Chapter 40 Care Of Patients With Central Nervous System Problems PDF

Chapter 40 CARE OF PATIENTS WITH PROBLEMS OF THE CENTRAL NERVOUS SYSTEM: THE SPINAL CORD Copyright © 2021, Elsevier Inc. All Rights Reserved. CONCEPTS The priority concepts in this chapter are Immunit...

Chapter 40 CARE OF PATIENTS WITH PROBLEMS OF THE CENTRAL NERVOUS SYSTEM: THE SPINAL CORD Copyright © 2021, Elsevier Inc. All Rights Reserved. CONCEPTS The priority concepts in this chapter are Immunity Mobility The interrelated concepts in this chapter are Pain Sensory perception Cognition Sexuality Copyright © 2021, Elsevier Inc. All Rights Reserved.  IMMUNITY CONCEPT EXEMPLAR: MULTIPLE SCLEROSIS (MS) Pathophysiology Overview Affects myelin and nerve fibers of the brain and spinal cord Chronic disease characterized by demyelination Types Relapsing-remitting Primary progressive Secondary progressive Progressive-relapsing Copyright © 2021, Elsevier Inc. All Rights Reserved. MULTIPLE SCLEROSIS (MS): ETIOLOGY AND GENETIC RISK Changes in immunity are the most likely etiology Colder climates Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. MULTIPLE SCLEROSIS (MS): INCIDENCE AND PREVALENCE Ages 20 to 50 400,000. in the U.S. 2.3 million people worldwide 100,000 in Canada More frequently occurs in white people of Northern European ancestry, but if found in people of all races and ethnicity Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. MULTIPLE SCLEROSIS (MS): ASSESSMENT: RECOGNIZE CUES (1 OF 2) History Vision, mobility, sensory perception changes Physical Assessment/Signs and Symptoms Muscle weakness and spasticity Tremors Dysmetria Dysphagia Psychosocial Assessment Anger and frustration at length of time to obtain diagnosis Copyright © 2021, Elsevier Inc. All Rights Reserved. MULTIPLE SCLEROSIS (MS): ASSESSMENT: RECOGNIZE CUES (2 OF 2) Laboratory assessment CSF Other diagnostic assessment MRI of the brain Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. MULTIPLE SCLEROSIS (MS): ANALYSIS: ANALYZE CUES & PRIORITIZE HYPOTHESES Impaired immunity due to the disease and drug therapy for disease management Decreased or impaired mobility due to muscle spasticity, intention tremors, and/or fatigue Decreased visual acuity and cognition due to dysfunctional brain neurons Copyright © 2021, Elsevier Inc. All Rights Reserved. MULTIPLE SCLEROSIS (MS): PLANNING AND IMPLEMENTATION: GENERATE SOLUTIONS & TAKE ACTION Managing impaired immunity Improving mobility Managing decreased visual acuity and cognition Copyright © 2021, Elsevier Inc. All Rights Reserved. MULTIPLE SCLEROSIS (MS): CARE COORDINATION AND TRANSITION MANAGEMENT Home care management Self-management education MS affects the whole family and is often unpredictable and uncertain in terms of disease course Health care resources National MS Society Copyright © 2021, Elsevier Inc. All Rights Reserved. MOBILITY CONCEPT EXEMPLAR SPINAL CORD INJURY Pathophysiology Overview Complete versus incomplete Mechanism of injury Hyperflexion Hyperextension Axial loading or vertical compression Excessive rotation Penetrating trauma Copyright © 2021, Elsevier Inc. All Rights Reserved. SPINAL CORD INJURIES (SCIS) (1 OF 2) The image to the right demonstrates and identifies hyperflexion injury of the cervical spine. Copyright © 2021, Elsevier Inc. All Rights Reserved. SPINAL CORD INJURIES (SCIS) (2 OF 2) The image to the right identifies axial loading (vertical compression) injury of the cervical spine and the lumbar spine. Copyright © 2021, Elsevier Inc. All Rights Reserved. SPINAL CORD INJURY: ETIOLOGY Trauma Falls Acts of violence Sports/recreation-related accidents Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. SPINAL CORD INJURY: INCIDENCE AND PREVALENCE 18,000 new SCIs every year in the U.S. 80% are young males Cervical cord injuries more common than thoracic or lumbar cord injuries Average age is 43 years old Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. SPINAL CORD INJURY: ASSESSMENT: RECOGNIZE CUES (1 OF 2) History How injury occurred Mechanism of injury Pre-hospital care Physical Assessment/Signs and Symptoms Priority is ABCs Sensory Perception and Mobility assessment Other assessments Psychosocial Assessment Copyright © 2021, Elsevier Inc. All Rights Reserved. SPINAL CORD INJURY: ASSESSMENT: RECOGNIZE CUES (2 OF 2) Laboratory and Imaging assessment Basic laboratory studies Spine CT and MRI X-ray series Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. SPINAL CORD INJURY: ANALYSIS: ANALYZE CUES & PRIORITIZE HYPOTHESES Potential for respiratory distress/failure due to aspiration, decreased diaphragmatic innervation, and/or decreased mobility Potential for cardiovascular instability (e.g., shock and autonomic dysreflexia) due to loss or interruption of sympathetic innervation or hemorrhage Potential for secondary spinal cord injury due to hypoperfusion, edema, or delayed spinal column stabilization Decreased mobility and sensory perception due to spinal cord damage and edema Copyright © 2021, Elsevier Inc. All Rights Reserved. SPINAL CORD INJURY: PLANNING AND IMPLEMENTATION: GENERATE SOLUTIONS & TAKE ACTION Managing the airway and improving breathing Monitoring for cardiovascular instability Preventing secondary spinal cord injury Managing decreased mobility Copyright © 2021, Elsevier Inc. All Rights Reserved. SPINAL CORD INJURY: CARE COORDINATION AND TRANSITION MANAGEMENT Home care management Self-management education Mobility skills Pressure injury prevention ADL skills Bowel and bladder program Sexuality education Prevention of autonomic dysreflexia Health care resources Copyright © 2021, Elsevier Inc. All Rights Reserved. SPINAL CORD INJURY: EVALUATION: EVALUATE OUTCOMES The expected outcomes are that the patient: Exhibits no deterioration in neurologic status Maintains a patent airway, a physiologic breathing pattern, and adequate ventilation Does not experience a cardiovascular event (e.g., shock, hemorrhage, autonomic dysreflexia) or receives prompt treatment if an event occurs Does not experience secondary spinal cord injury, including VTE and heterotopic ossification Is free from complications of decreased mobility Performs mobility skills and basic ADLs as independently as possible with or without the use of assistive/adaptive devices Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. LOW BACK PAIN (LUMBOSACRAL BACK PAIN) Pathophysiology overview Acute – usually self-limiting; less than 4 weeks Subacute – 4-12 weeks Chronic persistent – more than 12 weeks Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. LOW BACK PAIN: HEALTH PROMOTION AND MAINTENANCE Preventive measures Proper posture Exercise Ergonomics Copyright © 2021, Elsevier Inc. All Rights Reserved. LOW BACK PAIN: ASSESSMENT: RECOGNIZE CUES (1 OF 2) Complete pain assessment Vertebral alignment and tenderness Paresthesia Copyright © 2021, Elsevier Inc. All Rights Reserved. LOW BACK PAIN: ASSESSMENT: RECOGNIZE CUES (2 OF 2) Imaging assessment Plain x-rays CT MRI Bone scan Myelogram/post-myelogram CT Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. LOW BACK PAIN: INTERVENTIONS: TAKE ACTION Management varies with severity and chronicity Interprofessional nonpharmacologic interventions recommended Surgery may be indicated if conservative measures fail to provide relief Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. LOW BACK PAIN: SURGICAL MANAGEMENT Minimally invasive surgery Microdiskectomy Laser thermodiskectomy Laser-assisted laparoscopic lumbar diskectomy Conventional open surgical procedures Diskectomy Laminectomy Spinal fusion Copyright © 2021, Elsevier Inc. All Rights Reserved. LOW BACK PAIN: POSTOPERATIVE CARE Depends on type of surgery performed Those having MIS go home the same day or day after the procedure Early postop care focuses on preventing complications Copyright © 2021, Elsevier Inc. All Rights Reserved. LOW BACK PAIN: CARE COORDINATION AND TRANSITION MANAGEMENT Home care management Self-management education Health care resources Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. CERVICAL NECK PAIN Results most often from bulging or herniation of nucleus pulposus in a cervical intervertebral disk Can also result from muscle or ligament strain, aging, poor posture, etc. Treatment is conservative Physical therapy Surgical management if conservative treatment is ineffective Copyright © 2021, Elsevier Inc. All Rights Reserved. CASE STUDY (1 OF 4) A 33-year-old man is brought to the ED after being hit from behind in a motor vehicle accident. The car that hit him was traveling at 20 mph. He has a cervical immobilizer on, and is alert and oriented. He reports neck pain of a “5” on a 0 to 10 scale, and otherwise appears in no distress. 1. What is the priority nursing assessment for this client? A. Airway B. Circulation C. Sensory perception D. Level of consciousness Copyright © 2021, Elsevier Inc. All Rights Reserved. ANSWER TO CASE STUDY QUESTION 1 ANS: A Even if the client is in no apparent distress, airway must always be assessed first. Circulation, level of consciousness, and sensory perception can be assessed after the airway. Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. CASE STUDY (2 OF 4) 2. The client is admitted for observation. Upon reassessment an hour later, which finding will the nurse immediately report to the provider? A. Unresolved headache B. Blood pressure of 90/70 mm Hg C. Neck pain remains at “5” on a 0-to- 10 scale D. Increase in the Glasgow Coma Scale score Copyright © 2021, Elsevier Inc. All Rights Reserved. ANSWER TO CASE STUDY QUESTION 2 ANS: B Low systolic blood pressure can indicate a decrease in perfusion to the spinal cord, which could worsen the client’s condition. A headache may linger. Neck pain is the chief concern, but it is unlikely to resolve completely while in the ED. An increase in the GCS score indicates improvement in a client’s condition. Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  CASE STUDY (3 OF 4) The next morning, the nurse notes that the client’s heart rate is 48/min and blood pressure is 78/64. His skin is warm and dry. 3. What is the appropriate nursing action? A. Notify the provider immediately. B. Apply oxygen at 2 L per nasal cannula. C. Raise the head of the bed to 45 degrees. D. Increase the rate of IV fluids from 50 to 75 mL/hr. Copyright © 2021, Elsevier Inc. All Rights Reserved. ANSWER TO CASE STUDY QUESTION 3 ANS: A Signs of neurogenic shock include severe bradycardia, warm and dry skin, and severe hypotension. The physician should be notified immediately because this is an emergency. It is best treated by restoring fluids to the circulating blood volume. While increasing the IV rate is a good intervention, going from 50 to 75 mL/hr will not be enough, and a physician’s order is needed to make this change. Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. CASE STUDY (4 OF 4) Ten days later the client is scheduled for discharge to a rehabilitation facility. 4. What does the nurse identify as realistic initial priorities of care during rehabilitation? Copyright © 2021, Elsevier Inc. All Rights Reserved. ANSWER TO CASE STUDY QUESTION 4 During rehabilitation, clients learn about self-care, mobility skills, and work on bowel and bladder retraining. A typical stay is 1 to 2 months. Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.  CHAPTER 40 AUDIENCE RESPONSE SYSTEM QUESTIONS Copyright © 2021, Elsevier Inc. All Rights Reserved. QUESTION 1 In assessing a client with persistent low back pain, which question will the nurse ask as the priority? A. “Are you still going to work?” B. “What helps you to manage the pain?” C. “Can you describe how the pain feels?” D. “Have you ever had an MRI of your back?” Copyright © 2021, Elsevier Inc. All Rights Reserved. ANSWER TO QUESTION 1 ANS: B Obtaining a thorough assessment of the client’s pain level and effective interventions to treat pain is an important element of the nursing assessment. The priority assessment question helps the nurse more fully understand the client’s experience with pain, and how the client has attempted to address the pain. All other questions can be asked as follow-ups to the priority question. Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. QUESTION 2 The nurse understand which component is a risk factor associated with the development of multiple sclerosis? A. Age > 50 B. Smoking C. Low-carb diet D. Female gender Copyright © 2021, Elsevier Inc. All Rights Reserved. ANSWER TO QUESTION 2 ANS: D MS affects women two to three times more often than men, suggesting a possible hormonal role in disease development. Some studies show that the disease occurs up to four times more often in women than men. The other factors have not been associated as risk factors for MS. Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. QUESTION 3 A client with a spinal cord injury at C5–C6 becomes flushed and reports a sudden severe headache. Vital signs show a blood pressure of 190/100 mm Hg and heart rate of 50 beats/min. What is the appropriate nursing intervention? A. Notify the health care provider. B. Place the client in a sitting position. C. Check the client for fecal impaction. D. Check the urinary catheter for obstruction. Copyright © 2021, Elsevier Inc. All Rights Reserved. ANSWER TO QUESTION 3 ANS: B Autonomic dysreflexia is an excessive, uncontrolled sympathetic output and is a neurologic emergency in clients with spinal cord injury T6 and above. The first priority of care is to place the client in a sitting position. Then contact the health care provider to treat the increased blood pressure. The cause of this syndrome is a noxious stimulus—most often a distended bladder or constipation. Rapid treatment is essential to prevent a stroke. All other actions can be taken after placing the client in the sitting position. Copyright © 2021, Elsevier Inc. All Rights Reserved. Copyright © 2016, 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.