Neurologic Stressors II

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Neurologic Stressors II

• Victoria Siegel, RN, CNS, MSN
• Joy Borrero, RN, MSN

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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

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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/

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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.

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Spinal cord injury

• Hyperflexion forward cervical injury
• Hyperextension backward cervical injury
• Axial loading vertical compression
• Rotation rotate head beyond its range
• Penetration GSW ,knife

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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

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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.

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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

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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

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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.

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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

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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.

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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

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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.

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Spinal Shock

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

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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

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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

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Drug Therapy for SCI

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

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Surgical Management

• Emergency surgery necessary for spinal cord
  decompression
• Decompressive laminectomy
• Spinal fusion
• Harrington rods to stabilize thoracic spinal
  injuries

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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

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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

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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

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Conservative Management

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

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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.

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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

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Herniation of Cervical Disc

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

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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.

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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?vEvQPZxXr3Rs
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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.