Chapter 45: Care Of Pts With Problems Of the CNS: Spinal Cord

Question 0

Risk for LBP

Answer 0

˜Acute back pain usually results from injury or trauma such as hyperflexion or twisting during a vehicular crash, or lifting heavy objects
˜Obesity places increased stress on the back muscles and can cause back pain
˜Smoking has been linked to disk degeneration, possibly caused by constriction of blood vessels that supply the spine

Question 1

Lumbosacral Back pain
Low back pain
LBP

Answer 1

˜Lumbrosacral back pain, referred to as low back pain (LBP) is more common than cervical pain
˜Acute back pain is caused by muscle strain or spasm, ligament sprain, disk degeneration, or herniation of the disk in the fourth or fifth lumbar vertebrae or at other levels
˜A herniated disk in the lumbrosacral area can press on the sciatic nerve causing severe burning or stabbing pain down into the leg or foot.
˜In addition to pain, numbness and tingling may be felt in the affected leg because spinal nerves have both motor and sensory fibers.
˜If the herniated disk presses on the spinal cord itself, it can cause leg weakness and bowel and bladder dysfunction such as difficulty starting or stopping stream of urine.

Question 2

Assessment of LBP

Answer 2

˜Assessment
ØThe patient’s primary concern is continuous pain.
ØWalk stiff, flexed or bent over, or not able to bend at all, a limp indicating possible sciatic nerve impairment
ØAsk whether paresthesia (tingling sensation) or numbing in one or both legs
ØSevere problems may lose both bowel and bladder control
˜Diagnostic assessment
ØCT or MRI (with or without contrast), EMG

Question 3

Nonsurgical/conservative measures for LBP

Answer 3

˜Positioning
ØThe Williams position more comfortable for disk problems. Patient lies in semi-Fowler’s position with a pillow under the knees to keep them flexed or sits in a recliner. This position relaxes the muscles of the lower back and relieves pressure on the spinal nerve root.
ØChange frequently, avoid long standing, sitting or lying down
ØFirm mattress, shoe inserts, and floor pads
˜Drug therapy
ØAcetaminophen, NSAIDS
ØEpidural injection
˜Heat therapy temporary relief, moist heat 20 to 30 minutes 4x/day helps
˜Physical therapy
˜Weight control
˜Complementary and alternative therapies

Question 4

Surgical trtmnt LBP

Answer 4

˜Minimally invasive surgery:
ØPercutaneous lumbar diskectomy
ØThermodiskectomy
ØLaser-assisted laparoscopic lumbar diskectomy
˜Conventional open surgical procedures:
ØDiskectomy
ØLaminectomy
ØSpinal fusion

Question 5

Teaching LBP

Answer 5

˜Home care management
ØFirm mattress
ØLimit on climbing stairs, encourage walking
ØReturn to work 4-6 weeks with limitations

˜Health teaching to prevent recurrence
ØWeight reduction if needed
ØStop smoking, if applicable
ØMoist heat
ØExercises to strengthen
˜Health care resources
ØPhysical therapy, support systems (family, church)

Question 6

Cervical Neck Pain

Answer 6

˜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.
ØIf a cervical diskectomy is performed the priority for care in the immediate postoperative period is maintaining an airway and ensuring that the patient has no problems breathing. Swelling from the surgery can narrow the trachea, causing partial obstruction.

Question 7

Post operative care LBP

Answer 7

Goal is prevention and assessment of complications
˜Neurologic assessment; vital signs first 24 hours
ØAssess for fever and hypotension which could indicate bleeding or severe pain. Assess movement, strength, and sensation in the extremities.
˜Patient’s ability to void
ØOpioid analgesics, pain and a flat position in bed make voiding difficult for men particularly. Inability to void may indicate damage to sacral spinal nerves to the bladder
˜Pain control usually pain controlled analgesia (PCA) with morphine
˜Wound care in hospital and at home:
ØCheck for blood or any other type of drainage
ØBulging at incision site may be due to CSF leak or a hematoma
ØReport immediately to the surgeon!
˜CSF check if clear may be a CSF leak. Loss of CSF can cause a severe headache and risk of meningitis and surgeon is to be notified immediately
˜Patient positioning and mobility
ØCorrect turning is important (e.g., log rolling)
ØBedrest
ØBrace if ordered wear when out of bed during healing process.

Question 8

Post operative lumbar surgery complications

Answer 8

Cerebral spinal fluid leak (keep flaton back for few days), fluid volume deficit (hypotension tachycardia), acute urinary retention, paralytic ileus, fat embolism syndrome (chest pain, loc change, petechiae), persistent or progressive lumbar radiculopathy which is a nerve root pain, infection or hematoma.

Question 9

Spinal cord injuries

Answer 9

˜A spinal cord injury (SCI)can result in loss of motor function (mobility), sensation, reflex activity, and bowel and bladder control. SCI is paralysis below the level of injury.The effects of spinal cord trauma cannot be reversed.
˜Hyperflexion injury
ØHead on vehicle collisions or diving accidents
ØLower thoracic or lumbar spine fall on buttocks
ØDamage to the spinal cord, causing hemorrhage, edema, and necrosis
˜Hyperextension injury
ØVehicular accidents struck from behind
˜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

Question 10

Anterior cord syndrome

Answer 10

˜Page 992
˜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 intact

Question 11

Posterior cord lesion

Answer 11

˜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 sensation

Question 12

Brown-Séquard Syndrome

Answer 12

˜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.

Question 13

Central cord syndrome

Answer 13

˜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.

Question 23

Other assessment of SC Shock

Answer 23

˜Lower motor neuron assessment (usually lower thoracic or lumbrosacral injuries)
ØMuscle wasting results from long term flaccid paralysis
˜Upper motor neuron assessment (usually cervical and upper thoracic injuries) cause muscle spasticity, which can lead to contractures after spinal shock has resolved.
˜Skin assessment for reddened areas and over pressure points. Consider a pressure-reducing mattress, turning patient frequently
˜Heterotrophic ossification assessment
˜(bony overgrowth into the muscle)
˜ Psychosocial assessment : pre-injury coping mechanisms in illness, injury, or disappointments. Determine level of independence or dependence, support of family and friends, religious or spiritual beliefs, job security and finances.
˜Laboratory assessment check for blood in urine, ABG, CBC, clotting
˜Imaging assessment CT, MRI to determine the extent of damage to the spinal cord and to detect the presence of blood and bone or foreign body within the spinal column

Question 24

Neurogenic shock

Answer 24

˜Constant assessment VS, neurologic status, pulse oximetry, and pain score Q 4 hours
˜Assess for neurogenic shock is a type of hypovolemic shock and is spinal shock causing:
ØBradycardia
ØDecreased or absent bowel sounds
ØWarm, dry skin
ØHypothermia
ØHypotension
˜Notify the physician immediately if these symptoms occur, because this problem is an emergency! Neurogenic shock is treated symptomatically by restoring fluids to the circulating volume. Keep positioned well.
˜May occur within the first 24 hours after an injury and most commonly in patients with injuries above T6

Question 25

Immobilization for cervical

Answer 25

˜Regardless of the level of SCI, keep the patient in proper alignment to prevent further injury or irritability and deteroration
˜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 ropes

Question 26

Immobilization for T and L spine

Answer 26

˜For patients with thoracic injuries—bed rest 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 preferred

Question 27

Med therapy for SC shock

Answer 27

˜Methylprednisolone (controversial depends on physician preference and condition of patient)
ØDrug decrease inflammation such as that caused by injury to spinal cord and nerve tissue. Complications include infection, increased glucose, and stress ulcers
˜Dextran
ØA plasma expander to increase capillary blood flow within the spinal cord and to prevent or treat hypotension
˜Atropine sulfate
ØTo treat bradycardia is pulse falls below 50 to 60 beats/minute
˜Dopamine hydrochloride
ØFor severe hypotension
˜Tizanidine
ØHelp control muscle spasticity but causes severe drowsiness
˜Intrathecal baclofen. In a programmable catheter
ØUsed in place of Tizanidine to help control muscle spasticity. Do not withdraw sudden-seizures

Question 28

Surgical management of SCI

Answer 28

˜Emergency surgery necessary for spinal cord decompression
˜Decompressive laminectomy
˜Spinal fusion
˜Harrington rods to stabilize thoracic spinal injuries

Question 29

Ineffective airway and breathing pattern

Answer 29

˜Interventions for the patient with spinal cord injury:
ØAirway management is the priority.
ØPatients with injuries at or above the 6th thoracic vertebra are especially at risk for respiratory complications and pulmonary embolus during the first 5 days after injury.
ØThis is due to impaired functioning of the intercostal muscles and decreased mobility
ØProvide measures to maintain airway.
˜Closely monitor the patient for clinical manifestations of life-threatening respiratory complications, such as pneumonia, pulmonary emboli, and atelectasis. These problems decrease the life expectancy of SCI patients and have replaced renal failure as the leading cause of death.
ØAssisted coughing, quad cough, cough assist
ØUse of incentive Spiro meter

Question 30

Impaired physical mobility

Answer 30

˜Interventions include:
ØIn patients with spinal cord injury, monitor for risk of pressure ulcers, contractures, and deep vein thrombosis or pulmonary emboli.
ØProper positioning, skin inspection, ROM exercises, heparin, and graduated compression stockings.
ØPrevent orthostatic hypotension.
ØOccurs if the patient changes from a lying position to a sitting or standing position too quickly, he or she may experience hypotension, which could result in dizziness and falls.
ØDue to interrupted sympathetic innervation, the blood vessels do not constrict quickly enough to push blood up into the brain. This causes dizziness or light-headedness and possible falls with syncope (“blackout”).
ØPromote self-care.

Question 31

Impaired elimination

Answer 31

˜Interventions include:
ØA bladder retraining program try stroking the inner aspect of thigh, pouring warm water over the perineum, or tapping the bladder.
ØSpastic bladder—manipulating external area
ØFlaccid bladder—Valsalva maneuver(tightening abdominal muscles)
ØEncouraging consumption of 2000 to 2500 mL of fluid daily to prevent urinary tract infection
˜Long-term renal complications such as hydronephrosis, renal failure, and kidney stones.
ØUTIs are common because organisms are introduced into the urinary tract by urinary catheters
˜Signs and symptoms of urinary tract infection not perceived by the patient because:
ØThey cannot feel dysuria, urgency, or back pain.
ØMust rely on other signs and symptoms, such as foul smelling urine or fever

Question 32

Bowel retraining

Answer 32

˜Consistent time for bowel elimination
˜High fluid intake
˜High-fiber diet
˜Rectal stimulation (with or without suppositories)
˜Stool softener medications, as needed
˜Manual disempaction last resort

Question 33

Autonomic dysreflexia

Answer 33

˜Is a neurologic emergency!
˜Commonly seen in patients with upper spinal cord injury above the level of T6
˜Does not occur frequently and is an excessive, uncontrolled sympathetic output.
ØSevere hypertension
ØBradycardia
ØSevere headache
ØNasal stuffiness
ØFlushing above lesion, pale below
Nasal stuffiness, sweating, nausea, blurred vision, piloerection, apprehension
˜The cause of this syndrome is a noxious stimulus-usually a distended bladder or constipation
˜Treatment
ØThis is a neurogenic emergency and must be promptly treated to prevent hypertensive stroke!

Question 34

Impaired adjustment

Answer 34

Interventions include:
ØInvite patients to ask questions about significant life changes; reply openly and honestly.
ØEncourage patients to discuss their perceptions of their situation and coping strategies that can be used.
ØBegin a patient education program to clarify misconceptions.
˜Nursing assessment on coping strategies obtain information on spiritual or religious beliefs, family or friends support, level of independence/dependence, and source(s) of income, and coping strategies
˜Sexuality and intimacy:
˜Sexual function after spinal cord injury depends on the level and extent of injury.
˜Incomplete lesions allow some control over sensation and motor ability.
˜Complete lesions disconnect the messages from the brain to the rest of the body and vice versa.
˜Men with injuries above T6 are often able to have erections by stimulating the reflex activity such as stroking the penis will cause an erection. Ejaculations are less predictable, and may be mixed with urine. Remember urine is sterile and partner will not be at risk for an infection.
˜Women are a different challenge due to indwelling urinary catheter. Some do become pregnant, and due to the injury others stop ovulation. Can consider in vitro fertilization.
˜Alternative strategies for intimacy without intercourse.

Question 39

Diskectomy

Answer 39

Removal of a herniated disc.

Question 40

Laminectomy

Answer 40

Removal of part of the laminate joint to obtain access to the disk space. Many times a spinal fusion is performed to stabilize the area. Possible bone removal from the iliac crest.

Avoid prolonged sitting or standing

Question 41

SCI etiology

Answer 41

˜Trauma is the leading cause
˜Incidence/prevalence
˜250,000 to 400,000 people in the U.S. have SCI
˜Approximately 14,000 new injuries each year
˜Mean age is 30 years, peak incidence of injury in summer or warmer months
˜Men and Caucasian make up most SCI
˜Cervical cord injuries are more common than thoracic or lumbrosacral.

Question 42

Emergency treatment for autonomic dysreflexia

Answer 42

Place patient in sitting position is the first priority. Notified Dr., loosen tight clothing, Assess for and treat the cause, check catheter for kinks, check for bladder distention and catheterize if needed, check for fecal impaction and remove, Make sure room temperature is not too cool, monitor blood pressure every 10 to 15 minutes, give nitrates or hydralazine as prescribed

Question 43

SCI initial assessment

Answer 43

˜First priority is assessment of the patient’s ABC’s: airway (foreign body obstruction such as tongue, teeth due to facial trauma, injury to larynx, or a jaw fracture), breathing pattern (if cervical SCI high risk due to C3-C5 innervates the phrenic nerve, which controls the diaphram), and circulation status
˜Assessment for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around fracture sites.
ØIndicators of hemorrhage include hypotension and tachycardia with a weak and thready pulse.
˜Assessment of level of consciousness using Glasgow Coma Scale

˜Establishment of level of injury:
ØTetraplegia also called quadriplegia (paralysis), quadriparesis (weakness) involves all 4 extremities as seen in cervical cord and upper thoracic injury. Injuries above C4 equals paralysis of respiratory muscles and all 4 extremities.
ØRemember: the higher the injury the greater the loss of function.
Ø Paraplegia (paralysis), and paraparesis (weakness) involves only the lower extremities, as seen in lower thoracic and lumbosacral injuries or lesions
ØRefer to Memory Notebook Volume 2, 4th Ed., p. 117.

Question 44

Levels of spinal nerves

Answer 44

˜Breakfast at 8: there are 8 cervical vertebrae with nerves that control the diaphragm, chest wall muscles, arms, and shoulder.
˜Lunch at 12: there are 12 thoracic vertebrae with nerves that control upper body and gastrointestional function.
˜Dinner at 5: there are 5 lumbar and 5 sacral vertebrae with nerves that control lower body and bowel and bladder.

Question 45

Spinal shock syndrome

Answer 45

˜This condition occurs immediately as a concussion response to the injury. The patient has:
ØFlaccid paralysis
ØLoss of reflex activity below the level of the lesion
˜Usually lasts less than 48 hours but may continue for several weeks.
˜Muscle spasticity begins in patients with cervical or high thoracic injuries

Question 46

Assessment of spinal shock syndrome

Sensory and motor

Answer 46

˜Hypoesthesia refers to a reduced sense of touch or sensation, or a partial loss of sensitivity to sensory stimul
˜Hyperesthesia is a condition that involves an abnormal increase in sensitivity to stimuli of the sense
˜It is not unusual for these reflexes, as well as all movement or sensation, to be absent immediately after the injury because of spinal shock. After shock has resolved, the reflexes may return if the lesion is incomplete or involves upper motor neurons

C 5 or 6 Can often flex their arms but not extend them

Question 47

Assessment of spinal shock syndrome

Cardiovascular and respiratory

Answer 47

Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous system especially if the injury is above the 6th thoracic vertebra.
˜Bradycardia, hypotension, and hypothermia occur because of loss of sympathetic input.These changes may lead to cardiac dysrhythmias.
˜Systolic BP below 90 requires treatment because lack of perfusion to the spinal cord could worsen the patient’s condition.
˜Hypothermia due to lack of sympathetic or hypothalmic control

˜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.

Question 48

GI and GU assessments

Answer 48

˜Assess abdomen for indications of hemorrhage, distention, or paralytic ileus.
ØHemorrhage may result from the trauma, or it may occur later from a stress ulcer or the administration of steroids
ØMonitor for abdominal pain and changes in bowel sounds.
˜Assess for reflex or hypotonic bowel
ØParalytic ileus may develop within 72 hours of hospital admission.
ØDuring the period of spinal shock, peristalsis decreases, leading to a loss of bowel sounds and gastric distention
˜Assess for areflexic bladder (neurogenic bladder no reflex ability for gladder contraction), which later leads to urinary retention.
ØThe patient is at risk for urinary tract infection from an indwelling urinary catheter; intermittent catheterization; or bladder distention, stasis, and/or overflow.