2.8 Musculoskeletal

Question 1

Anesthesia

Answer 1

Anesthesia:

Absence of sensation, loss of pain and reflex

Question 2

Paresthesia

Answer 2

Paresthesia:

Altered sensation, prickling, burning, tingling

Question 3

Hyperesthesia

Answer 3

Hyperesthesia:

Increased sensitivity to stimulation

Question 4

Ipsilateral

Answer 4

Ipsilateral:

Same side of body

Question 5

Contralateral

Answer 5

Contralateral:

Opposite side of body

Question 6

-plegia

Answer 6

-plegia:

Complete paralysis

Question 7

-paresis

Answer 7

-paresis:

Partial paralysis, weakening

Question 8

Tetra-

Answer 8

Tetra-:

Four limbs, quadriplegia

Question 9

Hemi-

Answer 9

Hemi-:

One side of body

Question 10

Para-

Answer 10

Para-:

Two limbs, paraplegia

Question 11

Upper and lower motor neuron deficits comparison

Answer 11

Upper motor deficits:
Responsible for voluntary movement
Disruption leads to spastic paralysis and hyperreflexia
May have trouble carrying out skilled movement
May have a +Babinski reflex
Spastic bladder possible
May require bowel training

Lower motor deficits:
Responsible for skeletal muscle innervation and contraction
Muscles may be flaccid leading to atrophy
Loss of both voluntary and involuntary movement
Atonic (no sensation of voiding needs) bladder and bowel

Question 12

Spinal cord injuries

CONCUSSION

Answer 12

Momentary disruption in the brain function due to immediate and brief LOC

Temporary axonal disturbance with amnesia common

Other symptoms may include HA, drowsy, confusion, visual disturbances, N/V

Question 13

Spinal cord injuries

CONTUSION

Answer 13

A bruise on the surface of the brain or spinal cord (often due to the striking onto a bony prominence)

Coup-contrecoup (hyperflexion and hyperextension) is common

May result in edema and ICP

Question 14

Spinal cord injuries

COMPRESSION

Answer 14

Squeezing of the spinal cord due to pressure from an external force

May be caused by tumor or trauma

Hyperflexion, axial loading, and excessive rotation may cause spinal cord compression (ex. diving into shallow water, landing on feet)

Question 15

Spinal cord injuries

TRANSECTION: COMPLETE VS INCOMPLETE

Answer 15

A cut through the spinal cord

COMPLETE cut all the way through the cord (rare) with total loss of sensory and motor function below the level of injury

INCOMPLETE cut partially through the cord with mixed loss of voluntary motor activity, sensation or reflex

Question 16

Neuro assessment and nursing interventions used for spinal cord injuries
ACUTE PHASE
STABLE PHASE

Answer 16

Acute phase:

Stable phase:

Question 17

Compare and contrast, assessment findings, nursing interventions
SPINAL SHOCK
NEUROGENIC SHOCK

Answer 17

SPINAL shock:
The response of the spinal cord to an injury
Temporary loss of reflex function below level of injury, cervical or upper thoracic
Begins immediately after injury, may last 4-6 weeks, may mask post injury neurologic function
Sympathetic (“fight or flight”) function is lost; parasympathetic (“rest and digest”) function takes over

Characteristics:
Flaccid paralysis and loss of deep tendon reflexes
Loss of sensation below level of injury
Loss of bladder tone, intestinal peristalsis and vasomotor tone
Loss of perspiration and temperature control
Decreased BP and HR (autonomic dysfunction)
Resolves:
Gradual recovery of spinal shock begins; improved bladder tone, hyperreflexia, sacral reflexes

NEUROGENIC shock:
Cardiovascular compromise as a result of cervical or upper thoracic
Sympathetic nervous system is impaired and there is massive vasodilation below level of injury

Characteristics:
Decreased BP and HR due to vasodilation
Warm skin
Respiratory dysfunction
Paralytic ileus
Urinary retention
Poikilothermic (inability to regulate body temp)
Critical care support
May occur quickly, w/in 30 min of a T5 or higher SCI

Question 18

Autonomic dysreflexia

Answer 18

Autonomic Dysreflexia:

Medica emergency
Specific to spinal cord injuries involving T6 and above

How it occurs:
Irritation below the level of SCI
Constriction of blood vessels
Causing high blood pressure
Signals to brain
Slow pulse and dilation of blood vessels above the injury level as an attempt to compensate for the rise in BP causing symptoms
Attempted compensation message cannot pass through the spinal cord and blood pressure continues to rise

S/S:
BP 20-30mmHg above norm
Sweating
Pounding HA
Flushed
Tight chest
Stuffy nose
Blurred vision

Causes:
Bladder; distention, UTI, stones
Bowel; constipation, hemorrhoids, fissure, having bowel care preformed
Skin; pressure ulcers, tight clothing, ingrown toenail, blister/burn
Other; scrotal compression, sexual stimulation, labor during child birth, menstruations, or anything that causes ab pain

Emergency TX:
Call for assistance
Sit pt upright, lower legs
Loosen tight clothing/leg straps
Monitor BP

Treat first:
Bladder distention and constipation

If symptoms persist and cause unknown:
Admin prescribed medication
Nifedipine 10mg capsule “bite and swallow” method

Question 19

Sacral sparing and it’s effect on sexuality

Answer 19

Sacral Sparing:
Is proven by:
Perianal sensation
Rectal motor function
Flexor activity of great toe

Bladder training is possible
Highest level of sexual function is possible

If sacral function is preserved this may the only way to differentiate between COMPLETE and INCOMPLETE cord injury

If pt has no signs or sacral sparing and is paralyzed, they are considered to have a COMPLETE SCI

Question 20

Modifications in the administration of intramuscular drugs to cored injured patients

Answer 20

IM injections:
Give above the level of injury due to reduced blood flow to unused muscles

Impaired drug absorption

Increased risk for irritation and bleeding

May cause ulcerations of tissue

Question 21

Important elements taught to patients with musculoskeletal injuries

Answer 21

Preventative: helmets, seatbelts, no diving, safety devices
Rehabilitation and self care
Support independence and use of assistive devices
Bowel, bladder and skin care
S/S of autonomic dysreflexia
Medications
Nutrition: fiber, fluids, protein

Question 22

Nursing interventions and medications

Answer 22

NI:
Immobilize/stabilize the head/neck, maintain c-spine and longboard until cleared

Maintain airway patency and support breathing- suction/clear airway, give O2, assist with intubation

Monitor cardiovascular status- assess VS, tele, invasive monitor, risk for spinal and neurogenic shock

TX:
Administer IV fluids/medications
Volume support but monitor for fluid overload

Corticosteroids use is NOT supported as it was previously, control edema- may increase complications

Vasopressors (dopamine or dobutamine) for hypotension and atropine for bradycardia- if neurogenic shock

Antispasmodics (baclofen)

Antiemetics for N/V

Analgesics and narcotics for pain control

Proton pump inhibitors to prevent gastric ulcers related to stress

Anticoagulants to prevent DVT/PE

Stool softeners

Question 23

Nursing interventions

Assessment, monitoring, labs

Answer 23

Strict I/O
Foley if indicated
Prevent constipation, bowel training
Protect skin
Prevent infection- skin, urine, pneumonia/sepsis (greatest risk for death)
Administer dietary nutrition as tolerated (high fiber, adequate fluids)

Labs and testing:
ABG's
Electrolytes
Trauma panel
CT
Xray
MRI
Somatosensory- evoked potential studies, stimulates peripheral nerves to determine level of SCI by monitoring response time
Post void residual, bladder scan

Question 24

Nursing interventions

SUPPORT DEVICES ETC

Answer 24

Support stabilization and immobilization with traction devices and surgical procedures

Surgery: stabilization of the spine with metal rods, spinal fusion, decompression laminectomy

Traction/stabilization device: stabilization of the the cervical spine to prevent further damage

• Gardner-Wells tongs; not used much anymore
• Halo device; external fixation device, screwed into skull

Assist with thermoregulation