Mobility: Spinal cord injuries & guillain Barre syndrome Flashcards
1
Q
- Abnormal response to pain
- Extension or arms look like “E’s”
- Indicates problems with midbran or pons
A
Decerebrate posturing
2
Q
Types of spinal cord damage
A
- Contusion
- Laceration
- Transetion
- Vascular injury
3
Q
What type of Spinal cord injury is this?
- Some function preserved below primary injury
- Central cord syndrome
- Anterior cord syndrome
- Posterior cord syndrome
- Brown-sequard syndrome
A
Incomplete spinal cord injury
4
Q
Means same side of injury
A
Ipsilateral
5
Q
Head excessively turned, may tear ligaments, fracture articular surfaces, and cause compression fractures
Mechaism of injury for the spinal cord
A
Excessive rotaion
6
Q
Components of reflexes &sensory exam
A
- Gag, cough, and swallow
- Blink, corneal
- Assess DTR
- Stereognosis
- 2-point discrimination
- Paresthesia
- Response to pain
- Proprioception
7
Q
The ability to identify objects with eyes closed and sense of touch only
A
Stereognosis
8
Q
Surgical management for spinal cord injuries
A
- Decompression laminectomies
- Spinal fusion
9
Q
- Hyper response to stimulus that occurs after spinal shock has resolved, in T6 or higher SCI
- Stimulus could be pain, full bladder or bowel, broken bone, rapid temp. change, infection, DVT, pressure injury
- S/S: HTN, severe HA, nasal congestion, bradycardia, diaphoresis, nausea, impending doom, flushed warm skin above injury, pale/dry skin below injury, chills
A
Autonomic Dysreflexia
10
Q
Surgery used to treat a spinal cord injury that utilizes bone graft or insert rods
A
Spinal fusion
11
Q
Spinal cord injury that is a bruise
A
contusion
12
Q
- Autoimmune attack on peripheral nerve myelin
- Often triggered by a recent infection (2/3): Campylobacter jejuni, cytomegalovirus, Haemophilus influenzae, Zika virus, etc.
- S/S: Motor weakness, numbness, tingling, decresed/absend DTR, ascending or flaccid paralysis from lower extremities over several days
A
Guillain-Barre Syndrome (GBS)
13
Q
If Autonomic dysreflexia is not identified and treated what could it lead to?
A
- HTN stroke
- pulmonary edema
- MI
- cerebral hemorrhage
- death
14
Q
Treatment of neurogenic & spinal shock
A
- Maintain airway and immobilization
- Fluid replacement to increase BP
- Vasopressors to constrict blood volume to increase BP and HR
- Control of the environmental temperature to keep them warm
- Atropine may be used to increase HR
- Inotropic agents
15
Q
- Hemisection of spinal cord from penetrating injury or primary ischemia, infection, or hemorrhagic event
Clinical Manifestations: - Ipsilateral (same side of injury) loss of motor function, proprioception, and vibration
- Contralateral (opposite side of injury) loss of pain and temperature
A
Brown-Sequard syndrome
16
Q
- Cervical immobilization for cervical fractures
- Utilizes cranial pins and a device that encircles the head
A
Halo traction
17
Q
Interventions for Autonomic Dysreflexia
A
- Monitor BP close
- Elevate HOB
- Remove restrictive clothing
- Check bladder and bowel
- Check for skin breakdown
- Admin antihypertensive
18
Q
S/S of Guillain-Barre Syndrome
A
- Motor weakness
- Numbness
- Tingling
- Decreased/absent DTR or Areflexia
- Ascending flaccid paralysis from lower extremities over several days
19
Q
Surgical treatment for a spinal cord injury that removes laminae to allow for cord swelling
A
Decompression laminectomies
20
Q
Neurogenic shock is the only type of shock with ____________.
A
Bradycardia
21
Q
Ways to test responses to pain
A
- Sternal rub
- Nailbed pressure
22
Q
- Most common from hyperextension with central swelling
- Functional motor loss greater in arms than legs
- Bladder dysfunction
- Variable loss of sensation
A
Central cord syndrome
23
Q
GCS score that indicates a poor prognosis
A
< 8
24
Q
The following are S/S of what?
- Motor weakness
- Numbness
- Tingling
- Decreased/absent DTR or Areflexia
- Ascending flaccid paralysis from lower extremities over several days
A
Guillain-Barre Syndrome
25
Normal GCS
15
26
Pertinant social hx for a neuro exam
* Alcohol
* meds
* Illicit drugs
27
Complications to monitor for in a spinal cord injury patient
* PNA
* Chronic pain
* Spasticity
* Muscle loss
* Skin breakdown
* Paralytic ileus
* Sexual dysfunction
* Mental health issues - depression & anxiety
28
Injury that cuts through cord
transection
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The sense of self-movement, force, and body position
Proprioception
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Components of a neuro exam
* Health history
* Social history
* GCS
* Test cranial nerves
* Motor testing-strength, movement
* Reflexes
* Sensory testing (Tactile and painful responses)
* VS
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U-shaped for spinal traction with pressure controlled pins on opposite ends of skull
Gardner-wells tongs
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Who is most at risk for a spinal cord injury?
Men age 16-18
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What needs to be done immediately for a patient with a suspected cervical spine injury
Spine immobilized with cervical collar and backboard to prevent further damage
35
Spinal cord injury that is a partial cut
laceration
36
An injury at C8-T12 is considered what type of spinal cord injury
Thoracic injury
37
An injury at S1-S5 Is considered what type of injury?
Sacral injury
38
An injury at C1-C7 is considered what type of injury?
Cervical spine injury
39
Means opposite side of injury
Contralateral
40
PmHx that is pertinant for a neuro exam
* Pain
* Headache
* Seizures
* Dizziness
* Visual issues
* weakness
* abnormal sensation
41
Fusions result in decreased what?
ROM in the affected area
42
Mechanisms of injury for the spinal cord
* Hyperflexion
* Hyperextension
* Whiplash
* Axial loading
* Excessive rotation
43
Caused by chin hitting a surface area, such as dashboard/bathtub, usually causes central cord syndrome S&S
| Mechanism of injury for the spinal cord
Hyperextension
44
Quadriplegia and Tetraplegia is causedby what type of spinal injury
Cervical spine injury
45
Paraplegia is caused by what type of spinal cord injury
Thoracic or lumbar injury
46
# What type of spinal cord injury is this?
* Irrerersible
* Loss of sensory, motor, and autonomic funtion below the level of injury
Complete spinal cord injury
47
Diagnostic tests expected for someone with a suspected cervical spine injury
* Neuro exam
* X-ray
* CT scan
* MRI
* UA
* H&H/CBC
* ABG
*
48
Nursing interventions for spinal cord injury
* Maintain suction equipment at bedside
* Teach coughing and deep breathing
* Maintain spinal immobilization and stabilization
* Passive ROM to prevent contractures, loss of muscle tone, and DVT
* Repositioning q2h
* Performing routine pin site care
* Teaching S&S of respiratory distress and autonomic dysreflexia
* Teaching proper skin care and repositioning when using wheelchair
49
most common natural protective position, can cause neck to be unstable because stretching of ligaments
| Mechanism of injury for the spinal cord
Hyperflexion
50
Spinal cord injury that causes altered perfusion to the cord
Vascular injury
51
* Abnormal response to pain
* Flexion response to pain or arms move inwards like "C's"
* Indicates problems with spinal tract or cerebral hemisphere
Decorticate posturing
| "Think arms move towards the cord"
52
* Anterior compression from bony fragments or acute disk herniation
* Loss of function, pain, temparature, crude touch & pressure below injury
* Preserved proprioception, fine touch/pressure, and vibration
Anterior cord syndrome
53
# The following are S/S of what?
* HTN
* Severe headache
* Nasal congestion
* bradycardia
* Nausea
* Impending doom
* Flushed warm skin above injury
* pale dry skin below injury
* Chills
Autonomic Dysreflexia
54
An injury at L1-L5 is considered what type of injury?
Lumbar injury
55
Medications used to treat spinal cord injuries
* Lovenox/Enoxaparin/heparin for DVT prevention
* Gabapentin for neuropathic pain
* Opioids, non-opioids, and NSAIDs for pain
* Baclofen to reduce spasticity
* Atropine for bradycardia
* Vasopressors
56
S/S of autonomic dysreflexia
* HTN
* Severe headache
* Nasal congestion
* bradycardia
* Nausea
* Impending doom
* Flushed warm skin above injury
* pale dry skin below injury
* Chills
57
C3-C4 spinal cord injury can cause a patient to be what? Why?
Ventilator dependednt d/t loss of intercation of the diaphragm
58
Lumbar and sacral injuries cause what?
Decreased control of legs, bowel, bladder, and sexual dysfuntion
59
2-point discrimination test
Identifying between dull and sharp objects
60
Tests that will help idenify any internal bleeding for a patient with a spine injury
* UA
* CBC/H&H
* ABG
61
* Acute compression
* Loss of perception, fine touch/pressure, and vibration
* Intact pain, temp, and crude touch and pressure
Posterior cord Syndrome
62
What are the three stages of GBS
* Acute
* Plateau
* Recovery
63
# What stage of GBS is this?
Onset of clinical manifestations, edema, and inflammation, lasting 4 weeks
Acute stage
64
# What stage of GBS is this?
When demyelination ceases, lasts few days to weeks
Plateau stage
65
# What stage of GBS is this?
Remyelination and axonal regeneration begin and gradual improvement in S&S
Recovery stage
66
How to dx GBS
* PmHx
* Thorough exam
* Lumbar puncture
* Electromyography (EMG)
67
If someone has GBS what would a electromyography (EMG) show?
Slowed nerve conduction
68
If someone has GBS what would a lumbar puncture show?
elevated protein and normal cell count
69
Treatment for GBS
* Plasmaphersis & IVIG
* Monitor respiratory function and tidal volume compacity
* Can require mechanical ventilation
* Nutritional support and enternal feedings
70
If GBS progresses to diaphragm paralysis what will be needed?
Mechanical ventilation
71
If someone with GBS is experiencing dysphagia or if the cranial nerves are affected what will be required?
Nutritional support and enternal feedings
72
What can be given to GBS patients to decrease antibodies?
Plasmapheresis and IVIG
73
Complications of GBS
* Respiratory arrest
* Complications of imobility (DVT, Pressure injuries
74
Nursing care for patient with GBS
* Respiratory assessment with vital capacity
* Cranial nerve assessment (facial expression, speech, gag, swallow)
* Motor and sensory assessment
* Pain assessment
* Frequent turning and ROM
* VTE prevention (heparin, SCDs)
* Establish method of communication (Ex: soft call bell)
* Teach patient and family about each stage of GBS
75
The client with a C6 spinal cord injury is admitted to the ED complaining of a severe, pounding headache and has a BP of 180/110. Which intervention should the nurse implement?
A. Keep the client flat in bed.
B. Administer a narcotic analgesic.
C. Assess for bladder distention.
D. Monitor vital signs.
C. Assess for bladder distention
76
The nurse provides care for a client placed in a halo brace in the last 24 hours because of a spinal cord injury. Which of the following is the first priority of the nurse?
A. Loosen the connections on the vest to assess the skin.
B. Assess the pin sites.
C. Evaluate if the client is able to reposition self in bed.
D. Encourage active ROM exercises to lower extremities.
B. Assess the pin sites
77
Which clinical manifestation would the nurse assess for a client with a T12 spinal cord injury who is experiencing spinal shock?
A. Flaccid paralysis below the waist.
B. Inability to move upper extremities.
C. Complaints of a pounding headache.
D. Hypotension and tachycardia.
A. Flaccid paralysis below the waist
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