Transcript Chapter 34 - Faculty Sites

Nursing 1130
Traci J. Warren MSN
Revised spring 2013
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Nervous System
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Coordinates and regulates all bodily functions
Receives and interprets information from the
external environment
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Neuron or __________ cell
 Functional unit of the nervous system
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__________ neurons
◦ Transmit information from distal parts of the body or
environment toward the central nervous system
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__________ neurons
◦ Carry motor information from the CNS to the
periphery
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Axons and Dendrites
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Axons conduct impulses __________ from the
cell body
Dendrites convey impulses __________ the cell
body
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Myelin
 Material that covers many axons and dendrites
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Enhances conduction along nerve fibers
Gives the axons a white appearance; cell bodies
without myelin are gray
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Nerve Cell
Figure 27-1
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Central Nervous System (CNS)
 Made up of the brain and spinal cord
Peripheral Nervous System (PNS)
 All the nerves of the peripheral parts of the
body, including spinal and cranial nerves
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__________
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Divided into the cerebrum, cerebellum, and
brainstem
Cerebrospinal Fluid (CSF)
 Composed of water, glucose, sodium
chloride, and protein
 Acts as a shock absorber for the brain and
spinal cord
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Structures of the Brain
Figure 27-2
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Spinal Cord
 Extends from the first cervical vertebra (C1) to
the level of the second lumbar vertebra (L2)
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Thirty-one pairs of spinal nerve roots exit the
spinal cord
These roots, along with the 12 cranial nerves,
make up the peripheral nervous system
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Autonomic Nervous System (ANS)
 Maintains homeostasis for the body
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Controls the involuntary activities of the
viscera
Two major subdivisions: sympathetic nervous
system and the parasympathetic nervous
system
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Decreased number of nerve cells
Brain weight reduced; ventricles increase in
size
Increased plaques in nerve tissue
Pupils smaller; may respond to light more
slowly
Reflexes intact except for Achilles tendon jerk,
which is often absent
Reaction time increases
Tremors in the head, face, and hands are
common
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Developmental and genetic
Trauma
Infections and inflammation
Neoplasms
Degenerative processes
Vascular disorders
Metabolic and endocrine disorders
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Health history
◦ Note speech, behavior, coordination, alertness,
comprehension
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Chief complaint and history of present illness
◦ Document what prompted the patient to seek medical
attention
◦ Describe any injuries
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Past medical history
◦ Head injury, seizures, diabetes mellitus, hypertension,
heart disease, and cancer
◦ Record dates and types of immunizations
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Family history
◦ Have immediate family members had heart
disease, stroke, diabetes mellitus, cancer, seizure
disorders, muscular dystrophy, or Huntington’s
disease
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Review of systems
◦ Fatigue or weakness, headache, dizziness, vertigo,
changes in vision/hearing, tinnitus, dysphagia,
neck pain or stiffness, vomiting, bladder or bowel
function, sexual dysfunction, fainting, blackouts,
tremors, paralysis, numbness or tingling, memory
problems, mood changes
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Functional assessment
◦ Document whether present symptoms interfere
with the patient’s usual activities and occupation
◦ Explore sources of stress, usual coping strategies,
and sources of support
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Physical examination
◦ Level of consciousness, pupillary evaluation,
neuromuscular response, and vital signs
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Basic Neurologic Examination
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________ ___ ____________
◦ Glascow coma scale
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Pupillary evaluation
◦ Assess size, shape, and reactivity
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Neuromuscular response
Vital signs
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Advanced neurologic examination
◦ Cranial nerves
◦ Coordination and balance
◦ Neuromuscular function
◦ Sensory function
 Pain, temperature, light touch, vibration,
position, tactile discrimination
◦ Reflexes
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Olfactory
Optic
Oculomotor
Trochlear
Trigeminal
Abducens
Facial
Auditory
Glossopharyngeal
Vagus
Accessory
Hypoglossal
Smell
Vision
EOM
EOM; eyeball down
Sensation skin/ face
EOM; eyeball laterally
Facial expression
Equilibrium
Swallow
Swallow/ sensation
Head movement
Tongue movement
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Reflexes
Figure 27-6
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Babinski Reflex
Normal
Abnormal
Figure 27-7
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Lumbar puncture
Electroencephalography (EEG)
Electromyography (EMG)
Radiologic studies
◦ Brain scan
◦ Cerebral angiography and digital subtraction
angiography
◦ Computed tomography (CT)
◦ Magnetic resonance imaging (MRI)
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Lumbar Puncture
Figure 27-8
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Computed tomography
Figure 27-10
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MRI image
Figure 27-11
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Drug therapy
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Antimicrobials
Analgesics
Anti-inflammatory
Corticosteroids
Anticonvulsants
Diuretics
Chemotherapeutic agents
Dopaminergics
Anticholinergics
Cholinergics
Antihistamines
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Surgery
◦ ____________
 Surgical opening of the skull
◦ Craniectomy
 Excision of a segment of the skull
◦ Cranioplasty
 Any procedure done to repair a skull defect
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Life threatening
As intracranial pressure increases, the
perfusion to brain tissues ___________
Assessments:
◦ LOC, pupillary reaction, motor and sensory
function, and vital signs
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Abnormal posturing
◦ Decorticate
◦ Decerebrate
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Characterized by:
◦ Hypertension
◦ Bradycardia
◦ Widening pulse pressure
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Associated with increased intracranial
pressure
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Treatment
 Positioning
 Hyperventilation
 Fluid management
 Mechanical drainage
 Drug therapy
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__________ Headache
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Intracranial vasoconstriction followed by
vasodilation
Triggered by menstruation, ovulation, alcohol,
some foods, stress
Pain usually unilateral, often begins in the
temple or eye area and is very intense
Hypersensitive to light and sound; prefers dark,
quiet environment
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__________ Headache
 Occur in a series of episodes followed by a
long period with no symptoms
 Intensely painful and seem to be related to
stress or anxiety
 Usually have no warning symptoms
 Treatment may include cold application,
indomethacin (Indocin), and tricyclic
antidepressants
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__________ Headache
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Result from prolonged muscle contraction
Pain location may vary
Nausea and vomiting, dizziness, tinnitus, or
tearing
Treatment: correction of known causes,
psychotherapy, massage, heat application,
and relaxation techniques
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Seizures
 Electrical impulses in the brain are
conducted in a highly __________ pattern
that yields abnormal activity and behavior
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Related to trauma, reduced cerebral
perfusion, infection, electrolyte disturbances,
poisoning, or tumors
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Partial seizures
◦ Simple
 Affect part of one cerebral hemisphere
 Consciousness not impaired
 Abnormal activity begins in one area and spreads to
adjacent motor areas on the same side of the body
◦ Complex
 Consciousness impaired
 May exhibit bizarre or repetitive behavior
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Generalized seizures
◦ Involve the entire brain from the onset
◦ Consciousness lost during the ictal (seizure) period
◦ Types:
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Tonic-clonic,
Absence
Myoclonic
Atonic
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Status epilepticus
◦ Medical emergency: continuous seizures or
repeated seizures in rapid succession for ____
minutes or more
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Aura
◦ Dizziness, numbness, visual or hearing disturbance,
noting an offensive odor, or pain may precede a
seizure
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Medical treatment
◦ Resolution of the underlying condition
◦ Anticonvulsant drug therapy. Refer to table 27-5,
page 458
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Surgical treatment
◦ Removal of seizure foci in the temporal lobe and
pallidotomy
◦ Vagal nerve stimulator
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Assessment
◦ Describe the seizure episode, including the
postictal period (following the seizure), and
document drug therapy
◦ Refer to Box 27-3 for seizure management do’s
and do not’s
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Risk for Injury
Ineffective Coping
Deficient Knowledge
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Scalp injuries
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____________
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Contusion
◦ Lacerations, contusions, abrasions, and
hematomas
◦ Trauma with no visible injury to the skull or brain
◦ Loss of consciousness lasting less than 5 minutes
◦ Bruising and bleeding in the brain tissue
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Hematoma-a collection of blood
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Intracerebral hemorrhage
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Penetrating injuries
◦ Subdural hematoma
 Tearing of the veins that drain the brain; blood
accumulates beneath the dura
 Acute, sub-acute, and chronic
◦ Epidural hematoma
 Arterial bleeding
 _______ deterioration
◦ From lesions within the tissue of the brain itself
◦ Sharp objects penetrate the skull and brain tissue
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Surgical treatment
◦ Directed at evacuating hematomas
◦ Débriding damaged tissue
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Ineffective ________ ___________
Ineffective Breathing Pattern
Risk for Injury
Risk for Infection
Impaired __________ _________
Disturbed Body Image
Ineffective Role Performance
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Etiology and risk factors
◦ Generally unknown etiology, some congenital, or may be
related to heredity
◦ Drug/environmental factors may play a role in
development
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Signs and symptoms
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Directly related to area of brain invaded by the tumor
Visual disturbances and headache
New-onset seizure activity
Difficulties with balance and coordination
May involve cranial nerves
Medical treatment
◦ Surgery often followed by radiation with or without
chemotherapy
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Acute ________
Disturbed Thought Processes
Disturbed Sensory Perception
Impaired Physical Mobility
Self-Care Deficit
Ineffective Coping
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Etiology and risk factors
◦ Inflammation of the meningeal coverings of the
brain and spinal cord caused by either viruses or
bacteria
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Signs and symptoms
◦ Headache, ________ rigidity, irritability, diminished
level of consciousness, photophobia,
hypersensitivity, and seizure activity
◦ Positive Kernig’s sign and Brudzinski’s sign
Medical diagnosis
◦ Lumbar puncture to obtain CSF for lab analysis
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Kernig Sign
Figure 27-16A
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Brudzinski Sign
Figure 27-16B
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Medical treatment
◦ Bacterial infections usually respond to
antimicrobial therapy, but no specific drugs
effective against most viral infections
◦ Anticonvulsants used to control seizure activity if
necessary
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Assessment
◦ Assess neurologic status and vital signs frequently
to determine further deterioration or onset of
complications
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Ineffective Tissue Perfusion
Ineffective Breathing Pattern
Acute Pain
Risk for Injury
Deficient _______ _______
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Etiology and risk factors
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Signs and symptoms
◦ Inflammation of brain tissue caused by a ________
◦ Fever, nuchal rigidity, headache, confusion, delirium,
agitation, and restlessness
◦ Comatose or exhibit aphasia, hemiparesis, facial
weakness, and other alterations in motor activity
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Medical treatment
◦ Enhance patient comfort and increase strength
◦ Because seizure activity is a potential problem, take
appropriate safety precautions
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The nursing plan of care parallels that of the
patient with meningitis
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Etiology and risk factors
◦ Although specific cause unknown, it is believed to
be an autoimmune response to a _______ infection
◦ Patients often report some recent viral infection or
vaccination
◦ Affects the motor and sensory component of the
peripheral nervous system
◦ Myelin sheath around peripheral nerves is
destroyed
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Initial phase
◦ ________ muscle weakness: begins in lower
extremities; ascends to trunk and upper
extremities
◦ Visual and hearing disturbances, difficulty
chewing, and lack of facial expression
◦ Mild paresthesias or anesthesia in feet and
hands in a glove or stocking distribution pattern
◦ Hypertension, orthostatic hypotension, cardiac
dysrhythmias, profuse sweating, paralytic ileus,
and urinary retention
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Plateau phase
◦ Remains essentially unchanged
◦ No further neurologic deterioration, but no
improvement either
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Recovery phase
◦ Remyelinization; muscle strength returns in a
proximal-to-distal pattern (head to toes)
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Diagnosis
Guillain-Barré Syndrome: Medical diagnosis
◦ Characteristic onset and pattern of ascending
motor involvement
◦ Elevated protein level in the CSF
◦ Nerve conduction velocity studies reveal slowed
conduction speed in the involved nerves
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Treatment
◦ Preserve vital function, particularly respiration
◦ Respiratory status is closely monitored and
mechanical ventilation initiated if vital capacity
falls to 15 mL/kg of body weight
◦ Massive doses of corticosteroids prescribed to
suppress the inflammatory process
◦ Plasmapheresis
◦ Rehabilitation
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Nursing Care
 Assessment
◦ Health history describes the progression of
symptoms
◦ Note fears, coping strategies, and sources of
support
◦ Physical examination focuses on cranial nerve,
motor, respiratory, and cardiovascular function
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Ineffective Breathing Pattern
Decreased Cardiac Output
Risk for Disuse Syndrome
Imbalanced Nutrition: Less Than Body Requirements
____________
Deficient Knowledge
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Etiology and risk factors
◦ Progressive degenerative disorder of the basal
ganglia: an eventual loss of coordination and control
over involuntary motor movement
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Signs and symptoms
◦ Tremor, rigidity, and bradykinesia
◦ Loss of dexterity and power in affected limbs,
aching, monotone voice, handwriting changes,
drooling, lack of facial expression, rhythmic head
nodding, reduced blinking, and slumped posture
◦ ______________ common; dementia may develop
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Medical diagnosis
◦ From health history and physical examination
◦ MRI to rule out other causes of the symptoms
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Medical treatment
◦ Control symptoms: physical therapy and drug
therapy
 Massage, heat, exercise, and gait retraining
 Dopamine receptor agonists, anticholinergic drugs,
or antidepressants
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Assessment
◦ Weakness, fatigue, muscle cramps, sweating,
dysphagia, constipation, difficulty voiding, and
unusual movements
◦ Note lack of facial expression, eyes fixed in one
direction, drooling, slurred speech, tearing,
tremors, muscle stiffness, and poor balance and
coordination
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Nursing Diagnoses
◦ Impaired Physical Mobility
◦ Risk for Injury
◦ Imbalanced Nutrition: Less Than Body
Requirements
◦ Ineffective Coping
◦ Deficient Knowledge
◦ _________ ___________ Deficit
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Etiology
◦ Chronic, progressive degenerative disease
◦ Attacks the protective __________ _________
around axons and disrupts the conduction of
impulses through the CNS
 Chronic, progressive MS: progresses steadily
 Exacerbating-remitting MS: exacerbations and
remissions
 Relapsing-progressive MS: less stable periods than
exacerbating-remitting
 Stable MS: stable; no active disease for a year
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Cause
◦ Exact cause of MS is unknown; viral infections and
autoimmune processes have been implicated
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Signs and symptoms
◦ Fatigue, weakness, and tingling in one or more
extremities; visual disturbances; problems with
coordination; bowel and bladder dysfunction;
spasticity; and depression
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Medical diagnosis
◦ Based on the physical examination and history
of cyclic remission-exacerbation periods
◦ Family history
◦ Magnetic resonance imaging of the brain and
spinal cord may reveal plaques characteristic of
MS
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Medical treatment
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Corticosteroids
Interferon  1b and interferon 1a
Immunosuppressants
Urinary retention treated with cholinergics
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Assessment
◦ Onset and progression of symptoms, especially
those that affect mobility, vision, eating, and
elimination
◦ Evaluation of range of motion and strength, gait
abnormalities, tremors, and muscle spasms
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Impaired Physical Mobility
Disturbed Sensory Perception
Self-Care Deficit
Functional Urinary Incontinence
Risk for Infection
Ineffective Coping
Deficient Knowledge
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Etiology
◦ Also known as Lou Gehrig’s disease; a
degenerative neurologic disease
◦ Virus suspected, but exact cause unknown
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Pathophysiology
◦ Degeneration of the anterior horn cells and the
corticospinal tracts, so patient exhibits upper and
lower motor neuron symptoms
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◦ Weakness of voluntary muscles of the upper
extremities, particularly the hands
◦ Difficulty swallowing and speaking
◦ Eventually, respirations shallow; difficulty
clearing airway of pulmonary secretions
◦ Spasticity of involved muscle groups
◦ Death results from aspiration, respiratory
infection, or _____________ _________
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Medical diagnosis
◦ History and physical examination findings
◦ Electromyography
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Medical treatment
◦ Because no known cure or treatment, therapy is
supportive; focuses on preventing complications
and maintaining maximum function
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Assessment
◦ Dyspnea, dysphagia, muscle cramps, weakness,
twitching, joint stiffness, muscle atrophy,
abnormal reflexes and gait, and paralysis
◦ Abnormal gait and paralysis
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◦ Ineffective Airway Clearance
◦ Impaired Physical Mobility
◦ Imbalanced Nutrition: Less Than Body
Requirements
◦ Impaired Verbal Communication
◦ Impaired Skin Integrity
◦ Anticipatory Grieving
◦ Situational Low Self-Esteem
◦ Interrupted Family Processes
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Inherited degenerative neurologic disorder
Usually begins in middle adulthood with
abnormal movements, emotional
disturbance, and intellectual decline
Symptoms progress steadily: increasing
disability and death in 15 to 20 years
Medical and nursing care are supportive
only; there is no cure
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Etiology
◦ May have an autoimmune basis
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Pathophysiology
◦ Insufficient receptor sites at the junction of the
motor nerve with the muscle
◦ With repeated stimulation, muscle becomes
exhausted; eventually unable to contract at all
◦ If respiratory muscles involved, death from
respiratory insufficiency or arrest possible
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Signs and symptoms
◦ Weakness of voluntary muscles, particularly those
of chewing, swallowing, and speaking
 Partial improvements of strength with rest
 Dramatic improvement with the use of
anticholinesterase drugs
◦ Ptosis and diplopia commonly seen
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Medical diagnosis
◦ Administering edrophonium (Tensilon)
 Muscle tone is markedly improved within 1
minute of injection; persists for 4 to 5 minutes
Medical treatment
◦ Anticholinesterase drugs
◦ Corticosteroids
◦ Cytotoxic therapies
◦ Thymectomy
◦ Plasmapheresis
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Assessment
◦ Health history describes the onset of symptoms:
muscle weakness, diplopia, dysphagia, slurred
speech, breathing difficulties, and loss of balance
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Nursing Diagnoses
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Ineffective Breathing Pattern
Impaired Physical Mobility
Self-Care Deficit
Impaired Swallowing
Deficient Knowledge
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Nursing 1130
Traci J Warren
Revised Spring 2013
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Cerebrum
 Complex functions: initiation of movements,
recognition of sensory input, higher-order
thinking, regulating emotional behavior and
endocrine and autonomic functions

Divided into two halves: hemispheres
◦ Each hemisphere controls the opposite side of the
body
◦ The cortex of each hemisphere is divided into the
parietal, frontal, temporal, and occipital lobes;
each has a different area of function
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
Brainstem
◦ Includes midbrain, pons, medulla, and part of
the reticular activating system
◦ Controls vital, basic functions, including
___________ , heart rate, and consciousness
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Cerebellum


Uses information received from the cerebrum,
muscles, joints, and inner ear to coordinate
movement, balance, and posture
Controls functions on the same side of the body
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Circulation

_________ system
◦ Begins as one common artery; later divides into
the external and internal carotid arteries
 The external carotid arteries supply blood to
the face
 The internal arteries further divide into the
middle cerebral artery and the anterior
cerebral artery to supply blood to the brain
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Circulation

___________ arteries
◦ Originate from the subclavian artery, travel up the
anterior neck to merge and form the basilar artery
at the brainstem
◦ Second division forms posterior cerebral artery

Internal carotid and vertebrobasilar arteries
unite to form the circle of Willis
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Risk Factors
 Nonmodifiable factors
◦ Risk factors that cannot be changed
 Age, race, __________, and heredity

Modifiable factors
◦ Those that can be eliminated or controlled
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


Temporary neurologic deficit caused by
impairment of cerebral blood flow
Blood vessels occluded by spasms,
fragments of plaque, or blood clots
Important warning signs for the individual
experiencing a full stroke
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
Signs and symptoms
◦
◦
◦
◦
◦
◦
◦
◦
◦
◦
Dizziness
Momentary confusion
Loss of speech
Loss of balance
Tinnitus
Visual disturbances
Ptosis
Dysarthria, ____________, drooping mouth
Weakness
Tingling or numbness on one side of the body
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
Medical diagnosis
◦ Health history, physical examination findings,
and results of brain imaging studies
◦ Laboratory studies, electrocardiography (ECG),
duplex ultrasonography, and cerebral
angiography
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
Medical treatment
◦ Depends on the location of the narrowed vessel
and the degree of narrowing
 Acetylsalicylic acid (aspirin)
 Ticlopidine hydrochloride (Ticlid)
 Extended-release dipyridamole (Aggrenox)
 Clopidogrel bisulfate (Plavix) to decrease
platelet clumping
 Warfarin (Coumadin) and heparin
◦ __________ endarterectomy and transluminal
angioplasty
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Carotid Endarterectomy
Figure 28-3
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

An abrupt impairment of brain function
resulting in a set of neurologic signs and
symptoms that are caused by impaired
blood flow to the brain and last more than
24 hours
Causes lingering motor, sensory, or
cognitive damage with varying disabilities
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Pathophysiology
 Hemorrhagic stroke
◦ Blood vessel in brain ruptures; bleeding into the
brain occurs
 Intracerebral
 Subarachnoid

__________ stroke
◦ Obstruction of blood vessel by atherosclerotic
plaque, blood clot, or a combination of the two, or
by other debris released into vessel that impedes
blood flow to an area of the brain
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Types of Strokes
Figure 28-4
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Signs and Symptoms

Different signs and symptoms, depending
on the type, location, and extent of brain
injury
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
Hemorrhagic stroke
◦ Occurs suddenly; may include severe headache
described as “the worst headache of my life”
◦ Stiff neck, loss of consciousness, vomiting, and
seizures

Embolic stroke
◦ Appear without warning
◦ One or more of the following signs and
symptoms: one-sided weakness, numbness,
visual problems, confusion and memory lapses,
headache, dysphagia, and language problems
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Right Sided vs Left Sided Stroke
Figure 28-5
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Signs and Symptoms





___________
◦ A defect in the use of language; speech, reading,
writing, or word comprehension
Dysarthria
◦ The inability to speak clearly
___________
◦ Swallowing difficulty
Dyspraxia
◦ The partial inability to initiate coordinated
voluntary motor acts
Hemiplegia
◦ Defined as paralysis of one side of the body
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



Sensory impairment
◦ Unable to feel touch, pain, or temperature in
affected body parts
Unilateral neglect
◦ Do not recognize one side of the body as
belonging to them
Homonymous hemianopsia
◦ Perceptual problem: involves loss of one side of
field of vision
Elimination disturbances
◦ Neurogenic bladder
◦ Flaccid bladder
◦ Bowel incontinence
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
Blood studies, electrocardiogram (ECG),
computed tomography, magnetic resonance
imaging, carotid ultrasound studies,
cerebral and carotid angiography,
electrocardiography, positron-emission
tomography, and single-photon emission
computed tomography
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



Impaired neuromuscular function
Severe motor impairment
Sensory losses
Swallowing difficulties
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



Prognosis for TIA or stroke increasingly hopeful
Critical variables for recovery: patient’s condition
before the stroke, time between stroke and
diagnosis, treatment and support in acute phase
(usually the first 48 hours), severity of patient’s
symptoms, and access to rehabilitative therapy
Long-term recovery may depend on the care
received immediately after the stroke
Most recovery takes place in the first 3-6 months,
but progress often continues long after that
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


Begins with the onset of signs and
symptoms and continues until vital signs,
particularly blood pressure and neurologic
condition, stabilize
This phase usually lasts 24 to 48 hours
Medical management interventions are
directed at minimizing complications and
deterioration of the patient’s condition after
a stroke
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
Major focus areas
 ______________
 Oxygenation
 Hyperthermia
 Hyperglycemia
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
Drug therapy
◦ Tissue plasminogen activator
 Given to dissolve clots in acute ischemic strokes

Other medications




Mannitol
Nimodipine
Phenytoin and phenobarbital
Acetylsalicylic acid, ticlopidine hydrochloride,
Aggrenox, and clopidogrel
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
Surgical intervention
◦ An option for some patients with hemorrhagic
strokes
◦ Decisions about surgery are based on patient’s
age, intracranial pressure, and location of the
hemorrhage
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
Fluids and nutrition
◦ Intravenous fluids
◦ Dietary order based on patient’s nutritional
requirements and ability to eat
 Regular, soft, or pureed
◦ Total parenteral nutrition may be ordered for
the malnourished patient
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
Urine elimination
◦ Indwelling catheter to manage urinary
incontinence
◦ Intermittent catheterization: controlling
incontinence caused by a flaccid bladder
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
Assessment
◦ Evaluate type and extent of the stroke: time of
onset, symptoms, other details
◦ Cincinnati Pre-hospital Stroke Scale
◦ http://youtu.be/sADAJrEvzfc

Health history
◦ Chief complaint and history of present illness
◦ Medical history
◦ Family history
◦ Review of systems
◦ Functional assessment
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
Physical examination
◦ Frequently repeat neurologic checks: evaluating
level of consciousness, pain, pupil appearance
and response to light, mental status, the patient’s
ability to follow commands, movement and
sensation of extremities, and bowel/ bladder
incontinence
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◦
◦
◦
◦
◦
◦
◦
◦
◦
Ineffective Airway Clearance
Ineffective Breathing Patterns
Risk for Injury
Deficient Fluid Volume
Excess Fluid Volume
Imbalanced Nutrition
Disturbed Sensory Perception
Ineffective Thermoregulation
Disturbed Thought Processes
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◦
◦
◦
◦
◦
◦
◦
◦
Ineffective Thermoregulation
Disturbed Thought Processes
Impaired Verbal Communication
Impaired Physical Mobility
Total or Functional Urinary Incontinence
Constipation and/or Bowel Incontinence
Ineffective Coping
Interrupted Family Processes
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

The earlier rehabilitation is initiated, the
shorter the recovery time- the goal is to
maximize function
Requires an interdisciplinary team
◦ Doctors, nurses, physical therapists, recreational
therapists, dieticians, and social work

Assessment
◦ Reassess patient’s abilities, expectations,
knowledge, motivation, and resources
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◦
◦
◦
◦
◦
◦
◦
◦
Self-Care Deficit
Risk for Injury
Ineffective Coping
Impaired Verbal Communication
Imbalanced Nutrition
Impaired Physical Mobility
Constipation
Total and Functional Urinary Incontinence
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Assistive Devices for Eating
Figure 28-7
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



Discharged home or to specialized
rehabilitation centers for continued therapy
Outpatient therapy
When able, patients are transitioned back
into the home setting
Essential to include family, friends, and
significant others in this process
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

Identify appropriate resources to help
patients and families deal with continuing
disabilities
In rehabilitation, the patient is respectfully
challenged to return to the highest level of
function possible
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Nursing 1130
Traci J Warren MSN
Revised Spring 2013
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
Vertebral Column
◦ Consists of 33 vertebrae
 7 cervical (C1 through C7)
 12 thoracic (T1 through T12)
 5 lumbar (L1 through L5)
 5 sacral (S1 through S5)
 4 fused coccygeal
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Vertebral Column
Figure 29-1
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Vertebral Column
 Each vertebra consists of a body and an arch
 The spinal cord passes through an opening in
the center of each arch
 Each arch has articulating surfaces against
which adjacent vertebrae smoothly glide with
movement
 The bony column is supported by muscles
and ligaments, which permit __________ and
__________
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Disks
 Vertebrae separated by disks which serve as
shock absorbers for the vertebral column
 Composed of anulus fibrosus and nucleus
pulposus
◦ anulus fibrosus: ring of tissue; encircles nucleus
pulposus
◦ Nucleus pulposus: saclike structure with a
gelatinous filling that has a high water content

As we age, nucleus pulposus loses much of
its water; less effective as a shock absorber
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Intervertebral disks
Figure 29-2
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Spinal Cord
 Extends from the brainstem to ____ in the pelvic
cavity
 Surrounded by three protective meningeal layers
◦ Dura mater
 Outermost layer
◦ Arachnoid
 Middle layer: spaces containing cerebrospinal fluid (CSF)
◦ Pia mater
 Innermost layer: directly covers the spinal cord

CSF circulates through the brain and spinal column,
bathing and protecting the entire central nervous
system
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Spinal Cord
 Gray matter
◦ Consists of the bodies of nerve cells that
control motor and sensory activities
 _______ matter
◦ Myelinated (surrounded by a sheath);
consists of bundles of fibers
◦ Convey information between the brain and
the spinal cord
◦ Tracts may be ascending or descending
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Spinal Cord
 Blood supply
◦ Major arterial supply to the spinal cord;
consists of the vertebral arteries posteriorly
and the anterior spinal artery
 Reflexive activity
◦ The sensory stimulus is received, and a
response is initiated at the level of the
spinal cord. Example- the knee jerk
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Spinal Cord
 Relay activity
◦ Stimulus enters spinal cord; travels up ascending
tracts to relay sensory signals to the brain
◦ Information processed in the brain; responses
initiated by impulses transmitted to the body by
way of descending tracts

Information conveyed to brain and spinal
cord via peripheral nervous system
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
Neurologic examination
◦ Initial evaluation of the spinal cord: injured
patient provides the nurse with a baseline
assessment of function and problems
◦ Ongoing assessment necessary to monitor the
effects of neurologic injury, detect related
complications, and determine patient’s need
for assistance in activities of daily living
◦ Focuses on the motor and sensory systems
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
Imaging studies
◦ Radiography
 Detects vertebral compression, fractures, or
problems with alignment
 Coned-down views
◦ Computed tomography (CT)
 Noninvasive examination of the specific levels of
the spinal cord to be visualized, bony vertebrae,
and the spinal nerves
 Detects bony fractures, floating bones,
dislocations, tumors, hemorrhage, and cord/ nerve
compressions
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◦ Magnetic resonance imaging (MRI)
 Produces precise, clear images of internal
structures
 Remove all metal objects
◦ Myelogram
 Invasive procedure
 Visualizes the spinal cord and vertebrae
 Dye injected into subarachnoid space between
L3 and L4
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
Location
◦ Cervical, thoracic, or __________

Open or closed
◦ Closed: the skin and meningeal covering that
surround the spinal cord remain intact
◦ Open: damage to the protective skin and meninges

Extent of damage to the cord
◦ Complete: the cord has been completely severed
◦ Incomplete: partial cutting of the cord
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


Factors include extent of cut and level of
injury
Sometimes cannot be fully determined
because the symptoms of spinal cord edema
may mimic partial or complete transection
With incomplete spinal cord injuries some
function remains below the level of the injury
◦ Specific tracts may be involved, causing particular
patterns of neurologic dysfunction
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

The higher the level of injury, the more
encompassing the neurologic dysfunction
Quadriplegia/ ____________
◦ High cervical spine injuries; loss of motor and
sensory function in all four extremities

Paraplegia
◦ Injuries at or below T2 may cause paralysis of the
lower part of the body
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Respiratory Impairment
 Injuries at or above the level of C5 may
result in instant death because the nerves
that control respiration are interrupted
 Cervical injuries below the level of C4 spare
the diaphragm but can involve impairment
of intercostal and abdominal muscles
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Spinal Shock
 An immediate, transient response to injury
in which reflex activity below the level of the
injury temporarily ceases
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Autonomic Dysreflexia
 Exaggerated response of autonomic nervous
system to noxious (painful) stimuli
 With injury at or above the level of T6
 The _____________ nervous system is
stimulated, but an appropriate
parasympathetic modulation response
cannot be elicited because of the spinal cord
injury that separates the two divisions of the
autonomic nervous system
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Autonomic Dysreflexia cont.
 Arterioles constrict causing severe
hypertension
 Regulatory mechanisms cause the blood
vessels to ________ (above the level of the
injury)
◦ Flushing, profuse sweating, facial flushing,
pounding headache, nasal congestion

Increased blood pressure stimulates the
vagus nerve
◦ Bradycardia
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Autonomic Dysreflexia cont.
 Triggered by various stimuli including a
distended bladder, constipation, renal calculi,
ejaculation, or uterine contractions, but also
may be caused by pressure sores, skin rash,
enemas, or even sudden position changes
Treatment
 Elevate head of bed to 45 degrees
 Check catheter for occlusion
 Remove fecal impaction
 Monitor vitals
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Spasticity
 Defined as: ___________ _________ _______
 Muscle spasms may be incapacitating for
these patients, hampering efforts at
rehabilitation
 Muscle tone is evaluated by assessing the
amount of resistance to passive movement
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Impaired Sensory and Motor Function
 Impaired motor function can affect the
patient’s mobility and self-care, thus
resulting in complications from immobility
 Loss of sensation puts patient at risk for
skin breakdown and other injuries because
pressure and pain are not perceived
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Impaired Bladder Function
 During spinal shock, all bladder and bowel
function ceases
 Once spinal shock resolves, reflex activity
returns
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Impaired Bowel Function
 Most spinal cord–injured patients can
maintain bowel function because the large
bowel musculature has its own neural center
that responds to distention by the fecal
mass
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Impaired Temperature Regulation
 May lose these regulatory mechanisms and
be unable to adapt to temperature extremes
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Impaired Sexual Function
 Spinal levels S2, S3, and S4 control sexual
function, so injury at or above these levels
results in sexual dysfunction
 Ability to achieve erection and ejaculation is
variable
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Impaired Skin Integrity
 Because immobile patient can’t change
positions, skin in sacral area and across
bony prominences may break down
 Loss of tone results in ______________ and
pooling of blood in the periphery; impedes
perfusion of the skin; and encourages the
development of pressure sores
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Altered Self-Concept and Body Image
 French and Phillips (1991) describe the
effects of spinal cord injury on body image
as occurring in four phases: impact, retreat,
acknowledgment, and reconstruction
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Establish Airway
 Conventional head-tilt–chin-lift:
inappropriate with spinal injury; increases
risk of cord damage
 Risk of additional damage is especially high
with cervical injury
 Neck flexion, even that caused by a pillow or
other support, must be avoided
 _____ ________ method of opening the
airway is preferred for these patients
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Establish Airway
 Once airway is open, administer 100%
oxygen by mask and manual resuscitator
 Endotracheal or tracheostomy tube is placed
to allow direct access to the airway and
facilitate optimal oxygenation
 Any injury that compromises ventilation
must be treated immediately
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
Traction
◦ Immobilization with skeletal traction manages
cervical spinal cord injuries acutely
 Gardner-Wells tongs
 Crutchfield tongs
◦ Halo vest: immobilizes and aligns cervical
vertebrae; placed when surgery is done to
internally stabilize fractures and relieve the
compression of nerve roots
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Gardner-Wells Tongs
Figure 29-7
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Halo Device
Figure 29-8
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
Special beds and cushions
◦ Kinetic bed, such as the Roto-Rest bed,
continually rotates the patient from side to side
◦ Overlay air mattresses: flotation devices placed on
standard hospital beds
 Air-fluidized and flotation beds may be used after
the spine has been stabilized
◦ Wedge-Stryker frame: canvas and metal frame
bed that may be used to help turn the patient
◦ Types of cushions include those inflated with air,
flotation devices, and gel pads
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
Drug therapy
◦ Methylprednisolone
 Reduces the damage to the cellular membrane
 Administered within the first __ hours of
injury
 Completely paralyzed patients often regain
about 20% of function
 Partially paralyzed have regained up to 75% of
function
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
Early surgical intervention to repair cord
damage
◦ Cord compression by bony fragments, compound
vertebral fractures, and gunshot and stab wounds
◦ Surgery within the first ___ hours is most desirable

Laminectomy
◦ Involves removing all or part of the posterior arch
of the vertebra

Spinal fusion
◦ If multiple vertebrae are involved
◦ Placing a piece of donor bone into area between
the involved vertebrae
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
Monitor the patient’s level of consciousness,
vital signs, respiratory status, motor and
sensory function, and intake and output
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
Present illness
◦ Event that brought the patient to the hospital
◦ Specific injuries incurred in the incident
◦ Describe pain and other symptoms in detail
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



Other accidents or injuries and chronic
illnesses such as diabetes, hypertension,
heart disease, cancer, or seizure disorder
Previous hospitalizations and operations
Obstetric history from female patient
Identify and record current medications and
allergies
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
Routine family history taken but not
considered specifically relevant to a
diagnosis of spinal cord injury resulting
from trauma
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
Skin condition, headache or dizziness,
vision disturbances, hearing impairment or
tinnitus, nasal or ear drainage, dyspnea,
nausea and vomiting, constipation or
diarrhea, fecal incontinence, bladder
dysfunction, sexual dysfunction, and
impaired motor and sensory function
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





Patient’s self-care abilities
Patient’s roles and responsibilities as a
family member
Occupation, hobbies, usual activity pattern,
habits, and diet
Emotional response to the spinal injury
Usual coping strategies
Spiritual beliefs; other sources of support
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






Record the patient’s reported height and
weight
Take vital signs
Take the temperature
Level of responsiveness, posture, and
spontaneous movements
Inspect the skin for lesions
Evaluate tissue turgor
Inspect head for lesions and palpate for
masses and swelling
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





Examine pupils for size, equality, reaction to
light
Respiratory effort and breath sounds
Inspect abdomen; auscultate for bowel
sounds
Inspect extremities for open fractures or
abnormal positions
Range of motion
Ability to perceive sharp and dull sensation;
use a dermatome chart
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Ineffective Breathing Pattern
Risk for Injury and Disturbed Sensory
Perception
Risk for Autonomic Dysreflexia
Risk for Disuse Syndrome
Bowel Incontinence
Impaired Urinary Elimination
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Risk for Infection
Ineffective Thermoregulation
Feeding/Dressing/Grooming Self-Care
Deficit
Sexual Dysfunction
Ineffective Coping
Ineffective Therapeutic Regimen
Management
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Activities that assist individual to achieve
highest possible level of self-care and
independence
Well-organized interdisciplinary team that
can address all aspects of function
Patient and family must be emotionally and
physically prepared to make adjustments
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Team helps the patient accomplish activities
of daily living and self-care and addresses
successful adjustment to social integration
and gainful employment in the workplace
Although this phase of treatment may take
more than a year, patient, family, and
rehabilitation team can take pride in the
realization that a life can once again be
productive and happy
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Preoperatively
◦ Assess patient’s vital signs and neurologic status
to establish baselines
◦ Patient’s understanding of surgical routines
◦ Tell patient what to expect in the immediate
postoperative period
◦ Ongoing assessment of neurologic status and on
promoting healing at the operative site
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Assessment
◦ Vital signs, neurologic status, and breath sounds
◦ Frequently assess movement, strength, range of
motion, and ability to localize sensory stimulus
◦ Fluid intake and output
◦ Abdomen for bowel sounds; palpate bladder
◦ Inspect the surgical dressing for bleeding, clear
cerebrospinal fluid drainage, and foul drainage
◦ If the patient has pain, obtain a complete
description
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◦ Risk for Injury
◦ Ineffective Tissue Perfusion
◦ Acute Pain
◦ Impaired Urinary Elimination
◦ Constipation
◦ Impaired Physical Mobility
◦ Deficient Knowledge
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