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PNS Disorders & Spinal Cord Injury
Megan McClintock, MS, RNFall 2011 – NRS 440
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Trigeminal Neuralgia (tic douloureux)
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Dx/TreatmentCT & MRI
Tegretol (carbamazepine) or Trileptal (oxcarbazepine)
Nerve blocks
Biofeedback
Glycerol rhizotomy
Microvascular decompression
Gamma knife
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InterventionsStrong opiods are usually avoided
Environmental management during attacks
Soft-bristled, small toothbrush
Foods high in protein/calories, easy to chew, lukewarm
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Bell’s Palsy
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TreatmentMoist heat
Gentle massage
Electrical stimulation of the nerve
Facial exercises
Corticosteroids (prednisone)
Mild analgesics
Antivirals
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InterventionsPrevention
Hot, moist packs
Protect the face from cold and drafts
Good nutrition (chew on unaffected side)
Meticulous oral hygiene
Dark glasses
Artificial tears
Taping eyelid closed or protective shield
Facial sling
Gentle massage
Facial exercises
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Guillian-Barré Syndrome
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Dx/Treatment• Diagnosis based on history, s/s
• Supportive care
• Ventilatory support in acute phase
• Plasmapheresis
• IV high-dose immunoglobulin (Sandoglobulin)
• Nutritional support
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InterventionsCareful assessment
Prepare for intubation if vital capacity less than 800 mL
Careful prevention of infection
Establish a communication system early
Catheterization
ROM
Meticulous eye care
Nutrition (risk of aspiration)
F&E balance
Prevention of constipation
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BotulismMost serious type of food poisoning
Thought that the neurotoxin prevents Ach from working
Sx – n/v, diarrhea, abdominal cramping, afebrile, no mental deficits, decscending paralysis with cranial nerve deficits
Death 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-Barre
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Tetanus (Lockjaw)
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Spinal Cord Injury
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Spinal Cord Injury
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ShockSpinal Shock
50% experience this
Decreased reflexes
Loss of sensation
Flaccid paralysis
All below the level of the injury
Can last days to months
Still start active rehabilitation
Neurogenic ShockOccurs due to loss of vasomotor tone
Hypotension
Bradycardia
Peripheral vasodilation
Venous pooling
Decreased cardiac output
Usually associated with cervical or high thoracic injury
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Degree of Paralysis
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Degree of Paralysis
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Degree of Paralysis
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Syndromes of Spinal Cord LesionsCentral Cord Syndrome
Anterior Cord Syndrome
Brown-Séquard Syndrome
Posterior Cord Syndrome
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Signs/SymptomsRespiratory
Above C4 have total loss of resp muscle function
Below C4 can have problems with the phrenic nerve
Cervical/thoracic injuries cause paralysis of abdominal/intercostal muscles
Ma have a tracheostomy
Neurogenic pulmonary edema
CardiovascularAbove T6 decreases the activity of the SNS
Bradycardia, hypotension
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Signs/SymptomsUrinary
Urinary retention
Spinal shock causes retention, atonic bladder
Begin intermittent cath as soon as possible
GIAbove T5, problems are related to hypomobility
Stress ulcers
Intraabdominal bleeding (signs are masked)
Below T12 and spinal shock - neurogenic bowel
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Signs/SymptomsSkin
Potential for skin breakdown
ThermoregulationPoikilothermism
Decreased ability to sweat/shiver below level of injury
Worse with high cervical injuries
Metabolic needsMetabolic alkalosis, Na, K levels (from NG suctioning)
Acidosis (from decreased tissue perfusion)
High protein, high calorie diet
Peripheral vascular ProblemsDVT & PE risk (harder to detect)
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Dx/TreatmentCT
Treat systemic and neurogenic shock
If cervical injury, must maintain all body systems (pg 1552)
Assess muscle groups, sensory status, brain injury, musculoskeletal injuries, internal injuries
Logroll during transfers/repositioning
Stabilization of injury – traction, realignment, surgery
DrugsHigh dose methylprednisolone w/in 8 hours of injury
Vasopressors (dopamine)
All drugs may be metabolized differently with SCI
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Acute InterventionsImmobilization
Stabilize the neck to prevent lateral rotation
Keep body correctly aligned
Logroll when turning
If traction is used, it must be maintained at all times
Kinetic therapy bed
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Halo FixationPin Site care
Skin care under vestBe able to insert 1 finger under vest
Do 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
weekly
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Acute Interventions
RespiratoryCritical to assess during first 48 hrs
Above C3 requires mechanical
ventilation
Assess carefully
Chest PT
Assisted coughing or incentive spirometry
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Acute Interventions
CardiovascularLimit vagal stimulation (turning, suctioning)
Assess VS frequently
Give anticholinergics (atropine) for bradycardia
Give vasopressors (dopamne) for hypotension
Sequential compression devices
ROM and stretching exercises
Prophylactic heparin (Lovenox)
Watch closely for signs of hypovolemic shock
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Acute Interventions
Fluid & NutritionNG tube
Gradually start food/fluids will bowel sounds are active or flatus is passed
High protein, high calorie diet
Evaluate swallowing before starting oral feeding
Enteral or parenteral nutrition may be needed
Creative ways to encourage eating
Dietary supplements as needed
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Acute Interventions
Bladder & BowelIndwelling catheter
Lots of fluid intake
Watch for UTIs
Transition to intermittent catheterization as soon as possible every 3-4 hours
Bowel programRectal stimulant followed by gentle digital stimulation
Temperature ControlMaintain environmental temp
Don’t overload with covers or expose too long (baths)
Cooling blanket for fevers
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Acute Interventions
Stress UlcersUsually occur 6-14 days after injury
Test stool/gastric contents for blood
Give steroids with antacids or food
Histamine receptor blockers (Zantac, Pepcid) or proton pump inhibitors (Protonix, Prilosec)
Sensory DeprivationStimulate patient above the level of injury
Prism glasses, conversation, music, smells, flavors
ReflexesExplain that this is not always a return to function
Antispasmodic drugs (baclofen, Dantrium, Zanaflex)
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Autonomic Dysreflexia
Life threatening emergency!!!
Massive uncompensated cardiovascular reaction caused by the SNS
Occurs in response to visceral stimulation
Sx – 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 patient
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Home CareRespiratory
If ventilator-dependent can still be mobile
Assisted coughing, incentive spirometry
Neurogenic BladderTypes – reflexic, areflexic, sensory
Identify appropriate drainage method
Surgical options
Anticholinergic drugs, adrenergic blockers, antispasmodic drugs
Avoid long-term use of indwelling catheters if possible
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Home CareNeurogenic Bowel
High fiber diet, adequate fluid intake
Suppositories (dulcolax, glycerin) or small-volume enemas with digital stimulation 20-30 minutes later
Stool 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
Exercise
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Home CareNeurogenic Skin
Twice daily comprehensive visual and tactile exam
Carefully watch ischia, trochanters, heels, sacrum
Reposition every 2 hours
Pressure relieving cushions, special mattresses
Adequate intake of protein
Protection from thermal injury
Use pillows to protect bony prominences
In a wheelchair, lift self up and shift weight every 15-30 min
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Home CareSexuality
See table 61-13 (pg 1562)
If upper motor neuron lesion, can have reflex sexual function
If lower motor neuron lesion, may be capable of psychogenic erection (ejaculation may retrograde into bladder)
Tx – drugs, vacuum devices, surgical procedures
Fertility a problem with men
Women have problems with lubrication
Open communication is important
Sexual activity may be less spontaneous
May have incontinence during sexual activity
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Home CareGrief and Depression
Can feel an overwhelming sense of loss
Believe they are useless and a burden to their family
May have regression
Expect a wide fluctuation of emotions
Table 61-14 (pg 1563) Mourning Process
Counseling for caregiver and family
Sympathy is not helpful, insist that care be performed
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Spinal Cord TumorRare
Can be primary or secondary
Can be extradural, intradural extramedullary, or intradural intramedullary
Most 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 down
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TreatmentDx with spinal xray, MRI, CT
Surgical Treatment: tumor removal
Radiation Therapy (may also do chemo)
Compression of the cord is an emergency!!!!
Give high-dose corticosteroids
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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.
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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.
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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 922. A reddened area over the patient’s coccyx3. Marked perspiration on the patient’s face and
arms4. A light inspiratory wheeze on auscultation of
the lungs