NURS 444 week 10 Flashcards
Cervical injury
- anterior cord syndrome
- posterior cord lesion
- brown- sequard syndrome
- central cord syndrome
*the higher the injury, the most severe the consequence
Initial Assessment
- assessment of respiratory pattern and ensuring adequate airway
- assess for indications of intraabdominal hemorrhage or hemorrhage around fracture site
- assess GCS
- establishment of level of injury; tetraplegia, quadraplegia, quadriparesis, paraplegia, paraparesis
Spinal Shock
> flaccid paralysis
loss of reflex activity below the level of lesion
bradycardia
paralytic ileus
hypotension
Cardiovascular assessment
- due to disruption of the ANS
- bradycardia, hypotension, and hypothermia result from a loss of sympathetic input.
Can lead to dysrhythmias - systolic bp <90. needs tx because loss of perfusion to spinal cord makes it worse
Autonomic dysreflexia
stimulates SNS, life-threatening
- commonly in upper spinal cord injuries
- severe hypertension
- bradycardia
- severe headache
- nasal stuffiness
- flushing
- treatment
- blurred vision
assessment for spinal cord injury
> resp assessment
GI and GU
musculoskeletal
psychosocial assessment
labs
CT or x-ray
Interventions for autonomic dysreflexia
SIT PATIENT UP! elevate HOB to 40 degrees
find underlying cause like bladder distention
notify
loosen clothing
give nitro or hydralazine (antihypertensive)
maintain bowel function- dis-impact if necessary
ineffective tissue perfusion interventions
> reduction and immobilization of the fracture to prevent further damage to spinal cord from bone fragments
> traction and external fixation but surgery may be necessary
immobilization for Cervical injuries
- fixed skeletal traction to realign, facilitate bone healing and prevent further injury
- halo fixation and cervical tongs
- stryker frame, totational bed, kinetic tx table
- pin site care and monitoring of ropes
immobilization of thoracic and lumbosacral injuries
^ for thoracic injuries: bedrest and possible immobilization with a fiberglass or plastic body cast
^ lumbar and sacral injuries: immobilization of spine with a brace or corset worn when the client is out of bed; custom-fit thoracic lumbar sacral orthoses preferred
Drug therapy for spinal injuries
+ dantrolene
+ 4-AP potassium channel b.
+ baclofen
+ etidronate disodium
+ dextran
+ atropine sulfate
+ dopamine hydrochloride
+ naloxone and TRH
+ sygen
+ methylprednisone (contraversial)
Airway/ Breathing interventions for spinal cord injuries
- Airway management is priority.
- injuries at or above t-6 are at high risk for resp. complications
- assisted coughing, quad cough (help bring up secretions), cough assist
- use of incentive spirometer
Interventions: Impaired physical mobility; Self-care deficit
< spinal cord injuries: monitor for risk of pressure ulcers, contractures, and DVT/ pulm. emboli
< proper positioning, skin inspection, ROM exercises, heparin, and graduated compression stockings
< prevent orthostatic hypotension
< promote self-care
Interventions; Impaired Urinary Elimination: Constipation
~ a bladder retraining problem
~ spastic bladder: manipulating external area
~ flaccid bladder: valsava maneuver
~ encourage consuption of 2000- 2500 mL of fluid daily to prevent UTI
~ long-term renal comp.
~ s&s of UTI not perceived by client
Establishing a Bowel retraining program
- consistent time w/ bowel elimination
- high fluid intake: at least 2000mL/day
- high fiber diet
- rectal stimulation
- stool softeners PRN
Interventions: impaired adjustments
> invite clients to ask questions about life changes: reply openly and honestly
encourage clients their perceptions and coping strategies options
education to clarify misconceptions
Myasthenia Gravis
^ autoimmune of neuromuscular junction
^ characterized by fluctuating weakness
^ 14 cases per 100,000 in US
^ most common- ages 10 and 65, peak between 20-30
^ 3x more common in women
^ weakness primarily in muscles innervated by cranial nerves, skeletal, resp.
^ Thynoma- encapsulated thymus gland
^ antibodies that attack ACh receptors found in blood 80-90% of clients. excessive thyroid hormone also found
^ progressive and partially resolved by rest
Most common MG symptoms
- involvement of eye muscles; ocular palsies, ptosis, diplopia, weak or incomplete eye closure
Myasthenia Crisis
exacerbation of symptoms caused by undermedication with anticholinesterase
Cholinergic Crisis (in MG)
acute exacerbation of muscle weakness caused by overmedication of cholinergic (anticholinesterase) drugs
Myasthenia Gravis Crisis s&s
!! resp. distress
!! increased pulse and BP
!! poor cough
!! secretion aspiration
!! dysphagia
!! weakness
!! improve w/ edrophonium (tensilon test)
Cholinergic crisis s&s
!! ABD. CRAMPS
!! DIARRHEA
!! N&V
!! EXCESSIVE SECRETIONS
!! MIOSIS
!! fasciculations
!! weakness
!! worse w/ edrophonium (tensilon test)
First interventions in MG crisis
- Tension test
- PRIORITY: maintain adequate resp. function
- cholinesterase inhibiting drugs are withheld because they increase resp. secretions and are usually ineffective for the first few days after the crisis begins.
Tensilon Testing
within 30 to 60 sec. after injection of Tensilon, most myasthenic clients show marked improvement in muscle tone that lasts 4 to 5 minutes.
- prostaglandin is also used
- cholinergic crisis is due to overmedication
- MG crisis is due to undermedication
- atropine sulfate if the antidote for Tensilon complications
Tensilon
cholinesterase inhibitor to allow more acetylcholine to reach receptor sites
Cholinergic Emergency Crisis: interventions
+ anticholinergic drugs are withheld while the client is maintained on a vent.
+ atropine may be given and repeated, if necessary
+ observe for thickened secretions due to drugs
+ improvement is usually rapid after appropriate drugs
Atropine
given if patient worsens with Tensilon test
Cholinergic crisis management
- immunosuppression
- plasmapheresis
- resp. support
- promoting self-care guidelines
- assisting w/ communication
- nutritional support
- eye protection: inability to close eyes, fake tears in day and lub at night
- surgical management (thymectomy)
- small frequent high-calorie meals
Plasmapheresis
removes circulating antibodies.
- plasma selectively separated from whole blood; blood cells are returned to the client without plasma
- plasma usually replaces itself. If not, then client is transfused w/ albumin
Education for Myasthenia G.
< exacerbations include; stress, infection, surgery, hard physical exercise, sedatives, enemas, and strong cathartics (laxative)
< avoid overheating, crowds, overeating, erratic changes in sleeping patterns, emotional extremes
< teach warning signs
< importance of compliance
MS
- autoimmune
- Destruction of myelin sheath of CNS
- between 20-40
- > 2x more likely in whites
- women 2x more than men
Major type of MS
- relapsing-remitting
- progressive- relapsing
- primary progressive
- secondary progressive
Common physical assessment findings
> flexor spasms at night
intention tremor
dysmetria
blurred vision, diplopia, decreased visual acuity, scotomas, nystagmus
hypalgesia, numbness, tingling or burning
bowel and bladder dysfunction
Drug Therapy MS
+ biological response modifiers
+ immunosuppressives
+ steroids
+ antispasmodic drugs
+ adjunctive
MS management
promoting mobility and self-care
managing cognitive probs
adapting to changes in sexual functioning
managing bladder & bowel
treating visual disturbances
complementary and alt. therapies
causes of seizures
_ drugs/ toxins
_ trauma
_ infection
_ lesions
_ fever
_ metabolic alterations
_ extra-cranial disorders
_ genetics
_ idiopathic (75% of seizures)
three major classes of seizure onset
- generalized onset
- focal onset
- unknown onset
Seizure phases
Prodromal phase- can occur a week before. Trigger
Aural phase- sensory warning
Ictal phase- onset of symptom to end
Postictal phase- recovery phase
Generalized onset seizure
both hemispheres involved
Motor;
- tonic: sudden stiffness arms, trunk or legs
- clonic: repeated jerking of arms, legs
- tonic-clonic
- myoclonic: jerking of muscle or muscle group
- atonic: muscles become limp
Focal Onset
1 hemisphere
-awareness
-impaired awareness
-motor
-non-motor
non-motor seizure
Absence:
typical
atypical
myoclonic
non-motor: Absence
Typical absence:
usually in children, brief starry spell that lasts <10 sec
Atypical absence seizures:
starring spells w other manifestations
- eye blinking
- jerking movements of lips
- lasts >10 sec
- usually continue into adulthood.
***more dangerous because not aware of them, can occur 100x/ day and glucose consumption is greater»_space;> hypoxemia, hypoglycemia
Atonic & myoclonic
Atonic (motor)
- “drop” attack
- typically < 15 sec
Myoclonic (motor/ non)
- rhythmic arm abduction (3 ratcheting movements per sec.) leading to progressive arm elevation
- usually 10-60 sec
- eyelid myoclonia- jerking of eyelids
Focal-onset seizures
Described by level of awareness
- focal awareness seizure: conscious and alert
- focal impaired awareness seizures: loss of consciousness or awareness: eyes open but no interaction
Status Epilepticus
- emergency
- can occur with any type of seizure
- neuron can seize to function due to exhaustion > permanent brain damage risk
- continuous seizure or recurrence of seizures w/o return to consciousness
Convulsive status epilepticus
*most common form
- can lead to fatal resp. insufficiency, hypoxemia, dysrhythmias, hyperthermia, systemic acidosis (not breathing)
nonconvulsive status epilepticus
long or repeated focal impaired awareness seizures
Refractory status epilepticus (RSE)
continuous seizure activity despite administration of first and second line therapy
Sudden unexplained death in epilepsy (SUDEP)
higher in men and people without medication therapy with seizure disorder
Nurse’s role in status epilepticus
- protect head
- ease patient to the floor
- maintain patent airway
- turn to the side
- loosen constrictive clothing
- initially; rapid-acting lorazepam (Ativan), diazepam (Valium)
- assess and record details
- give oxygen, glucose, D50
Psychosocial complications in seizure disorders
** effects on lifestyle is most common
** suicide risk higher (r/t tx drugs?)
Diagnostics for seizure disorders
+ accurate health hx
+ blood work (liver&kidney, CBC, serum chems), urine: to rule out metabolic
+ EEG
+ CT or MRI
+ cerebral angiography, SPECT, MRS, MRA, and PET (certain situations)
+
Goal for seizure disorder caare
minimize seizures with little or no drug effects
Drug Therapy in seizures
Aimed at prevention
- stabilize nerve cell membranes and prevent spread
- 70% patients controlled with meds.
- monitor drug serum levels
Seizure drug SE
many have long half-life: may be given 1-2 x/day
!! idiplopia
!! drowsiness
!! ataxia
!! mental slowness
What a nurse should assess regarding anti-seizure drugs
Teach not to discontinue abruptly
- a simplified drug regimen helps with compliance
assess:
- nystagmus
- hand & gait coordination
- cog. functioning
- mental awareness
unusual SE for anti-seizure drugs
- rashes
- gingival hyperplasia (Dilantin)
- blood dyscrasias
- hisituism (women grow hair in unusual areas)
- renal/ hepatic toxicity
3 requirements for surgery (seizures)
1) confirmed seizure disorder diagnosis
2) trial and failure of drug therapy
3) defined electroclinical syndrome
Surgery (seizures)
+ anterior temporal lobe resection
+ may remove cortex
+ separate two hemispheres (corpus colostomy)
-about 80% seizure-free in 5 years
- about 72% seizure-free in 10 yrs
- not all seizure types benefit
Vagal Nerve Stimulation
(seizure interventions)
other adjunct to drugs when foci is not accessible
- may increase blood flow
- may raise levels of neurotransmitters
Responsive stimulation
(seizure interventions)
continually monitors EEG to detect abnormalities, then responds to seizure activity by delivering electrical stimulation to exact point
- similar to cardiac pacemaker
- neuropace RNS system
Nursing Assessment: Objective
> Tonic-clonic;
` loss of consciousness, muscle tightening, then jerkingdilated pupils, hyperventilation then apnea
postictal somnolence
> Focal (aware);
` aura
`sensory, motor, cognitive phenomena
> Focal: impaired awareness;
` altered consciousness w/ inappropriate behaviors, automatism, amnesia of event
