Test 1 Chapter 45 Care of Patients with problems of the CNS: The spinal Cord Flashcards Preview

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Flashcards in Test 1 Chapter 45 Care of Patients with problems of the CNS: The spinal Cord Deck (64):
1

What is the Etiology of Lumbosacral Back Pain?

Usually starts off with an acute injury.

Muscle sprains/spasms,
Ligament sprain,
Disk degeneration,
Osteoarthritis,
Herniation,
Spondylosis,
Stenosis,
Obesity,
Smoking.

2

How long does a person have to have Lumbosacral Back Pain before it can be considered chronic?

Greater than 3 Months makes it chronic.

3

What are the signs and symptoms of Lumbosacral Back Pain?

Pain
Paresthesia or numbness
Weakness in the lower legs

4

** What are the factors that contribute to Low Back Pain?

Changes in support structures
- Spinal stenosis
- Hyperatrophy of the intraspinal ligaments
- Osteoarthritis
- Osteoporosis

Changes in vertebral support and malalignment
- Scoliosis
- Loridosis

Vascular Changes
- Diminished blood supply to the spinal cord or
cauda equina caused by arteriosclerosis
- Blood Dyscrasias

Intervertebral disk degeneration

5

Spondylolysis

a defect in one or more of the vertebre usually in the lumbar spine.

6

Spondylolisthesis

occurs when one vertebrae slips forward on the one below it, often as a result of Spondylolysis

7

Spinal stenosis

a narrowing of the spinal, nerve root canals, or intravertebral foramina.

Is typically seen in people older than 50 years old.

the narrowing may be caused by trauma, infection, herniated disc, arthritis, and disc degeneration.

8

What is the most common reason that people make Doctors visits or go to the Emergency Room?

Lower Back Pain

9

Where is the most common area to be injured in the spine and why?

The Lower back and cervical area because it is more flexible there.

10

Nursing Interventions for Back pain include-

Education
Ergonomics
X-ray/CT/MRI
Cold/Heat application
Physical Therapy
Chiropractic
Acute: - William's Position
- Drug therapy
Chronic: - Drug therapy
- Weight Control
Surgical Management

11

What are some things that you would educate your patient about back pain?

**Good Posture
**Lift with your legs
**Exercise (esp stomach muscles)

Use proper body mechanics, with specific attention to bending, lifting, sitting

Assess the need for assistance with your household chores or other activities

Participate in regular excercise program, especially one that promotes back strenghthening, such as swimming and walking

Do not wear high heeled shoes

Use good posture while sitting, standing, walking

Avoid prolonged sitting or standing.

Keep weight within 10% of ideal body weight.

Adequate calcium intake

Stop Smoking

12

What are some things that you can educate your patient about ergonomics in the workplace to prevent or manage back pain?

Avoid prolonged sitting or standing.

Use a footstool and ergonomic chairs and tables to lessen back strain.

Be sure that equipment in the workplace is ergonomically designed to prevent injury.

13

When dianosing back pain, the doctor may complete an X-Ray, CT, or MRI. Which one of these will the doctor likely chose first and why?

The X-Ray because it is less expensive.

The doctor is looking for broken or bulging discs.

14

What are the parameters of Cold Application as an intervention for back pain?

How long- 15 to 20 Minutes at a time only

Always use cold first for at least 48 hours

Cold reduces bleeding by vasoconstriction, and reduces pain and swelling.

15

What are the parameters of Heat Application as an intervention for back pain?

Use heat 2nd. Always use cold first.

Typically can use heat after 48 hours except for a new injury (sprain or break) because you want to keep the swelling down.

Heat causes vasodilation so it increases bleeding.

How long- heat should be on and off for 20 min at a time just like cold therapy.

16

True or false

Weight loss will help with chronic back pain?

True

17

Williams position

is when you place pillows under the patients knees while in bed.

this helps with acute back pain

18

Name 3 conventional surgical procedures that are an intervention for back pain.

1. Diskectomy- removal of a herniated disk

2. Laminectomy- Removal of the injured part of the
spine

3. Spinal Fusion- stabilization of the spine

19

Nurses are responsible for the post operative care if a patient has a surgical procedure. What are some of the things that a nurse needs to monitor post operatively?

Notes from class

Assess: airway stable, at risk for pneumonia and atelectasis, teach get up at certain time and IS and coughing, at risk for constipation, Infection (monitor temp)

First day or 2,
monitor closely because it is the lower back must monitor bladder for voiding (because sacral spinal nerve could be damaged) Monitor urinary output.

Do log rolling

Monitor DVT and do DVT Prevention

Monitor for CSF fluid leak

20

***Post Op CSF Leak-

Observe for clear fluid on or around the dressing.

If leak occurs, place the patient flat.

Report CSF imediately to the surgeon.

(Patient may be placed flat for several days until it heals.)

21

Post Op Fluid Volume Deficit

Monitor intake and output

Monitor drain output which should not be more than 250 ml in 8 hours during the first 24 hours

Monitor vital signs closely for tachycardia and hypotension

22

***Post Op Acute Urinary retention

Assist the patient to the bathroom or a bedside commode as soon as possible postoperatively.

Assist male patients to stand at the beside as soon as possible postoperatively

23

Post Op Paralytic ileus

Monitor for flatus or stool

Assess for abdominal distention, nausea, and vomiting

24

Post Op Fat Embolism Syndrome (more common with people who had a spinal fusion)

Observe for and report chest pain, dyspnea, anxiety, and mental status changes (particulary common in older adults)

Note Petechiae around the neck, upper chest, buccal membrane, and conjuntiva

Monitor arterial blood gas values for decreased PaO2.

25

Post Op Persistent or progressive lumbar radiculopathy (Nerve root pain)

report pain not responsive to opiods

document the location and nature of the pain

administer analgesics as prescribed

26

***Post Op Infection

Monitor the patients temperature carefully (slight elevation is normal) Increased temperature elevation or a spike after the 2nd postoperative day is probable indicative of an infection.

Give antibiotics as prescribed if infection is confirmed

Use clean technique for dressing changes,

27

Teach the patient the typical excercises for chronic postoperative lower back pain

Extension Excercises
- Stomach lying: lie face down with a pillow under
your chest. Lift legs stright up and alternate legs
- Upper Trunk Extention: lie face fown with your
arms at your sides, and lift your head and neck.
- Prone Push-ups: Lie face down on a mat and,
keeping your body stiff, push up to extend your
arms.

Flexion Excercises:
- Pelvic Tilt: Lying on your back with your knees
bent, tighten your abdominal muscles to push
your lower back against the mat.
- Semi-Sit ups- Lying on your back with your knees
bent, raise your upper body at a 45* angle and
hold this position for 5-10 seconds.
- Knee to chest- Lying on your back with your
knees bent, tighten your abdominal muscles to
push your lower back against the mat. Now bring
1 or both knees to your chest and hold this
position for 5-10 seconds.

28

Drug therapy for Acute and Chronic Back pain

Acute-
Tylenol
muscle relaxants
NSAIDS
short term oral steroids

Opioid analgesics are no more effective than nonseroidal analgesics and should be avoided if at all possible

Chronic-
antiepileptic drugs (Neurontin) (Triliptal) to treat neuropathic nerve pain

Monitor hyponatremia, skeletal weakness, headache, dizziness, and diarrhea. Old people at risk for falls on this med

Tricylic antidepressants (amitriptyline)

29

****Nursing Safety Priority Critical Rescue

For the patient after back surgery, instect the surgical dressing for blood or any other type of drainage.

Clear drainage may mean cerebrospinal fluid leakage. The loss of a large amount of fluid may cause the patient to report having a sudden headache.

Report signs of drainage to the surgeon immediately.

Buldging at the incision site may be due to CSF leakage or hematoma, both of which should be reported to the surgeon.

30

****Nursing Safety Priority Critical Rescue

For patients who have a neurostimulator implanted in the epideral space, assess neurologic status below the level of insertion frequently.

Monitor for early changes in sensation, movement, and muscle strength.

Ensure that the patient can void without difficulty.

If any changes occur, document and report them immediately to the surgeon.

31

What is the etiology of Cervical Neck pain?

Buldging or Herniation of nucleus pulposus (HNP)
Muscle Strain
Ligament sprain
Poor posture
Lifting
Tumor
Infection
Arthritis

32

How is Cervical Neck pain diagnosed?

X-Ray
CT
MRI
Electromyography (EMG)

33

What is the pathophysiology of Cervical Neck pain?

Most often is from Buldging or Herniation of nucleus pulposus (HNP) in an intravertebral disk. The result is spinal nerve root compression.

34

What is the conservative treatment for acute neck pain?

it is the same as lower back pain except the excercises are focused on the shoulders and neck.

Acute-
Tylenol
muscle relaxants
NSAIDS
short term oral steroids

Chronic-
antiepileptic drugs (Neurontin) (Triliptal) to treat neuropathic nerve pain

Cold/Heat therapy

Physical therapist teaches shoulder shrug, shoulder squeeze, and seated rowing

soft collar to stabilize the neck at night (never use longer than 10 days continuously)

surgery

35

****Nursing Safety Priority Critical Rescue

The priority care in the immediate postoperative period after neck surgery is maintaining an airway and ensuring that the patient has no problem with breathing.

Swelling from the surgery can narrow the trachea, causing partial obstruction.

36

Post Op Interventions after an Anterior Cervical Diskectomy and fusion

Assess **Airway, Breathing, Circulation FIRST PRIORITY, ** swelling from trachea can cause obstruction, if the tongue swells you must trach!!**

Check for bleeding and drainage at the insertion site

Monitor Vital Signs and neurological status frequently

****Check for swallowing ability

Monitor Intake and output

Assess the patients ability to void (due to opiates)

Manage pain adequately

Assist the patient with ambulation within a few hours of surgery if able

37

What are the types of spinal cord injuries?

Complete- Total fracture of the spinal cord and everything is torn

Incomplete- Not damaged all of the way through.

This is why some people have more movement and sensation than other people.

38

What is the difference between primary and secondary mechanisms of injury involving the spinal cord?

Primary:
Hyperflexion- Can be caused by head on collision

Hyperextension- Can be caused by getting rear-ended.

Axial Loading-(vertical compression) can be caused by fall injuries (roof, ladders) or diving injuries (pool, lake)

Tumors and clots

Secondary:
Something that is caused by the primary injury such as bleeding or ischemia

39

What is the etiology of a spinal cord injury?

Trauma, Falls, Violence

40

What level of injury results in Quadriplegia?

C4 Injury Cervical Neck
C6 Injury

basically anything T5 and up

41

What level of injury results in Paraplegia?

T6 Injury down

42

If a patient comes in with a vertebre fracture, regardless of where it is located, what is your number 1 nursing priority?

Place them on a back-board with a C collar. You do this to stabilize them because you can make it worse.

So number 1 priority is keeping the spine aligned.

Then give Medications

The ABC's

43

What is the first drug that we give for a spinal injury?

Methylprednisone-

This decreases the inflammation to give it a chance to heal. The more pressure that is in there can result in an incomplete spinal injury becoming complete.

44

Thoracic Injury- What is your number 1 Priority after Stabilization and meds?

Worry more about breathing than airway. They can typically maintain their airway because they are not parylized.

So post op with these patients. Really Focus on Incentive Spirometer and Cough and deep breath excercises to prevent breathing complications.

Monitor for fever

And skin Breakdown (people hide their bedsores)

45

Spinal Cord Injury Assessment

**Autonomic Nervous System now is damaged and is not working right

Cardio-
- Bradycardia,
- Hypotension- HR less than 90 causes us to not
perfuse the spinal area. CONCERN
- Hypothermia- these patients are usually cold
because they take on the temperature of the
environment. GIve Blankets.

Stress Ulcers- from steriods

Urinary Retention- right off the bat, then will have
spells throughout their lives.

Muscle Wasting/Skin Breakdown/Psychosocial-
usually we always send them to rehab, helps with skin issues and prevents patient from getting worse than they are. Helps psychologically

Moving/Transferring- Log rolling, done by 3 to 4 people to keep everything aligned.

Rehabilitation- PT and OT

46

Assessing Motor Function in the patient with a spinal cord injury

- to assess C4-5, apply downward pressure while the patient shrugs shoulders upward

- to assess C5-6, apply resistance while patient pulls up his or her arms

- to assess C7, apply resistance while patient straightens their flexed arms

- to assess C8, make sure a patient is able to grasp an object and form a fist

-to assess L2-4, apply resistance while the patient lifts their legs from the bed

- to assess L5, apply resistance while the patient dorsiflexes their feet

- to assess S1, apply resistance while the patient plantar flexes their feet

47

****Autonomic Dysreflexia Notes from class

happens with the T6 root and above.

What happens is the sympathetic nervous system overkills, which causes the patient to present in a certain way:
Hypertension (200/180)
Bradycardic (40-50)
Headache
Flushing of the face
Anxiety

They present as if there is something wrong. There is no confusion that there is something wrong.

What causes this is tightening around the waste.
Could be from tight pants or from bladder being over full. Fecal Impaction.

48

****Nursing Safety Priority Critical Rescue

Observe the patient with an upper SCI (Above the level of T6) for signs of autonomic dysreflexia (hyperreflexia).

Although it does not occur frequently, autonomic dysreflexia is an excessive, uncontrolled sympathetic output.

It is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing.

The cause of this syndrome is a noxious stimulus- usually a distended bladder or constipation. This is a neurologic emergency and must be promptly treated to prevent hypertesive stroke!

49

***Autonomic Dysreflexia Chart 45-9

sudden onset of severe, throbbing headache

severe, rapidly occuring hypertension

bradycardia

flushing above level of lesion (Face and Chest)

Pale Extemities below level of lesion

nasal stuffiness

sweating

nausea

blurred vision

piloerection

Anxiety

50

**Emergency Care of a person experiencing autonomic dysreflexia: Immediate Interventions

- Place patient into a sitting position (1st Priority)
- Call the provider
- Loosen Tight Clothing on the patient
- Check foley for kinks (if they have one)
- Check Bladder for distention then cath
- Place anesthetic ointment on tip of the cath
before insertion
- Check the patient for fecal impaction, if present
remove immediately with anesthetic ointment
- Check the room temperature to make sure not
cold
- Monitor blood pressure every 10 to 15 minutes
- Give nitrates or hydralazine (Apresoline) as
prescribed.

51

Spinal Cord Tumors general manifestations

Pain
Sensory Loss or Impairment
Motor Loss or Impairment
Sphicter disturbance (bladder before Bowel)

52

***Spinal Cord Tumors High Cervical Manifestations

Respiratory distress
diaphragm paralysis
Occipital Headache
Quadriparesis
Stiff Neck
Nystagmus
Cranial Nerve Dysfunction

53

Spinal Cord Tumors Low Cervical manifestations

Pain the the arms and the shoulders
weakness
Parasthesia
Motor Loss
Horner's syndrome
increased reflexes

54

***Spinal Cord Tumors Thoracic Manifestations
(Most Common in this area)

Sensory Loss
Spastic Paralysis
Positive Babinski's sign
Bladder and Bowel Dysfunction
Pain in the chest and back
Muscle atrophy
Foot Drop

55

Spinal Cord Tumors Lumbosacral Manifestations

Lower back pain
Paresis
Spastic Paralysis
Sensory Loss
Bladder and Bowel Dysfunction
Sexual Dysfunction
Decreased to absent ankle and knee reflexes

56

Spinal Cord Tumor Management

First they Do surgery to remove the tumor then radiate the area to keep it from growing back.

57

Primary spinal cord tumor =

Originated at that site

58

Secondary spinal cord tumor =

Started some place else and metastasized there

59

Spinal Cord Tumors cause

compression of the spinal cord and the nerve roots, where the tumor is determines the symptoms

60

What is Multiple Sclerosis

An autoimmune disease that affects the myelin sheath and conduction pathway of the CNS

Hard to diagnose because it mimicks other neurological disorders.

Patients often have periods of remission and exacerbation.

Nystagmus is typically first symptom

Over time symptoms become perm

61

What is the etiology of MS

Viral,
Immunologic,
Environmental,

***Genetic- predisposition that causes the body to dysfuntion and attack itself.

62

What are the nursing interventions for a person with MS

Drug therapy

Methylprednisone- steroid that decreases inflammation

Gilenya- oral immunomodulator

Both medications cause the patient to be at risk for infection. Teach to avoid crowds and sick grandchildren.

Teach to monitor pulse because can cause bradycardia

63

Clinical Manifestations of MS

Muscle Weakness
Fatigue
Intention Tremors
Numbness
Increased sensitivity to pain
Inability to direct or limit movement
dysphasia
slurred speech
ataxia
bowel bladder dysfunction
Tinnitus
Diplopia
nystagmus
cognitive changes

64

What is Amyotrophic Lateral Sclerosis (ALS)

adult onset upper and lower neuron disease

no cause, no cure, No specific treatment

With ALS upper and lower motor neurons are destroyed. Patients become weaker and eventually are paralyzed. Brain is 100% intact.

People are usually young when diagnosed 40-60.

Men get it more than women.

Drug therapy Riluzole (Rilutek)- halt respiratory symptoms for 3-6 months