Management of Neurological Disorders and Intervertebral Disk Prolapse PDF

 Prepared by Dr. Badria Abd Elshahed Elkattan Introduction Assessment of neurological disorder Management of patient with neurological dysfunction Herniation of a cervical intervertebral disk & lumber disk  Neurologic diseases are common a...

 Prepared by Dr. Badria Abd Elshahed Elkattan Introduction Assessment of neurological disorder Management of patient with neurological dysfunction Herniation of a cervical intervertebral disk & lumber disk  Neurologic diseases are common and costly. According to estimates by the World Health Organization, neurologic disorders affect over 1 billion people worldwide, constitute 12% of the global burden of disease, and cause 14% of global deaths. 1-Health history  Include details about chief complain, onset, signs& symptoms, predisposing factors , aggravating and relieving factors  Medications , Alcohol and recreational drugs  Any history of trauma or falls that may have involved the head or spinal cord.  Allergies  Habits / Lifestyle Changes  Family history Nervous system  Disturbance in level of consciousness, Memory Loss, Headache, Pain , Dizziness& vertigo, Seizures Musculoskeletal system  Weakness, Loss of Coordination, Tremors, Numbness, Paralysis Gastrointestinal system  Nausea / Vomiting, Bowel or Bladder Difficulties and Swallowing Difficulties Others  Visual disturbance, speech difficulties ( Aphasia) The neurologic examination includes the following:  Mental status  Cranial nerves  Motor system  Muscle strength  Gait, stance, and coordination  Sensation  Reflexes  Autonomic nervous system Glasgow Coma Scale (GCS) Three Categories: Eye opening Best motor response Best verbal response Eye opening response Spontaneous 4 To voice 3 To pain 2 None 1 Best verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensive sound 2 Non 1 Best motor response Obeys command 6 Localized pain 5 Withdraws 4 Flexion 3 Extention 2 Non 1 Total  Glasgow coma scale is a tool for assessing a patient's response to stimulate the level of consciousness at regular interval. The lowest score is '3' least responsive indicate deep coma, the highest is 15 most responsive, a GCS between 3 & 8 is generally accepted as indicating a severe head injury  Positron Emissions Tomography (PET) Scans  Cerebral Angiography  Lumbar Puncture (Spinal Tap)  Myelography  -Electroencephalogram (EEG)  Involves artery access (usually femoral),then a contrast medium is injected to visualized cerebral circulation. Used to detect aneurysms, tumors. A radioactive substance is either inhaled or injected ,used to assess blood flow , tissue composition ,measure brain function PET plus CT Combining a PET scan with an MRI or CT scan can help make the images easier to interpret. At left is a CT scan, while the center image is from a PET scanner. The image on the right is a combined CT-PET scan. The bright spot in the chest, seen best on the PET and CT-PET scans is lung cancer.  Nursing consideration cerebral angiography Prior to the procedure :  Assess for allergies to iodine  Injection of contrast medium may cause a burning or flushing sensation Post procedure :  Maintain bed rest with HOB elevated 30 degree  Neurovascular & puncture site assessment A needle is inserted into the subarachnoid space between the third and fifth lumber vertebrae.  Used to measure CSF fluid or pressure or inject a contrast medium or a medication  Contraindicated with increase intracranial pressure.  Is an X –ray of the spinal subarachnoid space taken after the injecting of a contrast agent into spinal subarachnoid space through lumbar puncture ,Allows for visualization of the vertebral column, intervertebral disks  Records the electrical activity of the brain through a series of electrodes on the scalp. Used to diagnose and evaluate seizures disorders, identify tumors, brain abscesses or infections and to confirm of brain death Cerebrospinal Fluid (CSF) Analyses Normal Findings:  pH 7.35-7.45  Specific Gravity: 1.007  Appearance: Clear, colorless and odorless  Cells: minimal number of WBCs and no RBCs  Positive Protein and Positive Glucose (2/3 blood sugar value) Definition  is a protrusion of the nucleus volvulus into the annulus fibrous with nerve compression  Types of Disc Herniaion:  1. Cervical  2. Thoracic (rare)  3. Lumbar  1. Degeneration  2. Trauma e.g. accidents, strain, repeated minor stresses  3. Congenital predisposition  Depends on location, size, rate of development, acute or chronic; effect on surrounding structures. -  1. Pain and stiffness of the neck and top of the shoulders and in the region of the scapulae.  2. Pain in upper extremities and head.  3. Numbness or tingling.  1. Low back pain accompanied motor impairment.  2. Pain in buttocks and increased by sneezing and straining  3. Postural deformity of the lumber spine  4. Pain induced by stretch  5. Muscle weakness.  1. X-ray of the spine  2. Myelogram:  3. Computerized Tomography  4. Neurological Examination  5. Electromyography  1. Herniation relapse  2. Arachnoiditis  3. Adhesion and scarring  4. Chronic neuritis  5. Failed disc syndrome(chronic back and leg pain that occur after spinal surgery  6- paralysis  1. Immobilize and rest the cervical spine by one of the following methods:  a. Cervical collar  b. Cervical traction  c. Bed rest  2. Muscle relaxant to control muscle spasm.  3. Give analgesics and sedative to control discomfort and anxiety.  4. Prepare for surgical intervention if significant neurological deficit from nerve root compression occurs.  5. Discharge planning and health teaching:  a. Avoid extreme flexion, extension and rotation of the cervical spine while working.  b. Keep head in a neutral position while sleeping.  c. Avoid excessive automobile riding during acute phase vibration has adverse effect on spine.  1. Encourage the patient to remain on bed rest  2. Use appropriate drug therapy: e.g. analgesic, anti inflammatory drugs.  3. Utilization of heat and massage by physiotherapist to relax the muscles.  4. Watch for development of neurological deficit: a. Muscle weakness and atrophy b. Loss of sensory and motor function c. Unrelieved acute pain  5. Have the patient increase his activity gradually.  6. Prepare for surgical intervention when indicated(laminectomy with removal of ruptured disc.)  7. Discharge planning and health teaching:  a. Encourage patient to do lumbar flexion exercises  b. Advise patient to sleep on side with knees and hips in position of flexion (pillow between knees).  c. Encourage proper posture while standing, sitting, walking, working.  d. A Jumbo- sacral support (corset) may be necessary  Laminectomy: Is the removal of the lamina, to expose the neural elements of the spinal canal. It allows inspection of the spinal canal and identification and removal of pathology and compression from the cord and roots.  1. Check neurological and vital signs at frequent intervals. 2-Be aware that a sore throat will be a major complaint of the patient.  A-Do not give any spray that numbs the throat since this may cause choking.  b. Observe for pulmonary secretions Pre –operative assessment  1. Assess for past injury to the neck.  2. Assess for pain onset, location, radiation.  3. Assess the area around the cervical spine by palpation to assess muscle tone and tenderness.  4. Asses, for range of motion in the neck and shoulders.  5. The nurse determines the patient's need for information about the operative procedure. , Post operative assessment includes:  A. Monitoring the BP and pulse.  B. Evaluate bleeding.  C. Inspect dressing for serosanguineous drainage.  D. Assess for headache  E. Check for weakness of the upper and lower extremities.  Pain related to the surgical procedure. Goal :Relief of pain Intervention:  1. Keep the patient flat in bed for 12 - 24 hours.  2. Give Analgesics, according to the patient's needs.  3. Soft diet may be given if the patient complains of dysphagia. 2-Impaired physical mobility related to post operative surgical regimen. Goal: Improved Mobility Intervention:  1. Cervical collar usually worn after the procedure.  2. Teach the patient to turn the body instead of the neck when looking from side to side.  3. Patient should wear shoes when ambulating to increase stability. C- Patient Teaching and Home Health Care:  1. The cervical collar is usually worn for about 6 weeks.  2. Patients are cautioned against flexing, extending, rotating the neck in any extreme manner while exercising or working.  3-Teach the patient while sleeping, the prone position should be avoided  4. Teach the patient to monitor signs and symptoms of fever, wound drainage.increased pain.  5. Avoid sitting or standing more than 30 minutes because this may induce neck strain.  6. Advise the patient to alternate tasks in which the body does not move: e.g. reading.