupt daily routines of the patient such as school or extracurricular activities.

The main goal of a successful bladder program is to maintain continence while ensuring that the urinary system is not at risk for deterioration.6 There are many techniques commonly used today by the pediatric SCI population to maintain urinary stability. One form of treatment, clean intermittent catheterization, can be applied to all age groups including newborns and infants.7

For children under the age of 3, the caregiver is primarily responsible for the child's catheterization program. Educational plans of health care providers should focus on the needs of the caregiver. Caregivers should be encouraged to verbalize any problems they may be experiencing or concerns related to the procedure. At 3-years-of-age, most children are developmentally able to assist in the catheterization process. Caregivers should encourage physically able children to participate in the gathering and setup of supplies.

At this age, the caregiver usually performs the actual catheterization. Any interest that the child demonstrates in self-performance should be supported and directed by the caregiver. Modalities such as teaching dolls and educational videos or books can be used to familiarize the child with the procedure.7 By 5 to 7 years of age, children with adequate hand function can begin self-catheterization.8 The role of the caregiver is now converted to that of the observer, ensuring that the child demonstrates proper technique and adheres to a routine schedule. Caregivers or health care providers should present motivational aids and offer positive reinforcement. By age 9, the child should be developmentally able to assume full responsibility for the catheterization process.7 Supervision by caregivers is now at a minimal level and may include slight cueing to the sometimes-forgetful child.

Self-catheterization may not be a practical approach of bladder management for every SCI patient. Those with higher cervical injuries may not have the physical capability to perform the procedure independently. In some cases, indwelling catheters such as urethral or suprapubic Foleys are preferred by patients for urinary management. This method increases independence by alleviating the need for intermittent catheterization, yet places the patient at greater risks for complications such as urinary tract infections, stones, and renal compromise.8

Surgical and technological advances have also allowed for increased functional independence for the pediatric SCI patient. Surgical procedures such as the creation of a Mitrofanoff, or continent catheterizable stoma, have allowed patients to perform intermittent self-catheterization through a stoma, brought to the abdominal wall, usually at the umbilicus. This technique has greatly influenced the independence of SCI patients, both male and female, who may not have the upper extremity strength, manual dexterity, or physical mobility to perform urethral catheterization.6 A sphincterotomy, or surgical incision in the urinary sphincter, is an option for males who do not have the physical capability or emotional desire to perform intermittent catheterization.9 This procedure usually requires the need for a condom catheter to be worn externally and urine collection devices to be changed periodically through the day. Use of an implantable stimulator uses electrical activation of sacral nerves to assist with emptying of bowel and bladder, eliminating the need for catheterization and/or use of suppository.5

Surgical procedures alone may not be sufficient for achieving independence in those patients with a high degree of physical impairment or tetraplegia. Use of adaptive equipment and devices can be implemented in the plan of care to achieve the highest level of self-sufficiency. Adaptive devices for assisting in bladder management can include mirrors, fabricated materials for visualization of the perineal area, clamps or splints for proper gripping of catheters, adaptive scissors for the opening of packages, and equipment to assist with removal of clothing.

Goals of a successful bowel program include the elimination of unplanned bowel movements, evacuation of stool in an acceptable time frame, and prevention of gastrointestinal complications such as constipation or diarrhea.10 Bowel programs are usually initiated at 2 to 4 years, which is considered a developmentally appropriate time frame.8 Appropriate bowel care routines can differ depending on type of injury. Those with an upper motor neuron injury and intact reflex arc usually result in automatic emptying of the bowel every 2 to 3 days. A lower motor neuron injury that is reflexive is associated with frequent emptying of soft stool.4 Care for reflexive bowel consists of placing a chemical stimulant into the rectum, allowing time for the medication to take effect, and then performing digital stimulation.10 Patients with C6 SCI and below can increase independence by incorporating the use of adaptive equipment and devices into their routine. For those with a C6-T1 SCI, further independence can be achieved with the use of equipment such as a roll-in shower chair, commode chair, or tub bench, along with adjunct use of devices such as digital stimulators and/or suppository inserters.2 Those with T2 SCI and below can achieve independence by incorporating the use of tub benches and padded or raised toilet seats.2 A reflexive bowel care incorporates the use of Valsalva maneuvers and/or manual evacuation.11 Caring for children and adolescents with SCI requires a unique approach to address their ever-changing physical, medical, developmental, and psychosocial needs.

References
1. Vogel L, De Vivo M. Pediatric spinal cord injury issues: etiology, demographics, and pathophysiology. Topics in Spinal Cord Injury Rehabilitation. 1997;3(2):1-8.
2. Nelson A, Malassigne P, Cors M, Amerson T. Promoting safe use of equipment for neurogenic bowel management. SCI Nursing. 2000;17(3):119-124.
3. Zedjlik C. Management of Spinal Cord Injury. 2nd ed. Boston: Jones and Bartlett, 1992.
4. Edwards P, Hertzberg D, Hays S, Youngblood N. Pediatric Rehabilitation Nursing. Philadelphia: WB Saunders; 1999: 233-237; 325-326.
5. Creasey GH, Kachourbos MJ. Health promotion in motion: improving quality of life for persons with neurogenic bladder and bowel using assistive technology. SCI Nursing. 2000;17(3):125-129.
6. Pontari M, Weibel B, Morales V, Dean G, Gaughan J, Betz R. Improved Quality of Life After Continent Urinary Diversion in Pediatric Patients with Tetraplegia after Spinal Cord Injury. Topics in Spinal Cord Injury Rehabilitation. St Louis: Thomas Land Publishers Inc; 2000:25-29.
7. McLaughlin J, Murrey M, Van Zandt K, Carr M. Clean intermittent catheterization. Available at: www.staff.washington.edu/nel/jfmcl/g/CATH03.html. Accessed August 2, 2001.
8. Vogel L, Pontari M. Pediatric Spinal Cord Injury Issues: Medical Issues. Topics in Spinal Cord Injury Rehabilitation. Frederick, Md: Aspen Publishers Inc; 1997:20-30.
9. Wells J. Surgical approaches: surgery to facilitate urine drainage. SCI Nursing. 1998;15(2):48.
10. Paralyzed Veterans of America. Neurogenic bowel management in adults with SCI. Presented at: Consortium for Spinal Cord Medicine; 1998; Washington, DC.

Lisa A. Merenda, MSN, RN, CRRN, is the assistant director of rehabilitation services, and Michele Bakun, RN, is the spinal cord injury care coordinator, at Shriners Hospitals for Children, Philadelphia.

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