Overcoming Obstacles

By Carol Lindsay, RN
November 11, 2002

Clinical nurse specialist Cindy Gatens, MN, RN, grew up wanting to be a nurse. Her plans were interrupted six months into a three-year nursing program when she suffered a spinal cord injury. Despite being in a wheelchair since that time, Gatens' injuries did not deter her from completing her goal of being a nurse-after completing rehab, she enrolled in a four-year nursing program. Gatens now works at Ohio State University Medical Center Rehabilitation Center. She has worked with spinal cord injury patients for more than 30 years.

Throughout her years as a nurse, Gatens has seen many changes in how spinal cord injury patients are managed. Higher-level spinal cord injured patients now are surviving and being discharged. Even with the more severely injured patients, the length of hospitalization has shortened. In the past, newly injured patients were hospitalized for three months or more. Now, patients are being discharged from the hospital to rehabilitation one to two weeks after an injury.

"We know people are ready for rehab as soon as they are stable. We admit them right from the intensive care unit," said Sandra DeLeon, RN, spinal cord injury coordinator at the Kessler Institute for Rehabilitation in New Jersey. Nurses in all settings need to be knowledgeable about the proper handling of patients immediately post-trauma and about caring for the patient in the acute setting. "The more time a patient is recovering from a pressure ulcer, the less time they have to focus on recovery," said Marilyn Pires, MS, RN, FAAN, rehabilitation clinical specialist at Rancho Los Amigos in Downey, Calif.

Along with the new standard of shorter hospital stays, insurance companies also frequently limit the amount of time they will pay for rehabilitation. This requires nurses to speed up the education process. "In the past, we had the luxury of letting the patient adapt to the disability before we started bombarding the family with education," Pires said. She believes there is a fine line in deciding when to inject reality into a patient with a spinal cord injury. "You never remove hope. What they are hoping for may not come for a long time so they need to take really good care of themselves in the meantime," Pires said.

Pires, like the other rehab nurses, spends time with patients to help them reassess their life goals and decide how to work toward them and what adaptations will be required. Pires has worked with many spinal cord injury patients who were in gangs. "They expected to be dead, and now they have a different future," Pires said. For these patients, they work together to establish goals based on a future they never considered.

Because she is a paraplegic, Gatens finds herself in a unique position when educating patients with spinal cord injuries. "I try not to put myself in front of patients and say, 'See what I can do.' But it is nice for them to see someone successful when the future is so unknown. It gives them hope," Gatens said.

Despite advances, the goal of caring for the recovering spinal cord injury patient hasn't changed and continues to concentrate on the prevention of secondary complications, such as urinary tract infection, pressure ulcers and deep vein thrombosis. Although more sophisticated medications and equipment are available, nurses and patients must remember that the new equipment does not replace frequent turning. DeLeon compares the new pressure cushions available to air bags. "Cushions are beneficial, but turning prevents skin breakdown. It is just like an air bag. It is only effective when you wear your seat belt."

Another obstacle for spinal cord injury patients is access to the world. "Transportation is a huge issue," DeLeon said. Technology such as improved wheelchairs and voice-activated computers have made parts of life easier to access.

All three rehabilitation nurses interviewed by NURSEWEEK would like to see a decrease in the number of spinal cord injuries due to education about injury prevention. Pires said she is hopeful that future research into the prevention of secondary cell death at the time of injury will reduce the amount of neurological deficits of spinal cord injury patients.

"The cell death is caused by anoxia. The cells that die release a toxin that kills other cells in the area. I think we are close to stopping this secondary death," Pires said.