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PNS Disorders & Spinal Cord Injury PNS Disorders & Spinal Cord Injury

PNS Disorders & Spinal Cord Injury - PowerPoint Presentation

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Uploaded On 2016-02-24

PNS Disorders & Spinal Cord Injury - PPT Presentation

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

spinal injury care cord injury spinal cord care high level interventions neurogenic acute stimulation patient drugs treatment paralysis shock

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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 SyndromeSlide20
Slide21

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