Neurologic Stressors II

1. Neurologic Stressors II Victoria Siegel, RN, CNS, MSN Joy Borrero, RN, MSN 12/10

2. 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

3. 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/

4. 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.

5. 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

6. 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

7. 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.

8. 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

9. 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

10. 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.

11. 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

12. 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.

13. 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

14. 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.

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

16. 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

17. 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

18. Drug Therapy for SCI • Corticosteroids - Methylprednisolone , solumedrol • Plasma expanders - Dextran • Atropine sulfate • Vasopressor - Dopamine hydrochloride • Analgesics – opiods /NSAIDS • Antispasmodics-Dantrolene, Baclafen • DVT prophylactics –

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

20. 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

21. 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

22. 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

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

24. 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.

25. 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

26. Herniation of Cervical Disc • Immobilization – collar, traction or brace • Pain relief – hot, moist compresses, meds • MIS cervical diskectomy with/without fusion • Postop care

27. 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.

28. 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

29. 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.