Problems of the CNS: The Spinal Cord Flashcards
What is lumbosacral back pain (Low Back Pain)
Herniated nucleus pulposus
What are preventative measures
Good posture Proper lifting Exercise Ergonomics Equipment that can be used
What are nonsurgical management
Positioning Drug therapy Heat therapy Physical therapy Weight control Complementary and alternative therapies
Minimally invasive surgery
Percutaneous lumbar diskectomy
Thermodiskectomy
Laser-assisted laparoscopic lumbar diskectomy
Conventional open surgical procedures
Diskectomy
Laminectomy
Spinal fusion
Postoperative care
Prevention/assessment of complications Neurologic assessment; vital signs Patient’s ability to void Pain control Wound care CSF check Patient positioning/mobility Discharge teaching (Home care management Community resources)
Cervical neck surgical management
Anterior cervical diskectomy
Fusion
Spinal cord secondary injuries
Hemorrhage Metabolic (Inflammatory Processes) Cellular changes Vasoconstriction/Thrombosis Vasospasms/Edema Decreased spinal cord blood flow Spinal cord ischemia and hypoxia
Spinal cord injuries
Hyperflexion
Hyperextension
Axial loading or vertical compression (e.g., caused by jumping)
Excessive head rotation beyond its range
Penetration (e.g., caused by bullet or knife)
Frequently seen at C5 & C6
Deceleration motion
Head-on collisions
HYPERFLEXION
Hyperflexion results in
Compression of cord from fractures
Rupture or tearing of muscles or ligaments
Back and downward motion of the head
Rear-end collisions (Whiplash)
Diving accidents
HYPEREXTENSION
Hyperextension results in
Spinal cord is stretched and distorted resulting in contusion or ischemia
Displacement of spinal column
Tearing of the posterior ligaments & displacement of the spinal column
Occurs along with extension flexion injuries
ROTATION
Rotation results in
May disrupt ligaments, vessels, tissue, bone, and related organs
Vertical force on cord
Long fall landing on feet or buttocks
Burst fractures (Bony fragments into spinal canal)
Axial Loading
Axial loading results in
vertical compression that may result in such force on the vertebral body to cause a “burst” fracture with fragments that impinge upon the cord.
Knife or Gun shot wounds
Cut cord
PENETRATING
Penetrating results in
May partially or completely severe the vertebra, cord, ligaments, and blood supply or indirectly cause injury by heat or shock wave.
Total loss of sensory and motor function below level of injury
Complete injury
Types of complete injury
Tetraplegia (Quadriplegia)
Paraplegia
Paralysis of both arms and legs
Injury to cervical region C1-C8
Airway management
Paralysis of diaphragm if injury above C3
Requires wheelchair with breath, head or shoulder control
Tetraplegia
Paralysis of both legs
Injury to thoracolumbar region T2-L1
May have full use of arms
May require wheelchair or have some limited use lower extremities
May have some respiratory compromise (varying degrees of intercostals and abdominal muscle paralysis
Paraplegia
Mixed loss of voluntary motor activity and sensation below level of injury
Incomplete Injury
Types of incomplete injuries
Brown-Sequard Syndrome
Central Cord Syndrome
Anterior Cord Syndrome
Posterior Cord Syndrome
Transection/Damage of one side of spinal cord
Brown-Sequard
Below injured site cord
Loss voluntary motor function (same side as Injury)
Loss of pain, temperature, & sensation (opposite side of injury)
Brown-Sequard
Associated with cervical flexion/extension injury
Hematoma formation in center of cervical cord
Central Cord Syndrome
Motor weakness (upper extremities weaker than lower) Sensory function varies Varying degrees bowel and bladder dysfunction
Central Cord Syndrome
Acute compression of anterior portion of spinal cord
Associated with flexion injuries or acute herniation of an intervertebral disc
Anterior Cord Syndrome
Loss motor function below site of injury
Loss pain, temperature,& crude sensation
Anterior Cord Syndrome
Associated with cervical hyperextension injury
Damage to the posterior column
Posterior Cord Syndrome
Loss position sense, vibration, and pressure (May not have ability to walk)
Motor function, pain and temperature sensation intact
Posterior Cord Syndrome
Assessment findings of injures
Pain at level of injury
Numbness/weakness, loss of sensation below level of injury
Complete/incomplete
Respiratory distress
Alterations in bowel and bladder function
Alterations in temperature control
Initial period of flaccid paralysis and loss of sensation and reflexes
Lasts between 48 hrs to several weeks
Spinal shock
Occurs within days to weeks
Hyperreflexic and spastic
Muscle spasms
Nursing Diagnosis for spinal cord injuries
Respiratory
Circulation (CO, Tissue Perfusion, Dysrhythmias, Emboli)
Skin Integrity
Airway management of spinal cord injuries
Goal: Maintain patent airway
If unresponsive insert oral airway, keeping neck in neutral position
Jaw thrust method to open airway
Provide oxygen/ventilator
IF injury above C3 need mechanical ventilation
Monitor ABG’s, suction prn
Circulation management of spinal cord injuries
Cardiac output: Sympathetic nervous system interrupted
Loss of vasomotor response
Blood vessels cannot constrict
(Hypotension, venous pooling, decreased CO)
Tissue perfusion: Orthostatic hypotension, DVT prophylaxis Loss of thermoregulation
Cervical immobilization of spinal cord injuries
Immobilize and stabilize in neutral position
Sandbags, cervical collars, and backboards
Body should be correctly aligned, log roll
Surgical stabilization of cervical immobilization
Laminectomy, Spinal fusion, Rods
Spinal cord injury management
Cervical traction using skull tongs
Traction provided by pulley system and weights
Cleanse pin sites twice a day
Halo traction
Halo vest management
Cervical traction using specially designed jacket
Allows greater mobility
Inspect skin under jacket for breakdown
Keep Allen wrench taped to jacket
Body shells for stable thoracolumbar injuries
Management of cord edema
Corticosteroids High dose Methylprednisolone IV Administer within 8 hours of injury Start bolus, then, continuous drip for 24-48 hours Complications from this therapy?
What is neurogenic shock
Loss of vasomotor tone & sympathetic innervation of heart
Hypovolemia, vasodilitation, ↓SVR, ↓Venous Return, ↓Stroke Volume, ↓CO, ↓Preload, Inhibited Baroreceptor response
Blood vessels unable to constrict
Low HR
Poikilothermic
Skin warm & dry
Neurogenic shock management
Careful fluid resuscitation
Vasopressors
Maintain normothermia
Position to avoid orthostasis
Spinal cord injury nursing goals
Altered elimination pattern
Bladder
Retention urine due to loss of autonomic and reflex control of bladder and sphincter.
Results in over-distention and may reflux into kidney
Bowel
Prevent spasms
Management of altered elimination pattern (initial)
indwelling catheter
Management of altered elimination pattern (long term)
intermittent catheterization
How to prevent UTI’s
cranberry, apple, and grape juice
Management of bowel
Constipation due to loss of voluntary and involuntary evacuation.
How to prevent bowel problems
Scheduled bowel program Encouraging food high in fiber Increase fluid intake Suppository and stool softeners Digital stimulation for UMN injuries Enemas
How to relieve spasms
warm baths, muscle relaxants, antispasmodics
How to prevent contractures and decubiti
Turn Q2h
OOB to Chair ASAP
Specialty beds that provide side-to-side lateral rotation
How to prevent DVTs
anitcoagulants
Complications
Autonomic Dysreflexia/Hyperflexia
Exaggerated autonomic response to stimuli resulting in profound hypertension
Occurs mostly in tetraplegics
Autonomic Dysreflexia/Hyperflexia
Autonomic Dysreflexia/Hyperflexia is caused by
Distended bladder or rectum
Stimulation of skin, pain
A condition where the blood pressure in a person with a spinal cord injury (SCI) above T5-6 becomes excessively high due to the over activity of the Autonomic Nervous System.
Autonomic Dysreflexia, also known as Hyperreflexia
Autonomic Dysreflexia is usually caused when
a painful stimulus occurs below the level of spinal cord injury. The stimulus is then mediated through the Central Nervous System (CNS) and the Peripheral Nervous System (PNS).
Autonomic Dysreflexia/Hyperreflexia findings
Severe HTN (SBP may be 300) Bradycardia Severe HABlurred vision Nausea, Restlessness Skin Flushed above injury, Pale below Distended bladder, bowel
Priority Problems for Long-Term Management
Difficulty breathing
Impaired physical mobility (safety)
Spastic or flaccid bladder and bowel
Impaired adjustment
Types of spinal cord tumors
Primary
Intramedullary
Extramedullary
Surgical management
emergency surgery
Nonsurgical management
radiation, chemotherapy
Autoimmune disorder characterized by plaque in the white matter of the CNS
Multiple Sclerosis
Types of Multiple Sclerosis
Relapsing-remitting
Primary progressive
Secondary progressive
Progressive-relapsing
MS risk factors & triggers
Viruses or infectious agents Cold climate Physical injury Emotional stress Pregnancy Overexertion Temperature extremes Hot shower/bath
MS symptoms
Fatigue Pain or paresthesia Diplopia Tinnitus Dysphagia Muscle spasticity Ataxia Bladder dysfunction
Medications to treat medications
Immunosuppressive agents (Azathioprine & cyclosporine) Corticosteroids (Prednisone) Immunomodullators (Interferon beta) Anticonvulsants (Carbamazepine) Antispasmodics (Dantrolene, baclofen)
Lou Gehring’s disease Progressive motor neuron disease Upper & lower motor neurons Destruction of motor neurons Brain Anterior gray horns of the spinal cord Sensory pathways not effected Etiology unknown
Amytrophic Lateral Sclerosis (ALS)
ALS findings
Muscle weakness, wasting, atrophy Muscle spasticity & hyperreflexia Fasciculations Brain stem signs (Dysarthria, dysphagia) Dyspnea, respiratory paralysis Fatigue
How to diagnosis ALS
History Neuro exam Electromyogram (EMG) CPK elevated Muscle biopsy
Management of ALS
No known cure
Riluzole (slows the progression, hepatotoxic risk)
Anti-spasmodics
Physical therapy, Speech therapy, Occupational therapy
Nutrition
Enteral feedings
Monitor for progression (Airway, trach, home vents)
Counseling, support groups
End of life discussions
