Acute Neurological Health Challenges (Week 6)

Question 1

When older people suffer spinal cord injury (SCI), it is usually more?

Answer 1

traumatic, more complicated, and results in longer hospitalization.

Question 2

Tetraplegia

Answer 2

is the correct term for quadriplegia; arms and legs all paralyzed.

Question 3

What is tetraplegia caused by?

Answer 3

It is caused by spinal cord damage at the C8 vertebrae or above. Most anatomical charts only show 7 cervical vertebrae. In this case, C8 must be what is usually referred to as T1.

Question 4

The major problems associated with SCIs are:

Answer 4

1) Disruption of individual growth and development.
2) Altered family dynamics.
3) Economic loss d/t absence from work.
4) High cost of rehabilitation and long term healthcare.

Question 5

The most common causes of SCIs are:

Answer 5

1) Motor vehicle (and motorcycle) collisions.
2) Falls and industrial accidents.
3) Sportsinjuries.
4) Medical conditions.
5) Violence.

Question 6

There are four types of actions that can damage spinal cord components:

Answer 6

1) Compressive forces.
2) Traction forces.
3) Interruption of blood supply.
4) Penetrating forces (i.e. knife or gunshot).

Question 7

Primary spinal cord injury

Answer 7

is the initial symptoms that occur at the time of the initial trauma d/t the disruption in nerve function.

Question 8

Secondary spinal cord injury

Answer 8

is the ongoing, progressive damage that occurs after the initial injury.

Question 9

Most of the secondary damage that occurs is due to?

Answer 9

ischemia causing cell death in affected tissues. The ischemia is usually due to vasoconstriction from the release of vasoactive chemicals from the damaged tissues or edema. It occurs because of the “housed” nature of spinal cord components; there is little room for expansion so, when things swell up, the damage is severe. Hemorrhage is also a cause of expansion and tissue hypoxia.

Question 10

There are two types of shock that occur in many patients following an SCI, what are they?

Answer 10

spinal shock and neurogenic shock.

Question 11

Spinal shock

Answer 11

includes decreased reflexes, loss of sensation, and flaccid paralysis below the level of injury. Think of spinal
shock as being an exaggerated state of damage that is temporary; it usually resolves in days to months.

Question 12

Neurogenic shock

Answer 12

results from a decrease in vasomotor function (vasodilation/constriction) in events where spinal cord damage occurs at the T5 vertebrae or above. It is associated with a loss of (excitatory) sympathetic nervous function. Excessive vasodilation occurs and we see symptoms of hypotension, venous pooling and warm, dry extremities. Also, the loss of sympathetic cardiac excitation results is bradycardia and decreased cardiac output. In summary, neurogenic shock = hypotension, bradycardia, and warm, dry extremities. The severity of the neurogenic shock symptoms depends on the level of the injured vertebrae. Starts at T5 (less severe neurogenic shock) and increases as we move upwards to the cervical column.

Question 13

Classification of spinal cord injury is by:

Answer 13

1) Mechanism of injury.
2) Level of injury.
3) The degree of injury.
* * Think of these as “how it happened” “where it happened” and “how much damage.”

Question 14

Mechanisms of injury include the ways the spinal cord was moved that caused the injury. These are?

Answer 14

1) Flexion.
2) Hyperextension.
3) Flexion-rotation. Most severe because it results in ligamentous tearing in the cord.
4) Extension-rotation.
5) Compression.

Question 15

The level of injury is classified by?

Answer 15

skeletal level and the neurological level

Question 16

The skeletal level of injury

Answer 16

refers to which vertebrae the most damage occurred at.

Question 17

The neurological level of injury

Answer 17

is indicated by the lowest vertebrae that still has normal function.

Question 18

The degree of injury is classified as either?

Answer 18

complete or incomplete spinal cord involvement.

Question 19

Complete spinal cord involvement

Answer 19

results in a total loss of sensory and motor function below the level of the lesion.

Question 20

Incomplete spinal cord involvement

Answer 20

results in partial losses of sensory and motor function below the level of the lesion.

Question 21

Complete spinal cord injury is absolute; all the nervous pathways are severed. Incomplete spinal cord involvement, however, is classified into six different syndromes, what are they?

Answer 21

1) Central cord syndrome
2) Anterior cord syndrome
3) Brown-Sequard syndrome
4) Posterior cord syndrome
5) conus medullaris syndrome
6) cauda equina syndrome

Question 22

Central cord syndrome

Answer 22

is damage to the central spinal cord. It involves motor weakness and loss of sensory function and the symptoms are greater in the upper extremities.

Question 23

Anterior cord syndrome

Answer 23

is caused by damage to the anterior spinal cord artery and usually results from severe compression in flexion injury. In it, we see motor paralysis and a loss of temperature and pain sensations below the level of injury. Because the posterior nerve tracts are responsible for conduction of touch, position, vibration, and motion senses, these sensations are not affected.

Question 24

Brown-Sequard syndrome

Answer 24

is caused by damage to one half (left or right) of the spinal cord. With it, we see spastic paralysis (everything pulls together and locks up), loss of vibration and position senses, and vasomotor paralysis on the same side as the injury (ipsilateral). The contralateral side sees a loss of pain and temperature sensations.

Question 25

Posterior cord syndrome

Answer 25

results from compression or other damage to the posterior spinal artery. Touch, vibration, motion, and position senses are lost but pain, temperature, and motor function are unaffected.

Question 26

The conus medullaris syndrome and the cauda equina syndrome

Answer 26

occur due to damage in the lumbar portions of the spinal cord. They involve lumbar and sacral nerves and result in paralysis of the legs and a loss of bladder and bowel function.

Question 27

When we have a client with a recent SCI in clinical, the priorities are? (think ABCs)

Answer 27

1) Maintaining a patent airway.
2) Ensuring respiratory function.
3) Ensuring adequate circulating blood volume.
4) Preventing further cord damage.

Question 28

Damage at C4 or above can result in?

Answer 28

total loss of respiratory function and mechanical ventilation will be required to keep the patient alive.

Question 29

Damage at C4 or below can see the loss of most?

Answer 29

Breathing muscles. If the phrenic nerve remains intact, the client will exhibit diaphragmatic breathing. Because of the loss of the other breathing muscles, affecting lung volumes, diaphragmatic breathing usually involves hyperventilation.

Question 30

When abdominal and intercostal muscles are affected, such as with cervical and thoracic sc injuries, what happens?

Answer 30

Coughing becomes ineffective; the patient cannot cough out their lung secretions which leads to atelectasis and pneumonia. Neurogenic pulmonary edema can also occur.

Question 31

SC injuries at T5 or above cause?

Answer 31

impaired sympathetic nervous system function and bradycardia and peripheral vasodilation can occur. This vasodilation results in a state of relative hypovolemia. If bradycardia is severe enough <40bpm, drugs to increase the heart rate such as atropine (epinephrine) will be administered. If the relative hypovolemia results in low enough blood pressures, IV fluids to increase volume will be administered.

Question 32

atonic bladder

Answer 32

loss of muscle tone that compromises urinary elimination.

Question 33

What happens to the urinary system with a SC injury?

Answer 33

Spinal cord injuries can often initially result in an atonic bladder (loss of muscle tone) that compromises urinary elimination. Sometime later, in the post-acute period, the bladder can become hyperirritable resulting in reflex emptying. Indwelling catheters are frequently used in the acute phase, but, because of the risk of infection, intermittent catheterization is preferable once the client has stabilized and high-volume IV fluid supplementation is no longer required.

Question 34

What happens to the GI system with a SC injury?

Answer 34

When the sc injury is at T5 or above, GI problems are associated with gastric hypomotility. Paralytic ileus and gastric distension may occur. A nasogastric suction tube may be used to relieve this distension. Metoclopramide, an antiemetic, can be used to improve gastric emptying. Excessive HCl in the stomach can result in stress ulcers, which can be avoided with the use of medications such as Zantac and Pepcid. Intraabdominal bleeding can also occur, which is difficult to detect. Look for continued hypotension, decreased HGb and hematocrit, and expanding abdominal girth.
Bowel symptoms are much like the urinary symptoms. In the acute phase, the bowels are somewhat paralyzed. In the post- acute phase, they may become hyperirritable and result in reflex emptying.

Question 35

What happens to the Integumentary system with a SC injury?

Answer 35

Lack of movement d/t paralysis can result in pressure ulcers, especially over areas of bony prominence. Turning or rotation schedules must be implemented with extreme caution, if at all, because of the possibility of exacerbating the SCI.

Question 36

What happens to thermoregulation with a SC injury?

Answer 36

In the event of an SCI, afferent temperature sensory pathways may be impaired, preventing the brain from sensing the external environment. There may also be an impaired ability to temperature regulate by shivering or sweating. The result is poikilothermism, the adjustment of body temperature to room temperature. As with most things SCI, the level and degree of injury correspond to the impairment of the body’s thermoregulatory systems (higher=worse).

Question 37

What happens to metabolic needs with a SC injury?

Answer 37

If nasogastric suctioning is used, depletion of the body’s acid may result in metabolic alkalosis and electrolytes can be lost resulting in imbalances. Hypotension and hypovolemia may result in decreased tissue perfusion (=↑ CO2) and acidosis. The spinal cord injured patient’s metabolic needs usually increase significantly, despite their immobility, and can benefit from a high- protein, high-nitrogen diet.

Question 38

What are some peripheral vascular problems that come with a SC injury?

Answer 38

With immobility, there is a great risk of developing DVTs or VTEs and can result in a pulmonic embolus. This risk is greatest in the first three months following the traumatic event.

Question 39

XRays are used to determine?

Answer 39

the presence of damage.

Question 40

CTs are used to assess?

Answer 40

the specific location, degree, and stability of bony injury as well as soft and neural tissue changes.

Question 41

MRIs are used to?

Answer 41

assess changes in the event of neurological problems.

Question 42

Vertebral angiography (contrast dye imaging) is used in

Answer 42

cervical SCIs with altered mental status to rule out vertebral artery damage.

Question 43

After the injured person’s spine is stabilized at the scene of the injury, they are transferred into an acute care unit. Injuries involving T5 and above have systemic symptomology, such as?

Answer 43

bradycardia, hypotension, and respiratory compromise, and require more intensive care than lower injuries resulting in mainly losses of sensation and/or motor function.

Question 44

Muscle testing is done on the basis of?

Answer 44

Muscle groups; not individual muscles.

Question 45

Touch and pain sensation can be tested with?

Answer 45

pinpricking in various dermatomes.

Question 46

Touch and temperature sensation can be tested with?

Answer 46

Ice.

Question 47

Position and vibration senses can be tested if?

Answer 47

time and resources permit.

Question 48

Because, in the event of SCI, people often hit their head, the nurse should always asses?

Answer 48

bouts of unconsciousness, signs of concussion, and increased cranial pressures.

Question 49

Various internal organs may be assessed with specific procedures, what are they?

Answer 49

Are they voiding and eliminating? Is there gastric distension? Are there signs of internal bleeding such as expanding abdominal girth or presence of blood in urine or stool?

Question 50

Nonoperative treatments of the SCI involve?

Answer 50

stabilizing and decompressing the injured vertebral section. This reduces further secondary spinal cord injury by eliminating damaging movement at the site of the injury.

Question 51

Surgical interventions are mainly focused on?

Answer 51

stabilizing the spinal cord and relieving compression. Additionally, they are used to remove bony fragments from circulation and to repair penetrating injuries. Penetrating injuries are where the dura, the spinal cord “wrapping” gets punctured, such as with a knife or bullet wound.

Question 52

A laminectomy is?

Answer 52

a surgical procedure where the anterior or posterior portion of the injured vertebrae is removed to allow the surgical fusion and stabilization of the surrounding vertebrae. Fusion is performed using slices of bone, lengths of acrylic wire, and/or steel rods.

Question 53

Drug therapy using methylprednisone is used to?

Answer 53

prevent edema and inflammatory responses that contribute to spinal cord tissue ischemia. It is only effective if it is administered within 8 hours of the initial injury and is usually maintained for about 48 hours. The adverse effects of methylprednisone include immunosuppression and increased risk of infection as well as increased risk of GI bleeding.

Question 54

Vasopressor agents, such as dopamine, are used to?

Answer 54

offset the hypotension that occurs d/t sympathetic NS inhibition and peripheral vasodilation.

Question 55

Planning for nursing management of patients with SCI are focused on :

Answer 55

1) Maintaining an optimal level of neurological functioning.
2) Minimize or eliminate the complications of immobility.
3) Learn new skills, acquire new knowledge, and acquire new behaviours to care for self or direct others to.
4) Return to home and community at an optimal level of function.

Question 56

Nursing interventions for injury prevention include?

Answer 56

education and support of legislation regarding use of helmets, child safety seats, and increased penalties for drunk driving.

Question 57

After an SCI, nursing interventions should focus holistically on the person and include the usual:

Answer 57

1) Diet and exercise.
2) Smoking cessation.
3) Alcohol intake reduction.

Question 58

halo fixation device

Answer 58

In a stable injury where surgery was not performed, cervical stabilization and traction can be achieved with a halo fixation device. The halo device allows the client to be more active which promotes recovery.

Question 59

traction therapy

Answer 59

it is performed by attaching tongs or a sling to the head that are attached via cable to a force- inducing system. The duration of traction therapy, where traction is maintained at all times, is usually 1 to 4 weeks. When tongs are attached to the head via skull pins, there is the added risk of infection at those sites.

Question 60

kinetic therapy beds

Answer 60

slowly turn from side to side to constantly redistribute pressure and reduce the risk of developing pressure sores.

Question 61

Regular respiratory assessments should be performed, including:

Answer 61

1) Adventitious lung sounds.
2) Arterial blood gases.
3) Lung capacities (tidal and vital) 4) Skin color.
5) Breathing patterns (esp use of accessory muscles).
6) Subjective comments about the ability to breathe.
7) The volume and color of sputum.

Question 62

A client should be able to count out loud to ten in one breath. If they cannot, they require?

Answer 62

respiratory intervention.

Question 63

Respiratory interventions include?

Answer 63

1) Assisted coughing, a procedure where the nurse thrusts upwards against the bottom of the sternum, can help the client to mobilize lung secretions.
2) Tracheal suctioning may be indicated if crackles or wheezes are present.

Question 64

Interventions for cardiovascular instability.

Answer 64

1) medications
2) compression stalkings
3) administration of blood
* these depend on the patient*

Question 65

There are many reasons why an SCI client may become anorexic, such as:

Answer 65

1) Depression.
2) Boredom with hospital food.
3) Discomfort at being fed.

Question 66

Catabolism often occurs in the event of an SCI. What is it?

Answer 66

It is the body breaking down its own tissues for energy. Think “cannibal.” To offset catabolic effects, a high protein, high calorie, diet should be administered.

Question 67

Care should be taken to ensure a client’s adequate nutritional intake, such as:

Answer 67

1) Providing a pleasant eating environment.
2) Allowing ample time for eating.
3) Encouraging the family to bring in special foods.
4) Planning social rewards for dietary compliance.

Question 68

Acute interventions for bladder and bowel control.

Answer 68

Often, an indwelling catheter will be used in this period of SCI treatment. Once the post-acute phase has arrived, the indwelling catheter can be removed and intermittent catheterization begun. Intermittent catheterization should be performed every 3-4 hours to prevent urinary stasis and bacterial growth. The acute phase of bowel function insufficiency can be addressed with the liberal application of laxatives.

Question 69

Acute interventions for temperature control.

Answer 69

Because of vasodilation, loss of temperature sensation, lack of piloerection, and loss of shivering and sweating, the SCI client’s thermoregulation can be severely compromised. Their body will simply adjust to room temperature. This is called poikilothermism. Blankets should be used to retain their body heat and their temperature should be closely monitored.
SCI patients may also develop a fever and require cooling, such as with a cooling blanket.

Question 70

Acute interventions for stress ulcers.

Answer 70

Food should be given with the corticosteroids. Histamine H2 receptor blocker medications such as Pepcid or Zantac may be administered to offset the acidic damage to the stomach wall. Proton pump inhibitors, such as omeprazole or pantoprazole (note the –zole suffix) may be given prophylactically to decrease the stomach’s production of HCl.

Question 71

Acute interventions for sensory deprivation.

Answer 71

Because of the sensory impairment that often comes with an SCI, these clients should be stimulated otherwise to avoid their withdrawing from the environment. Music, television, reading, aromatherapy, and flavorful foods can help to prevent this from happening.

Question 72

Acute interventions for reflexes.

Answer 72

Once the spinal cord shock has resolved, the client’s reflexes often come back hyperexaggerated. They will often exhibit spastic movement ranging from twitches to convulsions that may require antispasmodic medications such as baclofen (Lioresal), dantrolene (Dantrium), and tizanidine (Zanaflex).

Question 73

Status epilicticus

Answer 73

is a state of nonstop convulsions that can accompany autonomic dysreflexia. Autonomic dysreflexia can also result in stroke, MI, and death.

Question 74

Autonomic dysreflexia

Answer 74

is a condition involving the autonomic (organs) nervous system and can occur in clients with sc injury at T6 or higher. It occurs as the client regains their reflexes as a response to visceral stimulation.

Question 75

AD occurs when?

Answer 75

the visceral stimulation, all the organs below the level of the sc lesion reflexively constrict. This causes blood pressure to spike and baroreceptors in the aortic arch and carotid sinus respond by lowering the heart rate. Because of the lack of ability to peripherally vasodilate, however, BP does not decrease.

Question 76

AD can be detected by?

Answer 76

Close BP monitoring. Client’s complaining of a headache should be very closely monitored.

Question 77

When AD occurs, the client’s head should be?

Answer 77

elevated to 45 degrees or sitting upright

Question 78

neurogenic bladder

Answer 78

is any type of bladder dysfunction related to absent or abnormal enervation. Neurogenic bladders may see decreased or increased detrusor function or a lack of coordination with detrusor constriction and urethral relaxation. Urinary retention or incontinence may result.

Question 79

Seizures

Answer 79

are events sudden, uncontrolled, intense electrical discharge from neurons in the brain that interrupt normal function
and lead to involuntary contractions of muscle groups. They are often symptoms of other, underlying illness.

Question 80

Epilepsy

Answer 80

is a condition in which a person has at least two spontaneous seizures more than 24 hours apart. It is caused by a chronic underlying pathology.

Question 81

The most common causes of seizures during the first six months of life:

Answer 81

1) Birth Injury
2) Congenital Defects
3) Infections
4) Metabolic Problems

Question 82

The most common causes of seizures between 2-20 yrs:

Answer 82

1) Birth Injury
2) Infection
3) Trauma
4) Genetic Factors

Question 83

The most common causes of seizures between 20-30 yrs:

Answer 83

1) Structural Lesions i.e. Trauma, Brain Tumors, or Vascular Disease

Question 84

The most common causes of seizures after 50 yrs:

Answer 84

1) Cerebrovascular Lesions

2) Metastatic Brain Tumors

Question 85

Idiopathic seizure

Answer 85

causes remain unknown

Question 86

generalized seizure

Answer 86

when the whole brain is involved

Question 87

astrocytes

Answer 87

CNS “maintenance” cells

Question 88

What do astrocytes do?

Answer 88

release glutamate, which triggers neurons to fire. With this knowledge, medication to control epilepsy is now focusing on reducing astrocyte’s production of glutamate, their signaling mechanism.

Question 89

Depending on the type of seizure, they may be up to four phases involved:

Answer 89

1) Prodromal Phase
2) Aural Phase
3) Ictal Phase
4) Postictal Phase

Question 90

Prodromal Phase

Answer 90

This is the phase before the seizure that may include signs or activity indicative of the coming event.

Question 91

Aural Phase

Answer 91

This also occurs before the seizure and is identifiable by the sensory disturbances that accompany it.

Question 92

Ictal Phase

Answer 92

This is the convulsive phase of the seizure

Question 93

Postictal Phase

Answer 93

This is the recovery period following the seizure.

Question 94

Tonic-clonic seizures

Answer 94

are the most common generalized seizure. The person will lose consciousness, fall to the ground, and their body will stiffen (tonic phase) for 10-20 seconds followed by 30-40 seconds of jerking the extremities (clonic phase). In the postictal phase, the client will have muscle soreness and likely need to sleep. Cyanosis, excessive salivation, tongue or cheek biting, and incontinence may accompany this type of seizure. Both tonic and clonic seizures may occur independently; they don’t necessarily always happen together.

Question 95

Typical absence seizures

Answer 95

usually only occur in children and rarely continue beyond adolescence. It begins as a brief staring spell followed by an extremely brief loss of consciousness. When untreated, these seizures may occur up to 100 times a day. Children with these types of seizures are often misdiagnosed as having attention deficit disorders. Hyperventilation and flashing lights may precipitate absence seizures.

Question 96

Atypical absence seizures

Answer 96

begin as a brief staring spell but do not necessarily progress to unconsciousness. Instead, there may be other signs and symptoms such as peculiar behaviour during the seizure and confusion afterwards. ** Atypical absence seizures may have warning signs that appear before the staring spell begins.

Question 97

Myoclonic seizure

Answer 97

A sudden jerk of the body or the extremities. It is basically a massive twitch.

Question 98

Atonic seizure

Answer 98

When someone suddenly drops to the ground. It may be precipitated by a tonic period. Consciousness usually returns by the time the person hits the ground. These people are generally good to go after the event but are at risk of head injury and sometimes wear helmets.

Question 99

Partial seizures are divided into two categories:

Answer 99

simple and complex

Question 100

When a seizure occurs, the nurse should observe and record all details, including:

Answer 100

1) What events precipitated the seizure?
2) When did the seizure occur?
3) How long did each phase (of the four) last?
4) What occurred during each phase? (tongue-biting, loss of consciousness, stiffening, jerking, etc.)

Question 101

Simple partial seizures

Answer 101

do not involve loss of consciousness and rarely last for more than 1 minute. They may involve motor, autonomic, or sensory phenomena or a combination of them.

Question 102

Complex partial seizures

Answer 102

can involve behavioural, cognitive, emotional, and/or affective symptomology, and usually originate from a temporal lobe focal point (aka temporal lobe seizure). They usually last for more than one minute and are frequently followed by a period of postictal confusion. The primary distinction between complex and partial seizures is the involvement of changes in consciousness (in complex ones). Complex partial seizures often involve lip-smacking or other repetitive, inappropriate movements (automatisms) like pill-rolling. Often, the person undergoing a complex partial seizure will continue with whatever activity they were previously involved in but, after the seizure, will have no recollection of events that occurred in the seizure period. Auditory and visual hallucinations may occur, and the person may experience déjà vu. Some people will experience heightened or depressed sexual impulses (or erectile dysfunction) following a seizure of this type.

Question 103

Psychosocial complications

Answer 103

of seizure disorders include the stigma of loss of control or independence. People with these medical problems may be discriminated against in finding employment and may be prohibited from driving. In Canada, driving prohibition varies by province and ranges from 3 months (BC) to a year (AB). Many (42%) of seizure patients will experience depression. For those that do, depressive symptoms may be relieved by treating the seizure disorder and preventing seizures from recurring.

Question 104

Most seizures do not require emergent medical care, with the exception of:

Answer 104

1) First-time seizures.

2) Treatment for injury incurred during seizure.
3) Status epilepticus.