Nursing the Spinal Patient Flashcards
why is a neurological exam performed?
breaks complex presentations into manageable steps
can localise disease
monitor progress or deterioration of disease
what are the aims of a neurological exam?
is the issue neurological
if so, where is it located
what may be causing it
what are the main areas that neurological issues can be localised to?
brain
spinal cord
peripheral nerves
neuromuscular
what areas of the brain can the neuro exam localise a lesion to?
brainstem
forebrain
cerebellum
what areas of the spinal cord can the neuro exam localise a lesion to?
C1-C5
C6-T2
T3-L3
L4-S2
what areas of the neuromuscular junction can the neuro exam localise a lesion to?
anywhere within the NMJ
what are the 5 components of the five finger rule for diagnoses?
signalment
onset
progression
summetry
pain
what may be asked about the onset of a neurological condition?
acute or chronic (speed)
what needs to be assessed about the progression of a neurological issue?
is it static, worsening or improving
what needs to be discussed about the symmetry of neuro issues?
are both sides of the body affected or just one
what aids diagnosis of neurological issues?
5 finger rule
localisation
what are the 2 key areas of the neurological exam?
hands off
hands on
what is involved in the hands off portion of the neuro exam?
mentation
gait and posture
what is involved in the hands on portion of the neuro exam?
postural reactions
spinal reflexes
cranial nerves
sensory evaluation
palpation
what can be observed about mentation during the neuro exam?
normal?
alert, obtunded, stuporous, comatose
are reactions to the environment appropriate
what can be observed about posture during the neuro exam?
is it normal
head tilt
head turn
recumbancy
curving of the spine
ventroflexion of the neck
decerebrate rigidity
decerebellate rigidity
wide based stance
what is involved in sensory evaluation during a neuro exam?
deep pain
are deep pain and spinal reflexes the same?
no - spinal reflexes may be seen even if patient is DP -ve
what is one of the most common neurological presentations?
gait abnormality
what is assessed about a patients gait during assessment in a neuro exam?
can the animal generate and make coordinated movements
do they walk normally
is there any hopping/ataxia/dragging of a limb
how is gait analysis performed?
owner walks animal up and down
cats will be allowed loose in the consult room
what should be done during gait analysis if no attempt to walk is made / the patient is unable to walk?
sling/support should be used so they can be assessed and localisation performed
describe a head tilt
one ear is below the other
describe head turn
nose turned towards the body - head is still in line
describe ventroflexion of the neck
low head carriage
what is scoliosis?
lateral curve of the spine
what is lordosis?
inward curvature of the spine
what is kyphosis?
outward curvature of the spine
define decerebrate rigidity
extension of all limbs, head and neck in lateral recumbency
define decerebellate rigidity
extension of all thoracic limbs, head and neck
hind limbs flexed or flaccid (could still do ballet!)
what stages are involved in testing postural reactions?
proprioceptive positioning
hopping
visual placing
tactile placing
hemi-walking
wheelbarrowing
what aspects of the neurological system do postural reactions test?
sensory nerves
ascending tracts of spinal cord
ascending tracts of brainstem
forebrain
descending tracts of brainstem
descending tracts of spinal cord
motor nerves
muscles
what is the purpose of postural reactions testing?
screening test to localise a rough area
where are upper motor neurones located?
between the cerebral cortex and spinal cord
what is the role of upper motor neurones?
send signals to lower motor neurones
where are lower motor neurones located?
between the CNS and the effector organ
what is the role of lower motor neurones?
connect CNS to effector organ (muscle) and send signal to make them contract
what types of lesion can affect upper and lower motor neurones?
brain
spinal cord
how does a lower motor neurone injury present?
any reflexes are weaker or absent
muscle atrophy
severe muscle weakness
no or reduced muscle tone
flaccid paresis
how does an upper motor neurone injury present?
reflexes more exadurated and easier to elicit
inhibited reflexes may be seen
increase in muscle tone
muscle atrophy but chronic
what is assessed in the thoracic limbes during the spinal reflex section of a neuro exam?
withdrawal reflex
extensor carpi radialis
biceps brachii and triceps
what is assessed in the pelvic limbs during the spinal reflex section of a neuro exam?
withdrawal
patella
cranial tibial and gastrocnemius
what are the main spinal reflexes tested during a neuro exam?
thoracic limbs
pelvic limbs
perineal reflex
panniculus
what is the panniculus reflex?
shrugging or flinching of the skin adjacent to the spine when it is stimulated by pinching
how is the withdrawal reflex assessed?
gentle pinching of toes
does a withdrawal reflex indicate that the patient has pain perception?
no
what is the withdrawal refelx?
upon pinching limb is withdrawn upwards towards the body
how is the patella reflex checked?
patella hammer used below the patella
what is the patella reflex?
leg extension when area below patella is hit with patella hammer
how is the perineal reflex checked?
pinching or stroking around the anus
what is the perineal reflex?
contraction of the anal sphincter in response to stroking or pinching of perineum
what is tested by the cutaneous trunci reflex?
segmental nerves
spinal cord cranial to pinched area up to T1
lateral thoracic nerve
where is the cutaneous trunci tested?
alongside the spine either side until reflex is seen
what is the cutaneous trunci reflex used to for?
localisation
pre op measure is used post op to check for recovery or deterioration
is pain evaluation the same as withdrawal reflex?
no - withdrawal may be seen with no deep pain sensation
when are deep pain tracts affected by spinal cord injury?
if cord is significantly damaged as they are deep tracts
how is deep pain sensation assessed?
pinching or pressure applied to digits of each limb
what is a deep pain positive response?
turning
vocalising
trying to bite
what is involved in cranial nerve assessment?
menace
palpebral
PLR
gag
occulocephalic
nystagmus
what is the occulocephalic reflex?
eyes moving when head is moved side to side
when may nystagmus be normal?
physiological nystagmus - during rotation of the body
what is miosis?
constricted pupil
what is mydriasis?
dilated pupil
what is anisocoria?
asymmetric pupils
what is indicated by pupils moving from miotic to mydriatic?
neurological deterioration
what should be done if pupils move from miotic to mydriatic?
notify VS immediately
what is seen in the pupils that is indicative of grave prognosis?
mid sized, fixed and unresponsive to light
what may be indicated by mid sized, fixed and unresponsive to light pupils?
brain herniation
what is involved in palpation of a patient?
head to tail feeling of patient looking for pain or abnormaility
when should palpation of a patient be done with caution?
if painful or fractures suspected
what is the purpose of spinal cord injury grading?
objective assessment
monitoring
prognostication
what are the grades of spinal cord injury?
grade 1-5
describe a grade 1 spinal cord injury
pain only
no neurological defecits
how would a grade 1 spinal cord injury patient be walking?
normally
describe a grade 2 spinal cord injury
walking with neurological deficits causing weakness or incoordination in both pelvic limbs
how is the mobility of a grade 2 spinal cord injury patient described?
ambulatory paraparesis
describe a grade 3 spinal cord injury
unable to walk without assistance but has good movement in the pelvic limbs
how is the mobility of a grade 3 spinal cord injury patient described?
non-ambulatory paraparesis
describe a grade 4 spinal cord injury
no voluntary movement in pelvic limbs but can feel the toes
how is the mobility of a grade 4 spinal cord injury patient described?
paraplegia with intact nociception
describe the pain sensation seen in a grade 4 spinal cord injury
deep pain present (DP +)
describe a grade 5 spinal cord injury
no voluntary movement in pelvic limbs and lack of feeling in the toes
how is the mobility of a grade 5 spinal cord injury patient described?
paraplegia without nociception
describe the pain sensation seen in a grade 5 spinal cord injury
lack of deep pain sensation (DP-)
which grade of spinal injury has the worse prognosis?
5
is it likely that sensation would return in deep pain negative patients?
no guarenteed even with surgery
what may happen to grade 4 spinal cord injury patients following surgery?
may lose DP sensation due to swelling but hopefully should return
what is needed to ensure correct care of the spinal patient is given?
assessment of the patient
who is involved in the assessment of a neurological patient?
patient
owner
what needs to be understood about the patient to ensure they get correct care?
previous and current ailments
normal activity level
owners desired and anticipated outcomes
owners ability to provide care and time
what are the main considerations when nursing neuro patients?
ambulation (ambulatory vs non-ambulatory)
surgical or non surgical
continence
temperament
recumbency
normal routine
what are the main complications seen in neuro patients?
decreased motor activity so require walking aids
bladder and bowel management
pressure sores
wound management
pain
respiratory issues
what is involved in preventing common neuro complications?
gold standard nursing care
physical rehab
why is physiotherapy important?
imporves local and whole body circulation
can help to reduce pain
creates bond between physio and patient
can help prevent pressure sores
aids motor recovery
how can physio aid motor recovery?
maintains joint health
limits muscle wastage
helps prevent contracture
what is the main aim of physio?
help promote motor and sensory recovery by generating the movement for the patient
how can physio aid motor recovery?
relearning movement
how can physio aid sensory recovery?
stimulation of proprioceptive relearning and retraining of gait
what are the main areas involved in physio?
massage
PROM
assisted exercises
active exercise
proprioceptive exercise
neuromuscular electrical stimulation
what other therapies may fall under physio?
hot/cold therapy
laser
hydrotherapy
what is the purpose of massage?
helps to calm the patient and get them used to being handled
aids with improvement in local and whole body circulation
mobilised dermal and sub-dermal tissues
warms muscles and tissues before further physio
how is massage performed?
application of light pressure to the patients limbs in long strokes or circular movements
how may massage be altered if the patient has oedema?
leg only massaged towards the body
what is the aim of PROM?
put each joint through the normal range of motion and improve joint health without active muscle contraction
help with gait pattern
what is involved in PROM?
gentle flexion and extension of each joint of the limb through its normal range of motion 10-15 times
what exercises are involved in assisted exercise?
assisted standing/walking
assisted sit to stand
three legged standing
weight shifting
what are the main active exercises used in physio?
walking (straight line, circles, figure of 8)
unassisted sit to stand
unassisted sit to down
hydrotherapy
what are the main proprioceptive exercises?
standing
wobble board
uneven surface
over poles
weaving
different surfaces
what is the purpose of using different surfaces to do proprioceptive exercises?
aids sensory relearning
what may be used for hydrotherapy?
treadmill
pool
what is the benefit of hydrotherapy?
water takes body weight so patient may be able to move more
what is the benefit of hot or cold therapy?
muscle relaxant
analgesia
reduction of swelling
what is the purpose of neuromuscular electrical stimulation?
increase tissue perfusion
minimization of onset and severity of neurogenic muscle atrophy
how is neuromuscular electrical stimulation performed?
sustained muscle contraction using dermal electrodes over the muscles
in what patients is neuromuscular electrical stimulation used?
patients who can’t produce active muscle contractions
what are the main physiotherapy considerations?
previous injury or surgery
client expectations
client limit (time and expertise)
disease process
neurolocalisation may make some exercises contraindicated
temperament
what is often seen in patients post spinal surgery?
urinary incontinance
what are the main bladder signs developed post spinal surgery?
upper motor neurone bladder
lower motor neurone bladder
what are the signs of an upper motor neurone bladder?
distended
very difficult to express
what are the signs of an lower motor neurone bladder?
distended
easy to express
what can failing to empty the bladder adequately lead to?
UTI
bladder atony
pyelonephritis
what is bladder atony?
weakening of bladder muscle
why are patients who cannot empty their bladder at risk of developing UTIs?
urine is static
what may cause pain in patients who are unable to empty their bladders?
distention of bladder and ureters
when does overflow incontinence occur?
when the patient is unaware their bladder is full and so once it overflows they leak urine
what are side effects of overflow incontinence?
leaking urine can go onto a patients skin and cause urine scalding
continuously full bladder is at risk of UTI
what can be done to manage overflow incontinence?
catheterisation
bladder expression
what are the main bladder management techniques?
manual expression
intermittent aseptic catheterisation
indwelling catheterisation with closed collection
drug therapy
how often should manual bladder expression occur?
3-4 times a day
how often should intermittent aseptic catheterisation occur?
twice a day
how often should emptying of an indwelling catheter and closed system occur?
3-4 times a day
what is the risk with intermittent aseptic catheterisation?
trauma to urethra
what is the role of drug therapy in bladder management?
relaxation of detrusor to aid manual expression
what should urine be monitored for daily?
changes in colour and odour
what bladder type is more likely to constantly leak urine?
lower motor neurone
what must be monitored if a patient is leaking urine?
skin of HL and perineium to check for sores
do neuro patients often have problems passing faeces?
no
why do neuro patients often not have problems passing faeces?
defecation initiated by the stretch of the rectal wall
what is the main issue with neuro patients and bowel management?
cannot move away once they’ve passed faeces
what can happen to faecal continence in patients with upper motor neuron injuries?
reflex may become over active so a small amount of distention can lead to defecation
how should patients be managed to prevent faecal scalding?
recumbent and paraplegic animals shoudl be checked and cleaned regularly so they are not lying in faeces
important to offer patients opportunity to toilet on different surfaces and outside
monitor for any signs of scalding especially if diarrhoea is seen
what is a common complication for recumbent patients?
pressure sores
why does recumbency increase risk of pressure sores?
increased pressure over bony prominances
how are pressure sores caused?
pressure over bony prominences leads to compression of local circulation and so tissues undergo ischemic necrosis
what can pressure sores be like?
anything from mild erythema to full thickness ulcers
how quickly may pressure sores form?
rapidly
what must be done once pressure sores are identified?
aggressive and rapid treatment to prevent lesion from becoming larger
what are the stages of pressure sores?
stage 1 - mild erythema
stage 2 - injury through the skin
stage 3 - larger wound, open to the muscle
stage 4 - down to bone, infected
how can pressure sores be prevented?
thick padded bedding
turn patients regularly (2-4 hours)
donut bandage over bony prominences
porous bedding
incontinence pads
non-slip flooring
physio
monitoring patients
ensure skin is dry
bladder manegment
clean and dry bedding
how often should recumbent patients be turned?
2-4 hours
what is the benefit of porous bedding in preventing pressure sores?
draws urine away from the skin to prevent scauld
why can physio prevent pressure sores?
promotion of circulation and movment
what are spinal patients prone to developing?
sores on distal limbs when they are dragged
how can injuries to distal limbs be avoided in plegic or paretic patients?
use bandages or foot covers on feet when walking
how are pressure sores treated?
keep clean and dry
debride if necessary
antibiotics if infection suspected
bandaging
where is spinal patients surgical wound often located?
back or under the neck
are ventral slot or hemilaminectomy patients more at risk of seroma?
hemilaminectomy
why are hemilaminectomy patients more at risk of seroma?
more skin movement
separation of multiple layers of tissues
over the midline
why are ventral slot patients at reduced risk of wound complications?
fewer layers disturbed to access surgical site
what therapy may be prescribed for hemi and ventral slot patients?
cold therapy
what is the purpose of cold therapy?
analgesia
decreases inflammation
how frequently should cold therapy be used for surgical patients?
4 times a day
how long should each cold therapy treatment last for?
15 mins
how long after surgery should cold therapy continue?
48-72 hours
what precautions must be taken when performing cold therapy?
always wrap in a towel, not placed directly on the skin
what is the main role of primapore on surgical wounds?
prevent patient interference
what must you be cautious about when walking patients post ventral slot?
use a harness not a neck lead
in what patients may self mutilation be seen?
deep pain negative animals
why may self mutilation occur in deep pain negative animals?
paraesthesia
boredom
stress
what is paraesthesia?
pins and needles
what should done if a patient starts to lick or bite at any part of their body?
buster collar on
check for presence of sores
where may post operative pain in the neuro patient originate from?
intervertebral disc
facets
nerve roots
muscles
meninges
what is the cause of pain post neuro surgery?
compression / inflammation following tissue damage
what are the 4 types of pain?
inflammatory
neuropathic
acute
chronic
what must be done to avoid chronic pain?
prevention of acute pain
how can pain be identified in our patients?
observation of demenour
self mutilation
palpation including wound
using pain scoring
what can be used to prevent pain post neuro surgery?
opioids
NSAIDs
corticosteroids
alpha-2 agonists
LA
cold therapy
what respiratory issues are spinal patients prone to?
hypoventilation
atelectasis
pneumonia
what area of the spine does the presence of a lesion make respiratory issues more likely?
cervical
what sort of patient is more at risk of respiratory issues?
recumbent
what causes aspiration pneumonia?
inhalation of GI contents into lungs
how does inhalation of GI contents lead to aspiration pneumonia?
aspirates cause pulmonary damage and an inflammatory response
what does an inflammatory response in the lungs predispose a patient to?
bacterial infection
what are the clinical signs of aspiration pneumonia?
coughing
tachypnoea
harsh lungs sounds
crackles on auscultation
how can aspiration pneumonia be treated?
careful and close monitoring
early administration of antibiotics
IVFT
O2 therapy
respiratory physio
what may be required in severe cases of aspiration pneumonia?
mechanical ventilation
what is the purpose of respiratory physio in aspiration pneumonia patients?
mobilisation and expulsion of aspirated contents
what are the main respiratory physio techniques used?
nebulisation
vibration
coupage
how can aspiration pneumonia be prevented?
walking and turning patients
feeding balls of food from height
recumbent animals regularly placed in sternal
why is feeding balls of food from height of benefit in patients at risk of aspiration?
larger balls of food
less likely to aspirate
what part of respiratory physio should be performed first?
nebulisation
how should nebulisation be performed?
place patient in sternal if appropriate
hold nebuliser close to patients nose/mouth for 10-15 minutes
mask can be used if tolerated
how is vibration performed?
place hands either side of patients chest and create shaking movements each time the patient exhales
what is the purpose of vibration in respiratory physio?
loosens aspirates
what is the purpose of coupage?
loosening of respiratory contents to allow patient to cough them up
how is coupage performed?
cup hands over patients chest and perform rhythmic clapping movements cranially up the chest
how long should coupage last for?
10 mins
how often should coupage be performed?
three to four times daily
why is nutrition so important in neurological patients?
most will have undergone physical and psychologcial stress
what are the main areas of nutrition to consider in neuro patients?
some patients may unwilling or unable to eat so this should be factored into RER
calculate RER
patients should be weighed daily
what is the purpose of weighing patients daily?
note weight loss trends
what can be done if patients are unwilling to eat?
hand feeding
asking owners to come in and try to feed their pet
