Chapter 45 Spinal Cord Lumbosacral Back Pain Low Back Pain Herniated nucleus pulposus Health Promotion and Maintenance Good posture Proper lifting Exercise Ergonomics PatientCentered Collaborative Care ID: 663715
Download Presentation The PPT/PDF document "Care of Patients with Problems of the Ce..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Care of Patients with Problems of the Central Nervous System: The Spinal Cord
Chapter 45Slide2
Spinal CordSlide3
Lumbosacral Back Pain (Low Back Pain)
Herniated nucleus pulposusSlide4
Health Promotion and Maintenance
Good posture
Proper lifting
Exercise
Ergonomics Slide5
Patient-Centered Collaborative Care
Assessment
Diagnostic assessmentSlide6
Nonsurgical Management
Positioning
Drug therapy
Heat therapy
Physical therapy
Weight control
Complementary and alternative therapiesSlide7
Surgical Management
Minimally invasive surgery:
Percutaneous lumbar diskectomy
Thermodiskectomy
Laser-assisted laparoscopic lumbar diskectomy
Conventional open surgical procedures:
Diskectomy
Laminectomy
Spinal fusionSlide8
Postoperative Care
Prevention and assessment of complications
Neurologic assessment; vital signs
Patient’s ability to void
Pain control
Wound care
CSF check
Patient positioning and mobilitySlide9
Community-Based Care
Home care management
Health teaching
Health care resourcesSlide10
Cervical Neck Pain
Conservative treatment is the same as described for back pain except that the exercises focus on shoulder and neck.
If these treatments do not work, soft collar may be used at night for a period of no longer than 10 days.
If conservative treatment is ineffective, surgery such as an anterior cervical diskectomy and fusion is commonly performed.Slide11
Spinal Cord Injuries
Hyperflexion injury
Hyperextension injury
Axial loading injury or vertical compression such as those that occur in jumping
Excessive rotation of the head beyond its range
Penetration injury, such as those wounds caused by a bullet or a knife Slide12
Spinal Cord Injuries (Cont’d)Slide13
Spinal Cord Injuries (Cont’d)Slide14
Common Spinal Cord Syndromes
Complete lesion
Anterior cord syndrome
Posterior cord lesion
Brown-S
é
quard syndrome
Central cord syndromeSlide15
Common Spinal Cord Syndromes (Cont’d)Slide16
Anterior Cord Syndrome
Damage to the anterior portion of both gray and white matter of the spinal cord
Usually a result of decreased blood supply
Motor function and pain and temperature lost below the level of the injury
Sensations of touch, position, and vibration remain intactSlide17
Posterior Cord Lesion
Damage to the posterior gray and white matter of the spinal cord
Motor function remains intact
Patient experiences loss of vibratory sense, touch, and position sensationSlide18
Brown-Séquard Syndrome
Results from penetrating injuries that cause hemisection of the spinal cord, or injuries that affect half of the spinal cord.
Motor function, proprioception, vibration, deep touch sensations are lost on the same side (ipsilateral) of the body as the lesion.
Opposite side (contralateral) of the body sensations of pain, temperature, light touch are affected.Slide19
Central Cord Syndrome
Lesions of the central portion of the spinal cord.
Loss of motor function is more pronounced in the upper extremities than in the lower extremities.
Varying degrees and patterns of sensation remain intact.Slide20
SCI: Etiology
Trauma is the leading cause
Incidence/prevalenceSlide21
Patient with SCI: Initial Assessment
First priority is assessment of the patient’s airway, breathing pattern, and circulation status
Assessment for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around fracture sites
Assessment of level of consciousness using Glasgow Coma ScaleSlide22
Initial Assessment (Cont’d)
Establishment of level of injury: tetraplegia, quadriplegia, quadriparesis, paraplegia, and paraparesisSlide23
Spinal Shock/Spinal Shock Syndrome
This condition occurs immediately as a concussion response to the injury. The patient has:
Flaccid paralysis
Loss of reflex activity below the level of the lesion
Usually resolves within 24 hours
Muscle spasticity begins in patients with cervical or high thoracic injuriesSlide24
Assessment of Sensory and Motor Ability
Hypoesthesia
Hyperesthesia Slide25
Cardiovascular and Respiratory Assessment
Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous system especially if the injury is above the 6th thoracic vertebra.
Cardiac dysrhythmias may result.
Systolic BP below 90 requires treatment because lack of perfusion to the spinal cord could worsen the patient’s condition.
Hypothermia.
Slide26
Cardiovascular and Respiratory Assessment (Cont’d)
Patients with cervical SCI are at risk for respiratory problems resulting from immobility or from an interruption of spinal innervations to the respiratory muscles.
Continued respiratory assessment including vital capacity and minute volume.Slide27
Gastrointestinal and Genitourinary Assessment
Assess abdomen for indications of hemorrhage, distention, or paralytic ileus.
Assess for reflex or hypotonic bowel.
Assess for areflexic bladder, which later leads to urinary retention.
Assess for neurogenic bladder.Slide28
Other Assessments
Lower motor neuron assessment
Upper motor neuron assessment
Skin assessment
Heterotrophic ossification assessment
Psychosocial assessment
Laboratory assessment
Imaging assessmentSlide29
Nonsurgical Management
Constant assessment
Assess for neurogenic shock. Neurogenic shock is spinal shock with:
Bradycardia
Decreased or absent bowel sounds
Warm, dry skin
Hypothermia
HypotensionSlide30
Immobilization for Cervical Injuries
Fixed skeletal traction to realign the vertebrae, facilitate bone healing, and prevent further injury
Halo fixation and cervical tongs
Stryker frame, rotational bed, kinetic treatment table
Pin site care and monitoring of traction ropesSlide31
Immobilization of Thoracic and Lumbosacral Injuries
For patients with thoracic injuries
—
bedrest and possible immobilization with a fiberglass or plastic body cast
For patients with lumbar and sacral injuries
—
immobilization of the spine with a brace or corset worn when the patient is out of bed; custom-fit thoracic lumbar sacral orthoses preferredSlide32
Drug Therapy
Methylprednisolone (controversial)
Dextran
Atropine sulfate
Dopamine hydrochloride
Tizanidine
Intrathecal baclofenSlide33
Surgical Management
Emergency surgery necessary for spinal cord decompression
Decompressive laminectomy
Spinal fusion
Harrington rods to stabilize thoracic spinal injuriesSlide34
Ineffective Airway Clearance and Breathing Pattern
Interventions for the patient with spinal cord injury:
Airway management is the priority.
Patients with injuries at or above the 6th thoracic vertebra are especially at risk for respiratory complications.
Provide measures to maintain airway.Slide35
Ineffective Airway Clearance and Breathing Pattern (Cont’d)
Assisted coughing, quad cough, cough assist
Use of incentive Spiro meterSlide36
Impaired Physical Mobility; Self-Care Deficit
Interventions include:
In patients with spinal cord injury, monitor for risk of pressure ulcers, contractures, and deep vein thrombosis or pulmonary emboli.
Proper positioning, skin inspection, ROM exercises, heparin, and graduated compression stockings.
Slide37
Impaired Physical Mobility; Self-Care Deficit (Cont’d)
Prevent orthostatic hypotension.
Promote self-care.Slide38
Impaired Urinary Elimination; Constipation
Interventions include:
A bladder retraining program
Spastic bladder
—
manipulating external area
Flaccid bladder
—
Valsalva maneuver
Encouraging consumption of 2000 to 2500 mL of fluid daily to prevent urinary tract infectionSlide39
Impaired Urinary Elimination; Constipation (Cont’d)
Long-term renal complication
Signs and symptoms of urinary tract infection not perceived by the patientSlide40
Autonomic Dysreflexia
Commonly seen in patients with upper spinal cord injury
Severe hypertension
Bradycardia
Severe headache
Nasal stuffiness
Flushing
Treatment Slide41
Establishing a Bowel Retraining Program
Consistent time for bowel elimination
High fluid intake
High-fiber diet
Rectal stimulation (with or without suppositories)
Stool softener medications, as neededSlide42
Impaired Adjustment
Interventions include:
Invite patients to ask questions about significant life changes; reply openly and honestly.
Encourage patients to discuss their perceptions of their situation and coping strategies that can be used.
Begin a patient education program to clarify misconceptions.Slide43
Community-Based Care
Home care management
Health teaching
Health care resourcesSlide44
Spinal Cord Tumors
Primary spinal cord tumors
Intramedullary tumors
Extramedullary tumorsSlide45
Patient-Centered Collaborative Management
Assessment
Diagnostic assessment
Surgical management
—
need for emergency surgery
Nonsurgical management
—
radiation, chemotherapySlide46
Community-Based Care
Home care management
Health teaching
Health care resources Slide47
Multiple Sclerosis
Chronic autoimmune disease affecting the myelin sheath and conduction pathway of the CNS
Characterized by periods of remission and exacerbation
Inflammatory response resulting in random or patchy areas of plaque in the white matter of the CNSSlide48
Multiple Sclerosis (Cont’d)
Etiology
Genetic risk
Incidence
Prevalence Slide49
Major Types of Multiple Sclerosis
Relapsing-remitting
Primary progressive
Secondary progressive
Progressive-relapsing Slide50
Patient-Centered Collaborative Care
Patient history
Physical assessment/clinical manifestations
FatigueSlide51
Common Physical Assessment
Findings include:
Flexor spasms at night
Intention tremor
Dysmetria
Blurred vision, diplopia, decreased visual acuity, scotomas, nystagmus
Hypalgesia, numbness, tingling, or burning
Bowel and bladder dysfunctionSlide52
Assessment
Psychosocial assessment
Laboratory assessment
Other diagnostic testsSlide53
Drug Therapy
Therapies include:
Interferon beta
Monoclonal antibodies
Copaxone
Novantrone
Immunosuppressive therapy
MethylprednisoloneSlide54
Drug Therapy (Cont’d)
Muscle relaxants
Treatment of paresthesia
Treatment of bladder dysfunctionSlide55
Other Interventions
Promoting mobility
Managing symptoms
Complementary and alternative therapiesSlide56
Community-Based Care
Home care management
Health teaching
Health care resourcesSlide57
Amyotrophic Lateral Sclerosis
Known as
Lou Gehrig’s disease,
an adult onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity eventually leading to paralysis
Early symptoms
—
fatigue while talking, tongue atrophy, dysphagia, weakness of the hands and arms, fasciculations, nasal quality of speech, dysarthriaSlide58
Interventions
No known cure, no treatment, no preventive measures
Riluzole, only drug approved by FDA to extend survival time
Exercise and mobility program
Management of swallowing difficulties
Respiratory support