Neurologic stressors ii
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Neurologic Stressors II. Victoria Siegel, RN, CNS, MSN Joy Borrero, RN, MSN. Spinal Cord Injury. Incidence- 10-12,000/year 50-60% are cervical Cervical spine injury- C5, C6, C7 most common

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Neurologic Stressors II

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Neurologic stressors ii

Neurologic Stressors II

Victoria Siegel, RN, CNS, MSN

Joy Borrero, RN, MSN

12/10


Spinal cord injury

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 injury1

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 injury2

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 injury3

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

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 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 injury4

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

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

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

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 dysreflexia

Spinal Cord Injury- Autonomic Dysreflexia

Emergency:

  • Severe, pounding headache

  • Paroxysmal hypertension, flushing

  • Profuse diaphoresis, bradycardia

    Interventions:

  • Remove stimulus – e.g., empty bladder…

  • Sit patient up to decrease BP

  • Apresoline may be given IVP.


Spinal cord injury5

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

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

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

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

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

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

Surgical Management

  • Emergency surgery necessary for spinal cord decompression

  • Decompressive laminectomy

  • Spinal fusion

  • Harrington rods to stabilize thoracic spinal injuries


Spinal cord tumors

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 tumors1

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

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

Conservative Management

  • Positioning

  • Firm mattress

  • Exercise and physical therapy

  • Pharmacology

  • Heat and Ice

  • Diet therapy

  • Complementary and alternative tx


Herniated disc

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 disc1

Herniated disc

Nursing 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

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

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 management1

Surgical Management

  • Preop care

  • Diskectomy

  • Laminectomy

  • Spinal fusion (arthrodesis)

  • Minimally invasive lumbar procedures, such as percutaneous lumbar diskectomy, microdiskectomy, laser-assisted laparoscopic lumbar diskectomy

http://www.youtube.com/watch?v=EvQPZxXr3Rs


Post op care

Post –op care

  • Neurovascular checks

  • Log rolling

  • Muscle relaxants, pain management

  • Bowel and bladder function

  • Prevent infection, assess CSF leakage

  • Prevent complications

    Patient 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.


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