MS II CVA and Spinal Cord Injuries.docx

[[Quiz \#9 CVA, Spinal Cord Injury \[SAC-VN 2023 SAC10 T3-VN304-23SC10T3\]]](https://www.google.com/calendar/event?eid=MjViZWgwZG4ycXNwMmRuNWx2cXIycHZibzggZmF5ZW1tYTAyQG0) [[YT Playlist]](https://youtube.com/playlist?list=PLPOo1m1W7UGr6gieBaP0FwJxR9hat9BId&si=KoZethGklRC-iywE) Table of Contents ==...

[[Quiz \#9 CVA, Spinal Cord Injury \[SAC-VN 2023 SAC10 T3-VN304-23SC10T3\]]](https://www.google.com/calendar/event?eid=MjViZWgwZG4ycXNwMmRuNWx2cXIycHZibzggZmF5ZW1tYTAyQG0) [[YT Playlist]](https://youtube.com/playlist?list=PLPOo1m1W7UGr6gieBaP0FwJxR9hat9BId&si=KoZethGklRC-iywE) Table of Contents ================= [[Table of Contents 1]](#table-of-contents) [[Spinal Cord Injuries 13]](#spinal-cord-injuries) Aug 19, 2024 Cerebrum -------- Divided into two hemispheres Each hemisphere controls the opposite side of the body Right hemisphere Controls the left side of the body Emotional and artistic abilities Left hemisphere Controls the right side of the body Often the dominant side Language, math and reasoning abilities ### CIRCULATION The brain requires 20% of the blood\'s oxygen supply every minute TRANSIENT ISCHEMIC ATTACK (TIA) ------------------------------- Temporary neurologic deficit caused by impairment of cerebral blood flow Blood vessels of the brain are temporarily occluded by spasms, fragments of plaque, or blood clots Important warning signs of an impending full stroke ### Signs and symptoms Dizziness Momentary confusion Loss of speech Loss of balance Tinnitus Visual disturbances ### Medical diagnosis Magnetic Resonance Imaging MRI Auscultation of a bruit over the carotid artery indicates partial obstruction ### Medical treatment Acetylsalicylic acid (aspirin) clopidogrel bisulfate (Plavix) Warfarin (Coumadin) Heparin Carotid endarterectomy and transluminal angioplasty STROKE ------ [[Stroke & Cerebrovascular Accident (CVA) - Medical-Surgical - Nervous System \| \@LevelUpRN]](https://www.youtube.com/watch?v=xPDtaEXHuiM) Abrupt impairment of brain function lasting more than 24 hours Caused by impaired blood flow to the brain Results in neurologic signs and symptoms ### Hemorrhagic stroke Blood vessel in brain ruptures Bleeding into the brain occurs #### Signs and Symptoms Occurs suddenly Severe headache Stiff neck Loss of consciousness Vomiting Seizures #### Intracerebral Occurs within the cerebral hemispheres #### Subarachnoid Occurs in the subarachnoid space between the arachnoid and pia mater layers of the meninges ### Ischemic stroke Obstruction of blood vessel By atherosclerotic plaque, blood clot, or other debris Impedes blood flow to an area of the brain Tissue death of that area of the brain occurs #### Embolic stroke Plaque or clot is traveling through the bloodstream and lodges in a large cerebral artery ##### Signs and Symptoms Appears without warning One-sided weakness Numbness Visual problems Confusion and memory lapses Headache Dysphagia Language problems #### Thrombotic stroke Occurs when atherosclerotic plaque narrows the lumen of large cerebral arteries and a thrombus forms in the artery Occurs when atherosclerotic plaque narrows the lumen of large cerebral arteries and a thrombus forms in the artery #### Lacunar stroke Occlusions of small, deep arteries within the brain Produce less pronounced neurologic changes ### Signs and Symptoms Signs and symptoms vary depending on the: Type of stroke Location of injury (which part of the brain was deprived of oxygen Extent of brain injury that occurred Aphasia A defect in the use of language; speech, reading, writing, or word comprehension Receptive aphasia: difficulty understanding spoken or written comprehension Receptive aphasia: difficulty understanding spoken or written word Expressive aphasia: difficulty speaking and writing Nonfluent aphasia: difficulty initiating speech Global aphasia: difficulty with all aspects of communication Dysarthria The inability to speak clearly Dysphagia Swallowing difficulty Dyspraxia The partial inability to initiate coordinated voluntary motor acts Hemiplegia Defined as paralysis of one side of the body Sensory impairment Unable to feel touch, pain, or temperature in affected body parts Unilateral neglect Do not recognize one side of the body as part of themselves Homonymous hemianopsia Loss of one side of field of vision Elimination disturbances Neurogenic bladder Flaccid bladder: no muscle tone, cannot empty completely Bowel incontinence ### COMPLICATIONS Constipation Dehydration Contractures Urinary tract infections Thrombophlebitis Urinary tract infections Thrombophlebitis Decubitus ulcers Pneumonia Sensory losses put patient at risk for traumatic and thermal injuries Swallowing difficulties place patient at risk for choking and aspiration pneumonia ### PROGNOSIS Long-term recovery may depend on the care received immediately after the stroke Most recovery takes place in the first 3 to 6 months, but progress often continues long after that ### MEDICAL TREATMENT: ACUTE PHASE Acute phase begins with the onset of signs and symptoms Ends when vital signs, blood pressure and neurologic condition, stabilize This phase usually lasts 24 to 48 hours Goal of treatment is to minimize complications and deterioration of pt condition Hypertension BP initially high, needs to be controlled BP generally starts decreasing in 48 hours, continues to do so for 10-14 days Monitor for secondary hypotension Oxygenation Patient may likely be hypoxic Initiate oxygen therapy if O2 Sat is less than 94% Hyperthermia Fever is common, can increase brain damage Treat with Tylenol and cooling measures Hyperglycemia Treat with Tylenol and cooling measures Occurs as a result of the bodies response to the stress of the stroke Check blood glucose often Treat with insulin ### Drug therapy Recombinant tissue plasminogen activator (rt-PA) Thrombolytic Given to dissolve clots in acute ischemic strokes Must be given within 3 hours of onset of symptoms Mannitol for cerebral edema Nimodipine (Nimotop) prevents cerebral spasms in a subarachnoid hemorrhage Phenytoin (Dilantin) and phenobarbital for seizures Acetylsalicylic acid (aspirin), Aggrenox, and clopidogrel (Plavix) to prevent further strokes ### Fluids and nutrition IV fluids Diet will vary on pt ability, may be regular, soft, or puréed Possible TPN or enteral feeding Urine elimination Indwelling catheter Intermittent catheterization every 4-6 hours for flaccid bladder ### NURSING CARE: ACUTE PHASE #### Physical examination Assess patient's responsiveness and behavior Assess for restlessness or agitation Measure vitals Inspect the face for symmetry; mouth for moisture and drooling Assess patient's ability to swallow Inspect pupils for size, equality, and reaction to light Assess vision Inspect skin color, moisture and turgor Assess extremities muscle tone and strength, sensation, and voluntary movement Assess for incontinence or bladder distention Perform frequent neuro checks #### Interventions [[NIH Stroke Scale]](https://www.ninds.nih.gov/sites/default/files/2024-05/KnowStroke_NIHStrokeScale_May2024_508c.pdf) Elevate HOB 25-30 degrees Unconscious pt should be side lying Monitor swallow and gag reflex Assess for increased ICP, can cause resp depression Suction as ordered Acute phase after hemorrhagic stroke: Forceful coughing discouraged as it increases ICP Keep bed in low position with side rails up, per policy Seizure precautions Fall precautions Aspiration precautions Immobility complication prevention In patients with diminished sensation: Protect from temperature extremes Inspect the skin for injury often Vision loss can put pt at risk for injury Vision loss can put pt at risk for injury Pt's with unilateral neglect may ignore one half of their body resulting in significant injury Pt's with homonymous hemianopsia only see half of their visual field, possibly resulting in injury Place objects in the unaffected visual field Monitor for hemorrhage r/t drug therapy Encourage fluids and monitor for excess or deficient fluid volume Manage TPN or enteral feedings if indicated Monitor blood glucose levels Monitor for fever and treat promptly Orient patients and determine cognitive ability Ask "yes" or "no" questions Provide alternate means of communication Turn and reposition pt every 2 hours However, pt should not lie on affected side more than 30 min Therapeutic beds Range of motion, PT, OT Assess urinary output, monitor for retention Prevent and manage constipation ### NURSING CARE: REHABILITATION PHASE #### Interventions Assist pt to return to the highest functionable level possible Encourage participation in ADLs Provide and teach pt how to use adaptive equipment Adapt the environment to maximize patient's independence Pt's with homonymous hemianopsia Place objects in the affected visual field (where they cannot see) to encourage them to scan their environment ### DISCHARGE Pt may be discharged home or to rehab May be discharged on outpatient therapy When able, patients are transitioned back into the home setting Essential to include family, friends, and significant others in the rehab process Help families to be aware of resources available to them In rehabilitation phase, the patient is challenged to return to the highest level of function possible ### Key Points CVA, commonly called a stroke, is an interruption of blood flow to part of the brain. The risk factors for CVA are atherosclerosis, atrial fibrillation, hypertension, diabetes mellitus, cardiac disease, excessive alcohol consumption, and, for women, smoking while taking oral contraceptives. CVA can be classified as a TIA, a stroke in evolution, or a completed stroke. TIA is an episode of temporary neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia that occurs without acute infarction. TIA, sometimes considered a warning sign of impending stroke, is treated with diet modification, exercise, drug therapy to prevent clot formation, surgery to clear or bypass obstructed blood vessels, or a combination of these therapies. A stroke is a set of neurologic signs and symptoms caused by impaired blood flow to the brain that persists for more than 24 hours. A hemorrhagic stroke is caused by rupture of a blood vessel in the brain, and an ischemic stroke is caused by obstruction of a blood vessel by an embolus or a thrombus. Signs and symptoms of stroke depend on the type, location, and extent of brain injury but may include one-sided weakness, numbness, visual problems, confusion and memory lapses, headache, dysphagia, and speech problems. Aphasia is the inability to understand words or respond with appropriate messages. Dysarthria is the inability to speak clearly because of neurologic damage that affects the muscles of speech. Dysphagia is difficulty swallowing. Dyspraxia is the partial inability to initiate coordinated voluntary motor acts in a nonparalyzed extremity. Paralysis of one side of the body (the side opposite the brain injury) is called hemiplegia. Medical treatment of CVA may use oxygen therapy, diuretics, corticosteroids, anticoagulants, thrombolytics, intravenous fluids, dietary modifications, and catheterization, as well as treatment of risk factors. After experiencing a stroke, the patient may regain complete independent functioning, partially recover previous abilities, or lose functional abilities completely. The goal of rehabilitation after stroke is to enhance the recovery of functional abilities through a program of stimulation and practice. Spinal Cord Injuries ==================== Aug 21, 2024 [[1. Spinal Cord Injury.pdf]](https://drive.google.com/open?id=11dECRrd_YyNf7cTqMxYZhgSqur7vwh_a) Vertebral Column ---------------- Consists of 33 vertebrae 7 cervical (C1 through C7) 12 thoracic (T1 through T12) 5 lumbar (L1 through L5) 5 sacral (S1 through S5) 4 fused coccygeal ### Disks Vertebrae separated by disks which serve as shock absorbers for the vertebral column Composed of anulus fibrosus and nucleus pulposus Anulus fibrosus: ring of tissue; encircles nucleus pulposus Nucleus pulposus: saclike structure with a gelatinous filling that has a high water content As we age, nucleus pulposus loses water and becomes less effective as a shock absorber ### Spinal Cord Extends from the brainstem to the second lumbar vertebra (L2) in pelvic cavity Surrounded by three protective meningeal layers Dura mater Outermost layer Arachnoid Middle layer: contains CSF Pia mater Innermost layer: directly covers the spinal cord CSF circulates through the brain and spinal column, protecting the entire central nervous system Diagnostic Tests and Procedures ------------------------------- Imaging studies Radiography Detects vertebral compression, fractures, or problems with alignment Coned-down radiographs are views that can more clearly reveal fractures Computed tomography (CT) Magnetic resonance imaging (MRI) Myelogram Dye injected into the subarachnoid space Visualizes the spinal cord and vertebrae Types of Injuries -------------------------------------- Classified by: - - - Closed: trauma in which the skin and meningeal covering that surround the spinal cord remain intact Open: damage to the protective skin and meninges ### Extent of damage to the cord Complete injury: the cord has been completely severed Incomplete injury: results from partial cutting of the cord Effects of Spinal Cord Injury ----------------------------- Extent of cut and level of injury determine the effect the injury will have on the patient Initial symptoms of spinal cord edema may mimic partial or complete transection making level of injury difficult to determine ### Incomplete spinal cord injuries: Some function remains below the level of the injury #### Central cord syndrome: Hyperextension injury to the cord Results in: Motor and sensory loss in upper extremities #### Brown-Sequard syndrome: Transverse hemisection of the cord Results in: Ipsilateral loss of motor function Same side of body Contralateral loss of pain and temperature perception Opposite side of body The higher the level of injury, the more severe the neurologic dysfunction #### Quadriplegia (tetraplegia) High cervical spine injuries; loss of motor and sensory function in all four extremities #### Paraplegia Injuries at or below T2 may cause paralysis of the lower part of the body #### Respiratory Impairment Injuries at or above C5 may result in instant death Nerves that control respiration are affected Injuries below C4 spare the diaphragm but can affect intercostal and abdominal muscles This patient may be able to breathe independently May have respiratory difficulty, weakened muscles and cough depending on involvement #### Spinal Shock An immediate, temporary response to injury Reflex activity below the level of the injury temporarily ceases Can mask the true extent of the patient's injury Permanent effects not known until spinal shock subsides Occurs 30-60 minutes after injury Lasts from days to months Causes flaccid paralysis: No muscle tone Eventually, affected neurons will gradually regain excitability Resolution: When pt's extremities have spastic, involuntary movements Autonomic Dysreflexia --------------------- [[2. Autonomic Dysreflexia.pdf]](https://drive.google.com/open?id=128FykI20l1MvPXT1YVgStMmUD52KxmCh) One of the most serious complications: medical emergency Exaggerated response of autonomic nervous system to painful stimuli With injury at or above T6 Risk increases when spinal shock subsides and reflexes return Sympathetic nervous system is stimulated Parasympathetic response cannot be elicited because the spinal cord injury separates the two divisions of the autonomic nervous system Triggered by various stimuli including - - - - - - - - - #### Symptoms - - - - - - - - - - - - - - - - - - - - - - - - - - - - ### Saving the Patients Life: Establish Airway Establishing an airway is first priority Conventional head tilt--chin lift: Inappropriate with spinal injury - - - *Jaw-thrust method of opening the airway is preferred* Once airway is open, administer 100% oxygen by mask Endotracheal or tracheostomy tube is placed to allow direct access to the airway and facilitate optimal oxygenation Any injury that compromises ventilation must be treated immediately ### Preventing Further Injury #### Traction Immobilization with skeletal traction manages cervical spinal cord injuries acutely ##### Gardner-Wells tongs Secured just above the ears Don't penetrate skull ##### Crutchfield tongs Applied directly to the skull just behind the hairline Halo vest: Immobilizes and aligns cervical vertebrae Placed as soon as surgery is done Internally stabilizes fractures and relieves the compression of nerve roots Vest allows the patient to be moved out of bed, ambulate and be more mobile Elevate patient's HOB to allow for proper alignment and positioning while in bed #### Special beds and cushions Kinetic bed, such as the Roto-Rest bed, continually rotates the patient from side to side Overlay air mattresses: flotation devices placed on standard hospital beds Air-fluidized and flotation beds may be used after the spine has been stabilized Stryker wedge frame: canvas and metal frame bed that may be used to help turn the patient Types of cushions include those inflated with air, flotation devices, and gel pads ### Drug therapy Methylprednisolone Reduces the damage to the cellular membrane May limit the neurologic effects of the injury Administered within the first 8 hours of injury Completely paralyzed patients often regain about 20% of function Partially paralyzed have regained up to 75% of function ### Preserving Cord Function Early surgical intervention to repair cord damage Cord compression by bony fragments, compound vertebral fractures, and gunshot and stab wounds Surgery within the first 24 hours is most desirable #### Laminectomy Involves removing all or part of the posterior arch of the vertebra #### Spinal fusion If multiple vertebrae are involved Placing a piece of donor bone into area between the involved vertebrae ### Physical Exam Take vital signs Level of responsiveness, posture, and spontaneous movements Inspect the skin for lesions Evaluate tissue turgor Inspect head for lesions and palpate for masses and swelling Examine pupils for size, equality, reaction to light Respiratory effort and breath sounds Inspect abdomen; auscultate for bowel sounds Inspect extremities for open fractures or abnormal positions #### Range of motion Ability to perceive sharp and dull sensation Patients with a C8 injury may still have upper extremity mobility and ability to use hand knobs and devices Assess for depression evidenced by decreased concentration ### Interventions Pt with C5 or above injury will need mechanical ventilation Monitor respiratory status Logroll patients in cervical traction Safety precautions for pt's with uncontrolled spasms DVT prevention -------------- Administer injections above the level of paralysis Poor circulation below the level of paralysis Monitor for autonomic dysreflexia: it is an emergency Immediately elevate HOB 45 degrees to decrease pressure Checks for kinks in the catheter (urinary retention causes AD) ### Prevent immobility complications ROM Turning and reposition every 2 hours Splint extremities to prevent contractures Keep skin clean and dry Keep humidity above 40% Provide pin care to the pt in traction to prevent infection Keep room temp at 70 degrees Prevent hypothermia or hyperthermia ### Rehabilitation Goal is to achieve highest possible level of self-care and independence IDT team Physician, nurse, physical therapist, occupational therapist, speech therapist, dietitian, social worker, psychologist, and counselor Patient and family must be emotionally and physically prepared to make adjustments Laminectomy Removal of part of the vertebra to reduce pressure on spinal nerves Preop Baseline vitals and neuro assessment Pt teaching ### Assessment Vital signs, neurologic status, and breath sounds Frequently assess movement, strength, range of motion, and ability to localize sensory stimulus Fluid intake and output Abdomen for bowel sounds Palpate bladder, urine output should return within 6 hours Inspect the surgical dressing for bleeding, clear CSF drainage, and foul drainage Assess pain in detail Monitor and prevent surgical complications Listen to lung sounds ever 2-4 hours Assess for DVT Soft neck collar for cervical laminectomy Medications