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NURS 1130 Unit 4 Neurologic Disorders.

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1 NURS Unit 4 Neurologic Disorders

2 Anatomy and Physiology of the Nervous System

3 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 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 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 Figure 27-1

7 Central Nervous System (CNS)
Made up of the brain and spinal cord

8 Peripheral Nervous System
Comprises all the nerves of the peripheral parts of the body, including spinal and cranial nerves

9 Brain Divided into the cerebrum, cerebellum, and brainstem

10 Cerebrospinal Fluid (CSF)
Composed of water, glucose, sodium chloride, and protein Acts as a shock absorber for the brain and spinal cord

11 Figure 27-2

12 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 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 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 Pathophysiology of Neurologic Diseases

16 Types of Disorders Developmental and genetic Trauma
Infections and inflammation Neoplasms Degenerative processes Vascular disorders Metabolic and endocrine disorders

17 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 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 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 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 Figure 27-5

22 Figure 27-6

23 Figure 27-7

24 Diagnostic Tests and Procedures
Lumbar puncture Electroencephalography Electromyography Radiologic studies Brain scan Cerebral angiography and digital subtraction angiography Computed tomography Magnetic resonance imaging

25 Figure 27-8

26 Figure 27-9

27 Figure 27-10

28 Figure 27-11

29 Common Therapeutic Measures
Drug therapy Antimicrobials Analgesics Anti-inflammatory Corticosteroids Anticonvulsants Diuretics Chemotherapeutic agents Dopaminergics Anticholinergics Cholinergics Antihistamines

30 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 Disorders of the Nervous System

32 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 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 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 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 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 Seizure Disorder Status epilepticus Aura Medical treatment
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 Seizure Disorder Surgical treatment
Removal of seizure foci in the temporal lobe and pallidotomy or vagal nerve stimulator

39 Seizure Disorder: Nursing Care
Assessment Describe the seizure episode, including the postictal period (following the seizure), and document drug therapy

40 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 Head Injury: Types Scalp injuries Concussion Contusion Hematoma
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 Head Injury Surgical treatment
Directed at evacuating hematomas and débriding damaged tissue

43 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 Brain Tumors Etiology and risk factors Signs and symptoms
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 Brain Tumors: Nursing Care
Interventions Acute Pain Disturbed Thought Processes Disturbed Sensory Perception Impaired Physical Mobility and Self-Care Deficit Ineffective Coping

46 Meningitis Etiology and risk factors Medical diagnosis
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 Figure 27-16A

48 Figure 27-16B

49 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 Meningitis: Nursing Care
Assessment Assess vital signs and neurologic status frequently to determine further deterioration or onset of complications

51 Meningitis: Nursing Care
Interventions Ineffective Tissue Perfusion Ineffective Breathing Pattern Acute Pain Risk for Injury Deficient Fluid Volume

52 Encephalitis Etiology and risk factors Signs and symptoms
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 Encephalitis: Nursing Care
The nursing plan of care parallels that of the patient with meningitis

54 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 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 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 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 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 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 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 Parkinson’s Syndrome Etiology and risk factors Signs and symptoms
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 Figure 27-17

63 Parkinson’s Syndrome Medical diagnosis Medical treatment
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 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 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 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 Figure 27-18

68 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 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 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 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 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 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 ALS Medical diagnosis Medical treatment
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 ALS: Nursing Care Assessment
Dyspnea, dysphagia, muscle cramps, weakness, twitching, joint stiffness, muscle atrophy, abnormal reflexes and gait, and paralysis

76 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 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 Myasthenia Gravis Etiology Pathophysiology
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 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 Myasthenia Gravis Medical diagnosis Medical treatment
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 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 Cerebrovascular Accident
NURS Unit 4 Cerebrovascular Accident

83 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 Figure 28-1

85 Cerebrum Brainstem Includes midbrain, pons, medulla, and part of the reticular activating system Controls vital, basic functions, including respiration, heart rate, and consciousness

86 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 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 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 Figure 28-2

90 Cerebrovascular Accidents

91 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 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 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 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 Figure 28-3

96 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 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 Figure 28-4

99 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 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 Figure 28-5

102 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 Figure 28-8

104 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 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 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 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 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 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 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 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 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 Medical Treatment in the Acute Phase
Urine elimination Indwelling catheter to manage urinary incontinence Intermittent catheterization: controlling incontinence caused by a flaccid bladder

114 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 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 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 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 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 Nursing Care in the Rehabilitation Phase
Assessment Reassess patient’s abilities, expectations, knowledge, motivation, and resources

120 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 Figure 28-6

122 Figure 28-7

123 Figure 28-9

124 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 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 NURS Unit 4 Spinal Cord Injury

127 Anatomy and Physiology of the Spinal Cord

128 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 Figure 29-1

130 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 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 Figure 29-2

133 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 Figure 29-3

135 Spinal Cord Gray matter White 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 Figure 29-4

137 Spinal Cord Blood supply Reflexive activity
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 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 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 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 Pathophysiology of Spinal Cord Injury

142 Types of Injuries Location Open or closed Extent of damage to the cord
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 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 Figure 29-6

145 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 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 Spinal Shock An immediate, transient response to injury in which reflex activity below the level of the injury temporarily ceases

148 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 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 Spasticity Muscle spasms may be incapacitating for these patients, hampering efforts at rehabilitation

151 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 Impaired Bladder Function
During spinal shock, all bladder and bowel function ceases Once spinal shock resolves, reflex activity returns

153 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 Impaired Temperature Regulations
May lose these regulatory mechanisms and be unable to adapt to temperature extremes

155 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 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 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 Medical Treatment in the Acute Phase

159 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 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 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 Figure 29-7

163 Figure 29-8

164 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 Figure 29-9

166 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 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 Assessment Monitor the patient’s level of consciousness, vital signs, respiratory status, motor and sensory function, and intake and output

169 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 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 Family History Routine family history taken but not considered specifically relevant to a diagnosis of spinal cord injury resulting from trauma

172 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 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 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 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 Figure 29-10

177 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 Interventions Risk for Infection Ineffective Thermoregulation
Feeding/Dressing/Grooming Self-Care Deficit Sexual Dysfunction Ineffective Coping Ineffective Therapeutic Regimen Management

179 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 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 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 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 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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