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
