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NUR 213 > SCI & GBS Unit 4 exam > Flashcards

SCI & GBS Unit 4 exam Flashcards

1
Q

Avoid the use of what when cleansing the pin sites of an immobilization device?

A

Hydrogen peroxide

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2
Q

List S/S of Neurogenic shock

A
  • Vasodilation
  • Bradycardia
  • Body temperature instability
  • Hypotension
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3
Q

How often should pin sites of halo traction and Gardner-Wells Tongs be cleaned? What should be used to clean them?

A
  • Q shift
  • Using clean cotton tipped applicator or gauze soaked with NS
  • Use a new clean applicator/gauze for each site
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4
Q

Complications associated with plasmapheresis

A
  • Septicemia
  • PNA
  • Cardiac arrhythmias
  • Malise
  • Bleeding/clotting abnormalities
  • Hypocalcemia
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5
Q

Pt with a halo traction device is complaining of their vest “not fitting right” what needs to be done ASAP? What do you suspect?

A
  • Contact HCP immediately and prepare for radiological testing to assess for change in spinal alignment
  • Halo will likely need to be reapplied using new pin sites
  • Migrated pins
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6
Q

List S/S of Spinal Shock

A
  • flaccid paralysis of all skeletal muscles
  • absence of deep tendon reflexes
  • impaired proprioception
  • decreased visceral and somatic sensations
  • penile reflex
  • urinary and fecal retention
  • anhidrosis
  • paralytic ileus
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7
Q

Where would this injury be on the spine to cause this type of function loss?

Quadriplegia with biceps intact, diaphragmatic breathing

A

C6-C7

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8
Q

What stage of GBS is this?

onset of clinical manifestations, edema, and inflammation, lasting 4 weeks

A

Acute Stage

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9
Q

Four types of incomplete SCI

A
  • Central Cord Syndrome
  • Anterior Cord Syndrome
  • Posterior Cord Syndrome
  • Brown-Séquard syndrome
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10
Q

All of the following are S/S of what?

  • severe headache
  • hypertension
  • bradycardia or tachycardia
  • diaphoresis
  • flushing above and pallor below the injury level
  • Nasal congestion
  • Anxiety or feelings of doom
  • Blurred vison
  • Chest pain
A

Autonomic dysreflexia

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11
Q

What indicates the end of spinal shock

A

The return of activity below the level of injury

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12
Q

Assessments for pt with GBS

A
  • Preform respiratory assessment with vital capacity measurement. This is priority d/t resp compromise. If vital compacity is below 1 L contact HCP
  • Cranial nerves VII, IX, X, XI, XII
    o Focus on facial expression, speech, gag, swallow
  • Assess for motor and sensory impairment 2nd to demyelination of peripheral nerves
  • Assess pain
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13
Q

on the same side as the injury

A

Ipisilateral

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14
Q

Where would this injury be on the spine to cause this type of function loss?

Quadriplegia with triceps, biceps, and wrist extension intact and some function of intrinsic hand muscles

A

C7-C8

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15
Q

What type of immobilization/stabalization device is this?

  • Used to maintain cervical immobilization for specific types of cervical fractures.
  • Made up of a ring around the patients head attached to a special vest by 4 rods.
  • Titanium screws are screwed into the skull bone and attached to the device
  • Weights connect to the halo at the head of the bed over a pulley system
  • Weights are slowly added w/xray to confirm alignment
A

Halo traction

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16
Q

S/S of GBS

A
  • Parenthesia/pain involving shoulder back, buttock and upper legs
  • Numbness, Tingling, pain
  • Muscle atrophy
  • Decreased/absent DTR or Areflexia
  • Ascending flaccid paralysis and motor weakness from lower extremities over several days – Starts at toes and up it goes
  • Autonomic manifestations: sweating and tachycardia
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17
Q

Nursing interventions for neurogenic shock

A
  • Monitor for S/S of shock
  • Monitor for hypotension &bradycardia
  • Monitor reflex activity/return of reflexes
  • Assess for bowel sounds
  • Monitor for bowel and urinary retention
  • Provide supportive measures as prescribed based on symptoms
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18
Q

Where would this injury be on the spine to cause this type of function loss?

Paraplegia with fair ability to control balance and trunk, little or no voluntary bowel or bladder control

A

T6-T12

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19
Q

Treatment for Neurogenic Shock

A
  • Fluid resuscitation
  • Vasopressors
  • Atropine
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20
Q

Where would this injury be on the spine to cause this type of function loss?

Paraplegia with trunk and leg involvement, normal arm and hand movement

A

T1-T5

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21
Q

Disorder of the PNS causing acute demylenation of peripheral nerves. Often occurs after an infection or vaccine

A

Guillian-Barre Syndrome or GBS

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22
Q

Where would this injury be on the spine to cause this type of function loss?

Quadriplegia with gross arm movements, phrenic nerve intact

A

C5-C6

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23
Q

What type of incomplete SCI is this?

  • Etiology: hemisection of the spinal cord resulting from penetrating injury (i.e., gunshot or knife injury); may also occur as result of primary ischemia, infection, or hemorrhagic event
  • Clinical manifestations: ipisilateral loss of motor function, proprioception, and vibration; contralateral loss of pain and temperature
A

Brown-Séquard syndrome

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24
Q

All of the following are S/S of what?

  • Parenthesia/pain involving shoulder back, buttock and upper legs
  • Numbness, Tingling, pain
  • Muscle atrophy
  • Decreased/absent DTR or Areflexia
  • Ascending flaccid paralysis and motor weakness from lower extremities over several days – Starts at toes and up it goes
  • Autonomic manifestations: sweating and tachycardia
A

GBS

25
Q
  • Recommended tmnt for non-ambulatory pt’s with GBS
  • Tmnt needs to be started within 4 wks of onset of neuropathic symptoms.
  • Recommended for pt’s who are ambulatory need to start tmnt within 2 wks of onset of neuropathic symptoms
  • Requires special cath – can only be placed by specialized nurse
  • Pt’s receiving this therapy are at an increased risk for infection & hemorrhage d/t the removal of immunoglobulins and clotting factors.
  • A/E: Hypotension, bradycardia, fever, chills, and rash
A

Plasmapheresis

26
Q

Things that can cause Autonomic dysreflexia

A
  • Full bladder #1
  • Full bowel #2
  • Tight clothing
  • GI Disturbances
  • DVT
  • Pressure injury
  • Bladder or Kidney infection
  • Temperature extremes
  • A minor injury
27
Q

On the opposite side of the injury

A

Contralateral

28
Q

How long to S/S of spinal shock last?

A

anywhere from 24hrs to 1-6 wks

29
Q

All of the following are S/S of what?

  • severe headache
  • hypertension
  • bradycardia or tachycardia
  • diaphoresis
  • flushing above and pallor below the injury level
  • Nasal congestion
  • Anxiety or feelings of doom
  • Blurred vison
  • Chest pain
A

Autonomic Dysreflexia

30
Q

Where would this injury be on the spine to cause this type of function loss?

Cauda equina injury, variable motor and sensory loss in lower extremities; a reflexive bowel and bladder

A

Below L1

31
Q

Absence of sweat production

A

Anhidrosis

32
Q

What phase of GBS is this?

remyelination and axonal regeneration begin and gradual improvement in S/S

A

Recovery phase

33
Q

All of the following are S/S of what?

  • flaccid paralysis of all skeletal muscles
  • absence of deep tendon reflexes
  • impaired proprioception
  • decreased visceral and somatic sensations
  • penile reflex
  • urinary and fecal retention
  • anhidrosis
  • paralytic ileus
A

Spinal shock

34
Q

Where would this injury be on the spine to cause this type of function loss?

Quadriplegia with possible phrenic nerve involvement

A

C4-C5

35
Q

Nursing actions for autonomic dysreflexia

A
  • Raise HOB and call PHCP
  • Remove restrictive clothing
  • Assess bowel, bladder, look for other causative stimuli
  • Admin Antihypertensives
  • Document
36
Q

When assessing pin sites of an immobilization device what needs to be done if crusting is noted?

A
  • Wrap a gauze soaked with NS around pin site for 15 min
  • After removing gauze use clean cotton-tipped applicator to gently remove crust at pin site
37
Q

A SPI that is incomplete structural damage with some function preserved below the primary injury level.

A

Incomplete SCI

38
Q

All of the following are S/S of what?

  • Vasodilation
  • Bradycardia
  • Body temperature instability
  • Hypotension
A

Neurogenic Shock

39
Q

Where would the injury on the spine be with this type of function loss?

Quadriplegia with loss of spontaneous respiratory function

A

C1-C4

40
Q

If autonomic dysreflexia is not caught and treated what can it lead to?

A
  • Pulmonary edema
  • MI
  • Cerebral hemorrhage
  • Death
41
Q

The body’s ability to sense movement, action, and location

A

Proprioception

42
Q

What type of incomplete SCI is this?

  • Most common
  • Etiology: hyperextension injury with central cord swelling
  • Clinical manifestations: functional motor loss greater in arms than legs, bladder dysfunction, and variable loss of sensation
A

Central Cord Syndrome

43
Q

Occurs immediately after injury and applies to all phenomena surrounding spinal cord transection. This results in a complete but temporary loss or depression of all or most spinal reflexes as well as sensory, motor, and autonomic activity below the injury level

A

Spinal shock

44
Q
  • A syndrome of massive imbalanced reflex sympathetic discharge occurring in 80% of patients with SCI above the T5–T6 level.
  • It most often occurs after the first year of injury but can occur any time after spinal shock subsides.
  • Impulses are blocked
A

Autonomic Dysreflexia

45
Q

What stage of GBS is this?

When demyelination ceases, lasts few days to weeks

A

Plateau stage

46
Q

What type of immobilization/stabilization device is this?

  • Used for spinal traction
  • U shaped tongs
  • Pressure controlled pins are inserted into the skull at opposite ends to permit longitudinal force to be applied to the axis of the spinal column.
  • Tongs are attached to weights using a pulley system at the head of bed
A

Gardner-Wells Tongs

47
Q

How to treat Autonomic dysreflexia

A

One the inciting stimulus is removed then reflex HTN resolves

48
Q
  • Treatment for GBS
  • Shortens recovery time by 50%
  • This therapy is recommended for patients who need help to walk within 2 to 4 weeks of clinical presentation of GBS
  • Dosing is 2G/KG IV over 5 days.
  • Adverse effect of therapy: aseptic meningitis & acute renal failure
  • FVO can occur in pt’s with HF or renal insufficiency
A

Intravenous Immunoglobulin Therapy
or
IVIG

49
Q

What type of incomplete SCI is this?

  • Etiology: acute compression
  • Clinical manifestations: loss of proprioception, fine touch and pressure, and vibration; intact pain, temperature, and crude touch and pressure
A

Posterior cord syndrome

50
Q

SCI that results in a total loss of motor and sensory function below the level of injury.

A

A complete SCI

51
Q

When caring for a patient with GBS and upon assessment the nurse realizes cranial nerve X is involved what should the nurse do?

A

Call HCP

52
Q

Stages of GBS

A
  1. Acute stage
  2. Plateau Stage
  3. Recovery Improvement
53
Q

A distributive type of shock that occurs in patients with brain, upper thoracic, and cervical injuries and is caused by the sudden loss of the autonomic nervous system signals to the smooth muscle in the vessel walls. This results in loss of vasomotor tone and sympathetic innervation of the heart.

A

Neurogenic Shock

54
Q

Complications associated with SCI

A
  • Autonomic Dysreflexia
  • Neurogenic Shock
  • Spinal Shock
55
Q

Complications associated with SCI

A
  • halo Brace/Traction Device complications
  • Pin infections
  • Skin breakdown
  • Loosening or movement of pins
  • Swallowing issues
  • Possible dural tears
56
Q

What type of incomplete SCI is this?

  • Etiology: acute anterior compression from bony fragments or acute disk herniation
  • Clinical manifestations: Loss of motor function (paresis or paralysis), pain, temperature, crude touch and pressure below the level of injury; preserved sense of proprioception (position sense), fine touch and pressure, and vibration
A

Anterior cord syndrome

57
Q
  • Abnormal response to pain
  • Extension
  • Arms look like E’s
  • Indicates problems with midbrain or pons
A

Decerebrate

58
Q
  • Abnormal response to pain
  • Flexion
  • Arms look like C’s
  • Idicates problems with spinal tract or cerebral hemisphere
A

Decorticate

NUR 213 (29 decks)

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