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1 1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. NURS 1130 Unit 4 Neurologic Disorders

2 2Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of the Nervous System

3 3Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Neuron (Nerve Cell)  Functional unit of the nervous system that conducts electrical impulses from one area of the brain to another  Sensory neurons ◦ Transmit information from distal parts of the body or environment toward the central nervous system  Motor neurons ◦ Carry motor information from the CNS to the periphery

4 4Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Axons and Dendrites  Branch off the main cell body  Axons conduct impulses away from the cell body  Dendrites convey impulses toward the cell body

5 5Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Myelin  Material that covers many axons and dendrites  Enhances conduction along nerve fibers  Gives the axons a white appearance; cell bodies without myelin are gray

6 6Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-1

7 7Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Central Nervous System (CNS)  Made up of the brain and spinal cord

8 8Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Peripheral Nervous System  Comprises all the nerves of the peripheral parts of the body, including spinal and cranial nerves

9 9Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Brain  Divided into the cerebrum, cerebellum, and brainstem

10 10Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cerebrospinal Fluid (CSF)  Composed of water, glucose, sodium chloride, and protein  Acts as a shock absorber for the brain and spinal cord

11 11Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-2

12 12Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Spinal Cord  Extends from the border of the first cervical vertebra (C1) to the level of the second lumbar vertebra (L2)  Thirty-one pairs of spinal nerve roots exit the spinal cord, each consisting of a posterior sensory (afferent) root and anterior motor (efferent) root  These roots, along with the 12 cranial nerves, make up the peripheral nervous system

13 13Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Autonomic Nervous System  Controls the involuntary activities of the viscera, including smooth muscle, cardiac muscle, and glands  Two major subdivisions: sympathetic nervous system and the parasympathetic nervous system

14 14Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Age-Related Changes  The number of nerve cells decreases  Brain weight is reduced; ventricles increase in size  Lipofuscin: aging pigment deposited in nerve cells with amyloid, a type of protein  Increased plaques and tangled fibers in nerve tissue  Eye pupil often smaller; may respond to light more slowly  Reflexes intact except for Achilles tendon jerk, which is often absent  Reaction time increases, especially complex reactions  Tremors in the head, face, and hands are common  Some develop dizziness and problems with balance

15 15Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pathophysiology of Neurologic Diseases

16 16Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Types of Disorders  Developmental and genetic  Trauma  Infections and inflammation  Neoplasms  Degenerative processes  Vascular disorders  Metabolic and endocrine disorders

17 17Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Assessment of Neurologic Function  Health history ◦ Note speech, behavior, coordination, alertness, comprehension  Chief complaint and history of present illness ◦ Document what prompted the patient to seek medical attention ◦ Describe any injuries ◦ If patient has pain, note the onset, severity, location, and duration  Past medical history ◦ Head injury, seizures, diabetes mellitus, hypertension, heart disease, and cancer ◦ Record dates and types of immunizations

18 18Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Assessment of Neurologic Function  Family history ◦ Have immediate family members had heart disease, stroke, diabetes mellitus, cancer, seizure disorders, muscular dystrophy, or Huntington’s disease?  Review of systems ◦ Fatigue or weakness, headache, dizziness, vertigo, changes in vision/hearing, tinnitus, drainage from ears or nose, dysphagia, neck pain or stiffness, vomiting, bladder or bowel function, sexual dysfunction, fainting, blackouts, tremors, paralysis, incoordination, numbness or tingling, memory problems, mood changes

19 19Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Assessment of Neurologic Function  Functional assessment ◦ Document whether present symptoms interfere with the patient’s usual activities and occupation ◦ Explore sources of stress, usual coping strategies, and sources of support  Physical examination ◦ Level of consciousness, pupillary evaluation, neuromuscular response, and vital signs

20 20Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures  Advanced neurologic examination ◦ Cranial nerves ◦ Coordination and balance ◦ Neuromuscular function ◦ Sensory function  Pain  Temperature  Light touch  Vibration  Position  Tactile discrimination

21 21Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-5

22 22Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-6

23 23Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-7

24 24Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures  Lumbar puncture  Electroencephalography  Electromyography  Radiologic studies ◦ Brain scan ◦ Cerebral angiography and digital subtraction angiography ◦ Computed tomography ◦ Magnetic resonance imaging

25 25Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-8

26 26Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-9

27 27Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-10

28 28Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-11

29 29Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Common Therapeutic Measures  Drug therapy ◦ Antimicrobials ◦ Analgesics ◦ Anti-inflammatory ◦ Corticosteroids ◦ Anticonvulsants ◦ Diuretics ◦ Chemotherapeutic agents ◦ Dopaminergics ◦ Anticholinergics ◦ Cholinergics ◦ Antihistamines

30 30Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Common Therapeutic Measures  Surgery ◦ Craniotomy  Surgical opening of the skull ◦ Craniectomy  Excision of a segment of the skull ◦ Cranioplasty  Any procedure done to repair a skull defect

31 31Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Disorders of the Nervous System

32 32Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Migraine Headache  Intracranial vasoconstriction followed by vasodilation  Triggered by menstruation, ovulation, alcohol, some foods, stress  Pain usually unilateral, often begins in the temple or eye area and is very intense  Tearing and nausea and vomiting may occur  Hypersensitive to light and sound; prefers dark, quiet environment  Mild migraines treated with acetaminophen or aspirin; severe ones with ergotamine (Cafergot) or sumatriptan (Imitrex) tablet or autoinjector for self-injection

33 33Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cluster Headache  Occur in a series of episodes followed by a long period with no symptoms  Intensely painful and seem to be related to stress or anxiety  Usually have no warning symptoms  Treatment may include cold application, indomethacin (Indocin), and tricyclic antidepressants

34 34Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Tension Headache  Result from prolonged muscle contraction from anxiety, stress, or stimuli from other sources, such as a brain tumor or an abscessed tooth  Pain location may vary; may have nausea and vomiting, dizziness, tinnitus, or tearing  Treatment: correction of known causes, psychotherapy, massage, heat application, and relaxation techniques  Analgesics, usually nonopioid, may be prescribed to reduce anxiety

35 35Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Seizure Disorder  Electrical impulses in the brain are conducted in a highly chaotic pattern that yields abnormal activity and behavior  Related to trauma, reduced cerebral perfusion, infection, electrolyte disturbances, poisoning, or tumors  Medical diagnosis ◦ Accurate history of the seizure disorder ◦ Electroencephalogram (EEG)

36 36Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Seizure Disorder: Classification  Partial seizures ◦ Simple  Part of one cerebral hemisphere; consciousness not impaired ◦ Complex  Consciousness impaired; may exhibit bizarre behavior  Generalized seizures ◦ Involve the entire brain from the onset ◦ Consciousness lost during the ictal (seizure) period ◦ Types: tonic-clonic, absence, myoclonic, and atonic

37 37Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Seizure Disorder  Status epilepticus ◦ Medical emergency: continuous seizures or repeated seizures in rapid succession for 30 minutes or more  Aura ◦ Dizziness, numbness, visual or hearing disturbance, noting an offensive odor, or pain may precede a seizure  Medical treatment ◦ Resolution of the underlying condition ◦ Anticonvulsant drug therapy

38 38Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Seizure Disorder  Surgical treatment ◦ Removal of seizure foci in the temporal lobe and pallidotomy or vagal nerve stimulator

39 39Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Seizure Disorder: Nursing Care  Assessment ◦ Describe the seizure episode, including the postictal period (following the seizure), and document drug therapy

40 40Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Seizure Disorder: Nursing Care  Risk for Injury ◦ Side rails of bed up and padded, suction machine readily available, bed maintained in the low position ◦ Quickly move objects away from the patient ◦ Do not attempt to restrain the patient  Ineffective Coping and Deficient Knowledge ◦ Teach family and patient about the seizure disorder and the therapy ◦ Teaching must be directed toward helping the patient and family adjust to a chronic condition ◦ Encourage questions and concerns

41 41Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Head Injury: Types  Scalp injuries ◦ Lacerations, contusions, abrasions, and hematomas  Concussion ◦ Trauma with no visible injury to the skull or brain  Contusion ◦ Bruising and bleeding in the brain tissue  Hematoma ◦ Subdural hematoma or epidural hematoma  Intracerebral hemorrhage ◦ From lesions within the tissue of the brain itself  Penetrating injuries ◦ Sharp objects penetrate the skull and brain tissue

42 42Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Head Injury  Surgical treatment ◦ Directed at evacuating hematomas and débriding damaged tissue

43 43Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Head Injury: Nursing Care  Interventions ◦ Ineffective Tissue Perfusion ◦ Ineffective Breathing Pattern ◦ Risk for Injury ◦ Risk for Infection ◦ Impaired Physical Mobility ◦ Disturbed Body Image and Ineffective Role Performance

44 44Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Brain Tumors  Etiology and risk factors ◦ Some congenital; others may be related to heredity ◦ Drug/environmental factors may play a role in development  Signs and symptoms ◦ Directly related to area of brain invaded by the tumor ◦ Visual disturbances and headache ◦ New-onset seizure activity ◦ Difficulties with balance and coordination  Medical treatment ◦ Surgery often followed by radiation with or without chemotherapy

45 45Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Brain Tumors: Nursing Care  Interventions ◦ Acute Pain ◦ Disturbed Thought Processes ◦ Disturbed Sensory Perception ◦ Impaired Physical Mobility and Self-Care Deficit ◦ Ineffective Coping

46 46Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Meningitis  Etiology and risk factors ◦ Inflammation of the meningeal coverings of the brain and spinal cord caused by either viruses or bacteria  Signs and symptoms ◦ Headache, nuchal rigidity (stiffness of the back of the neck), irritability, diminished level of consciousness, photophobia (sensitivity to light), hypersensitivity, and seizure activity ◦ Positive Kernig’s sign and Brudzinski’s sign  Medical diagnosis ◦ Lumbar puncture to obtain CSF for lab analysis

47 47Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-16A

48 48Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-16B

49 49Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Meningitis  Medical treatment ◦ Bacterial infections usually respond to antimicrobial therapy, but no specific drugs effective against most viral infections ◦ Anticonvulsants used to control seizure activity if necessary

50 50Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Meningitis: Nursing Care  Assessment ◦ Assess vital signs and neurologic status frequently to determine further deterioration or onset of complications

51 51Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Meningitis: Nursing Care  Interventions ◦ Ineffective Tissue Perfusion ◦ Ineffective Breathing Pattern ◦ Acute Pain ◦ Risk for Injury ◦ Deficient Fluid Volume

52 52Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Encephalitis  Etiology and risk factors ◦ Inflammation of brain tissue caused by virus  Signs and symptoms ◦ Fever, nuchal rigidity (stiff neck), headache, confusion, delirium, agitation, and restlessness commonly seen ◦ Comatose or exhibit aphasia, hemiparesis, facial weakness, and other alterations in motor activity  Medical treatment ◦ Enhance patient comfort and increase strength ◦ Because seizure activity is a potential problem, take appropriate safety precautions

53 53Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Encephalitis: Nursing Care  The nursing plan of care parallels that of the patient with meningitis

54 54Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Guillain-Barré Syndrome  Etiology and risk factors ◦ Although specific cause unknown, it is believed to be an autoimmune response to a viral infection ◦ Patients often report some recent viral infection or vaccination

55 55Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Guillain-Barré Syndrome  Initial phase ◦ Symmetric muscle weakness: begins in lower extremities; ascends to trunk and upper extremities ◦ Visual and hearing disturbances, difficulty chewing, and lack of facial expression ◦ Mild paresthesias or anesthesia in feet and hands in a glove or stocking distribution pattern ◦ Hypertension, orthostatic hypotension, cardiac dysrhythmias, profuse sweating, paralytic ileus, and urinary retention

56 56Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Guillain-Barré Syndrome  Plateau phase ◦ Remains essentially unchanged ◦ No further neurologic deterioration, but no improvement either  Recovery phase ◦ Remyelinization; muscle strength returns in a proximal-to-distal pattern (head to toes)

57 57Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Guillain-Barré Syndrome  Medical diagnosis ◦ Characteristic onset and pattern of ascending motor involvement ◦ Elevated protein level in the CSF ◦ Nerve conduction velocity studies reveal slowed conduction speed in the involved nerves

58 58Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Guillain-Barré Syndrome  Medical treatment ◦ Preserve vital function, particularly respiration ◦ Respiratory status is closely monitored and mechanical ventilation initiated if vital capacity falls to 15 mL/kg of body weight ◦ Massive doses of corticosteroids prescribed to suppress the inflammatory process ◦ Plasmapheresis

59 59Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Guillain-Barré Syndrome: Nursing Care  Assessment ◦ Health history describes the progression of symptoms ◦ Note fears, coping strategies, and sources of support ◦ Physical examination focuses on cranial nerve, motor, respiratory, and cardiovascular function

60 60Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Guillain-Barré Syndrome: Nursing Care  Interventions ◦ Ineffective Breathing Pattern ◦ Decreased Cardiac Output ◦ Risk for Disuse Syndrome ◦ Imbalanced Nutrition: Less Than Body Requirements ◦ Anxiety ◦ Deficient Knowledge ◦ Rehabilitation

61 61Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Parkinson’s Syndrome  Etiology and risk factors ◦ Progressive degenerative disorder of the basal ganglia: an eventual loss of coordination and control over involuntary motor movement  Signs and symptoms ◦ Tremor, rigidity, and bradykinesia ◦ Loss of dexterity and power in affected limbs, aching, monotone voice, handwriting changes, drooling, lack of facial expression, rhythmic head nodding, reduced blinking, and slumped posture ◦ Depression common; dementia may develop

62 62Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-17

63 63Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Parkinson’s Syndrome  Medical diagnosis ◦ From health history and physical examination ◦ MRI to rule out other causes of the symptoms  Medical treatment ◦ Control symptoms: physical therapy and drug therapy  Massage, heat, exercise, and gait retraining  Dopamine receptor agonists pramipexole (Mirapex) or ropinirole (Requip); L-dopa (L- dihydroxyphenylalanine); carbidopa/levodopa (Sinemet); anticholinergic drugs such as trihexyphenidyl (Artane) and benztropine (Cogentin)

64 64Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Parkinson’s Syndrome: Nursing Care  Assessment ◦ Weakness, fatigue, muscle cramps, sweating, dysphagia, constipation, difficulty voiding, and unusual movements ◦ Note lack of facial expression, eyes fixed in one direction, drooling, slurred speech, tearing, tremors, muscle stiffness, and poor balance and coordination  Interventions ◦ Impaired Physical Mobility ◦ Risk for Injury ◦ Imbalanced Nutrition: Less Than Body Requirements ◦ Ineffective Coping ◦ Deficient Knowledge

65 65Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Multiple Sclerosis  Etiology ◦ Chronic, progressive degenerative disease ◦ Attacks the protective myelin sheath around axons and disrupts the conduction of impulses through the CNS  Chronic, progressive MS: progresses steadily  Exacerbating-remitting MS: exacerbations and remissions  Relapsing-progressive MS: less stable periods than exacerbating-remitting  Stable MS: stable; no active disease for a year ◦ Exact cause of MS is unknown; viral infections and autoimmune processes have been implicated

66 66Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Multiple Sclerosis  Signs and symptoms ◦ Fatigue, weakness, and tingling in one or more extremities; visual disturbances; problems with coordination; bowel and bladder dysfunction; spasticity; and depression

67 67Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 27-18

68 68Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Multiple Sclerosis  Medical diagnosis ◦ Based on the physical examination and history of cyclic remission-exacerbation periods ◦ Magnetic resonance imaging of the brain and spinal cord may reveal plaques characteristic of MS

69 69Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Multiple Sclerosis  Medical treatment ◦ Corticosteroids (ACTH, prednisone, methylprednisolone) ◦ Interferon  1b (Betaseron) and interferon 1a (Avonex) ◦ Glatiramer acetate (Copaxone) ◦ Immunosuppressants: mitoxantrone (Novantrone) ◦ Amantadine (Symmetrel) ◦ Urinary retention treated with cholinergics, such as bethanechol (Urecholine) or neostigmine (Prostigmine)

70 70Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Multiple Sclerosis: Nursing Care  Assessment ◦ Onset and progression of symptoms, especially those that affect mobility, vision, eating, and elimination ◦ Range of motion and strength, gait abnormalities, tremors, and muscle spasms

71 71Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Multiple Sclerosis: Nursing Care  Interventions ◦ Impaired Physical Mobility ◦ Disturbed Sensory Perception ◦ Self-Care Deficit ◦ Functional Urinary Incontinence ◦ Risk for Infection ◦ Ineffective Coping ◦ Deficient Knowledge

72 72Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Amyotrophic Lateral Sclerosis (ALS)  Etiology ◦ Also known as Lou Gehrig’s disease; a degenerative neurologic disease ◦ Virus suspected, but exact cause unknown  Pathophysiology ◦ Degeneration of the anterior horn cells and the corticospinal tracts, so patient exhibits upper and lower motor neuron symptoms

73 73Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. ALS ALS  Signs and symptoms ◦ Weakness of voluntary muscles of the upper extremities, particularly the hands ◦ Difficulty swallowing and speaking ◦ Eventually, respirations shallow; difficulty clearing airway of pulmonary secretions ◦ Death results from aspiration, respiratory infection, or respiratory failure

74 74Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. ALS  Medical diagnosis ◦ History and physical examination findings ◦ Electromyography  Medical treatment ◦ Because no known cure or treatment, therapy is supportive; focuses on preventing complications and maintaining maximum function

75 75Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. ALS: Nursing Care  Assessment ◦ Dyspnea, dysphagia, muscle cramps, weakness, twitching, joint stiffness, muscle atrophy, abnormal reflexes and gait, and paralysis

76 76Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. ALS: Nursing Care  Interventions ◦ Ineffective Airway Clearance ◦ Impaired Physical Mobility ◦ Imbalanced Nutrition: Less Than Body Requirements ◦ Impaired Verbal Communication ◦ Impaired Skin Integrity ◦ Anticipatory Grieving ◦ Situational Low Self-Esteem ◦ Interrupted Family Processes

77 77Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Huntington’s Disease  Inherited degenerative neurologic disorder  Usually begins in middle adulthood with abnormal movements, emotional disturbance, and intellectual decline  Symptoms progress steadily: increasing disability and death in 15 to 20 years  Medical and nursing care are supportive only; there is no cure

78 78Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Myasthenia Gravis  Etiology ◦ May have an autoimmune basis  Pathophysiology ◦ Insufficient receptor sites at the junction of the motor nerve with the muscle ◦ With repeated stimulation, muscle becomes exhausted; eventually unable to contract at all ◦ If respiratory muscles involved, death from respiratory insufficiency or arrest possible

79 79Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Myasthenia Gravis  Signs and symptoms ◦ Weakness of voluntary muscles, particularly those of chewing, swallowing, and speaking  Partial improvements of strength with rest  Dramatic improvement with the use of anticholinesterase drugs ◦ Ptosis and diplopia commonly seen

80 80Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Myasthenia Gravis  Medical diagnosis ◦ Administering edrophonium (Tensilon)  Muscle tone is markedly improved within 1 minute of injection; persists for 4 to 5 minutes  Medical treatment ◦ Anticholinesterase drugs  Neostigmine and pyridostigmine (Mestinon) ◦ Corticosteroids ◦ Cytotoxic therapies ◦ Thymectomy ◦ Plasmapheresis

81 81Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Myasthenia Gravis: Nursing Care  Assessment ◦ Health history describes the onset of symptoms: muscle weakness, diplopia, dysphagia, slurred speech, breathing difficulties, and loss of balance  Interventions ◦ Ineffective Breathing Pattern ◦ Impaired Physical Mobility and Self-Care Deficit ◦ Impaired Swallowing ◦ Deficient Knowledge

82 82Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. NURS 1130 Unit 4 Cerebrovascular Accident

83 83Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cerebrum  Complex functions: initiation of movements, recognition of sensory input, higher-order thinking, regulating emotional behavior and endocrine and autonomic functions  Divided into two halves: hemispheres ◦ Each hemisphere controls the opposite side of the body: the right hemisphere controls the left side of the body, and the left hemisphere controls the right side of the body ◦ The cortex of each is divided into the parietal, frontal, temporal, and occipital lobes; each has a different area of function

84 84Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 28-1

85 85Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cerebrum  Brainstem ◦ Includes midbrain, pons, medulla, and part of the reticular activating system ◦ Controls vital, basic functions, including respiration, heart rate, and consciousness

86 86Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cerebellum  Uses information received from the cerebrum, muscles, joints, and inner ear to coordinate movement, balance, and posture  Unlike the cerebrum, the right side of the cerebellum controls the right side of the body, and the left side of the cerebellum controls the left side of the body

87 87Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Circulation  Carotid system ◦ Begins as one common artery; later divides into the external and internal carotid arteries  The external carotid arteries divide to supply blood to the face  The internal arteries further divide into the middle cerebral artery and the anterior cerebral artery to supply blood to the brain

88 88Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Circulation  Vertebral arteries ◦ Originate from the subclavian artery, travel up the anterior neck to merge and form the basilar artery at the brainstem ◦ Second division forms posterior cerebral artery  Internal carotid and vertebrobasilar arteries unite to form the circle of Willis

89 89Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 28-2

90 90Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Cerebrovascular Accidents

91 91Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Risk Factors for Stroke  Nonmodifiable factors ◦ Risk factors that cannot be changed  Age, race, gender, and heredity  Modifiable factors ◦ Those that can be eliminated or controlled

92 92Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Transient Ischemic Attack  Temporary neurologic deficit caused by impairment of cerebral blood flow  Blood vessels occluded by spasms, fragments of plaque, or blood clots  Important warning signs for the individual experiencing a full stroke

93 93Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Transient Ischemic Attack  Signs and symptoms ◦ Dizziness, momentary confusion, loss of speech, loss of balance, tinnitus, visual disturbances, ptosis, dysarthria, dysphagia, drooping mouth, weakness, and tingling or numbness on one side of the body  Medical diagnosis ◦ Health history, physical examination findings, and results of brain imaging studies ◦ Laboratory studies, electrocardiography (ECG), duplex ultrasonography, and cerebral angiography

94 94Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Transient Ischemic Attack  Medical treatment ◦ Depends on the location of the narrowed vessel and the degree of narrowing ◦ Acetylsalicylic acid (aspirin), ticlopidine hydrochloride (Ticlid), extended-release dipyridamole (Aggrenox), or clopidogrel bisulfate (Plavix) decrease platelet clumping ◦ Warfarin (Coumadin) and heparin ◦ Carotid endarterectomy and transluminal angioplasty

95 95Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 28-3

96 96Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Stroke  An abrupt impairment of brain function resulting in a set of neurologic signs and symptoms that are caused by impaired blood flow to the brain and last more than 24 hours

97 97Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Stroke: Pathophysiology  Hemorrhagic stroke ◦ Blood vessel in brain ruptures; bleeding into the brain occurs  Ischemic stroke ◦ Obstruction of blood vessel by atherosclerotic plaque, blood clot, or a combination of the two, or by other debris released into vessel that impedes blood flow to an area of the brain

98 98Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 28-4

99 99Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Stroke: Signs and Symptoms  Different signs and symptoms, depending on the type, location, and extent of brain injury  Hemorrhagic stroke ◦ Occurs suddenly; may include severe headache described as “the worst headache of my life” ◦ Other symptoms: stiff neck, loss of consciousness, vomiting, and seizures

100 100Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Stroke: Signs and Symptoms  Embolic stroke ◦ Appear without warning ◦ One or more of the following signs and symptoms: one-sided weakness, numbness, visual problems, confusion and memory lapses, headache, dysphagia, and language problems

101 101Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 28-5

102 102Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Stroke: Signs and Symptoms  Aphasia ◦ A defect in the use of language; speech, reading, writing, or word comprehension  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

103 103Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 28-8

104 104Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Stroke: Signs and Symptoms  Sensory impairment ◦ Unable to feel touch, pain, or temperature in affected body parts  Unilateral neglect ◦ Do not recognize one side of the body as belonging to them  Homonymous hemianopsia ◦ Perceptual problem: involves loss of one side of field of vision  Elimination disturbances ◦ Neurogenic bladder ◦ Flaccid bladder ◦ Bowel incontinence

105 105Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Diagnosis  Blood studies, electrocardiogram (ECG), computed tomography, magnetic resonance imaging, carotid ultrasound studies, cerebral and carotid angiography, electrocardiography, positron-emission tomography, and single-photon emission computed tomography

106 106Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Complications  Constipation, dehydration, contractures, urinary tract infections, thrombophlebitis, decubitus ulcers, and pneumonia  Sensory losses put patient at risk for traumatic and thermal injuries  Swallowing difficulties place patient at risk for pulmonary complications, such as choking and aspiration pneumonia

107 107Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Prognosis  Prognosis for TIA or stroke increasingly hopeful  Critical variables for recovery: patient’s condition before the stroke, time between stroke and diagnosis, treatment and support in acute phase (usually the first 48 hours), severity of patient’s symptoms, and access to rehabilitative therapy  Long-term recovery may depend on the care received immediately after the stroke  Most recovery takes place in the first 3-6 months, but progress often continues long after that

108 108Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment in the Acute Phase  Begins with the onset of signs and symptoms and continues until vital signs, particularly blood pressure and neurologic condition, stabilize  This phase usually lasts 24 to 48 hours  Many medical management interventions are directed at minimizing complications and deterioration of the patient’s condition after a stroke

109 109Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment in the Acute Phase  Major focus areas  Hypertension  Oxygenation  Hyperthermia  Hyperglycemia ◦ Drug therapy  Tissue plasminogen activator (rt-PA, alteplase, Activase)  Given to dissolve clots in acute ischemic strokes

110 110Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment in the Acute Phase  Other medications  Mannitol  Nimodipine (Nimotop)  Phenytoin (Dilantin) and phenobarbital  Acetylsalicylic acid (aspirin), ticlopidine hydrochloride (Ticlid), Aggrenox, and clopidogrel (Plavix)

111 111Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment in the Acute Phase  Surgical intervention ◦ An option for some patients with hemorrhagic strokes ◦ Decisions about surgery are based on patient’s age, intracranial pressure, and location of the hemorrhage

112 112Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment in the Acute Phase  Fluids and nutrition ◦ Intravenous fluids ◦ Dietary order based on patient’s nutritional requirements and ability to eat  Regular, soft, or pureed ◦ Total parenteral nutrition may be ordered for the malnourished patient

113 113Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment in the Acute Phase  Urine elimination ◦ Indwelling catheter to manage urinary incontinence ◦ Intermittent catheterization: controlling incontinence caused by a flaccid bladder

114 114Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care in the Acute Phase  Assessment ◦ Evaluate type and extent of the stroke: time of onset, symptoms, other details ◦ Cincinnati Pre-hospital Stroke Scale  Health history ◦ Chief complaint and history of present illness ◦ Medical history ◦ Family history ◦ Review of systems ◦ Functional assessment

115 115Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care in the Acute Phase  Physical examination ◦ Assess patient’s general appearance, responsiveness, and behavior ◦ Record restlessness or agitation ◦ Measure vital signs; weight and height if possible ◦ Inspect the face for symmetry; mouth for moisture and drooling ◦ Evaluate the alert patient’s ability to swallow ◦ Inspect pupils for size, equality, and reaction to light

116 116Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care in the Acute Phase  Physical examination ◦ Conduct a gross vision assessment ◦ Inspect skin color and palpate for moisture and turgor ◦ Assess extremities for muscle tone and strength, sensation, and voluntary movement ◦ Record evidence of incontinence or bladder distention ◦ Frequently repeat neurologic checks: evaluating level of consciousness, pupil appearance and response to light, the patient’s ability to follow commands, and the movement and sensation of extremities

117 117Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care in the Acute Phase  Interventions ◦ Ineffective Airway Clearance and Ineffective Breathing Patterns ◦ Risk for Injury ◦ Deficient Fluid Volume or Excess Fluid Volume ◦ Imbalanced Nutrition ◦ Disturbed Sensory Perception ◦ Ineffective Thermoregulation ◦ Disturbed Thought Processes

118 118Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care in the Acute Phase  Interventions ◦ Impaired Verbal Communication ◦ Impaired Physical Mobility ◦ Total or Functional Urinary Incontinence ◦ Constipation and/or Bowel Incontinence ◦ Ineffective Coping ◦ Interrupted Family Processes

119 119Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care in the Rehabilitation Phase  Assessment ◦ Reassess patient’s abilities, expectations, knowledge, motivation, and resources

120 120Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care in the Rehabilitation Phase  Interventions ◦ Self-Care Deficit ◦ Risk for Injury ◦ Ineffective Coping ◦ Impaired Verbal Communication ◦ Imbalanced Nutrition ◦ Impaired Physical Mobility ◦ Constipation ◦ Total and Functional Urinary Incontinence

121 121Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 28-6

122 122Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 28-7

123 123Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 28-9

124 124Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Discharge  Patients may be discharged to home or go to specialized rehabilitation centers for continued therapy  Outpatient therapy is an option for some patients  When able, patients are transitioned back into the home setting  Essential to include family, friends, and significant others in this process

125 125Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Discharge  During and after the rehabilitation phase, patients and families need to be made aware of resources to help them deal with continuing disabilities  In rehabilitation, the patient is respectfully challenged to return to the highest level of function possible

126 126Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. NURS 1130 Unit 4 Spinal Cord Injury

127 127Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Anatomy and Physiology of the Spinal Cord

128 128Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

129 129Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-1

130 130Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Vertebral Column  Each vertebra consists of a body and an arch  The spinal cord passes through an opening in the center of each arch  Each arch has articulating surfaces against which adjacent vertebrae smoothly glide with movement  The bony column is supported by muscles and ligaments, which permit mobility and flexibility

131 131Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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 much of its water; less effective as a shock absorber

132 132Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-2

133 133Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Spinal Cord  Extends from the brainstem to L2 in pelvic cavity  Surrounded by three protective meningeal layers ◦ Dura mater  Outermost layer ◦ Arachnoid  Middle layer: spaces containing cerebrospinal fluid (CSF) ◦ Pia mater  Innermost layer: directly covers the spinal cord  CSF circulates through the brain and spinal column, bathing and protecting the entire central nervous system

134 134Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-3

135 135Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Spinal Cord  Gray matter ◦ Consists of the bodies of nerve cells that control motor and sensory activities  White matter ◦ Myelinated (surrounded by a sheath); consists of bundles of fibers ◦ Convey information between the brain and the spinal cord ◦ Tracts may be ascending or descending

136 136Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-4

137 137Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Spinal Cord  Blood supply ◦ Major arterial supply to the spinal cord; consists of the vertebral arteries posteriorly and the anterior spinal artery  Reflexive activity ◦ The sensory stimulus is received, and a response is initiated at the level of the spinal cord

138 138Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Spinal Cord  Relay activity ◦ Stimulus enters spinal cord; travels up ascending tracts to relay sensory signals to the brain ◦ Information processed in the brain; responses initiated by impulses transmitted to the body by way of descending tracts  Information conveyed to brain and spinal cord via peripheral nervous system

139 139Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures  Neurologic examination ◦ Initial evaluation of the spinal cord: injured patient provides the nurse with a baseline assessment of function and problems ◦ Ongoing assessment necessary to monitor the effects of neurologic injury, detect related complications, and determine patient’s need for assistance in activities of daily living ◦ Focuses on the motor and sensory systems

140 140Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Diagnostic Tests and Procedures  Imaging studies ◦ Radiography  Detects vertebral compression, fractures, or problems with alignment ◦ Computed tomography (CT)  Noninvasive examination of the specific levels of the spinal cord to be visualized, bony vertebrae, and the spinal nerves ◦ Magnetic resonance imaging (MRI)  Produces precise, clear images of internal structures ◦ Myelogram  Visualizes the spinal cord and vertebrae

141 141Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Pathophysiology of Spinal Cord Injury

142 142Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Types of Injuries  Location ◦ Cervical, thoracic, or lumbar  Open or closed ◦ 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 spinal cord injury occurs when the cord has been completely severed, whereas an incomplete injury results from partial cutting of the cord

143 143Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Effects of Spinal Cord Injury  Factors include extent of cut and level of injury  Sometimes cannot be fully determined because the symptoms of spinal cord edema may mimic partial or complete transection  With incomplete spinal cord injuries some function remains below the level of the injury ◦ Specific tracts may be involved, causing particular patterns of neurologic dysfunction

144 144Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-6

145 145Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Effects of Spinal Cord Injury  The higher the level of injury, the more encompassing the neurologic dysfunction  Quadriplegia ◦ 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

146 146Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Respiratory Impairment  Injuries at or above the level of C5 may result in instant death because the nerves that control respiration are interrupted  Cervical injuries below the level of C4 spare the diaphragm but can involve impairment of intercostal and abdominal muscles

147 147Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Spinal Shock  An immediate, transient response to injury in which reflex activity below the level of the injury temporarily ceases

148 148Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Autonomic Dysreflexia  Exaggerated response of autonomic nervous system to noxious (painful) stimuli  With injury at or above the level of T6  The sympathetic nervous system is stimulated, but an appropriate parasympathetic modulation response cannot be elicited because of the spinal cord injury that separates the two divisions of the autonomic nervous system

149 149Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Autonomic Dysreflexia  Triggered by various stimuli including a distended bladder, constipation, renal calculi, ejaculation, or uterine contractions, but also may be caused by pressure sores, skin rash, enemas, or even sudden position changes

150 150Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Spasticity  Muscle spasms may be incapacitating for these patients, hampering efforts at rehabilitation

151 151Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Impaired Sensory and Motor Function  Impaired motor function can affect the patient’s mobility and self-care and thus result in complications from immobility  Loss of sensation puts patient at risk for skin breakdown and other injuries because pressure and pain are not perceived

152 152Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Impaired Bladder Function  During spinal shock, all bladder and bowel function ceases  Once spinal shock resolves, reflex activity returns

153 153Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Impaired Bowel Function  Most spinal cord–injured patients can maintain bowel function because the large bowel musculature has its own neural center that responds to distention by the fecal mass

154 154Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Impaired Temperature Regulations  May lose these regulatory mechanisms and be unable to adapt to temperature extremes

155 155Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Impaired Sexual Function  Spinal levels S2, S3, and S4 control sexual function, so injury at or above these levels results in sexual dysfunction  Ability to achieve erection and ejaculation is variable

156 156Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Impaired Skin Integrity  Because immobile patient can’t change positions, skin in sacral area and across bony prominences may break down  Loss of tone results in vasodilation and pooling of blood in the periphery; impedes perfusion of the skin; and encourages the development of pressure sores

157 157Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Altered Self-Concept and Body Image  French and Phillips (1991) describe the effects of spinal cord injury on body image as occurring in four phases: impact, retreat, acknowledgment, and reconstruction

158 158Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Medical Treatment in the Acute Phase

159 159Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Saving the Patient’s Life: Establish Airway  Conventional head-tilt–chin-lift: inappropriate with spinal injury; increases risk of cord damage  Risk of additional damage is especially high with cervical injury  Neck flexion, even that caused by a pillow or other support, must be avoided  Jaw-thrust method of opening the airway is preferred for these patients

160 160Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Saving the Patient’s Life: Establish Airway  Once airway is open, administer 100% oxygen by mask and manual resuscitator  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

161 161Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Preventing Further Cord Injury  Traction ◦ Immobilization with skeletal traction manages cervical spinal cord injuries acutely  Gardner-Wells tongs  Secured just above the ears; doesn’t actually penetrate skull  Crutchfield tongs  Applied directly to the skull just behind the hairline ◦ Halo vest: immobilizes and aligns cervical vertebrae; placed when surgery is done to internally stabilize fractures and relieve the compression of nerve roots

162 162Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-7

163 163Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-8

164 164Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Preventing Further Cord Injury  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 ◦ Wedge-Stryker 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

165 165Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-9

166 166Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Preventing Further Cord Injury  Drug therapy ◦ Methylprednisolone  Reduces the damage to the cellular membrane  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

167 167Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. 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

168 168Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Assessment  Monitor the patient’s level of consciousness, vital signs, respiratory status, motor and sensory function, and intake and output

169 169Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Health History  Present illness ◦ Event that brought the patient to the hospital ◦ Specific injuries incurred in the incident ◦ Describe pain and other symptoms in detail

170 170Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Past Medical History  Other accidents or injuries and chronic illnesses such as diabetes, hypertension, heart disease, cancer, or seizure disorder  Previous hospitalizations and operations  Obstetric history from female patient  Identify and record current medications and allergies

171 171Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Family History  Routine family history taken but not considered specifically relevant to a diagnosis of spinal cord injury resulting from trauma

172 172Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Review of Systems  Skin condition, headache or dizziness, vision disturbances, hearing impairment or tinnitus, nasal or ear drainage, dyspnea, nausea and vomiting, constipation or diarrhea, fecal incontinence, bladder dysfunction, sexual dysfunction, and impaired motor and sensory function

173 173Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Functional Assessment  Patient’s self-care abilities  Patient’s roles and responsibilities as a family member  Occupation, hobbies, usual activity pattern, habits, and diet  Emotional response to the spinal injury  Usual coping strategies  Spiritual beliefs; other sources of support

174 174Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physical Examination  Record the patient’s reported height and weight  Take vital signs  Take the temperature  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

175 175Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Physical Examination  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; use a dermatome chart

176 176Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Figure 29-10

177 177Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Interventions  Ineffective Breathing Pattern  Risk for Injury and Disturbed Sensory Perception  Risk for Autonomic Dysreflexia  Risk for Disuse Syndrome  Bowel Incontinence  Impaired Urinary Elimination

178 178Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Interventions  Risk for Infection  Ineffective Thermoregulation  Feeding/Dressing/Grooming Self-Care Deficit  Sexual Dysfunction  Ineffective Coping  Ineffective Therapeutic Regimen Management

179 179Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Rehabilitation  Activities that assist individual to achieve highest possible level of self-care and independence  Well-organized interdisciplinary team that can address all aspects of function ◦ 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

180 180Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Rehabilitation  Team helps the patient accomplish activities of daily living and self-care and addresses successful adjustment to social integration and gainful employment in the workplace  Although this phase of treatment may take more than a year, patient, family, and rehabilitation team can take pride in the realization that a life can once again be productive and happy

181 181Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care of the Laminectomy Patient  Preoperatively ◦ Assess patient’s vital signs and neurologic status to establish baselines ◦ Patient’s understanding of surgical routines ◦ Tell patient what to expect in the immediate postoperative period ◦ Ongoing assessment of neurologic status and on promoting healing at the operative site

182 182Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care of the Laminectomy Patient  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 ◦ Inspect the surgical dressing for bleeding, clear cerebrospinal fluid drainage, and foul drainage ◦ If the patient has pain, obtain a complete description

183 183Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Nursing Care of the Laminectomy Patient  Interventions ◦ Risk for Injury ◦ Ineffective Tissue Perfusion ◦ Acute Pain ◦ Impaired Urinary Elimination ◦ Constipation ◦ Impaired Physical Mobility ◦ Deficient Knowledge


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