spinal’cord’and’ peripheral’nerve’ spinal’cord’injury’...

Fall 2019 - Spring 2020

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Spinal Cord and Peripheral Nerve Problems

• Spinal Cord Injury • Guillain-‐Barre Syndrome

Cogni<on Mobility Oxygena<on Safety Sensory Percep<on Stress and Coping

*What concept is involved? *What nursing physical assessments are involved?


Spinal Cord Injury (SCI) E"ology Clinical Manifesta"ons Clinical Therapies

Spinal cord injury (general)

•  Pain •  Loss of sensa<on •  Loss of bladder and bowel control •  Paralysis •  Muscle spasms •  Spinal shock •  DVT •  Reproduc<ve problems

•  Immobiliza<on •  Spinal decompression surgery •  Methylprednisolone •  Analgesics •  An<spasmodics •  Catheteriza<on •  Skin care •  ROM exercises •  Rehabilita<on

Cervical injury Cord compression by: •  Bone displacement

Interrup<on of blood supply

•  Trac<on from pulling on cord

•  Penetra<ng trauma → tearing and transec<on

See Figure 60-‐2 pg. 1421

In addi'on to symptoms for general SCI: •  Tetraplegia •  Oddly twisted neck •  Weakness, loss of respiratory muscle control •  Hypotension •  Bradycardia, arrhythmias •  Autonomic dysrelexia •  Decreased peristalsis

In addi'on to symptoms for general SCI: Airway patency External fixa<on or trac<on Nasogastric decompresssion


Interprofessional Care –Prehospital Immediate goals:

•  Patent airway •  Adequate ven<la<on/breathing

•  Adequate circula<ng blood volume

•  Prevent extension of spinal cord damage

•  Immobiliza<on •  Rigid cervical collar

•  Backboard with straps

•  Spinal immobiliza<on with penetra<ng trauma not recommended

•  Maintain systolic BP >90mm Hg



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Interprofessional Care –Acute Care

Addi<onal assessment include: •  Brain injury and/or vertebral artery

injury •  History of unconsciousness •  Signs of concussion •  Increased intracranial pressure •  Musculoskeletal injuries •  Trauma to internal organs Ini<al care: •  Cervical injury requires more

intense support •  Obtain history, emphasizing

incident •  Assess extent of injury •  Medical interven<ons and

diagnos<cs

Ini<al assessment: •  Managing ABCs

and vital signs •  Move the

pa<ent in alignment as a unit (logroll)

•  Monitor respiratory, cardiac, urinary, GI func<ons


Interprofessional Care –Acute Care Nonopera"ve Stabiliza"on

•  Stabilization of injured spinal segment •  Eliminates

damaging motion

•  Prevent secondary damage

•  Decompression •  Traction or

realignment •  Early realignment

•  Closed reduction

•  Craniocervical traction


A patient is just admitted to the hospital following a spinal cord injury at the level of T4. What is the priority for the nurse to monitor? a.  Return of reflexes b.  Bradycardia with hypoxemia c.  Effects of sensory deprivation d.  Fluctuations in body temperature

Audience Response Ques<on



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Spinal Cord Injury

•  Related to level and degree of injury

•  Incomplete → variable

•  Sequelae more •  serious with

higher injury


Spinal Cord Injury –Diagnos"c Studies

Level of Injury: •  Skeletal vs. neurologic level •  Level of injury may be Cervical

–  Thoracic –  Lumbar –  Sacral

•  Tetraplegia (quadraplegia) •  Paraplegia •  Complete

–  Total loss of sensory and motor func<on below level of injury

•  Incomplete (par<al) – Mixed loss of voluntary motor ac<vity and sensa<on

–  Some tracts intact

•  CT scan •  Cervical x-‐rays •  MRI •  Comprehensive

neurologic examina<on

•  CT angiogram


SCI

Spinal Shock ¡  Characterized by

§  ↓ Reflexes §  Loss of sensation §  Absent thermoregulation §  Flaccid paralysis below level

of injury

¡  Lasts days to weeks

Neurogenic Shock ¡  Characterized by

§  Hypotension §  Bradycardia

¡  Loss of SNS innervation §  Peripheral vasodilation §  Venous pooling §  ↓Cardiac output

¡  T6 or higher injury



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Respiratory System •  Above level of C4

•  Total loss of respiratory muscle func<on

•  Below level of C4 •  Diaphragma<c breathing →

respiratory insufficiency •  Cervical and thoracic injuries

•  Paralysis of abdominal and intercostal muscles → ineffec<ve cough → risk for aspira<on, atelectasis, pneumonia

•  Risk for neurogenic pulmonary edema

•  Spinal cord edema may increase during first 48 hours

•  May need intuba<on and mechanical ven<la<on

•  Intervene to maintain ven<la<on •  Administer oxygen •  Provide ven<lator support •  Chest physiotherapy •  Assisted (augmented) coughing •  Tracheal suc<oning •  Incen<ve spirometry •  Appropriate pain management

•  ↑ Risk for pneumonia and atelectasis (VAP)

•  Mechanical ven<la<on: –  Round-‐the-‐clock caregiver –  Respiratory hygiene –  Tracheostomy care

•  Phrenic nerve s<mulator •  Diaphragma<c pacemaker •  Mobile ven<lators


Cardiovascular System Neurogenic shock leads to dysfunction of sympathetic nervous system •  Characterized by:

•  Bradycardia •  Hypotension

–  Relative hypovolemia because of ↑ in capacity of dilated veins

–  Reduced venous return decreasing cardiac output

•  Loss of SNS innervation •  Peripheral vasodilation •  Venous pooling •  ↓Cardiac output

•  T6 or higher injury •  ↑ Risk for DVT •  Dysrhythmias may occur

•  Frequently assess vital signs •  An<cholinergic drug/

pacemaker •  Fluid replacement,

vasopressor agent •  If blood loss occurred

•  Monitor hemoglobin and hematocrit

•  Possible blood administra<on •  Assess orthosta<c BP

•  Abdominal binders/compression stockings

•  Drug therapy •  VTE prophylaxis/PE


Cardiovascular System Autonomic Dysreflexia

•  Massive uncompensated cardiovascular reac<on mediated by sympathe<c nervous system –  SNS responds to s<mula<on of sensory receptors – parasympathe<c nervous system unable to counteract these responses

–  Hypertension and bradycardia

•  Most common precipitating factor is distended bladder or rectum



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Cardiovascular System Autonomic Dysreflexia

•  Manifestations: –  Hypertension (up to 300 mm

Hg systolic) –  Throbbing headache –  Marked diaphoresis above

level of injury –  Bradycardia (30 to 40 beats/

minute) –  Piloerection –  Flushing of skin above level of

injury –  Blurred vision or spots in

visual field –  Anxiety –  Nausea

Nursing interven<ons: •  Elevate head, sit upright •  No<fy HCP •  Assess for and remove

cause •  Immediate catheteriza<on •  Remove stool impac<on if

cause •  Remove constric<ve clothing/

<ght shoes •  Monitor and treat BP •  Pa<ent and caregiver

teaching


Urinary System •  Neurogenic bladder

•  Acute phase –  Urinary reten<on –  Bladder atonic,

overdistended, fails to empty •  Indwelling catheter

•  Postacute phase –  Bladder may become

hyperirritable –  Loss of inhibi<on from brain –  Reflex emptying and failure to

store urine

•  Indwelling urinary catheter •  Intermiient catheteriza<on

program, external •  Every 4-‐6 <mes daily •  Monitor for signs and

symptoms of urinary tract infec<ons

•  Drug therapy •  An<cholinergic drugs •  α-‐Adrenergic blockers •  An<spasmodic drugs

•  Drainage methods •  Bladder reflex training •  Urinary diversion surgery


Bowel Management Neurogenic bowel ini<ally

•  Voluntary control may be lost

•  Cons<pa<on

•  Bowel program started during acute care –  Stool sokener –  Oral s<mulant laxa<ves –  Daily rectal s<mulant

•  Suppository or small-‐volume enema

–  Digital s<mula<on or manual evacua<on

•  Adequate fluid and fiber intake

•  Increased ac<vity and exercise



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Gastrointestinal System

•  Decreased GI motor ac<vity •  Gastric disten<on •  Development of paraly<c ileus

•  Gastric emptying may be delayed

•  Excessive release of HCl may cause stress ulcers

•  Dysphagia may be present

•  Intraabdominal bleeding may be difficult to diagnose

•  NG suctioning → metabolic alkalosis: –  Monitor F&E, especially sodium

and potassium •  Stress ulcers:

–  ↑Risk secondary to severe trauma and physiologic stress

–  Monitor stool, gastric contents, and hematocrit

–  Prophylac<c medica<ons (famo<dine, pantoprazole)


Gastrointestinal System •  Nutri<on should be started within

72 hours –  Individualized solu<ons/

addi<ves –  High-‐protein, high-‐calorie

diet –  Possible parenteral nutri<on

•  ↑Nutritional needs: –  Nutritional support to focus

on caloric and nitrogen needs –  Prevent skin breakdown,

reduce infection, decrease muscle atrophy

•  Inadequate nutritional intake: –  Assess for cause –  General measures

•  Pleasant eating environment

•  Adequate time

–  Dietary supplements –  Increased dietary fiber


Integumentary System •  Potential for skin breakdown •  Poikilothermism

•  Interruption of SNS •  ↓Ability to sweat or shiver below the level of injury

•  More common with high cervical injury

•  No vasoconstric<on, piloerec<on, or heat loss through perspira<on below level of injury

•  Neurogenic Skin: •  Monitor environment and

body temperature •  Do not use excessive covers or

unduly expose pa<ent •  Comprehensive visual and

tac<le examina<on •  Careful posi<oning and

reposi<oning every 2 hours •  Every 15 to 20 minutes when

in a chair •  Specialty mairesses,

pressure-‐relieving cushions •  Protect from thermal injury



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Pain •  Nocicep<ve Pain

–  Musculoskeletal pain dull or aching, worsens with movement

–  Visceral pain in thorax, abdomen, pelvis -‐ dull, tender, or cramping

•  Neuropathic Pain –  Located at or below level of injury

–  Hot, burning, <ngling, pins and needles, cold, shoo<ng

–  May be extremely sensi<ve to s<muli

•  Musculoskeletal nocicep<ve pain –  An<inflammatory drugs –  Opioids

•  Visceral nocicep<ve pain –  Diagnos<c imaging to evaluate cause

•  Neuropathic pain –  Gabapen<n (Neuron<n) or pregabalin (Lyrica)

–  Teach about pain triggers and relaxa<on therapy

•  Acute vs. chronic pain


Sensory Depriva<on & Reflexes

•  Secondary to absent sensa<ons –  S<mulate pa<ent above level of injury

–  Conversa<on, music, and interes<ng foods

–  Prism glasses to read and watch TV

–  Help pa<ent avoid withdrawing from the environment

•  Return of reflexes may complicate rehabilita<on –  Hyperac<ve –  Exaggerated responses –  Penile erec<ons –  Spasms

•  Pa<ent teaching •  An<spasmodic drugs


Interprofessional Care Surgical Therapy

•  Used following acute SCI to fix instability and decompress the spinal cord

•  Surgery within first 24 hours associated with improved neurologic outcome

•  Posterior approach •  Anterior approach •  Fusion

Pre/postoperative care –see musculoskeletal unit*


Pin site care –based on hospital protocol


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Rehabilita<on and Home Care

¡  Complex ¡  Goal to function at

highest level of wellness

¡  Retraining focus ¡  Interprofessional team

effort

¡  Organized around patient’s goals and needs

¡  Patient expected §  To be involved in therapies

§  To learn self-‐care ¡  Can be very stressful ¡  Frequent

encouragement


Sexuality •  Important issue regardless of patient’s age or gender

•  Injury level and completeness of injury impacts function

•  Psychogenic versus reflex erection

•  Treatments for erectile dysfunction

•  Drugs •  Vacuum devices •  Surgical procedures

•  • 

•  Fer<lity not usually affected •  Pregnancy complicated •  Risk for precipitous delivery

•  Female sexual ac<vity •  Urinary catheteriza<on •  Planning for bowel evacua<on

prior •  Incon<nence •  Lubrica<on

•  Nurse must •  Have an awareness and an

acceptance of personal sexuality •  Have knowledge of human

sexual responses •  Use medical terminology


Grief and Depression •  Depression is common •  Overwhelming sense of loss

•  Loss of control •  Adjustment more than acceptance

•  Wide fluctua<on in emo<ons

•  Allow mourning while encouraging hope

•  Sympathy not helpful •  Encourage patient

participation •  Consistency of care •  Psychiatric consult if

needed •  Caregiver and family

counseling •  Support group



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Guillain-‐Barre Syndrome (GBS) E"ology Clinical Manifesta"ons Clinical Therapies

A demyelina<ng disorder of the peripheral nervous system •  Unknown cause •  Autoimmune

process that occurs a few days or weeks following a viral or bacterial infec<on

•  Pain •  Paresthesia •  Hypotonia •  Autonomic nervous system

dysfunc<on •  Cranial nerve involvement

(facial, ocular, dysphagia) •  Acute, ascending, rapidly progressive, symmetric weakness of the limbs –maximal weakness reached in 4 weeks

•  Respiratory failure -‐infec<on

•  Ven<latory support •  Immunomodula<ng treatments –plasmapheresis

•  IV immunoglobulin (IV Ig)

•  PT/OT/Speech


Guillain-‐Barre Syndrome (GBS)

•  Complica<ons of Immobility: –  Paraly<c ileus – Muscle atrophy –  VTE –  Pressure ulcers –  Orthosta<c hypotension –  Nutri<onal deficiencies

Nursing: •  Neurologic assessment •  Respiratory & cardiac •  Nutri<onal needs •  Pa<ent, family, caregiver support


spinal’cord’and’ peripheral’nerve’ spinal’cord’injury’...

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