NUR 230 Neuro Peripheral Nerve and Spinal Cord Injury (2) PDF

Spinal Cord Injury and Other Neurological Disorders NUR 230 Brunner & Suddarth Ch. 63, 65 Mrs. Greeley Objectives + Outline the classification of spinal cord injuries and associated clinical manifestations. + Describe the clinical manifestations in interprofessional and nursing management...

Spinal Cord Injury and Other Neurological Disorders NUR 230 Brunner & Suddarth Ch. 63, 65 Mrs. Greeley Objectives + Outline the classification of spinal cord injuries and associated clinical manifestations. + Describe the clinical manifestations in interprofessional and nursing management of neurogenic and spinal shock. + Discuss the nursing management of the patient with a spinal cord injury. + Discuss types and clinical manifestations as well as nursing management of spinal cord tumors. + Discuss the etiology and clinical manifestations of Trigeminal neuralgia and Bell's palsy. + Discuss the etiology and clinical manifestations of Guillain- Barre Syndrome and other polyneuropathies. + Discuss the etiology and clinical manifestations of neurological disorders related the pediatric population.  Traumatic Brain Injury + Falls – 48% + MVC 14% + Strike by an object – 15% + Assaults – 10% + 56,800 people will die each year from TBI + 80,000 – 90,000 will have lasting disability + Most common ages: Kids < 4 Teens 15 – 19 Adults > 65  Types of TBI + Primary Injury Contusions, lacerations, skull fracture, concussion + Secondary Injury Hours or days after initial injury Results from decreased glucose and/or oxygen to brain tissue Intracranial hemorrhage, cerebral edema, intracranial hypertension, seizures, vasospasm, hypoxia, inflammation Best way to decrease TBI is to implement precautions Chart 63-1 p. 2056 Preventing Head and Spinal Cord Injuries We will discuss brain injury more in lecture titled: Acute Intracranial Problems  Spinal Cord Injury (p. 2070) Etiology and Pathophysiology 78% are male Causes: Most related to trauma MVC Falls Violence (GSW) Sport Injuries Major causes of death are pneumonia, PE, and sepsis Types of SCI Primary injury- usually permanent Cord compression, laceration, or transection by bone displacement Interruption of blood supply to the cord or traction resulting from pulling on the cord Secondary Injury – may be reversible (first 4-6 hours) Permanent damage may occur from edema, ischemia, and hypoxia secondary to the inflammatory response Death from respiratory failure is leading cause of death in primary injury Spinal and Neurogenic Shock (p. 2075) + Spinal Shock Loss of DTR and sphincter reflexes: urinary retention, paralytic ileus Loss of sensation, flaccidity, and paralysis to the muscles below level of injury Keep MAP > 85 mmHg to prevent shock + Neurogenic Shock Loss of autonomic nervous system function below level of injury Vital organs are affected (bradycardia, hypotension, temp dysregulation d/t loss of perspiration to affected tissue) Blood pooling and vasodilation Mean Arterial Pressure (MAP) + Normal value 70-110 MAP = (2xDBP) + SBP 3 BP = 90/52 (104) + 90 = 194/3 = 64.666 3 SCI Classifications (Fig. 63-4 p. 2072-2073) + Mechanism of injury + Level of injury + Completeness of injury/impairment + American Spinal Injury Association (ASIA) Classification of SCI - MOI + Mechanism Of Injury Flexion Flexion-Rotation Extension-Rotation Hyperextension Vertical Compression  Classification of SCI – Level of Injury + C1 - C3 = ventilator dependent + C1 – T1 = tetraplegia + Below T2 = paraplegia Classification of SCI – Degree of Injury + Complete Total loss + Incomplete Mixed loss Clinical Manifestations + Respiratory Ventilator dependent C1-C3 + Cardiovascular Above T6 – Neurogenic shock. Must identify all causes of hypotension with SCI Clinical Manifestations + Urinary Urinary dysfunction above T7 Neurogenic bladder Flaccid/hypotonic Spastic Dyssynergia – disturbance in muscle and sphincter coordination Clinical Manifestations + GI System Decreased GI motor activity Neurogenic bowel Clinical Manifestations + Integumentary Decubitus ulcers + Thermoregulation Poikilothermia + Peripheral Vascular Risk for VTE/DVT + Pain Nociceptive Neuropathic Diagnostics + CT scan – preferred + Cervical xrays + MRI (myelogram if MRI contraindicated) + Neuro assessment + CT angiogram + ECG to detect bradycardia or asystole  Interprofessional Care Prehospital Acute Care Airway Stabilization Ventilation/breathing Diagnostics Adequate circulating blood Ample oxygenation to prevent volume secondary injury Stabilization of injury and Drug therapy (administration of prevention of further spinal corticosteroids controversial) cord damage VTE prophylaxis Vasopressors if MAP < 85 Surgical repair if appropriate within 24 hours Nursing Management of SCI – p. 2076 - 2080 Planning Goals + Maintain optimal level of neurologic functioning + Have minimal to no complications of immobility + Learn new skills, gain new knowledge, and acquire new behaviors to care for self or direct others to do so + Return to home at optimum level of functioning + Ongoing support for family – rehab is likely to complex and slow Nursing Care of the Acute Patient + Immobilization – maintain neck and spine in neutral position + Closed reduction with skeletal traction or halo Nursing Care of the Acute Patient + HALO vest + Spinal fractures with or without acute SCI; no surgery but immobilization needed + Contraindicated with: Ligament instability, severe cervical deformity, morbid obesity, older age, cachexia, or noncompliance + Requires patient and caregiver teaching  Immobilizers Stable Thoracic or Lumbar Spine Injuries Jewett Brace Unstable Thoracic or Lumbar Spine Injuries Surgery plus TLSO or LSO Nursing Considerations r/t Immobilization RotoRest Additional Nursing Care Considerations + Respiratory Dysfunction + Cardiovascular Instability + Fluid and Nutritional Management + Bladder and Bowel Management + Temperature Control + Stress Ulcers + Sensory Deprivation + Pain Management + Skin Care + Reflexes Autonomic Dysreflexia p. 2078 + Occurs in patients with a SCI above T6 + Stems from a trigger or SNS stimulus from below the site of injury (the higher the injury, the more likely the patient is to develop AD) + Vasodilation above the injury/vasoconstriction below the injury + Rapid hypertension + Common triggers include: Urinary retention Constipation/impaction Wounds or skin irritation Tight fitting clothing or socks/shoes  Autonomic Dysreflexia Flushed face with Elevated BP Headache diaphoresis Bradycardia Nausea Pale, cool BLE Autonomic Dysreflexia is a medical emergency + Raise HOB to decrease BP + Rapid assessment to identify cause + Remove any tight clothing + Empty bladder and replace any nonpatent catheters + Rectal exam for fecal mass/impaction + Examine skin for breakdown + If S/S not resolved by doing these, consider ganglionic block + Administer anti-hypertensive meds if needed + Note in medical record the risk of autonomic dysreflexia + Education on ways to avoid Autonomic Dysreflexia Video + https://www.youtube.com/watch?v=e3Gpdivn9WQ + Simple RN NCLEX Nursing Review  Increased with age. Falls are leading cause of SCI age > 65 Gerontologic Increased risk for complications, Considerations longer hospitalizations, death Longer rehab time  Brain Tumors (Ch. 65 p. 2113) + Primary – Arise from brain tissue Gliomas (astrocytomas, oligodendroglial) No cure for malignant gliomas Meningiomas Acoustic neuromas Pituitary adenomas + Secondary - From metastatic disease More common than primary tumors < 10% survivability at 2 years  + Increased ICP + Headache + Visual disturbances Clinical + Vomiting Manifestations of + Seizures Brain Tumors + Motor abnormalities + Cognition deficits + Language disturbances  Diagnostics + H&P + Neuro exam + CT with contrast + MRI + Stereotactic brain mapping + PET scan + EEG + Cytology Medical Management of Primary Tumors + Surgery + Chemotherapy Limited by the BBB Autologous bone marrow transplantation used after bone marrow is destroyed by chemo or radiation + External-beam radiation Iodine radioisotopes are used to protect surrounding brain tissue Stereotactic or Gamma knife – minute, precise, high-dose radiation beams + Electric field therapy + Medications to counteract hormonal secretions when present + Other pharmacologic treatments – mannitol, dexamethasone, seizure meds Metastatic Brain Tumor Treatment + Palliative care + Surgery + Chemotherapy + Radiation + Pain management + Poor outcomes without treatment Spinal Cord Tumors p. 2121  Spinal Cord Tumors Cause significant spinal compression and neurologic dysfunction Classified as: Primary Secondary Further classification Extradural—outside the dura Intradural-extramedullary— between the spinal cord and dura Intramedullary—within the substance of spinal cord  Spinal Cord Tumors Clinical Manifestations Motor and sensory problems Back pain or pain radiating along compressed nerve root worse when in prone position Slow increasing signs – if left untreated, paralysis can develop Treatment Goals Primary tumor Metastatic tumors Surgical indications or palliative care Prognosis Ability to ambulate is a sign of better prognosis Trigeminal Neuralgia (p. 2108) + Characterized by sudden, unilateral, severe, brief, stabbing, recurrent episodes of pain along the trigeminal nerve  Trigeminal Neuralgia + Goal: Pain relief: Usually outpatient treatment Medications Surgical Therapy 50% develop recurrent pain in 12-15 years + Nursing assessment Assess attacks Therapy responses Complimentary pain management options Environmental assessment  Bell’s Palsy + Unilateral temporary facial paralysis + Inflammation of CN VII + May be a type of pressure paralysis + Patho is unknown + S/S: tearing, pain in ear and eye on affected side, facial nerve pain (neuralgia) + Treatments: Prednisone Analgesia Heat Electrical stimulation Artificial tears Eye patch  Guillain-Barre Syndrome (GBS) + Autoimmune attack on the peripheral nerve myelin + Precipitated by an antecedent viral episode causing acute, rapidly progressive, symmetric weakness and ascending paralysis + If it reaches diaphragm, respiratory failure occurs + Does not affect cognition or LOC + Intubation, plasmapheresis, IVIG to reduce myelin antibody + DVT prophylaxis, ROM to paralyzed extremities + Catheter, ECG monitoring + Skin integrity, nutritional support + Full recovery can take 1-2 years  Tetanus Severe infection of the nervous system Clostridium tetani is organism responsible for tetanus Incubation 4-14 days Hallmark features are muscle rigidity, lockjaw, difficulty swallowing, and spasms Immunization and care wound care reduce incidence Booster of tetanus and diphtheria toxoid for adults every 10 years Wound care—thorough cleansing If not immunized within 5 years, contact HCP for booster Medical emergency with hospitalization Tetanus immune globulin (TIG) Antibiotics for 10-14 days Pediatric Considerations  Neural Tube Defects + Accounts for majority of CNS abnormalities + Etiology unknown Drugs Malnutrition Chemicals Genetics + Treatment + Prevention Folic Acid Ultrasound 16-18 weeks' gestation Spina Bifida + Spina Bifida Spina Bifida Occulta Benign Asymptomatic No adverse neurological signs + Meningocele + Myelomeningocele  Meningocele + Less serious form of spina bifida cystica Spinal cord usually normal Typically, no associated neurological deficits + Nursing assessment to ensure sac covering is intact + Nursing management is supportive + Hydrocephalus Myelomeningocele Most severe form of neural tube defect Increased risk of meningitis, hypoxia and hemorrhage at birth Spinal cord often ends at the defect Abnormal increase CSF Etiology Unknown but risk factors same as other neural tube defects Treatment Surgical closure, ASA Prevent trauma to the sac; cover with moist, sterile dressing  Hydrocephalus + Imbalance between the production and absorption of CSF Obstructive Non-obstructive + Results in signs and symptoms of increased ICP + Causes Genetics Spina Bifida Premature Birth Infections + Treatment Shunt placement to drain CSF  Cerebral Palsy + CP is range of non-specific clinical symptoms caused by abnormal development or damage to the motor areas of the brain, resulting in: Abnormal motor patterns Abnormal postures + Can occur before, during or after birth Preterm + Etiology - Multifactorial Mutations Maternal/Infant infections Fetal stroke Traumatic head injury Hypoxia  Cerebral Palsy + Disability determined by area damaged + Non progressive; however clinical manifestations change + Classified several ways; common is by type of movement disturbance Spastic Dyskinetic or athetoid Ataxic Mixed + Focus of nursing management is promoting mobility and nutrition + Manifestations Variations in muscle tone Lack of muscle coordination Tremors Motor delays Seizures