Megan McClintock MS RN Fall 2011 NRS 440 Trigeminal Neuralgia tic d ouloureux Dx Treatment CT amp MRI Tegretol carbamazepine or Trileptal oxcarbazepine Nerve blocks ID: 229877
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Slide1
PNS Disorders & Spinal Cord Injury
Megan McClintock, MS, RN
Fall 2011 – NRS 440Slide2
Trigeminal Neuralgia
(tic
douloureux)Slide3
Dx/Treatment
CT & MRI
Tegretol (carbamazepine) or Trileptal (oxcarbazepine
)Nerve blocksBiofeedbackGlycerol rhizotomy
Microvascular
decompression
Gamma knifeSlide4
Interventions
Strong
opiods are usually avoidedEnvironmental management during attacksSoft-bristled, small toothbrushFoods high in protein/calories, easy to chew, lukewarmSlide5
Bell’s PalsySlide6
Treatment
Moist heat
Gentle massageElectrical stimulation of the nerveFacial exercisesCorticosteroids (prednisone)Mild analgesicsAntiviralsSlide7
Interventions
Prevention
Hot, moist packsProtect the face from cold and draftsGood nutrition (chew on unaffected side)Meticulous oral hygieneDark glassesArtificial tears
Taping eyelid closed or protective shieldFacial slingGentle massageFacial exercisesSlide8
Guillian-Barré
SyndromeSlide9
Dx/Treatment
Diagnosis based on history,
s/sSupportive careVentilatory
support in acute phasePlasmapheresis
IV high-dose immunoglobulin (
Sandoglobulin
)Nutritional supportSlide10
Interventions
Careful assessment
Prepare for intubation if vital capacity less than 800 mLCareful prevention of infectionEstablish a communication system earlyCatheterization
ROMMeticulous eye careNutrition (risk of aspiration)F&E balance
Prevention of constipationSlide11
Botulism
Most serious type of food poisoning
Thought that the neurotoxin prevents Ach from workingSx – n/v, diarrhea, abdominal cramping,
afebrile, no mental deficits, decscending paralysis with cranial nerve deficitsDeath can occur from circulatory failure,
resp
paralysis, or
resp complications
Tx
– IV
botulinum
antitoxin, purge of GI tract
Prevention is key
Nursing care is like for
Guillian-BarreSlide12
Tetanus (Lockjaw)Slide13
Spinal Cord InjurySlide14
Spinal Cord InjurySlide15
Shock
Spinal Shock
50% experience thisDecreased reflexesLoss of sensationFlaccid paralysisAll below the level of the injuryCan last days to months
Still start active rehabilitationNeurogenic
Shock
Occurs due to loss of vasomotor tone
HypotensionBradycardia
Peripheral
vasodilation
Venous pooling
Decreased cardiac output
Usually associated with cervical or high thoracic injurySlide16
Degree of ParalysisSlide17
Degree of ParalysisSlide18
Degree of ParalysisSlide19
Syndromes of Spinal Cord Lesions
Central Cord Syndrome
Anterior Cord SyndromeBrown-Séquard SyndromePosterior Cord SyndromeSlide20Slide21
Signs/Symptoms
Respiratory
Above C4 have total loss of resp muscle functionBelow C4 can have problems with the phrenic nerve
Cervical/thoracic injuries cause paralysis of abdominal/intercostal musclesMa have a
tracheostomy
Neurogenic
pulmonary edemaCardiovascular
Above T6 decreases the activity of the SNS
Bradycardia
, hypotensionSlide22
Signs/Symptoms
Urinary
Urinary retentionSpinal shock causes retention, atonic bladderBegin intermittent cath as soon as possible
GIAbove T5, problems are related to hypomobilityStress ulcers
Intraabdominal
bleeding (signs are masked)
Below T12 and spinal shock - neurogenic
bowelSlide23
Signs/Symptoms
Skin
Potential for skin breakdownThermoregulationPoikilothermismDecreased ability to sweat/shiver below level of injury
Worse with high cervical injuriesMetabolic needsMetabolic alkalosis, Na, K levels (from NG suctioning)Acidosis (from decreased tissue perfusion)
High protein, high calorie diet
Peripheral vascular Problems
DVT & PE risk (harder to detect)Slide24
Dx/Treatment
CT
Treat systemic and neurogenic shockIf cervical injury, must maintain all body systems (pg 1552)Assess muscle groups, sensory status, brain injury, musculoskeletal injuries, internal injuries
Logroll during transfers/repositioningStabilization of injury – traction, realignment, surgeryDrugs
High dose
methylprednisolone
w/in 8 hours of injuryVasopressors (dopamine)
All drugs may be metabolized differently with SCISlide25
Acute Interventions
Immobilization
Stabilize the neck to prevent lateral rotationKeep body correctly alignedLogroll when turningIf traction is used, it must be maintained at all timesKinetic therapy bedSlide26
Halo Fixation
Pin Site care
Skin care under vest
Be able to insert 1 finger under vestDo not hold onto
halo to move
Weights must hang freely
Don’t release traction
Keep a set of wrenches close
Keep sheepskin pad under vest, wash
weeklySlide27
Acute Interventions
Respiratory
Critical to assess during first 48 hrsAbove C3 requires mechanical ventilationAssess carefullyChest PT
Assisted coughing or incentive spirometrySlide28
Acute Interventions
Cardiovascular
Limit vagal stimulation (turning, suctioning)Assess VS frequentlyGive anticholinergics (atropine) for
bradycardiaGive vasopressors (dopamne
) for hypotension
Sequential compression devices
ROM and stretching exercisesProphylactic heparin (
Lovenox
)
Watch closely for signs of
hypovolemic
shockSlide29
Acute Interventions
Fluid & Nutrition
NG tubeGradually start food/fluids will bowel sounds are active or flatus is passedHigh protein, high calorie dietEvaluate swallowing before starting oral feedingEnteral or
parenteral nutrition may be neededCreative ways to encourage eatingDietary supplements as neededSlide30
Acute Interventions
Bladder & Bowel
Indwelling catheterLots of fluid intakeWatch for UTIsTransition to intermittent catheterization as soon as possible every 3-4 hoursBowel program
Rectal stimulant followed by gentle digital stimulationTemperature ControlMaintain environmental temp
Don’t overload with covers or expose too long (baths)
Cooling blanket for feversSlide31
Acute Interventions
Stress Ulcers
Usually occur 6-14 days after injuryTest stool/gastric contents for bloodGive steroids with antacids or foodHistamine receptor blockers (Zantac, Pepcid
) or proton pump inhibitors (Protonix, Prilosec)
Sensory Deprivation
Stimulate patient above the level of injury
Prism glasses, conversation, music, smells, flavorsReflexes
Explain that this is not always a return to function
Antispasmodic drugs (
baclofen
,
Dantrium
,
Zanaflex
)Slide32
Autonomic
Dysreflexia
Life threatening emergency!!!Massive uncompensated cardiovascular reaction caused by the SNSOccurs in response to visceral stimulationSx
– HTN (up to 300), throbbing headache, sweating above the level of the lesion, bradycardia, piloerection, flushing of skin above the level of the lesion, blurred vision/spots, nasal congestion, anxiety, nausea
Tx
– elevate HOB to 45 degrees or sit upright, call
dr, assess for cause,
cath
(
lidocaine
jelly), ensure
cath
is not kinked, digital rectal exam (anesthetic ointment), remove constrictive clothing, monitor BP closely, give
Procardia
, teach the patientSlide33
Home Care
Respiratory
If ventilator-dependent can still be mobileAssisted coughing, incentive spirometryNeurogenic BladderTypes –
reflexic, areflexic, sensoryIdentify appropriate drainage method
Surgical options
Anticholinergic
drugs, adrenergic blockers, antispasmodic drugs
Avoid long-term use of indwelling catheters if possibleSlide34
Home Care
Neurogenic
BowelHigh fiber diet, adequate fluid intakeSuppositories (dulcolax, glycerin) or small-volume enemas with digital stimulation 20-30 minutes laterStool softener (
Colace)Valsalva and manual stimulation (for lower motor neuron lesions)
Time BM for 30-60 minutes after breakfast
Upright position with feet flat on floor or on stepstool if possible
ExerciseSlide35
Home Care
Neurogenic
SkinTwice daily comprehensive visual and tactile examCarefully watch ischia, trochanters, heels, sacrum
Reposition every 2 hoursPressure relieving cushions, special mattressesAdequate intake of proteinProtection from thermal injury
Use pillows to protect bony prominences
In a wheelchair, lift self up and shift weight every 15-30 minSlide36
Home Care
Sexuality
See table 61-13 (pg 1562)If upper motor neuron lesion, can have reflex sexual functionIf lower motor neuron lesion, may be capable of psychogenic erection (ejaculation may retrograde into bladder)Tx
– drugs, vacuum devices, surgical proceduresFertility a problem with menWomen have problems with lubricationOpen communication is important
Sexual activity may be less spontaneous
May have incontinence during sexual activitySlide37
Home Care
Grief and Depression
Can feel an overwhelming sense of lossBelieve they are useless and a burden to their familyMay have regressionExpect a wide fluctuation of emotionsTable 61-14 (pg 1563) Mourning ProcessCounseling for caregiver and family
Sympathy is not helpful, insist that care be performedSlide38
Spinal Cord Tumor
Rare
Can be primary or secondaryCan be extradural, intradural extramedullary
, or intradural intramedullaryMost are slow-growing and don’t cause secondary injury
May have sensory and motor problems
Early
sx – back pain with
radicular
pain causing
intercostal
pain, angina or herpes zoster; pain worsens with activity, coughing, straining, lying downSlide39
Treatment
Dx
with spinal xray, MRI, CTSurgical Treatment: tumor removalRadiation Therapy (may also do chemo)Compression of the cord is an emergency!!!!
Give high-dose corticosteroidsSlide40
1. A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for
1. return of reflexes.
2. bradycardia with hypoxemia.
3. effects of sensory deprivation.
4. fluctuations in body temperature. Slide41
2. A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to
1. breathe with respiratory support.
2. drive a vehicle with hand controls.
3. ambulate with long-leg braces and crutches.
4. use a powered device to handle eating utensils.Slide42
3. During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which of the following findings would concern the nurse the most?
1. A heart rate of 92
2. A reddened area over the patient’s coccyx
3. Marked perspiration on the patient’s face and arms
4. A light inspiratory wheeze on auscultation of the lungs