Nowadays, with the growing number of injuries, those of the spine and spinal cord continue to take up a more significant place. This, and the cause of injuries in general, lie in the modern pace of living growth in mechanization and industrialization, and especially in the fast growth of traffic.
Every injury of the spine or spinal cord causes nerve damage to the urinary bladder. Depending on the level and extent of the injury, there is also deformation of the urinary bladder.
The urinary bladder suffering of nervous damage, or neurogenic dysfunction of the urinary bladder is the morphologic basis which is the source of every urinary complication. Insufficient discharge of the urinary bladder and residium present provide a favorable environment for infections, while the inability of the urinary bladder to contract leads to its dilatation. This then spreads to the urethras causing reflux. A paraplegic's good neurogenic urinary bladder in a functional sense is the only boundary to retaining the function of the upper urinary tract.
Having had perceived the seriousness of this problem, in 1980 the hospital staff opened the Centre for Paraplegics, which offered complete nursing of these patients. This centre treats paraplegics with paralyzed lower extremities. Broken spines are treated surgically with the aim of stabilizing the spine so that the patient is enabled to sit in a chair independent of another person.
The establishment of this Centre for Paraplegics gave the Republic of Macedonia a medical institution which offers complete assistance and treatment to paraplegics, and patients with injuries of the spine and spinal cord.
This team consists of: an orthopedist, urologist, neurosurgeon, plastic surgeon, anesthesiologist, physiatrist, neurologist, internist, transfusion specialist, biochemist, radiologist, physiotherapists, nurses, trained male nurses and other assisting personnel.
Nursing of the paraplegics
Treatment of the decubitus
Methods for drainage of urine
Presentation - part of the job of the centre for paraplegia
Nursing of the paraplegics The team working with the paraplegics devotes particular attention to their care. The nursing plan must be closely related and coordi¬nated to the general aims of rehabilitation of the paraplegics. Therefore, whether fully or partially, the nursing of the paraplegics contributes to treatment of the following problems:
• medical treatment of the illness or injury that caused paraplegia;
• adapting the paraplegic to invalidity;
• prevention and therapy of stiffness deformities, and decubitusi;
• regulation of discharging of urinary bladder and intestines;
• prevention and therapy of urinary infection and calculuses;
• providing hygienic sanitary and other conditions for maintaining the good health of he paraplegic;
• taking appropriate measures as fast as possible for enabling the paraplegic to move as much as possible with the use of adequate appliances (wheel chair, crutches, walking devices, etc.);
• training of the paraplegic to take care of themselves and become independent in everyday activities;
• preparing the family to accept the paraplegic after his return from the hospital;
• cooperation with appropriate team members in creating work habits and consistence in their work for achievement of professional orientation of the paraplegic, etc.
Treatment of the decubitus
The prevention, or treatment of decubitus is a permanent problem of the rehabilitation of the paraplegic. There is danger that decubitus (an illness which is most common in the first 6 to 8 months) could appear and it practically remains throughout their entire life despite the relative adaptation of the skin to the variable conditions.
The level of success of the efforts and measures taken at the hospital for prevention and treatment of the decubitusi depends on the precisely designed and consistently carried out nursing plan, which is based on the conscientious and correct gathering of information regarding the form and degree of injury, and the form, scale, and duration of the existing complications. Therefore, the problem of decubitus is a specific and complicated task within the framework of the general rehabilitation plan.
At the hospital the main aims of the nursing and treating the decubitus are the following:
• maintenance of a clean body and increasing immunity of the body;
• regular examination of the skin, especially the paralyzed parts of the body;
• removal of local and general conditions and reasons that lead to decubitus and other pathologic skin changes;
• assistance through local and general means for curing the decubitus and other pathologic skin changes.
Preventive measures taken are the following:
• maintenance of personal hygiene of the patients and skin care;
• increasing immunity of the skin;
• protection of prominent parts;
• prevention of maceration and skin infection;
• improving blood circulation;
• passive and active exercises and adequate condition in bed, and separation of the patient from the bed as soon as possible.
Decubitus treatment is conducted through appropriate treatment in nursing, medical and technical procedures, and therapeutical treatment in an adequate manner, which depends on the localization, number, extent, and state of the decubitus wound. Treatment is conducted in the following manner:
• everyday treatment of the decubitus wound, i.e. bandaging and application of appropriate therapy;
• refreshing of the edges of the decubitus wound;
• drainage of matter and deep decubitusi;
• removal of necrotic mass from the decubitus;
• plastic surgery of decubitus wound;
• adequate position of the patient in bed, which must not interfere with treatment of decubitus wound;
• passive and active exercises in bed and enabling the patient to stand up as early as possible;
• strengthening of immunity and vitality of the patient, i.e. maintenance of a good general condition of health;
• avoiding physical effort which tire the patient.
Methods for drainage of urine
As regards the problem of rehabilitation of the patients with injuries of the spinal cord, it is of great importance to establish the functions of the urinary bladder, and of the lower urinary tract. The basic methods for drainage of urine where this is prevented in patients having injured spines only provide a passive flow, creating further conditions for serious complications.
One of the methods for drainage of the urinary bladder that is applied at our centre is the intermittent sterile catheterization using the non-touch method of Gutman. This technique demands intensive care of the doctors and good training of the assistant personnel, and prevents infection, although it is nevertheless present.
Discharging of the urinary bladder by the Krede approach and ,,trigger" mechanism failed to give good results due to the ,,rest urine", which remained and the possibility of uroinfection, and because of the dependence on assisting personnel.
The blockage of the pudendal nerves accompanied by impotence in 50% to 60% discredits this procedure, while the sacral neurotomy and risotomia treats permanently the problem of discharging of the urinary bladder, which is most important for full urination.
Surgical treatment, such as transurethral resection of the neck of the urinary bladder and the sphincterotomy of the external sphincter of the urethra do not promise much, and makes the patients completely incontinent, constantly led.
Surgical solution by tying up the ureter into an intestine is relatively contraindicated due to the poor control of the intestine functions, or the anus of these patients.
Dissatisfied with the previous treatment of patients with a neurogenic dysfunction of the lower urinary tract, and relying on the characteristic of the impulsive path to imitate effects of nervous impulses and to put nerve and muscle tissue into motion, we tried to introduce a new method, i.e. electrostimulation, and studying the elements and details which make this treatment better than the previous. For this reason, contacts were established with the Sesojuzni centre for injuries of the spinal cord at the ,,Burdenko" Institute in Moscow for full treatment of these patients, paraplegics.
In the Republic of Macedonia for the first time in our hospital a stimulator of the urinary bladder was implanted in 1987 with initial good results, with complete excretion of the urinary bladder and its balanced function. Three years later the lines broke and the receiver exited through the abdominal fascia through the skin, with incomplete excretion and appearance of residual urine.
During the period 1980 - 1990 the centre for paraplegics treated 217 patients, fully analyzed where a method was determined that gave the best results and least complications in the treatment of the neurogenic dysfunc-
tion of the lower urinary tract in paraplegics. This was the method of intermittent clean self-catheterization, i.e. the patient set up the catheter himself. As a result, the rehabilitation of the urinary tract was significantly shortened and was no longer a factor that determined the duration of hospitalization of the paraplegics. This method makes it possible to avoid constant and definite catheters. It has advantages in comparison to the intermittent catheterization because it engages no time or personnel, decreases urinary complications, shortens hospitalization.