Transcript Lou Gehrig`s disease

Chapter 45
Care of Patients with
Problems of the Central
Nervous System: The Spinal
Cord
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Spinal Cord
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Lumbosacral Back Pain (Low Back
Pain)
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Herniated nucleus pulposus
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Health Promotion and
Maintenance
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Good posture
Proper lifting
Exercise
Ergonomics
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Patient-Centered Collaborative
Care
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Assessment
Diagnostic assessment
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Nonsurgical Management
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Positioning
Drug therapy
Heat therapy
Physical therapy
Weight control
Complementary and alternative therapies
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Surgical Management
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Minimally invasive surgery:
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Percutaneous lumbar diskectomy
Thermodiskectomy
Laser-assisted laparoscopic lumbar
diskectomy
Conventional open surgical procedures:
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Diskectomy
Laminectomy
Spinal fusion
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Postoperative Care
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Prevention and assessment of
complications
Neurologic assessment; vital signs
Patient’s ability to void
Pain control
Wound care
CSF check
Patient positioning and mobility
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Community-Based Care
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Home care management
Health teaching
Health care resources
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Cervical Neck Pain
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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.
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Spinal Cord Injuries
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Hyperflexion injury
Hyperextension injury
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
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Spinal Cord Injuries (Cont’d)
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Spinal Cord Injuries (Cont’d)
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Common Spinal Cord Syndromes
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Complete lesion
Anterior cord syndrome
Posterior cord lesion
Brown-Séquard syndrome
Central cord syndrome
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Common Spinal Cord Syndromes
(Cont’d)
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Anterior Cord Syndrome
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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
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Posterior Cord Lesion
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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
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Brown-Séquard Syndrome
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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.
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Central Cord Syndrome
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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.
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SCI: Etiology
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Trauma is the leading cause
Incidence/prevalence
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Patient with SCI: Initial
Assessment
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First priority is assessment of the patient’s
airway, breathing pattern, and circulation
status
Assessment for indications of intraabdominal hemorrhage or hemorrhage or
bleeding around fracture sites
Assessment of level of consciousness
using Glasgow Coma Scale
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Initial Assessment (Cont’d)
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Establishment of level of injury: tetraplegia,
quadriplegia, quadriparesis, paraplegia,
and paraparesis
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Spinal Shock/Spinal Shock
Syndrome
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This condition occurs immediately as a
concussion response to the injury. The
patient has:
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Flaccid paralysis
Loss of reflex activity below the level of the
lesion
Usually resolves within 24 hours
Muscle spasticity begins in patients with
cervical or high thoracic injuries
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Assessment of Sensory and Motor
Ability
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Hypoesthesia
Hyperesthesia
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Cardiovascular and Respiratory
Assessment
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Cardiovascular dysfunction is usually the
result of disruption of the autonomic
nervous system especially if the injury is
above the 6th thoracic vertebra.
Cardiac dysrhythmias may result.
Systolic BP below 90 requires treatment
because lack of perfusion to the spinal
cord could worsen the patient’s condition.
Hypothermia.
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Cardiovascular and Respiratory
Assessment (Cont’d)
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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.
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Gastrointestinal and Genitourinary
Assessment
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Assess abdomen for indications of
hemorrhage, distention, or paralytic ileus.
Assess for reflex or hypotonic bowel.
Assess for areflexic bladder, which later
leads to urinary retention.
Assess for neurogenic bladder.
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Other Assessments
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Lower motor neuron assessment
Upper motor neuron assessment
Skin assessment
Heterotrophic ossification assessment
Psychosocial assessment
Laboratory assessment
Imaging assessment
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Nonsurgical Management
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Constant assessment
Assess for neurogenic shock. Neurogenic
shock is spinal shock with:
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Bradycardia
Decreased or absent bowel sounds
Warm, dry skin
Hypothermia
Hypotension
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Immobilization for Cervical Injuries
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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
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Immobilization of Thoracic and
Lumbosacral Injuries
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For patients with thoracic injuries—bedrest
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
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Drug Therapy
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Methylprednisolone (controversial)
Dextran
Atropine sulfate
Dopamine hydrochloride
Tizanidine
Intrathecal baclofen
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Surgical Management
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Emergency surgery necessary for spinal
cord decompression
Decompressive laminectomy
Spinal fusion
Harrington rods to stabilize thoracic spinal
injuries
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Ineffective Airway Clearance and
Breathing Pattern
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Interventions for the patient with spinal
cord injury:
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Airway management is the priority.
Patients with injuries at or above the 6th
thoracic vertebra are especially at risk for
respiratory complications.
Provide measures to maintain airway.
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Ineffective Airway Clearance and
Breathing Pattern (Cont’d)
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Assisted coughing, quad cough, cough assist
Use of incentive Spiro meter
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Impaired Physical Mobility; SelfCare Deficit
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Interventions include:
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In patients with spinal cord injury, monitor for
risk of pressure ulcers, contractures, and deep
vein thrombosis or pulmonary emboli.
Proper positioning, skin inspection, ROM
exercises, heparin, and graduated
compression stockings.
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Impaired Physical Mobility; SelfCare Deficit (Cont’d)
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Prevent orthostatic hypotension.
Promote self-care.
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Impaired Urinary Elimination;
Constipation
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Interventions include:
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A bladder retraining program
Spastic bladder—manipulating external area
Flaccid bladder—Valsalva maneuver
Encouraging consumption of 2000 to 2500 mL
of fluid daily to prevent urinary tract infection
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Impaired Urinary Elimination;
Constipation (Cont’d)
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Long-term renal complication
Signs and symptoms of urinary tract
infection not perceived by the patient
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Autonomic Dysreflexia
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Commonly seen in patients with upper
spinal cord injury
Severe hypertension
Bradycardia
Severe headache
Nasal stuffiness
Flushing
Treatment
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Establishing a Bowel Retraining
Program
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Consistent time for bowel elimination
High fluid intake
High-fiber diet
Rectal stimulation (with or without
suppositories)
Stool softener medications, as needed
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Impaired Adjustment
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Interventions include:
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Invite patients to ask questions about
significant life changes; reply openly and
honestly.
Encourage patients to discuss their
perceptions of their situation and coping
strategies that can be used.
Begin a patient education program to clarify
misconceptions.
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Community-Based Care
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Home care management
Health teaching
Health care resources
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Spinal Cord Tumors
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Primary spinal cord tumors
Intramedullary tumors
Extramedullary tumors
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Patient-Centered Collaborative
Management
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Assessment
Diagnostic assessment
Surgical management—need for
emergency surgery
Nonsurgical management—radiation,
chemotherapy
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Community-Based Care
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Home care management
Health teaching
Health care resources
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Multiple Sclerosis
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Chronic autoimmune disease affecting the
myelin sheath and conduction pathway of
the CNS
Characterized by periods of remission and
exacerbation
Inflammatory response resulting in random
or patchy areas of plaque in the white
matter of the CNS
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Multiple Sclerosis (Cont’d)
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Etiology
Genetic risk
Incidence
Prevalence
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Major Types of Multiple Sclerosis
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Relapsing-remitting
Primary progressive
Secondary progressive
Progressive-relapsing
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Patient-Centered Collaborative
Care
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Patient history
Physical assessment/clinical
manifestations
Fatigue
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Common Physical Assessment
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Findings include:
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Flexor spasms at night
Intention tremor
Dysmetria
Blurred vision, diplopia, decreased visual
acuity, scotomas, nystagmus
Hypalgesia, numbness, tingling, or burning
Bowel and bladder dysfunction
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Assessment
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Psychosocial assessment
Laboratory assessment
Other diagnostic tests
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Drug Therapy
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Therapies include:
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Interferon beta
Monoclonal antibodies
Copaxone
Novantrone
Immunosuppressive therapy
Methylprednisolone
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Drug Therapy (Cont’d)
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Muscle relaxants
Treatment of paresthesia
Treatment of bladder dysfunction
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Other Interventions
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Promoting mobility
Managing symptoms
Complementary and alternative therapies
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Community-Based Care
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Home care management
Health teaching
Health care resources
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Amyotrophic Lateral Sclerosis
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Known as Lou Gehrig’s disease, an adult
onset upper and lower motor neuron
disease characterized by progressive
weakness, muscle wasting, and spasticity
eventually leading to paralysis
Early symptoms—fatigue while talking,
tongue atrophy, dysphagia, weakness of
the hands and arms, fasciculations, nasal
quality of speech, dysarthria
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Interventions
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No known cure, no treatment, no
preventive measures
Riluzole, only drug approved by FDA to
extend survival time
Exercise and mobility program
Management of swallowing difficulties
Respiratory support
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