Nursing Spinal Patients Flashcards
Why do we carry out neurological exams?
Identify if NS involvement
Identify localisation
Aid diagnosis and prognosis
Continuous assessment of condition/progression
Where can we localise neurological signs to?
Brain
Spinal cord
Peripheral nerves
Neuromuscular
What are the main parts of a neuro exam?
Hands off - mentation, gait and posture
Hands on - postural reactions, spinal reflexes, cranial nerves, sensory evaluation, palpation
Define some postural abnormalities.
Head tilt = one ear below the other
Head turn = nose turned towards body
Ventroflexion of neck = low head carriage
Scoliosis (to the side) / lordosis (curved upwards) / kyphosis (curved downwards)
Decerebrate rigidity = extension of all limbs, head and neck
Decerebellate rigidity = extension of thoracic limbs, head and neck
Wide-based stance
What postural reaction tests can we carry out?
Proprioceptive positioning
Hopping
Visual placing
Tactile placing
Hemi-walking
Wheelbarrowing
Describe lower motor neurons and their clinical signs.
Connect CNS to effector organ (muscle) and send signal to make them contract
Existing reflexes are weaker or absent
Muscle tone reduces
Muscle mass decreased rapidly and severely
Flaccid paresis/paralysis, reduced or absent reflexes, reduced or absent muscle tone, muscle atrophy
Describe upper motor neurons and their clinical signs.
Located between cerebral cortex and spinal cord, send signals to LMNs
Existing reflexes are stronger and easier to elicit
Some normally inhibited reflexes become apparent
Muscle tone increases
Loss of motor function, paresis/paralysis, normal/increased reflexes, increased extensor muscle tone, chronic muscle atrophy
What spinal reflexes can we test?
Thoracic limbs - withdrawal reflex / extensor carpi radialis reflex / biceps brachii and triceps reflex
Pelvic limbs - patella reflex / cranial tibial and gastrocnemius
Perineal reflex
Panniculus reflex
Describe the cutaneous trunci reflex test.
Tests lateral thoracic nerve, segmental nerve and spinal cord cranial to segmental nerve up to T1
Used to monitor if localisation of spinal lesion changes post-op
How can we test for deep pain sensation?
Pinching/pressure applied to digits on each limb
Look for reaction e.g. turning, vocalising, trying to bite
What cranial nerve tests can we carry out?
Menace response
Palpebral reflex
Pupillary light reflex
Gag reflex
Oculocephalic reflex
Nystagmus
Define miosis.
Constricted pupils
Define mydriasis.
Dilated pupils
Define anisocoria.
Asymmetric pupil size
How can pupil size indicate prognosis of neuro patients?
If pupil goes from miotic to mydriatic - neurologically deteriorating
Mid-size fixed pupils unresponsive to light - grave prognosis
How and why do we grade spinal cord injuries?
Grade 1-5
Allows objective assessment and monitoring of progression
Allows for more accurate prognosis
Define grade 1 spinal injury.
Pain only - no neurological deficits
Walking normally
Define grade 2 spinal injury.
Walking but with neurological deficits, causing weakness/incoordination in both pelvic limbs
Ambulatory paraparesis
Define grade 3 spinal injury.
Not able to walk without assistance but has good movement in pelvic limbs
Non-ambulatory paraparesis
Define grade 4 spinal injury.
No voluntary movement in pelvic limbs but can feel toes
Paraplegia with intact nociception (deep pain positive)
Define grade 5 spinal injury.
No voluntary movement in pelvic limbs and lack of feeling in toes
Paraplegic without nociception (deep pain negative)
What important considerations should we have for neuro patients?
Owner expectations and ability to provide care at home
Ambulatory vs non-ambulatory
Surgical vs non-surgical
Continent vs incontinent
Temperament
Recumbency
Normal routine
What common complications can we see with spinal patients?
Decrease motor activity
Pressure sores
Urine/faecal scalding
Wound breakdown
Insufficient analgesia
Respiratory complications
Why is physiotherapy important?
Improves local/whole body circulation
Help to reduce pain
Bond between nurse and patient
Prevent pressure sores
Aid motor recovery
How can physiotherapy aid recovery?
Maintain joint health
Limit muscle wastage
Help prevent contracture
Motor - relearning movements
Sensory - stimulating proprioceptive relearning and retrain gait
What physiotherapy techniques can we offer?
Massage
PROM
Assisted exercises
Active exercises
Proprioceptive exercises
Neuromuscular e-stim
Hot/cold therapy
Hydrotherapy
Laser therapy
How does massage aid recovery?
Helps to calm patient and get used to being handled
Improves local/whole body circulation
Mobilises dermal/subdermal tissues
Warms muscles/tissues
How does PROM aid recovery?
Put each joint through normal range of motion
Improve joint health without active muscle contraction
What assisted exercises can we carry out?
Assisted standing/walking
Assisted sit-stand
Three-legged standing
Weight-shifting
What active exercises can we carry out?
Walking - straight line, circles, figure-of-8, incline
Sit-stand
Sit-down
Hydrotherapy
What proprioceptive exercises can we carry out?
Standing
Wobble board
Uneven surface
Over poles
Weaving
Different surfaces
Describe neuromuscular e-stim.
Sustained muscle contraction using dermal electrodes over muscles
Increases tissue perfusion
Can help to slow neurogenic muscle atrophy
What considerations should we have for physiotherapy candidates?
Previous injuries/surgeries
Client expectations and limitations - time/expertise
Disease process
Neurolocalisation
Temperament
Describe an upper motor neuron bladder.
Distended, difficult to express
Describe a lower motor neuron bladder.
Distended, easy to express
What bladder complications can we see if not managed appropriately?
UTIs due to static urine in bladder
Bladder atony and pyelonephritis
Distension of bladder/ureter leading to pain
Overflow incontinence
Describe overflow incontinence.
Patient unaware their bladder is full
Fills until overflowing, patient leaks urine onto skin, leads to urine scalding
Also high risk for UTIs
How can we manage bladders?
Manual expression 3-4x daily
Intermittent aseptic catheterisation 2x daily
Indwelling catheterisation with closed connection system
Drug therapy
What considerations should we have for bowel management of neurological patients?
Do not normally have issues passing issues as is initiated by stretch of the rectal wall
Upper motor neuron injury patients can have an overactive reflex, meaning small amount of distension can initiate defecation
Cannot move away so must keep beds clean, check for faecal scalding, take outside regularly
How can we prevent pressure sores from developing?
Thick padded bedding, checked regularly
Turn every 2-4 hours
Donut bandages on elbows and hocks
Pat dry after bathing
Inco sheets
Physiotherapy - promotes circulation and movement
Monitor closely
Express bladder/indwelling catheter
How can we treat pressure sores if they occur?
Keep clean and dry
Debride if necessary
Antibiotics if indicated
Bandaging
Why are seromas more of a risk in hemilaminectomy patients than ventral slot patients?
More skin movement
Separation of layers of tissues and over midline
How can we use cold therapy for wound management post-op?
Provide analgesia and decrease inflammation
15mins 4x daily for 48-72 hours
Describe self-mutilation.
Occurs in deep pain negative patients due to paraesthesia/boredom/stress
Use buster collar, look for triggers e.g. sores
Where can pain originate from?
Intervertebral discs
Facets
Nerve roots
Muscles
Meninges
Tissue damage leading to compression/inflammation
What are the types of pain?
Inflammatory
Neuropathic
Acute
Chronic
What drugs can we use to prevent pain?
Opioids
NSAIDs
Corticosteroids
Alpha-2 agonists
Local anaesthetics
Cold therapy
What respiratory issues are spinal patients prone to?
Hypoventilation
Atelectasis
Aspiration pneumonia
How does aspiration pneumonia occur and what are the clinical signs?
Inhalation of GI contents into lungs
Aspirates cause pulmonary damage and inflammatory response (leading to predisposition to bacterial infection)
Coughing, tachypnoea, harsh lung sounds/crackles on auscultation
How can we treat aspiration pneumonia?
Careful and close monitoring
Early admin of antibiotics
IV fluids
Oxygen therapy
Supportive care e.g. respiratory physiotherapy (mobilise and expel aspirated contents, e.g. nebulisation/vibration/coupage)
Severe cases may need mechanical ventilation
Feeding balls of food from height
