Lecture 8 - Ortho Neuro PDF

lOMoARcPSD|6976302 Lecture 8 - Ortho neuro, professor lindor Health Alterations Ii (Broward College) StuDocu is not sponsored or endorsed by any college or university Downloaded by Taje' St. John ([email protected]) ...

lOMoARcPSD|6976302 Lecture 8 - Ortho neuro, professor lindor Health Alterations Ii (Broward College) StuDocu is not sponsored or endorsed by any college or university Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 Lecture 8 (Headache / Spinal Cord Injury [Surgery/Tumors])  Headaches  The most common type of pain experienced by humans  The majority of people have functional headaches  Migraine headaches  Tension-type headaches  The remainder have organic headaches  Caused by intracranial or extracranial disease  Headache pain can arise from both intracranial and extracranial sources  Not all tissues of the cranium are sensitive to pain  The pain-sensitive structures in the head  Venous sinuses  Dura  Cranial blood vessels  Three divisions of the trigeminal nerve (CNV)  Facial nerve (CN VII)  Glossopharyngeal nerve (CN IX)  Vagus nerve (CN X)  First three cervical nerves  Headaches are classified as primary or secondary headaches  Primary  When the cause is not a disease or another medical condition ○ Tension-type ○ Migraine ○ Cluster headaches  Secondary  Headaches caused by conditions ○ Sinus infection ○ Neck injury ○ Stroke  A patient may have more than one type of headache  Tension-Type Headache  Most common type of headache  Characteristics  Bilateral location  Pressing/Tightening quality  Base of the skull  Mild or moderate intensity  Not aggravated by physical activity  Episodic or chronic  Can last from minutes to days  Etiology/Pathophysiology  Abnormal neuronal sensitivity and pain facilitation  Clinical Manifestations Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  No prodrome (early manifestation of impending disease)  Does not involve nausea or vomiting  May involve sensitivity to light (photophobia) or sound (phonophobia)  May occur intermittently for weeks, months, or even years  Diagnostic Studies  Careful history  Electromyography (EMG) ○ May reveal sustained contraction of the neck, scalp, or facial muscles  Many patients may not show increased muscle tension with this test  Patients with diagnosed migraine headaches may show increased muscle tension on EMG  If tension-type headache is present during physical examination ○ Increased resistance to passive movement of the head ○ Tenderness of the head and neck  Migraine Headache  Recurring headache  Characteristics  Unilateral (sometimes bilateral)  Commonly anterior  Throbbing pain  Triggering event or factor  Strong family history  Manifestations associated with neurologic and autonomic nervous system dysfunction  Risk factors  Family history  Low level of education  Low socioeconomic status  High workload  Frequent tension-type headaches  Etiology/Pathophysiology  The exact etiology is not known  A complex series of neurovascular events initiates a migraine headache  A state of neuronal hyperexcitability in the cerebral cortex ○ Especially in the occipital cortex  Associated with ○ Seizure disorders ○ Tourette's syndrome ○ Ischemic stroke ○ Asthma ○ Depression ○ Anxiety Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  No known precipitating events  The headache may be precipitated or triggered by ○ Foods  Chocolate  Cheese  Oranges  Tomatoes  Onions  Monosodium glutamate  Aspartame  Alcohol (particularly red wine) ○ Hormonal fluctuation ○ Head trauma ○ Physical exertion ○ Fatigue ○ Stress ○ Drugs  Clinical Manifestations  Migraines can be preceded by prodrome and aura ○ Prodrome  May precede the headache phase by several hours or days  Neurologic  Photophobia  Psychologic  Hyperactivity  Irritability  Others  Food craving manifestations ○ Aura  Immediately precedes the headache  May last for 10 to 30 minutes before the start of the headache  Complex of neurologic symptoms  Visual  Bright lights  Scotomas (patchy blindness)  Visual distortions  Zigzag lines  Sensory  Hearing voices or sounds that do not exist  Strange smells  Motor  Weakness  Paralysis  Feeling that limbs are moving  Common migraine Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Migraine without and aura ○ Most common type of migraine headache  Classic migraine ○ Migraine with an aura ○ Occurs in only 10% of migraine headache episodes  The headache may last 4 to 72 hours  During the headache phase ○ Some patients may tend to “hibernate” ○ They seek shelter from noise, light, odors, people, and problems  The headache is described as a steady, throbbing pain that is synchronous with the pulse  Not all migraine headaches are disabling ○ Many patients who have migraine headaches do not seek health care treatment for them  Although the headache is usually unilateral, it may switch to the opposite side in another episode  Diagnostic Studies  Usually made from the history  Neuroimaging techniques are not recommended for routine evaluation of headache unless abnormal findings are found on the neurologic examination ○ CT with or without contrast ○ MRI  Cluster Headache  Rare form of headache  Repeated headaches that can occur for weeks to months at a time  Followed by periods of remission  Etiology/Pathophysiology  The trigeminal nerve is implicated in the production of pain  Also involves ○ Dysfunction of intracranial blood vessels ○ Sympathetic nervous system ○ Pain modulation systems  Due to the circadian rhythmicity of the headaches, the hypothalamus is believed to play a role  Clinical Manifestations  Sharp/stabbing  Unilateral  One of the most severe forms of headache  Intense pain lasting from a few minutes to 3 hours  Can occur every other day and as often as eight times a day  The attacks occur in clusters  The clusters occur with regularity ○ Usually occurring at the same time each day, during the same seasons of the year Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  The pain is generally located around the eye, radiating to the temple, forehead, cheek, nose, or gums  Other manifestations ○ Swelling around the eye (ptosis) ○ Lacrimation (tearing) ○ Facial flushing or pallor ○ Nasal congestion (rhinitis) ○ Constriction of the pupil  During the headache, the patient is often agitated and restless, unable to sit still or relax  Triggers ○ Alcohol ○ Strong odors ○ Napping  Diagnostic Studies  Primarily based on history  Ask the patient to keep a headache diary  CT scan, MRI, or MRA may be performed ○ Rule out an aneurysm, tumor, or infection  Lumbar puncture ○ Sometimes used to rule out other disorders that may cause similar symptoms  Other Types of Headaches  Headache can accompany  Subarachnoid hemorrhage  Brain tumors  Intracranial masses  Arteritis  Vascular abnormalities  Trigeminal neuralgia  Diseases of the eyes, nose, and teeth  Systemic illness ○ Bacteremia ○ Carbon monoxide poisoning ○ Mountain sickness ○ Polycythemia vera  Collaborative Care  If no systemic underlying disease is found  Therapy is directed toward the functional type of headache  These therapies include  Drugs  Meditation  Yoga  Biofeedback ○ The use of physiologic monitoring equipment to give the patient information regarding muscle tension and peripheral blood flow Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Skin temperature of the fingers ○ The patient is trained to relax the muscles and raise the finger temperature ○ And is given reinforcement (operant conditioning) in accomplishing these changes  Cognitive-behavioral therapy  Relaxation training  Acupuncture  Acupressure  Hypnosis  Drug therapy  Tension-Type Headache ○ Nonopioid analgesic  Aspirin  Acetaminophen  Used alone or in combination with a sedative, muscle relaxant, tranquilizer, or codeine ○ Many of these drugs have serious side effects  Caution the patient about the long-term use of aspirin and aspirin-containing drugs  They can cause upper GI bleeding and coagulation abnormalities in susceptible patients  Long-term use of Fiorinal should be avoided  In addition to aspirin, it contains a barbiturate which may be habit forming  Drugs containing acetaminophen can cause kidney damage with chronic use and liver damage when large doses are taken or when combined with alcohol  Migraine Headache ○ Mild or moderate migraine  Aspirin or acetaminophen ○ Moderate to severe headaches  Triptans  sumatriptan (Imitrex)  Affect selected serotonin receptors  Treat the suspected primary cause of migraine  Reduce the neurogenic inflammation of the cerebral blood vessels and produce vasoconstriction  Available in various forms: oral, subcutaneous, nasal spray  These drugs cause constriction of coronary arteries  They need to be avoided in patients with heart disease  Triptans should be taken at the first symptom of migraine headache  Drug Alert: Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Should not be given to patients with the following:  History or manifestations of ischemic cardiac, cerebrovascular, or peripheral vascular problems  Uncontrolled hypertension as it may increase blood pressure  Excess dosage may produce tremor, decreased respirations ○ Antiseizure drugs  Topiramate (Topamax)  Taken daily has been shown to be an effective therapy for migraine prevention  Common side effects  Hypoglycemia  Paresthesia  Weight loss  Cognitive changes  Topiramate must be used for 2 to 3 months to determine its effectiveness  Drug Alert:  Instruct patient to do the following:  Not abruptly discontinue as this may cause seizures  Avoid tasks that require alertness until response to drug is established  Take adequate fluid intake to decrease risk of renal stone development  Depakote  Used in migraine prevention ○ Antihypertensives  β-adrenergic blockers  Inderal  Tenormin  Calcium channel blockers  Isoptin  angiotensin-converting enzyme (ACE) inhibitors  Zestril  angiotensin-receptor blockers (ARBs)  Atacand  alpha2-adrenergic agonists  Catapres ○ Antidepressants  Also used in migraine prophylaxis  Tricyclic antidepressants  Elavil  Selective serotonin reuptake inhibitors  Prozac Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Botulinum toxin A (Botox)  Has been used in the prophylactic treatment of chronic daily headaches and migraines that do not respond to other medications  It may take 2 to 3 months of injections in the scalp and temple before the frequency and severity of migraine headaches are lessened  This intervention is expensive  Must be repeated every 2 to 3 months  Must be continued for at least 3 to 6 months  Cluster Headache ○ Inhalation of 100% oxygen delivered at a rate of 6 to 8 L/min for 10 minutes  May relieve headache  Causes vasoconstriction  Increases the synthesis of serotonin in the central nervous system  Can be repeated after a 5-minute rest ○ The Triptans (Imitrex) are also effective in treating acute cluster headache ○ Prophylactic drugs  Verapamil  Lithium  Ergotamine  Divalproex  NSAIDs ○ Methysergide may be used prophylactically when the cluster headache recurs at a known time ○ Intranasal administration of lidocaine ○ Invasive nerve blocks ○ Ablative neurosurgical procedures ○ Deep brain stimulation  Other Headaches ○ Patients with frequent headaches may overuse analgesic drugs ○ Medication overuse headache (MOH)  Term used to describe an analgesic rebound headache ○ Treatment  Abrupt withdrawal of the offending drug  Except for opioids, which need to be tapered  Initiation of alternative drugs  Amitriptyline  Nursing Management  Assessment  Subjective Data ○ Past health history  Seizures Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Cancer  Recent fall or trauma  Cranial infection  Stroke  Asthma or allergies  Mental illness  Relationship of headache to overwork, stress, menstruation, exercise, food, sexual activity, travel, bright lights, or noxious environmental stimuli ○ Medications (use of..)  Apresoline  Bromides  Nitroglycerin  Ergotamine (withdrawal)  NSAID’s (in high daily doses)  Estrogen preparations  Oral contraceptives  Over-the-counter or prescription remedies ○ Surgery or other treatments  Craniotomy  Sinus surgery  Facial surgery ○ Health perception/Management  Positive family history  Malaise ○ Nutritional/Metabolic  Ingestion of alcohol, caffeine, cheese, chocolate, monosodium glutamate, aspartame, lunch meats (nitrites in cured meats), sausage, hot dogs, onions, avocados  Anorexia  N/V (migraine prodrome)  Unilateral lacrimation (cluster) ○ Activity/Exercise  Vertigo  Fatigue  Weakness  Paralysis  Fainting ○ Sleep/Rest  Insomnia ○ Cognitive/Perceptual  Migraine  Aura  Unilateral, severe, throbbing (possible switching of side) headache  Visual disturbances Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Photophobia  Phonophobia  Dizziness  Tingling or burning sensations  Cluster  Unilateral and severe, nocturnal headache  Nasal stuffiness  Tension-type  Bilateral, bandlike, dull and persistent, base-of-skull headache  Neck tenderness ○ Self-perception/Self-concept  Depression ○ Coping/Stress tolerance  Stress  Anxiety  Irritability  Withdrawal  Objective Data ○ General  Anxiety  Apprehension ○ Integumentary  Cluster  Forehead diaphoresis  Pallor  Unilateral facial flushing with cheek edema  Conjunctivitis  Migraine  Generalized edema (prodrome)  Pallor  Diaphoresis ○ Neurologic  Horner's syndrome  Restlessness (cluster)  Hemiparesis (migraine) ○ Musculoskeletal  Resistance of head and neck movement  Nuchal rigidity (meningeal, tension-type)  Palpable neck and shoulder muscles (tension-type) ○ Possible Diagnostic Findings  Possible evidence of disease, deformity, or infection on brain imaging (CT, MRI, MRA), cerebral angiogram, lumbar puncture, EEG, EMG  Nonspecific brain imaging or laboratory tests  The history provides the key to assessment of headache Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ It should include specific details of the headache itself  Location  Type of pain  Onset  Frequency  Duration  Relation to events (emotional, psychologic, physical)  Time of day of the occurrence  Information about previous illnesses, surgery, trauma, allergies, family history, and response to medication  Suggest that the patient keep a diary of headache episodes with specific details  Diagnoses  Acute Pain  Planning  Have reduced or no pain  Experience increased comfort and decreased anxiety  Demonstrate understanding of triggering events and treatment strategies  Use positive coping strategies to deal with chronic pain  Experience increased quality of life and decreased disability  Implementation  Chronic headaches may be related to an inability to cope with daily stresses  Help the patient identify precipitating factors and develop ways to avoid them  Things that can help decrease the recurrence of headache ○ Daily exercise ○ Relaxation periods ○ Socializing  Suggest alternative ways of handling the pain of headache through techniques ○ Relaxation ○ Meditation ○ Yoga ○ Self-hypnosis  Encourage the migraine sufferer to seek a quiet, dimly lit environment  Massage and moist hot packs to the neck and head can help a patient with tension-type headaches  For the patient whose headaches are triggered by food ○ Dietary counseling may be provided ○ The patient needs to be encouraged to eliminate foods that may provoke headaches ○ Active challenge and provocative testing with specific foods may be necessary to determine the specific causative agents Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Teach the patients to avoid smoking and exposure to triggers such as strong perfumes, volatile solvents, and gasoline fumes  Cluster headache attacks may occur at high altitudes with low oxygen levels during air travel ○ Ergotamine, taken before the plane takes off may decrease the likelihood of these attacks  Patient Teaching and Caregiver Teaching Guide  Keep a diary or calendar of headaches and possible precipitating events  Avoid factors that can trigger a headache  Foods containing amines (cheese, chocolate), nitrites (meats such as hot dogs), vinegar, onions, monosodium glutamate  Fermented or marinated foods  Caffeine  Oranges  Tomatoes  Aspartame  Nicotine  Ice cream  Alcohol (particularly red wine)  Emotional stress  Fatigue  Drugs ○ Ergot-containing preparations ○ Monoamine oxidase inhibitors  Learn the purpose, action, dosage, and side effects of drugs taken  Self-administer sumatriptan (Imitrex) subcutaneously if prescribed  Use stress reduction techniques such as relaxation  Participate in regular exercise  Contact health care provider if the following occur  Symptoms ○ Become more severe ○ Last longer than usual ○ Resistant to medication  Nausea and vomiting (if severe or not typical)  Change in vision  Fever occurs with the headache  Problems with drugs  Spinal Cord Injury  The spine transmits messages  Motor and sensory functions  Etiology  Causes  Motor vehicle crashes (majority)  Males ages 16-30 are at greatest risk Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Falls  Violence  Sports injuries  Major Problems  Premature death  Disrupts growth and development ○ Disrupts growth  Economic loss/Health care cost ○ Rehab  Common sites for injury  Cervical ○ C4-C7 ○ T1  Thoracolumbar junction ○ T12, L1-L2  Trauma to the spinal cord causes  Concussion  Contusion  Laceration  Hemorrhage ○ Leads to swelling/compression ○ Not much are for expansion in the spinal cord  Transaction ○ Complete or incomplete ○ Loss of motor/sensory  Pathophysiology  The spinal cord can be injured by  Direct forces (traumatic) ○ Penetration ○ Gun shot wound ○ Sports injury  Indirect forces (non-traumatic) ○ Compression ○ Tumor ○ Infection  Initial Injury  Spinal cord injury can be due to: ○ Cord compression by bone displacement ○ Interruption of blood supply to the cord  Traction  Pulling on the cord ○ Penetrating trauma  Gunshot and stab wounds  Can result in tearing and transaction  Primary Injury Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ The initial mechanical disruption of axons as a result of stretch or laceration ○ Actual physical disruption of axons  Secondary injury ○ The ongoing, progressive damage that occurs after the initial injury  Because secondary injury progresses over time  The extent of injury and prognosis for recovery are most accurately determined at least 72 hours or more after the injury ○ Ischemia ○ Hypoxia ○ Hemorrhage ○ Edema  The spinal cord has minimal ability to adapt to vasospasm  Permanent damage may occur because of the development of edema ○ Lack of space for tissue expansion ○ Compression of the cord ○ Increased ischemic damage  Spinal and Neurogenic Shock ○ Spinal Shock  Neurological problem  Below the level of the injury  Decreased reflexes  Loss of sensation  Flaccid paralysis  Lasts days to months  May mask postinjury neurologic function ○ Neurogenic Shock  Due to the loss of vasomotor tone caused by injury  Hypotension  Bradycardia  Loss of sympathetic nervous system innervation  Peripheral vasodilation  Venous pooling  Decreased cardiac output  Generally associated with a cervical or high thoracic injury  T6 or higher  Classification  Mechanism of Injury ○ Flexion  Respirations ○ Hyperextension ○ Flexion-rotation ○ Extension-rotation Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Compression  Bladder/bowel  Leg movement  Seen in the elderly  Due to osteoporosis (bones are brittle) ○ Dislocation ○ Penetrating  Level of Injury ○ Skeletal level  Vertebral level  Most damage to vertebral bones and ligaments ○ Neurologic level  Lowest segment of the spinal cord  Normal sensory and motor function on both sides of the body ○ The level of injury may be:  Cervical  Paralysis of all four extremities occurs (tetraplegia)  When the damage is low in the cervical cord  The arms are rarely completely paralyzed  The higher the level, the more serious the injury  Thoracic  Lumbar  If the thoracic or lumbar cord is damaged  Paraplegia (paralysis and loss of sensation in the legs)  Sacrum  Degree of Injury ○ Complete  Total loss of sensory and motor function below the level of injury ○ Incomplete (partial)  Mixed loss of voluntary motor activity and sensation  Some tracts are intact  Six syndromes are associated with incomplete lesions:  Central Cord Syndrome  Damage to the central spinal cord  Occurs most commonly in the cervical cord region  Manifestations  Complete loss of movement and sensation below the level of injury  Motor weakness and sensory loss in both the upper and lower extremities  Upper extremities are affected more  Anterior Cord Syndrome  Damage to the anterior spinal artery Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Compromised blood flow to the anterior spinal cord  Often a flexion injury  Posterior cord tracts are not injured  Sensations of touch, position, vibration, and motion remain intact  Manifestations  Motor paralysis and loss of pain and temperature sensation below the level of injury  Brown-Sequard Syndrome  Damage to one half of the spinal cord  Manifestations  Same side of the lesion (ipsilateral) o Loss of motor function, position, vibratory sense, and vasomotor paralysis  Opposite side of the lesion (contralateral) o Loss of pain and temperature sensation  Typically results from a penetrating  Posterior Cord Syndrome  Compression or damage to the posterior spinal artery  Very rare  Dorsal columns are damaged  Manifestations  Loss of proprioception (position sense), vibratory sense, and crude touch  Pain, temperature sensation, and motor function below the level of the lesion remain intact  Conus Medullaris Syndrome / Cauda Equina Syndrome  Damage to the very lowest portion of the spinal cord  Lumbar nerve roots  Conus medullaris  Manifestations  Flaccid paralysis of the lower limbs  Areflexic (flaccid) bladder and bowel  Functional Level of Spinal Cord Injury and Rehabilitation Potential  Tetraplegia (C1-C8) ○ C1-C3  Often fatal  Vagus nerve domination  Heart  Respiration  Blood vessels  Organs below injury  Movement Remaining  Neck and above  Loss of innervation to diaphragm Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Absence of independent respiratory function  Rehab Potential  Ability to drive electric wheelchair with portable ventilator by using chin control or mouth stick  Vent at all times  Headrest to stabilize head  Computer use with mouth stick, head wand, or noise control  24 hour attendant care  Able to instruct others ○ C4  Vagus nerve domination  Heart  Respirations  Vessels and organs below injury  Movement Remaining  Sensation and movement in neck and above  May be able to breathe without a ventilator  May not need vent continuously  Rehab Potential  Same as C1-C3 ○ C5  Vagus nerve domination  Heart  Respirations  Vessels and organs below injury  Movement Remaining  Full neck  Partial shoulder  Back  Biceps  Gross elbow  Inability to roll over or use hands  Decreased respiratory reserve  Rehab Potential  Ability to drive electric wheelchair with mobile hand supports  Indoor mobility in manual wheelchair  Able to feed self with setup and adaptive equipment  Attendant care 10 hours/day ○ C6  Vagus nerve domination  Heart  Respirations  Vessels and organs below injury  Movement Remaining Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Shoulder and upper back abduction  Rotation at shoulder  Full biceps to elbow flexion  Wrist extension  Weak grasp of thumb  Decreased respiratory reserve  Rehab Potential  Ability to assist with transfer and perform some self-care  Feed self with hand devices  Push wheelchair on smooth, flat surface  Drive adapted van from wheelchair  Independent computer use with adaptive equipment  Attendant care 6 hours/day ○ C7-C8  Vagus nerve domination  Heart  Respirations  Vessels and organs below injury  Movement Remaining  All triceps to elbow extension  Finger extensors and flexors  Good grasp with some decreased strength  Decreased respiratory reserve  Rehab Potential  Ability to transfer self to wheelchair  Roll over and sit up in bed  Push self on most surfaces  Perform most self-care  Independent use of wheelchair  Ability to drive car with powered hand controls (in some patients)  Attendant care 0-6 hours/day  Paraplegia (T1-L4) ○ Thoracic Injuries  Loss of movement of the chest, bowel, bladder, and legs  Autonomic dysreflexia (complication)  Visceral distention ○ T1-T6  Sympathetic innervation to heart, vagus nerve domination of all vessels and organs below injury  Movement Remaining  Full innervation of upper extremities  Essential intrinsic muscles of hand  Full strength and dexterity of grasp  Decreased trunk stability  Decreased respiratory reserve Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Rehab Potential  Full independence in self-care and in wheelchair  Ability to drive car with hand controls (in most patients)  Independent standing in standing frame ○ T6-T12  Vagus nerve domination  Only of leg vessels  GI and genitourinary organs  Movement Remaining  Full, stable thoracic muscles and upper back  Functional intercostals  Increased respiratory reserve  Rehab Potential  Full independent use of wheelchair  Ability to stand erect with full leg brace  Ambulate on crutches with swing  Inability to climb stairs ○ L1-L2  Vagus nerve domination  Leg vessels  Movement Remaining  Varying control of legs and pelvis  Instability of lower back  Rehab Potential  Good sitting balance  Full use of wheelchair  Ambulation with long leg braces ○ Lumbar and Sacral Injuries  Loss of movement and sensation of lower extremities  Neurogenic bladder  Ejaculation problems (males) ○ L3-L4  Partial vagus nerve domination  Leg vessels  GI and genitourinary organs  Movement Remaining  Quadriceps and hip flexors  Absence of hamstring function  Flail ankles  Rehab Potential  Completely independent ambulation with short leg braces and canes  Inability to stand for long periods  Clinical Manifestations  Related to the level and degree of injury  Incomplete lesion Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  May demonstrate a mixture of symptoms  The higher the injury  The more serious  Proximity of the cervical cord to the medulla and brainstem  Respiratory System  Cervical injury above the level of C4 ○ Total loss of respiratory muscle function. ○ Mechanical ventilation is required to keep the patient alive  Cervical injury below the level of C4 ○ Diaphragmatic breathing if the phrenic nerve is functioning ○ Spinal cord edema and hemorrhage can affect the function of the phrenic nerve and cause respiratory insufficiency  Cervical and thoracic injuries ○ Paralysis of abdominal/intercostal muscles  Patient cannot cough effectively enough to remove secretions  Atelectasis  Pneumonia  Neurogenic pulmonary edema may occur ○ Secondary to a dramatic increase in sympathetic nervous system activity  Shunts blood to the lungs ○ May occur in response to fluid overload  Cardiovascular System  Any cord injury above the level of T6 ○ Decreases the influence of the sympathetic nervous system  Bradycardia  HR < 40  Atropine  ↑ HR  Prevent hypoxemia  Peripheral vasodilation  Hypotension  Peripheral vasodilation ↓ venous return of blood to the heart  ↓ cardiac output  hypotension  IV fluids  Vasopressor drugs ○ Cardiac monitoring is necessary  Urinary System  Urinary retention  Spinal shock ○ Bladder is atonic ○ Becomes overdistended ○ Indwelling catheter is inserted to drain the bladder  Postacute phase ○ Bladder may become hyperirritable Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Loss of inhibition from the brain  Reflex emptying  GI System  Injury above the level of T5 ○ Hypomotility ○ Paralytic ileus ○ Gastric distention  NG tube for intermittent suctioning  May relieve gastric distention.  Reglan to treat delayed gastric emptying  Development of stress ulcers ○ Excessive release of hydrochloric acid in the stomach  Histamine (H2)-receptor blockers  Zantac  Pepcid  Proton pump inhibitors  Protonix IV  Prilosec  Prevacid  Intraabdominal bleeding may occur ○ Difficult to diagnose ○ No subjective signs are observed  Pain, tenderness, and guarding ○ Things that may indicate bleeding  Continuous hypotension inspite of treatment  ↓ hemoglobin and hematocrit  Expanding girth  Neurogenic bowel ○ Less voluntary neurologic control over the bowel ○ Early period after injury  Spinal shock is present  Injury level of T12 or below  Bowel is areflexic  Sphincter tone is decreased ○ As reflexes return  Bowel becomes reflexic  Sphincter tone is enhanced  Reflex emptying occurs ○ Both types of neurogenic bowel can be managed successfully with a regular bowel program  Integumentary System  Lack of movement is the potential for skin breakdown ○ Bony prominences ○ Areas of decreased or absent sensation  Pressure ulcers can occur quickly ○ Can lead to major infection or sepsis Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Thermoregulation  Poikilothermism ○ Adjustment of the body temperature to the room temperature ○ Interruption of the sympathetic nervous system  Prevents peripheral temperature sensations from reaching the hypothalamus  Decreased ability to sweat or shiver below the level of the lesion  which also affects the ability to regulate body temperature  Patients with high cervical injuries ○ Greater loss of the ability to regulate temperature  Metabolic Needs  Metabolic acidosis ○ Decreased tissue perfusion  Electrolyte levels ○ Can be altered by gastric suctioning  Metabolic alkalosis ○ Must be monitored until suctioning is discontinued and a normal diet is resumed  Loss of weight is common  Nutritional needs are much greater  Peripheral Vascular Problems  DVT ○ More difficult to detect  The usual signs and symptoms  Pain/tenderness will not be present ○ Techniques for assessment  Doppler examination  Impedance plethysmography  Measurement of leg and thigh girth  Pulmonary embolism ○ One of the leading causes of death  Diagnostic Studies  CT scan  Stability of the injury  Location and degree of bony injury  Degree of spinal canal compromise  Cervical x-rays  Obtained when CT scan is not readily available  MRI  Assess for soft tissue and neural changes  Neurologic examination  Assessment of the head, chest, and abdomen for additional injuries or trauma  Collaborative Care  Immediate postinjury goals:  Patent airway Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Adequate ventilation  Adequate circulating blood volume  Preventing extension of cord damage (secondary damage)  Systemic and neurogenic shock must be treated to maintain blood pressure  Injury at the cervical level  All body systems must be maintained until the full extent of the damage can be evaluated  The systemic support is less intense for SCI’s of the thoracic and lumbar vertebrae ○ Respiratory compromise is not as severe ○ Bradycardia is not a problem  Assess motor status  Test muscle groups rather than individual muscles ○ With and against gravity ○ Alone and against resistance ○ Both sides of the body  Note spontaneous movement  Ask the patient to move legs and then hands, spread fingers, extend wrists, and shrug shoulders  Sensory examination  Touch and pain ○ Tested by pinprick ○ Start at the toes and work upward  Position sense and vibration can also be assessed  The types of injury mechanisms that cause spinal cord trauma may also result in brain injury  Especially those involving the cervical cord  Assess ○ History of unconsciousness ○ Signs of concussion ○ Increased intracranial pressure  Careful assessment for musculoskeletal injuries and trauma to internal organs  There are no muscle, bone, or visceral sensations  The only clue to internal trauma with hemorrhage ○ Rapidly falling hematocrit level  Examine the urine for hematuria  Move the patient in alignment as a unit (“logroll”) during transfers and when repositioning  Prevent further injury  Monitor respiratory, cardiac, urinary, and GI functions  Nonoperative Stabilization  Stabilization of the injured spinal segment and decompression ○ Traction ○ Realignment Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Eliminate damaging motion at the injury site  Prevent secondary spinal cord damage caused by repeated contusion or compression  Surgical Therapy  Surgery stabilizes the spinal column  Criteria used in the decision for early surgery ○ Evidence of cord compression ○ Progressive neurologic deficit ○ Compound fracture of the vertebrae ○ Bony fragments (may dislodge and penetrate the cord) ○ Penetrating wounds of the spinal cord or surrounding structures  Surgical procedures ○ Decompression laminectomy by anterior cervical and thoracic approaches with fusion  Takes pressure off the spine ○ Posterior laminectomy with the use of acrylic wire mesh and fusion ○ Insertion of stabilizing rods  Drug Therapy  Methylprednisolone (Slumedrol) within 8 hours of injury ○ ↓ swelling ○ Thought to improve blood flow and reduce edema in the spinal cord ○ Side effects  Immunosuppression  Increased frequency of upper GI bleeding  Increased risk of infection  Vasopressor agents ○ dopamine (Intropin) ○ Used to maintain the mean arterial pressure at a level > 90\ ○ Perfusion to the spinal cord is improved  Nursing Management  Assessment  Subjective Data ○ Past Health History  Motor vehicle crash  Sports injury  Industrial incident  Gunshot or stabbing injury  Falls ○ Health Perception/Management  Use of alcohol or recreational drugs  Risk-taking behaviors ○ Activity/Exercise  Loss of strength, movement, and sensation below level of injury Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Dyspnea  Inability to breathe adequately (“air hunger”) ○ Cognitive/Perceptual  Presence of tenderness, pain at or above level of injury  Numbness, tingling, burning, twitching of extremities ○ Coping/Stress Tolerance  Fear  Denial  Anger  Depression  Objective Data ○ General  Poikilothermism (unable to regulate body heat) ○ Integumentary  Warm, dry skin below level of injury (neurogenic shock) ○ Respiratory  C1-3  Apnea  Inability to cough  C4  Poor cough  Diaphragmatic breathing  Hypoventilation  C5-T6  Decreased respiratory reserve ○ Cardiovascular  Above T5  Bradycardia  Hypotension  Postural hypotension  Absence of vasomotor tone ○ GI  Above T5  Paralytic ileus  Decreased or absent bowel sounds  Abdominal distention  Constipation  Fecal incontinence  Fecal impaction ○ Urinary  Between T1 and L2  Retention  Acute stage  Flaccid bladder  Later stage  Spasticity with reflex bladder emptying Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Reproductive  Priapism  Loss of sexual function ○ Neurologic  Complete  Flaccid paralysis and anesthesia below the level of injury  Above C8  Tetraplegia  Below C8  Paraplegia  Hyperactive deep tendon reflexes  Bilaterally positive Babinski test  After resolution of spinal shock  Incomplete  Mixed loss of voluntary motor activity and sensation ○ Musculoskeletal  Muscle atony (in flaccid state)  Contractures (in spastic state) ○ Possible Diagnostic Findings  Spinal x-ray  Location of level and type of bony involvement  CT scan and MRI  Lesion  Edema  Compression  Positive finding on myelogram  Diagnoses  Ineffective breathing pattern  Impaired skin integrity  Constipation  Impaired urinary elimination  Risk for autonomic dysreflexia  Ineffective coping  Planning  Maintain an optimal level of neurologic functioning  Have minimal or no complications of immobility  Learn new skills, gain new knowledge, and acquire new behaviors to be able to care for self or successfully direct others to do so  Return to home and the community at an optimal level of functioning  Implementation  Health Promotion ○ Identification of high-risk populations ○ Counseling ○ Education  Seat belt use in cars Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Helmets for motorcyclists and bicyclists  Child safety seats  Tougher penalties for drunk-driving offenses  Acute Intervention ○ Immobilization  Proper immobilization of the neck involves the maintenance of a neutral position  Safety Alert:  Use a blanket or towel roll, a hard cervical collar, and a backboard to stabilize the neck to prevent lateral rotation of the cervical spine  Body should always be correctly aligned  Turning should be performed so that the patient is moved as a unit (logrolling) to prevent movement of the spine  Cervical Injuries  Skeletal traction  Used less frequently  Realignment or reduction of the injury is targeted  Traction is provided by a rope that is extended from the center of the tongs over a pulley and has weights attached at the end  Traction must be maintained at all times  One disadvantage of skull tongs  Skull pins can be displaced  If this occurs, hold the head in a neutral position and summon help  Stabilize the head while the physician reinserts the tongs  Infection at the sites of tong insertion is another potential problem  Clean the sites twice a day with normal saline solution and applying an antibiotic ointment  Special beds  Often used  Allows a frequency of turns greater than 200 times per day  Used to decrease the likelihood of pressure sores  Hard cervical collar or sternal-occipital-mandibular immobilizer brace  Can be worn until the fusion becomes solid  A halo fixation apparatus may be applied  Most frequently used method of stabilizing cervical injuries  The apparatus can be attached to a body vest, stabilizing the injured area and allowing ambulation if the patient is neurologically intact Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Thoracic or Lumbar Spine Injuries  Immobilized with a custom thoracolumbar orthosis (“body jacket”)  Inhibits spinal flexion, extension, and rotation  Nursing Management  Meticulous skin care is critical  Decreased sensation and circulation make the patient particularly susceptible to skin breakdown  Patients should be removed from backboards as soon as possible  Cervical collars should be properly fitted  Inspect the areas under the halo vest or jacket or under braces or orthoses to assess the skin condition  Halo Vest Care  Inspect the pins on the halo traction ring  Report to health care provider if pins are loose or if there are signs of infection (redness, tenderness, swelling, or drainage at the insertion sites)  Clean around pin sites carefully with hydrogen peroxide, water, or alcohol on a cotton swab as directed  Apply antibiotic ointment as prescribed  To provide skin care, the patient should lie down on a bed with his or her head resting on a pillow to reduce pressure on the brace  Loosen one side of the vest  Gently wash the skin under the vest with soap and water, rinse it, and then dry it thoroughly  At the same time, check the skin for pressure points, redness, swelling, bruising, or chafing  Close the open side and repeat the procedure on the opposite side  If the vest becomes wet or damp, it can be carefully dried with a blow dryer  An assistive device (cane, walker) may be used to provide greater balance  Flat shoes should be worn  Turn the entire body, not just the head and neck, when trying to view sideways  In case of an emergency, keep a set of wrenches close to the halo vest at all times  Mark the vest strap such that consistent buckling and fit can be maintained  Avoid grabbing bars or vest to assist patient  Keep sheepskin pad under vest, change and wash at least weekly  If perspiration or itching is a problem Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 A cotton T-shirt can be worn under sheepskin The T-shirt can be modified with a Velcro seam closure on one side ○ Respiratory Dysfunction  Spinal cord edema  May increase the level of dysfunction  Respiratory distress may occur  Endotracheal intubation/Tracheostomy or Mechanical Ventilation  Injury that is at C3 or above  If the patient is exhausted from labored breathing  ABG’s deteriorate  Inadequate oxygenation or ventilation  Potential problems  Pneumonia/Atelectasis  Reduced vital capacity  Loss of intercostal and abdominal muscle function  Diaphragmatic breathing  Pooled secretions  Ineffective cough  Nasal stuffiness  Bronchospasms  Nursing Management  Regularly assess  Breath sounds  ABG’s  Tidal volume  Vital capacity  Skin color  Breathing patterns  Especially the use of accessory muscles  Subjective comments about the ability to breathe  Amount and color of sputum  A patient who is unable to count to 10 aloud without taking a breath needs immediate attention  Maintain ventilation  Administer oxygen until ABG’s stabilize  Chest physiotherapy and assisted coughing  Facilitate the raising of secretions  Assisted (augmented) coughing  Simulates the action of the ineffective abdominal muscles during the expiratory phase of a cough  Place the heels of both hands just below the xiphoid process and exert firm upward pressure to the area timed with the patient's efforts to cough  Tracheal suctioning Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  If crackles or rhonchi are present  Incentive spirometry  An additional technique that can be used to improve the patient's respiratory status ○ Cardiovascular Instability  Unopposed vagal response  Heart rate is slowed  Any increase in vagal stimulation can result in cardiac arrest  Turning  Suctioning  Loss of sympathetic tone in peripheral vessels  Chronic low blood pressure  Potential postural hypotension  Lack of muscle tone to aid venous return  Sluggish blood flow  Predispose the patient to DVT  Nursing Management  Assess vital signs frequently  Bradycardia  Anticholinergic drug (Atropine)  A temporary or permanent pacemaker may be inserted  Hypotension  Vasopressor agent  Dopamine  Norepinephrine  Fluid replacement  Prevent thromboemboli and promote venous return  Sequential compression devices  Compression gradient stockings  Stockings must be removed every 8 hours for skin care  Perform range of motion exercises and stretching regularly  Assess the thighs and calves of the legs every shift for signs of DVT  Prophylactic heparin or low-molecular-weight heparin  Lovenox  Contraindications (internal bleeding and recent surgery)  Blood loss from other injuries  Hemoglobin and hematocrit levels should be monitored  Blood should be administered according to protocol Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Monitor the patient for indications of hypovolemic shock secondary to hemorrhage ○ Fluid and Nutrition Maintenance  The GI tract may stop functioning  Paralytic ileus  Nasogastric tube must be inserted  The patient cannot have oral intake  Fluid and electrolyte needs must be carefully monitored  Specific solutions and additives are ordered based on individual requirements  Once bowel sounds are present or flatus is passed  Oral food and fluids can gradually be introduced  High-protein, high-calorie diet is necessary for energy and tissue repair  High cervical cord injuries  Evaluate swallowing before starting oral feedings  If the patient is unable to resume eating  Enteral or parenteral nutrition may be started  If the patient is not eating adequately  Thoroughly assess the cause  Provide a pleasant eating environment  Allow adequate time to eat  Encourage the family to bring in special foods  Plan social rewards for eating  Keep a calorie count  Record the patient's daily weight  Dietary supplements may be necessary to meet nutritional needs  Increased dietary fiber should be included to promote bowel function ○ Bladder and Bowel Management  Urine is retained  Loss of autonomic and reflex control of the bladder and sphincter  No sensation of fullness  Overdistention  Can result in reflux into the kidney  Eventual renal failure  Rupture of the bladder  An indwelling catheter is usually inserted as soon as possible  Constipation  Generally a problem during spinal shock  No voluntary or involuntary (reflex) evacuation of the bowels  A bowel program should be started during acute care Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Choosing a rectal stimulant (suppository or mini- enema)  Inserted daily at a regular time of day followed by gentle digital stimulation or manual evacuation until evacuation is complete ○ Temperature Control  No vasoconstriction  No piloerection  No heat loss through perspiration below the level of injury  Temperature control is largely external to the patient  Nursing Management  Monitor the environment closely to maintain an appropriate temperature  Monitor body temperature regularly  Do not overload patients with covers or unduly expose them ○ Stress Ulcers  Causes  Severe trauma  Psychologic stress  High-dose corticosteroids  Nursing Management  Test stool and gastric contents for blood  Observe the hematocrit for a slow drop  When corticosteroids are given  They should be given with antacids (decrease the secretion of hydrochloric acid) or food  Histamine (H2)-receptor blockers (Zantac, Pepcid)  Proton pump inhibitors (Protonix, Prilosec) ○ Sensory Deprivation  Compensate for the patient's absent sensations to prevent sensory deprivation  Stimulate the patient above the level of injury  Conversation  Music  Strong aromas  Interesting flavors  Make every effort to prevent the patient from withdrawing from the environment ○ Reflexes  Once spinal cord shock is resolved  Return of reflexes may complicate rehabilitation  Lacking control from the higher brain centers  Reflexes are often hyperactive and produce exaggerated responses  Penile erections can occur from a variety of stimuli Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Causing embarrassment and discomfort  Spasms range from mild twitches to convulsive movements below the level of the lesion may also occur  May be controlled antispasmodic drugs  Lioresal  Dantrium  Zanaflex  Botulism toxin injections may also be given to treat severe spasticity ○ Autonomic Dysreflexia  The return of reflexes after the resolution of spinal shock means that the patient with an injury level at T6 or higher may develop autonomic dysreflexia  Also known as autonomic hyperreflexia  Massive uncompensated cardiovascular reaction mediated by the sympathetic nervous system  It occurs in response to visceral stimulation once spinal shock is resolved  Life-threatening situation that requires immediate resolution  If resolution does not occur  Status epilepticus  Stroke  Myocardial infarction  Death  The most common precipitating cause  Distended bladder or rectum  Any sensory stimulation may cause autonomic dysreflexia  Contraction of the bladder or rectum  Stimulation of the skin  Stimulation of the pain receptors  Pathophysiology  Stimulation of sensory receptors below the level of the cord lesion  The intact sympathetic nervous system below the level of the lesion responds to the stimulation with a reflex arteriolar vasoconstriction  Increases blood pressure  But the parasympathetic nervous system is unable to directly counteract these responses via the injured spinal cord  Baroreceptors in the carotid sinus and the aorta sense the hypertension and stimulate the parasympathetic system  Decreased heart rate Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  But the visceral and peripheral vessels do not dilate because efferent impulses cannot pass through the cord lesion  Clinical Manifestations  Severe Hypertension ( spasm  rupture  hemorrhage)  Throbbing headache  Diaphoresis (above the level of the lesion)  Bradycardia  Piloerection (erection of body hair)  Flushing of the skin above the level of the lesion  Blurred vision  Spots in the visual fields (scotomas)  Nasal congestion  Anxiety  Nausea  Nursing Management  Measure blood pressure when a patient complains of a headache  Elevation of the head of the bed 45 degrees or sitting the patient upright  Notify of the physician  Assess to determine the cause  The most common cause is bladder irritation  Immediate catheterization  Relieve bladder distention  If a catheter is already in place  Checked for kinks or folds  If plugged, small-volume irrigation to open a plugged catheter  A new catheter may be inserted  Stool impaction can also result in autonomic dysreflexia  A digital rectal examination should be performed  Only after application of an anesthetic ointment to decrease rectal stimulation and to prevent an increase of symptoms  Remove all skin stimuli  Constrictive clothing  Tight shoes  Monitor blood pressure frequently during the episode  If symptoms persist after the source has been relieved  α-adrenergic blocker  Arteriolar vasodilator (Procardia)  Careful monitoring must continue until the vital signs stabilize Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Teach the patient and caregiver to recognize the causes and symptoms of autonomic dysreflexia  They must understand the life-threatening nature of this dysfunction and must know how to relieve the cause 1. Signs and symptoms o Sudden onset of acute headache o ↑ in BP and/or ↓ in pulse rate o Flushed face and upper chest (above the level of the lesion) and pale extremities (below the level of the lesion) o Sweating above the level of the lesion o Nasal congestion o Feeling of apprehension 2. Immediate interventions o Raise the person to a sitting position o Remove the noxious stimulus (fecal impaction, kinked urinary catheter, tight clothing) o Call the health care provider if above actions do not relieve the signs and symptoms 3. Measures to suppress the incidence of autonomic dysreflexia o Maintain regular bowel function o If manual rectal stimulation is used to promote bowel function, local anesthetics may prevent autonomic dysreflexia from occurring o Monitor urine output o Wear a Medic Alert bracelet indicating a history of autonomic dysreflexia  Rehabilitation and Home Care ○ Many of the problems identified in the acute period become chronic and continue throughout life ○ Progress may be slow  Frequent encouragement may be required ○ Respiratory Rehabilitation  High cervical spinal cord injury  May have greatly increased mobility with  Phrenic nerve stimulators  Electronic diaphragmatic pacemakers  Ventilators are also reasonably portable  Patients and caregivers should be taught all aspects of home ventilator care Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Patients with cervical-level injuries who are not ventilator dependent  Assisted coughing  Regular use of incentive spirometry  Deep-breathing exercises ○ Neurogenic Bladder  Types of Neurogenic Bladder  Reflexic  Spactic  Unhibited  Upper motor neuron  Characteristics  No inhibitions influence time and place of voiding  Bladder empties in response to stretching of bladder wall  Causes  Corticospinal tract lesion  Clinical Manifestations  Incontinence  Frequency  Urgency  Voiding is unpredictable and incomplete  Areflexic  Autonomous  Flaccid  Lower motor neuron  Characteristics  Bladder acts as if there were paralysis of all motor functions  Fills without emptying  Causes  Lower motor neuron lesion  S2-S4  Lesions of cauda equine  Pelvic nerves  Clinical Manifestations  If sensory function intact, feels bladder distention and hesitancy  No control of micturition  Overdistention of bladder  Overflow incontinence  Sensory  Characteristics  Lack of sensation of need to urinate  Causes Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Damage to sensory limb of bladder spinal reflex arc  Clinical Manifestations  Poor bladder sensation  Infrequent voiding of large residual volume  Any type of bladder dysfunction related to abnormal or absent bladder innervation  May have no reflex detrusor contractions (areflexic, flaccid)  May have hyperactive reflex detrusor contractions (hyperreflexic, spastic)  May have lack of coordination between detrusor contraction and urethral relaxation (dyssynergia)  Common problems with a neurogenic bladder  Urgency  Frequency  Incontinence  Inability to void  High bladder pressures  Reflux of urine into the kidneys  Require a comprehensive program to manage bladder function  Bladder reflex retraining  Indwelling catheter  Intermittent catheterization  Catheterization is done every 4 hours  The number of intermittent catheterizations per day is usually 5 or 6  External catheter (condom catheter)  Surgical options  Sphincterotomy  Bladder neck revision  Implantation of a functional electrical stimulation device  Urinary diversion  Repeated UTI’s with renal involvement  Repeated stones  Therapeutic intervention has been unsuccessful  Anticholinergic drugs  Suppress bladder contraction  Ditropan  Detrol  α-Adrenergic blockers  Decrease outflow resistance at the bladder neck  Hytrin  Cardura  Antispasmodic drugs  Decrease spasticity of pelvic floor muscles Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Lioresal  Reflexic Bladder  Anticholinergic drugs  Intravesical capsaicin  Botulinum A toxin  Areflexic Bladder  Intermittent catheterization  Indwelling catheter ○ Neurogenic Bowel  Careful management of bowel evacuation  Voluntary control of this function may be lost  Prevent constipation  High-fiber diet  Adequate fluid intake  Suppositories (Dulcolax)  Small-volume enemas  Digital stimulation  Performed 20 to 30 minutes after suppository insertion  Upper motor neuron lesion  Digital stimulation is necessary to relax the external sphincter to promote defecation  Stool softener (Colace)  Oral stimulant laxatives  Only if absolutely necessary for a day or two  Not on a regular basis  Lower motor neuron lesion  Valsalva maneuver  Requires intact abdominal muscles  Used in those patients with injuries below T12  Manual stimulation  A bowel movement every other day is considered adequate  Preinjury patterns should be considered  Incontinence  Too much stool softener  Fecal impaction  Careful recording of bowel movements  Amount  Time  Consistency  Bowel Management after a Spinal Cord Injury  Optimal nutritional intake includes the following:  Three well-balanced meals each day  Two servings from the milk group  Two or more servings from the meat group, including beef, pork, poultry, eggs, fish Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 Four or more servings from the vegetable and fruit  groups  Four or more servings from the bread and cereal group  Fiber intake should be approximately 20-30 g/day. The amount of fiber eaten should be increased gradually over 1-2 weeks  Two to three quarts of fluid per day should be consumed unless contraindicated  Water or fruit juices should be used  Caffeinated beverages such as coffee, tea, and cola should be limited  Fluid softens hard stools  Caffeine stimulates fluid loss through urination  Avoid foods that produce gas (beans) or upper GI upset (spicy foods)  Timing  A regular schedule for bowel evacuation should be established  A good time is 30 min after the first meal of the day  Position  If possible, an upright position with feet flat on the floor or on a stepstool enhances bowel evacuation  Staying on the toilet, commode, or bedpan for longer than 20-30 min may cause skin breakdown  Based on stability, someone may need to stay with the patient  Activity  Exercise is important for bowel function  Improves muscle tone  Increases GI transit time  Increases appetite  Muscles should be exercised  Stretching  Range of motion  Position changing  Functional movement  Drug treatment  Suppositories may be necessary to stimulate a bowel movement  Manual stimulation of the rectum may also be helpful in initiating defecation  Stool softeners should be used as needed to regulate stool consistency  Oral laxatives should be used only if necessary ○ Neurogenic Skin Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Prevent pressure ulcers  Visual and tactile exam of the skin should be done twice a day  Special attention given to areas over bony prominences  The areas most vulnerable to breakdown  Ischia  Trochanters  Heels  Sacrum  Careful positioning and repositioning should be done every 2 hours  Pressure-relieving cushions must be used in wheelchairs  Special mattresses  Movement during turns and transfers should be done carefully  Avoid stretching and folding of soft tissues (shear), as well as friction or abrasion  Assess nutritional status regularly  Body weight loss and weight gain can contribute to skin breakdown  Adequate intake of protein is essential for skin health  Measurement of prealbumin, total protein, and albumin can help identify inadequate protein intake  Avoid thermal injury  Hot food or liquids  Bath or shower water that is too warm  Radiators  Heating pads  Uninsulated plumbing  Thermal injury also can result from extreme cold (frostbite)  Skin Care for the Patient with Spinal Cord Injury  Change Position Frequently  If in a wheelchair, lift self up and shift weight every 15- 30 min.  If in bed, a regular turning schedule (at least every 2 hr) that includes sides, back, and abdomen is encouraged to change position  Use special mattresses and wheelchair cushions to reduce pressure  Use pillows to protect bony prominences when in bed  Monitor Skin Condition  Inspect skin frequently for areas of redness, swelling, and breakdown  Keep fingernails trimmed to avoid scratches and abrasions Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  If a wound develops, follow standard wound care management procedures ○ Sexuality  Use scientific terminology rather than slang whenever possible  Upper motor neuron lesion  Spontaneous erections  Short-lived  Uncontrolled  Orgasm and ejaculation are usually not possible  Lower motor neuron lesion  Unable to have erections  Incomplete lower motor neuron loss  Highest possibility of successful erection with ejaculation  Treatment  Drugs  Viagra  Penile injection of vasoactive substances  Papaverine  Prostaglandin E  Risks  Priapism  Scarring  Vacuum devices  Surgical procedures  Implantation of penile prosthesis  Male fertility is affected  Poor sperm quality  Ejaculatory dysfunction ○ Greif and Depression  Expect a wide fluctuation of emotions  Allow mourning as a component of the rehabilitation process  Mourning Process  Shock and Denial  Struggle for survival  Complete dependence  Excessive sleep  Withdrawal  Fantasies  Unrealistic expectations  Nursing Interventions  Meticulous nursing care  Provide honest information  Use simple diagrams to explain injury  Encourage patient to begin road to recovery Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Establish an agreement to use and improve all current abilities while not denying the possibility of future improvement  Anger  Refusal to discuss paralysis  Decreased self-esteem  Manipulation  Hostile and abusive language  Nursing Interventions  Coordinate care with patient and encourage self- care  Support family members; prevent alleviation of guilt by supporting dependency  Use humor liberally  Allow patient outbursts  Do not allow fixation on injury  Depression  Sadness  Pessimism  Anorexia  Nightmares  Insomnia  Agitation  Psychomotor retardation  “Blues”  Suicidal preoccupation  Refusal to participate in any self-care activities  Nursing Interventions  Encourage family involvement and resources  Plan graded steps in rehabilitation to give success with minimal opportunity for frustration  Give cheerful and willing assistance with activities of daily living  Avoid sympathy  Use firm kindness  Adjustment  Planning for future  Active participation in therapy  Finding of personal meaning in experience and continuation of growth  Return to premorbid personality  Nursing Interventions  Remember that patients have individual personalities  Balance support systems to encourage independence Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Set goals with patient input  Emphasize potentials.  Gerontologic Considerations  Experience more complications  Hospitalized longer  Cardiovascular disease  Most common cause of morbidity and mortality  Lack of sensation ○ Chest pain ○ May mask acute myocardial ischemia  Altered autonomic nervous system function and decreases in physical activity  At risk for cardiovascular problems ○ Hypertension  Health promotion  Fall prevention strategies  Rehabilitation may take longer  Other preexisting conditions  Poorer health status  Spinal Cord Tumors  Etiology/Pathophysiology  Primary  Arising from some component of the ○ Cord ○ Dura ○ Nerves ○ Vessels  Secondary  From primary growths in other areas of the body  Extradural  Outside the spinal cord ○ From bones of spine ○ In extradural space ○ In paraspinal tissue  Approximately 90% of all spinal tumors  Most often arise in the vertebral bodies  Can invade intradurally and compress the spinal cord  Most metastatic tumors are extradural lesions  Treatment ○ Relief of cord pressure by surgical laminectomy ○ Irradiation ○ Chemotherapy ○ Combination approach  Prognosis ○ Poor Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302  Intradural extramedullary  Within the dura but outside the actual spinal cord  Mostly benign meningiomas and neurofibromas  Treatment ○ Complete surgical removal of tumor (if possible) ○ Partial removal followed by irradiation  Prognosis ○ Usually very good if lack of damage to cord from compression  Intradural intramedullary  Within the spinal cord itself  Treatment ○ Partial surgical removal ○ Irradiation therapy (resulting in only temporary improvement)  Prognosis ○ Very poor  Many of these tumors are slow growing  Symptoms stem from the mechanical effects of ○ Slow compression ○ Irritation of nerve roots ○ Displacement of the cord ○ Gradual obstruction of the vascular supply  Complete functional restoration may be possible when the tumor is removed ○ Except with the intradural-intramedullary tumors  Clinical Manifestations  Both sensory and motor problems may result  The most common early symptom of a spinal cord tumor outside the cord  Pain in the back ○ Location of the pain depends on the level of compression ○ Worsens with activity, coughing, straining, and lying down ○ Radicular pain  Involving the nerve that is compressed  Sensory disruption ○ Coldness, numbness, and tingling in an extremity or in several extremities ○ Slowly progresses upward until it reaches the level of the lesion ○ Impaired sensation of pain, temperature, and light touch ○ Deficit in vibration and position sense ○ May progress to complete anesthesia  Motor weakness ○ Slowly increasing clumsiness ○ Weakness ○ Spasticity  The sensory and motor disturbances are ipsilateral to the lesion  Bladder disturbances Downloaded by Taje' St. John ([email protected])  lOMoARcPSD|6976302 ○ Urgency ○ Difficulty in starting the flow ○ Retention with overflow incontinence  Manifestations of intradural spinal tumor  Progressive damage to the long spinal tracts ○ Paralysis ○ Sensory loss ○ Bladder dysfunction  Pain can be severe as a result of compression of spinal roots or vertebrae  Nursing and Collaborative Management  Extradural tumors  Seen early on routine spinal x-rays  Intradural and intramedullary tumors  Require MRI or CT scans for detection  CSF analysis may reveal tumor cells  Often yellow when tumors are present  The cord is decompressed after removal of the tumor by a laminectomy  Compression of the spinal cord is an emergency  Goal of therapy ○ Relief of the ischemia related to compression  Treatment of tumor-related edema  Corticosteroids  Dexamethasone (Decadron) ○ ↓ tumor size and inflammation  Analgesics and NSAIDS to control pain  Treatment for nearly all spinal cord tumors is surgical removal  Extradural or intradural-extramedullary tumors  Can be completely removed  Intradural-intramedullary tumors  Less favorable prognosis  Radiation therapy after the operation is fairly effective  Chemotherapy has also been used in conjunction with radiation therapy  Ultimate goals of treatment  Relief of pain  Return of  Be aware of the neurologic status of the patient before and after treatment  The patient may need to be cared for as though recovering from an SCI  Rehabilitation of patients with spinal cord tumors is similar to SCI rehabilitation Downloaded by Taje' St. John ([email protected])