Nursing Spinal Patients

Question 1

Why do we carry out neurological exams?

Answer 1

Identify if NS involvement
Identify localisation
Aid diagnosis and prognosis
Continuous assessment of condition/progression

Question 2

Where can we localise neurological signs to?

Answer 2

Brain
Spinal cord
Peripheral nerves
Neuromuscular

Question 3

What are the main parts of a neuro exam?

Answer 3

Hands off - mentation, gait and posture
Hands on - postural reactions, spinal reflexes, cranial nerves, sensory evaluation, palpation

Question 4

Define some postural abnormalities.

Answer 4

Head tilt = one ear below the other
Head turn = nose turned towards body
Ventroflexion of neck = low head carriage
Scoliosis (to the side) / lordosis (curved upwards) / kyphosis (curved downwards)
Decerebrate rigidity = extension of all limbs, head and neck
Decerebellate rigidity = extension of thoracic limbs, head and neck
Wide-based stance

Question 5

What postural reaction tests can we carry out?

Answer 5

Proprioceptive positioning
Hopping
Visual placing
Tactile placing
Hemi-walking
Wheelbarrowing

Question 6

Describe lower motor neurons and their clinical signs.

Answer 6

Connect CNS to effector organ (muscle) and send signal to make them contract
Existing reflexes are weaker or absent
Muscle tone reduces
Muscle mass decreased rapidly and severely
Flaccid paresis/paralysis, reduced or absent reflexes, reduced or absent muscle tone, muscle atrophy

Question 7

Describe upper motor neurons and their clinical signs.

Answer 7

Located between cerebral cortex and spinal cord, send signals to LMNs
Existing reflexes are stronger and easier to elicit
Some normally inhibited reflexes become apparent
Muscle tone increases
Loss of motor function, paresis/paralysis, normal/increased reflexes, increased extensor muscle tone, chronic muscle atrophy

Question 8

What spinal reflexes can we test?

Answer 8

Thoracic limbs - withdrawal reflex / extensor carpi radialis reflex / biceps brachii and triceps reflex
Pelvic limbs - patella reflex / cranial tibial and gastrocnemius
Perineal reflex
Panniculus reflex

Question 9

Describe the cutaneous trunci reflex test.

Answer 9

Tests lateral thoracic nerve, segmental nerve and spinal cord cranial to segmental nerve up to T1
Used to monitor if localisation of spinal lesion changes post-op

Question 10

How can we test for deep pain sensation?

Answer 10

Pinching/pressure applied to digits on each limb
Look for reaction e.g. turning, vocalising, trying to bite

Question 11

What cranial nerve tests can we carry out?

Answer 11

Menace response
Palpebral reflex
Pupillary light reflex
Gag reflex
Oculocephalic reflex
Nystagmus

Question 12

Define miosis.

Answer 12

Constricted pupils

Question 13

Define mydriasis.

Answer 13

Dilated pupils

Question 14

Define anisocoria.

Answer 14

Asymmetric pupil size

Question 15

How can pupil size indicate prognosis of neuro patients?

Answer 15

If pupil goes from miotic to mydriatic - neurologically deteriorating
Mid-size fixed pupils unresponsive to light - grave prognosis

Question 16

How and why do we grade spinal cord injuries?

Answer 16

Grade 1-5
Allows objective assessment and monitoring of progression
Allows for more accurate prognosis

Question 17

Define grade 1 spinal injury.

Answer 17

Pain only - no neurological deficits
Walking normally

Question 18

Define grade 2 spinal injury.

Answer 18

Walking but with neurological deficits, causing weakness/incoordination in both pelvic limbs
Ambulatory paraparesis

Question 19

Define grade 3 spinal injury.

Answer 19

Not able to walk without assistance but has good movement in pelvic limbs
Non-ambulatory paraparesis

Question 20

Define grade 4 spinal injury.

Answer 20

No voluntary movement in pelvic limbs but can feel toes
Paraplegia with intact nociception (deep pain positive)

Question 21

Define grade 5 spinal injury.

Answer 21

No voluntary movement in pelvic limbs and lack of feeling in toes
Paraplegic without nociception (deep pain negative)

Question 22

What important considerations should we have for neuro patients?

Answer 22

Owner expectations and ability to provide care at home
Ambulatory vs non-ambulatory
Surgical vs non-surgical
Continent vs incontinent
Temperament
Recumbency
Normal routine

Question 23

What common complications can we see with spinal patients?

Answer 23

Decrease motor activity
Pressure sores
Urine/faecal scalding
Wound breakdown
Insufficient analgesia
Respiratory complications

Question 24

Why is physiotherapy important?

Answer 24

Improves local/whole body circulation
Help to reduce pain
Bond between nurse and patient
Prevent pressure sores
Aid motor recovery

Question 25

How can physiotherapy aid recovery?

Answer 25

Maintain joint health Limit muscle wastage Help prevent contracture Motor - relearning movements Sensory - stimulating proprioceptive relearning and retrain gait

Question 26

What physiotherapy techniques can we offer?

Answer 26

Massage PROM Assisted exercises Active exercises Proprioceptive exercises Neuromuscular e-stim Hot/cold therapy Hydrotherapy Laser therapy

Question 27

How does massage aid recovery?

Answer 27

Helps to calm patient and get used to being handled Improves local/whole body circulation Mobilises dermal/subdermal tissues Warms muscles/tissues

Question 28

How does PROM aid recovery?

Answer 28

Put each joint through normal range of motion Improve joint health without active muscle contraction

Question 29

What assisted exercises can we carry out?

Answer 29

Assisted standing/walking Assisted sit-stand Three-legged standing Weight-shifting

Question 30

What active exercises can we carry out?

Answer 30

Walking - straight line, circles, figure-of-8, incline Sit-stand Sit-down Hydrotherapy

Question 31

What proprioceptive exercises can we carry out?

Answer 31

Standing Wobble board Uneven surface Over poles Weaving Different surfaces

Question 32

Describe neuromuscular e-stim.

Answer 32

Sustained muscle contraction using dermal electrodes over muscles Increases tissue perfusion Can help to slow neurogenic muscle atrophy

Question 33

What considerations should we have for physiotherapy candidates?

Answer 33

Previous injuries/surgeries Client expectations and limitations - time/expertise Disease process Neurolocalisation Temperament

Question 34

Describe an upper motor neuron bladder.

Answer 34

Distended, difficult to express

Question 35

Describe a lower motor neuron bladder.

Answer 35

Distended, easy to express

Question 36

What bladder complications can we see if not managed appropriately?

Answer 36

UTIs due to static urine in bladder Bladder atony and pyelonephritis Distension of bladder/ureter leading to pain Overflow incontinence

Question 37

Describe overflow incontinence.

Answer 37

Patient unaware their bladder is full Fills until overflowing, patient leaks urine onto skin, leads to urine scalding Also high risk for UTIs

Question 38

How can we manage bladders?

Answer 38

Manual expression 3-4x daily Intermittent aseptic catheterisation 2x daily Indwelling catheterisation with closed connection system Drug therapy

Question 39

What considerations should we have for bowel management of neurological patients?

Answer 39

Do not normally have issues passing issues as is initiated by stretch of the rectal wall Upper motor neuron injury patients can have an overactive reflex, meaning small amount of distension can initiate defecation Cannot move away so must keep beds clean, check for faecal scalding, take outside regularly

Question 40

How can we prevent pressure sores from developing?

Answer 40

Thick padded bedding, checked regularly Turn every 2-4 hours Donut bandages on elbows and hocks Pat dry after bathing Inco sheets Physiotherapy - promotes circulation and movement Monitor closely Express bladder/indwelling catheter

Question 41

How can we treat pressure sores if they occur?

Answer 41

Keep clean and dry Debride if necessary Antibiotics if indicated Bandaging

Question 42

Why are seromas more of a risk in hemilaminectomy patients than ventral slot patients?

Answer 42

More skin movement Separation of layers of tissues and over midline

Question 43

How can we use cold therapy for wound management post-op?

Answer 43

Provide analgesia and decrease inflammation 15mins 4x daily for 48-72 hours

Question 44

Describe self-mutilation.

Answer 44

Occurs in deep pain negative patients due to paraesthesia/boredom/stress Use buster collar, look for triggers e.g. sores

Question 45

Where can pain originate from?

Answer 45

Intervertebral discs Facets Nerve roots Muscles Meninges Tissue damage leading to compression/inflammation

Question 46

What are the types of pain?

Answer 46

Inflammatory Neuropathic Acute Chronic

Question 47

What drugs can we use to prevent pain?

Answer 47

Opioids NSAIDs Corticosteroids Alpha-2 agonists Local anaesthetics Cold therapy

Question 48

What respiratory issues are spinal patients prone to?

Answer 48

Hypoventilation Atelectasis Aspiration pneumonia

Question 49

How does aspiration pneumonia occur and what are the clinical signs?

Answer 49

Inhalation of GI contents into lungs Aspirates cause pulmonary damage and inflammatory response (leading to predisposition to bacterial infection) Coughing, tachypnoea, harsh lung sounds/crackles on auscultation

Question 50

How can we treat aspiration pneumonia?

Answer 50

Careful and close monitoring Early admin of antibiotics IV fluids Oxygen therapy Supportive care e.g. respiratory physiotherapy (mobilise and expel aspirated contents, e.g. nebulisation/vibration/coupage) Severe cases may need mechanical ventilation Feeding balls of food from height