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Neuro 142 > Spinal Cord > Flashcards

Spinal Cord Flashcards

1
Q

• Gender - Male
• Age – young men
• Alcohol and drugs
o Hx often shows:
▪ Older men were drinking at the time when they fell in the bathroom
▪ Or they were under the influence at the time that the injury occurred
• Elderly –osteoporosis as a contributing factor
o They are at greater risk for falling
o They have compression Fx of the vertebral

A

Spinal cord injury risks

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2
Q

▪ The swelling, edema, and hematoma that results from the injury
▪ The pt may come into ER with motor and sensory loss and then lose it all
• They get flaccid paralysis below the area of injury
• The question is whether it is spinal shock or injury?
o Massive amounts of Decadron or steroids are given to reduce swelling
▪ The problem is that it may take 1 week to take effect
▪ May be reversed in 1-6 weeks

A

Spinal shock

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3
Q
  • Spinal cord able to transmit some impulse
  • Some motor some sensory
  • Classified according to area:
  • Central cord
  • Anterior cord
  • Lateral cord
A

Pathophysiology: Incomplete

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4
Q

Complete injury
No motor injury
QUAD

A

ASIA A

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5
Q

Sensory/ incomplete injury

No motor

A

ASIA B

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6
Q

Motor/ incomplete injury

Motor incomplete injury (more than half key muscle = grade

A

ASIA C

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7
Q

Normal

A

Asia E

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8
Q

Region of skin supplied by a ingle sensory nerve

A

Dermatones

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9
Q 
Opening of skull to gain access to intracranial structures. 
• remove tumor 
• relive ICP
• evacuate blood clot 
• control hemorrhage
A

Craniotomy

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10
Q

Supratentorial craniotomy

A

Tentorium

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11
Q

Above Tentorium
• incision made above the area to be operated on
• Maintain HOB 30-45 degrees with neck in neutral alignment

A

Nursing interventions

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12
Q
  • is tent like covering of meningeal layers that separates occipital lobe of cerebrum from the cerebellum.
  • It provides access to frontal, temporal, parietal and occipital lobes. Suture line located just behind hairline
  • is layer that holds up the lobes of brain
  • Surgical position is going to be in hair line
  • Share area of hairline
A

Tentorium

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13
Q

Concerns: Seizures
o Edema might become excessive and create herniation to brain
o Treat pt the same as IICP
• HOB 30˚ – 45˚
o Do not let pt lay on surgical site unless ordered
o Typically with small incision 30cc of CSF was evacuated
o With hemispherectomy half of brain is gone
o Pt can’t lie on affected area for 72 hrs until blood clot forms and brain is held in place
• Pt stays in bed for 24 – 48 hrs
• Fluid limited to 1500cc for 24hrs due to IICP
• Risk for seizures activity
• Risk for meningitis
• Monitor for dressing change
o CSF has a halo affect
o Yellow ring b/c CSF is clear

A

NURSING INTERVENTIONS FOR SUPRATENTORIAL CRANIOTOMY

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14
Q
  • Site of surgery is below tentorium into the cerebellum

* Incision made at nape of neck around occipital lobe

A

Infratentorial craniotomy

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15
Q

• Can’t put pt up because of weakness of surgical incision - brain can herniate
• Pt stays in bed for 3 to 5 days
• Pt is allowed to lay on their incision
• Pt has to lay flat with their neck straight
o Keep bed flat
o Avoid flexing neck
• NPO for 24 hr post op
• Gag reflex is decreased since cranial nerve # 9 is in cerebellum

A

Post op care for Infratntorisl craniotomy

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16
Q
  • Cerebral edema
  • Intracranial hemorrhage
  • Seizure
  • Infection
  • Venous thrombus
  • Leakage of CSF
  • GI bleed
  • Pt are at risk for developing ulcers
A

Complications of Infratentorial craniotomy

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17
Q
  • Antiseizure meds – dilantin
  • Corticosteroids – Decadoron 1-2 prior to surgery
  • Fluid restriction
  • Antibiotics
  • Dressings
  • education
A

Pre-op care

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18
Q

10-20 mcg/mL

A

Dilantin

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19
Q 
• Reduce ICP-Mannitol and decadron
o Monitor with ventricular cath
• Prevent Seizures – Dilantin/Ativan
• Eyes may swell
• Pain Tylenol
A

Post op Care

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20
Q

Removal of part of skull marzipulation

A

Craniectomy

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21
Q

initial damage

• Contusions, lacerations, damage to blood vessels, acceleration/deceleration injury, or foreign object penetration

A

Primary injury:

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22
Q

damage evolves after the initial insult

• Cerebral edema, ischemia, or chemical changes associated with the trauma

A

Secondary injury

23
Q
  • Loss of movement on the same side of cord damage
  • Loss of pain, sensation, temperatures near opposite side
  • caused by a transverse hemisection of the cord usually as a result of a knife or missile injury, fracture-dislocation of a unilateral articular process, or possibly an acute ruptured disk.
  • may be caused by a spinal cord tumor, trauma (such as a puncture wound to the neck or back), ischemia (obstruction of a blood vessel), or infectious or inflammatory diseases such as tuberculosis, or multiple sclerosis.
A

BROWN-SÉQUARD SYNDROME LATERAL CORD SYNDROME

24
Q
  • Focuses on the underlying cause of the disorder
  • Early treatment with high-dose steroids may be beneficial in many cases
  • Other treatment is symptomatic and supportive
A

Treatment

BROWN-SÉQUARD SYNDROME LATERAL CORD SYNDROME

25
Q

Motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved.
o Cause: Injury or edema of the central cord, usually of the cervical area. May be caused by hyperextension injuries.
•incomplete spinal cord injury
•damage to the large nerve fibers that carry information directly from the cerebral cortex to the spinal cord.

A

CENTRAL CORD SYNDROME

26
Q
  • Sensory loss below the site of the injury and loss of bladder control may also occur
  • Central cord syndrome is usually the result of trauma, but also may develop in persons over the age of 50 due to gradual weakening of the vertebrae and discs, which narrows the spinal column and may contribute to compression of the spinal cord.
  • Improvement occurs first in the legs, then the bladder, and may be seen in the arms. Hand function recovers last, if at all
A

CENTRAL CORD SYNDROME

27
Q
  • Loss of pain, temperature, and motor function is noted below the level of the lesion; light touch, position, and vibration sensation remain intact.
  • syndrome may be caused by acute disk herniation or hyperflexion injuries associated with fracture-dislocation of vertebra.
  • the blood supply to the anterior portion of the spinal cord is interrupted
A

ANTERIOR CORD SYNDROME

28
Q

• It is characterized by loss of motor function below the level of injury, loss of sensations carried by the anterior columns of the spinal cord (pain and temperature), and preservation of sensations carried by the posterior columns (fine touch and proprioception)
• o Patients can feel some type of coarse sensations that go through intact paths of the posterior spinal cored, but movements and the finest sensations are lost
o Patients generally worsen from this type of spinal cord injury

A

ANTERIOR CORD SYNDROME

29
Q

–Motor incomplete injury (at least half key muscle = grade > 3)

A

Asia D

30
Q

• Permanently paralyzed
• Some quads can move arms
• T-6 and above
o Autonomic dysreflexia occurs here

A

Quadraplegia

31
Q

-Paralysis of lower extremities

• T –7 and below

A

Paraplegia

32
Q

• Concussion
• Contusion
• Laceration
• Transsection – a cut across
• Hemorrhage and damage to blood vessels that supply spinal cord
o The one we are most concerned with
o It is important to do a baseline to ID problems such as swelling

A

Major causes

33
Q 
Immediate:
●stabilization & immobilization
●assure adequate oxygenenation
●prevent secondary injury:
●     pharmacology - IV steroids
●surgery- reduce fracture
●skeletal traction – tongs/ halo vest
●prevent complications
A

Emergency management

34
Q 
●corticosteroids – large dose
●vasopressors – dopamine      
●analgesics/ sedation
●antispasmotics baclofen (Lioresal)
●Oxybutynin chloride (Ditropan)
●anticoagulants
●stool softener/stool preps
A

Medications

35
Q

●NEVER use bracket to pull pt
●pin care- different applicator for each, NS only, check pins for loosening
●removable liner to clean
●NEVER use powder
●must have emergency access (buckle, key)

A

Halo Traction

36
Q

to test peripheral nerves

A

EMT

37
Q

an instrument that is attached to the skull to hyperextend the head and neck of patients with fractured cervical vertebrae for the purpose of immobilizing and aligning the vertebrae.
• A rope tied to the center of the tongs passes over a pulley at the head of the bed and is attached to a weight of 10 to 20 pounds, which hangs freely.

A

Crutchfield tongs

38
Q
  • The insertion sites of the tongs are inspected and cleaned every 1 to 2 hours
  • patient is turned and assisted in deep breathing every other hour and is given scalp and skin care every 2 to 4 hours
  • back rubs are administered to prevent pressure ulcers
  • Sandbags may be used to prevent the patient from sliding to the head of the bed, and the call bell is placed within easy reach
A

Crutchfield interventions

39
Q

Hygiene consists of cleaning each pin two to three times a day as prescribed by a physician. The patient should be instructed on how to use a mirror to inspect the sites for signs of infection, e.g., redness of the skin, or purulent drainage from around the pins. If the vest becomes wet, it should be dried with a hairdryer set on its lowest temperature setting. The shoulders and thorax should be inspected for signs of irritation from the vest. Additional padding may be required around pressure-sensitive areas.

A

Halo vest interventions

40
Q

Pins that are attached to the skull of patients immobilized with cervical injuries. The pins are used to apply traction to reduce a fracture or dislocation

A

Gardner-Wells tongs

41
Q

Corticosteroids – Decadron , neurological steroid
o Reduces edema
o Vasopressors – dopamine
o Antispasmotics baclofen (Lioresal)
o Used to help expand bladder so it doesn’t spasm and create incontinence
o These pts have tremendous pain above the fx injury
o If the fx is at C-6, at C-7 and above, they will complain of terrible pain in their arms and shoulders
o They are learning to breathe w/ their accessory muscles in their neck and shoulder
o They will have spasms in their good muscles which are now responsible for all movement, the wheelchair

A

SCI pharmacology

42
Q 
Oxybutynin chloride (Ditropan)
o Used to expand the amount of urine that can go into the bladder
o Want to cath pt q6h, not q4h
▪ Start at q4, build up to q6 so intermittent cath done QID
o Analgesics
o Some pt refuse pain meds
o Others want them every 3-4 hours
▪ OxyContin  2 tabs q12h
▪ Percoset 2 tabs q4h around the clock
A

SCI pharmacology

43
Q

Histamine H2 antagonist
o Head trauma and spinal cord injury pts are at a greater risk for gastric ulcers
• They have an increased histamine release and are given Prilosec (hs) and Pepcid (bid)
• Anticoagulants
o Put on heparin or lovenox
• Stool softener- Every day or night the pt must have a bowel movement

A

SCI PHARMACOLOGY

44
Q

when they touch the anus, external sphincter, does it retract?
• If yes, that is great
• If not, nurses must be in complete control of the bowels

A

Anal wink

45
Q
  • shock caused by the sudden loss of the autonomic nervous system signals to the smooth muscle in vessel walls
  • the vessels suddenly relax resulting in a sudden decrease in peripheral vascular resistance (vasodilation) and decreased blood pressure
  • These pts put on Dopamine, salt tabs, and give them meds to increase their blood pressure to 100-110
A

Neurogenic Shock

46
Q

caused by disruption of SNS
●↓ BP, ↓HR, ↓cardiac output
●hypothermia
●peripheral vasodilatation
●paralyzed portions do not perspire (blocked sympathetic activity)
• The body has lost the ability to generate heat
o Pt must be dressed warmly – they will complain about being cold
o They do not perspire below their level of injury
o Peripheral vasodilatation
o Decrease CO2
o Paralyzed portions do not perspire

A

Neurogenic shock

47
Q

●imbalance
●parasympathetic & sympathetic
●affects bowel, bladder and skeletal system
●temporary loss of reflexes sensation, flaccid paralysis below level of injury- may return in 1 – 6 weeks
●active rehab can begin

A

Complication of Spinal Shock

48
Q

o Seen very early in the injury – 48-72 hrs after injury
o Defined as the loss of motor and sensory below the injury, flaccid paralysis and the loss of reflexes
o Pt comes in fine, goes to surgery and then suddenly loses it all – it could be spinal shock
o This is r/t swelling and may or may not be permanent
• o Affects bowel, bladder and MS

A

Spinal Shock

49
Q

●profound bradycardia, hypotension
●flaccid paralysis of skeletal muscles below injury
●reflexes absent below level of injury
●absence of temperature, pain sensation below injury
●bowel and bladder dysfunction
●loss of ability to perspire
●with injury to cervical and upper thoracic spinal cord have loss of respiratory muscles

A

Clinical Manifestations: Spinal Shock

50
Q

o Absence of proprioception below level of injury
o Do the toe test – is it up or out or down
• Bowel and bladder dysfunction
• o With injury to cervical and upper thoracic spinal cord have loss of respiratory muscles
o Many pts are trached and are weaned off
▪ They will then need to use their accessory muscles to help them to breathe

A

Spins shock

51
Q 
●an exaggerated sympathetic response that occurs in patients with injury at T-6 or above  
● occurs when a stimulus triggers a sympathetic nervous system response
●urinary bladder distention
●distended bowel
●bladder infection
●ejaculation
●ingrown toenails
●draft from open door, wrinkled sheets
A

Autonomic Dysreflexia: “Going Hyper”

52
Q

o Urinary bladder distention
o Number one causes is a distended bladder
o Intermittent cath done instead of Foley cath – less risk of UTI
o Distended bowel
o Bladder infections
o Ejaculation
o One way quads realize they have sex is by getting Autonomic Dysreflexia – not pleasant, but rewarding to them
o Ingrown toenails
o Draft from open door, wrinkled sheets

A

Common causes of Autonomic Dysreflexia

53
Q 
o Pounding headache
o Bradycardia –early sign
o Flushing above level of injury
o Pale cold skin below
o Diaphoresis (especially of the forehead)
o Sudden acutely elevated blood pressure 300/160
o Nausea
o Piloerection – goose bumps
o Nasal stuffiness
o Visual disturbances
A

Clinical Manifestations: Autonomic Dysreflexia

54
Q

o Remove cause – most common is bladder and stool
o The time of last bowel movement is one of the most important things to get from report on an SCI pt
• o The 1st thing to do is raise the bed
o Elevate HOB 45˚
o Decrease BP if needed
o Give a Ca channel blocker – rarely done
▪ Problem is that if it was caused by a wrinkled sheet, when the sheet is adjusted, the BP goes way down and needs vassopressors to get it back up
o Check the BP
o Pt needs to be able to sit upright

A

Treatment of Autonomic Dysreflexia

Neuro 142 (13 decks)

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