Neurologic Stressors II

Victoria Siegel, RN, CNS, MSNJoy Borrero, RN, MSN

12/10

Spinal Cord Injury Incidence- 10-12,000/year 50-60% are cervical Cervical spine injury- C5, C6, C7 most

common Damage range is from concussion (with full

recovery, to contusion, laceration and compression to complete transection

Early tx prevents total and permanent damage

Spinal Cord Injury Stressors: Congenital – Spina bifida,meningomyelocele. Physical Trauma – Sports injuries, car

accidents, gunshot wounds, diving. Microbiological – Polio, meningitits. Physiological- neoplasms, herniated disc,

scoliosis.http://www.spinalcord.org/

Spinal Cord Injury Extent of alteration in function depends on: Degree and Location of injury Quadriplegia, tetraplegia- above C4 Paraplegia= lesion thoracic or lumbar region Spinal cord compression- function may be

preserved with prompt surgical intervention.

Spinal cord injury Hyperflexion – forward cervical injury Hyperextension – backward cervical injury Axial loading – vertical compression Rotation – rotate head beyond it’s range Penetration – GSW ,knife

Initial Assessment Assessment of the respiratory pattern

and ensuring an adequate airway Assessment for indications of intra-

abdominal hemorrhage or hemorrhage or bleeding around fracture sites

Assessment of level of consciousness using Glasgow Coma Scale

Establishment of level of injury: tetraplegia, quadraplegia, quadriparesis, paraplegia, and paraparesis

Cardiovascular Assessment Cardiovascular dysfunction is usually the result of

disruption of the autonomic nervous system. Bradycardia, hypotension, and hypothermia result

from a loss of sympathetic input and may lead to cardiac dysrhythmias.

Systolic blood pressure lower than 90 mm Hg requires treatment because lack of perfusion to the spinal cord worsens the condition.

Spinal Cord Injury Complete- spinal cord has been severed Incomplete- cord not completely severed C2 or C3 fractures- complete respiratory

paralysis, complete flaccidity and loss of reflexes, death

C1-C3 needs mechanical ventilation C4- may need CPAP or BiPAP for nocturnal

hypoventilation C5,C6,C7- most common injury

Effects of injury can be reversed depending on level of injury Loss of: 1. Motor function 2. Sensation 3. Reflex activity 4. Bowel/bladder control Behavior/emotional problems 1. Changes in body image 2. Role performance 3. Self-concept

Spinal Cord Injury- management Scene of accident- maintain proper

alignment. Pt kept on back board until x –rays are taken. Diagnostic tests – X-ray, CT, cardiac

monitoring- cervical injuries. Pharmacotherapy- high dose corticosteroids

to decrease edema. Dextran –plasma volume expander, maintain

BP and capillary flow.

Autonomic dysreflexia Commonly seen in clients with upper spinal

cord injury Occurs after spinal shock Cause is some noxious stimuli such as … s/s include severe hypertension,

bradycardia,,severe headache ,nasal stuffiness, flushing above site of SCI, piloerection

Spinal Cord Injury- Autonomic DysreflexiaEmergency: Severe, pounding headache Paroxysmal hypertension, flushing Profuse diaphoresis, bradycardiaInterventions: Remove stimulus – e.g., empty bladder… Sit patient up to decrease BP Apresoline may be given IVP.

Spinal Cord Injury Teaching Plan for pt. with SCI:

Physical mobility and activity skills ADL skills Bowel and bladder retraining Skin Care Medication regimen Sexuality education

Spinal Cord Injury-Outcomes Evaluation of Nursing Interventions:

Attain highest level of mobility Maintain healthy, intact skin Bladder control, free of infection Bowel control Reduction in spasticity Free of complications.

Spinal Shock

Condition characterized by: Flaccid paralysis Loss or reflex activity below injury. Bradycardia Paralytic ileus (occasionally) Hypotension

Immobilization for Cervical Injuries to prevent Ineffective Tissue Perfusion

Fixed skeletal traction to realign the vertebrae, facilitate bone healing, and prevent further injury

Halo fixation and cervical tongs Stryker frame, rotational bed, kinetic

treatment table Pin site care and monitoring of traction

ropes

Immobilization of Thoracic and Lumbosacral Injuries For clients with thoracic injuries: bedrest

and possible immobilization with a fiberglass or plastic body cast

For clients with lumbar and sacral injuries: immobilization of the spine with a brace or corset worn when the client is out of bed; custom-fit thoracic lumbar sacral orthoses preferred

Drug Therapy for SCI Corticosteroids - Methylprednisolone ,

solumedrol Plasma expanders - Dextran Atropine sulfate Vasopressor - Dopamine hydrochloride Analgesics – opiods /NSAIDS Antispasmodics-Dantrolene, Baclafen DVT prophylactics –

Surgical Management Emergency surgery necessary for spinal

cord decompression Decompressive laminectomy Spinal fusion Harrington rods to stabilize thoracic

spinal injuries

Spinal Cord Tumors Surgical management: goal of removing as

much of the tumor as possible Nonsurgical management: radiation therapy,

chemotherapy, pain control Nonsurgical management- RT, CT, pain control Diagnosis – Neuro exam, CT, MRI. Assess- Pain,sensory & motor loss, sphinctor

disturbances

Spinal Cord Tumors Post –op nursing care: Neuro assessment – motor and sensory Resp compromise- assess with cervical

tumors Bladder and bowel functioning Pain management Observe dressing for possible leakage of

CSF

Back Pain Low back pain Herniated nucleus pulposus Physical assessment: continuous acute

pain, altered gait, vertebral alignment, paresthesia

Diagnostic assessment using MRI, CT, and electromyography

Conservative Management Positioning Firm mattress Exercise and physical therapy Pharmacology Heat and Ice Diet therapy Complementary and alternative tx

Herniated disc Herniated disc – The nucleus of the disc

protrudes out, causing nerve compression. Diagnostic tests – Neuro exam and history, Xrays, CT and MRI, myelogram, EMG.

Herniated discNursing Diagnoses; Pain related to surgical procedure Impaired physical mobility Knowledge deficit related to procedure or home care

management.Nursing Interventions: Relieve pain Monitor for complications Improve mobility Pt. education and home care management

Herniation of Cervical Disc

Immobilization – collar, traction or brace Pain relief – hot, moist compresses, meds MIS cervical diskectomy with/without fusion Postop care

Herniation of a Lumbar Disc L4 or l5 – S1 Sciatic pain, straight leg raise

test. Neuro exam and history. MRI, CT, and myelogram.

Management- Bed rest, not supported by research Anti inflammatory and muscle relaxants Moist heat and massage, Heat/Ice Epidural corticosteroids.

Surgical Management Preop care Diskectomy Laminectomy Spinal fusion (arthrodesis) Minimally invasive lumbar procedures,

such as percutaneous lumbar diskectomy, microdiskectomy, laser-assisted laparoscopic lumbar diskectomyhttp://www.youtube.com/watch?v=EvQPZxXr3Rs

Post –op care Neurovascular checks Log rolling Muscle relaxants, pain management Bowel and bladder function Prevent infection, assess CSF leakage Prevent complicationsPatient Teaching: Body mechanics, avoid strain, maintain alignment Sit with knees higher than hips Maintain appropriate weight Exercise 15 min BID. Avoid standing long periods,

foot stool. Sleep on side with pillow between knees.