Transcript Chapter 34 - Faculty Sites

Neurologic
Disorders
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Functional unit of the nervous system that
conducts electrical impulses from one area
of the brain to another
Sensory neurons
◦ Transmit information from distal parts of the body
or environment toward the central nervous system
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Motor neurons
◦ Carry motor information from the CNS to the
periphery
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Branch off the main cell body
Axons conduct impulses away from the cell
body
Dendrites convey impulses toward the cell
body
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Material that covers many axons and
dendrites
Enhances conduction along nerve fibers
Gives the axons a white appearance; cell
bodies without myelin are gray
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Figure 27-1
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Made up of the brain and spinal cord
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Comprises all the nerves of the peripheral
parts of the body, including spinal and
cranial nerves
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Divided into the cerebrum, cerebellum, and
brainstem
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Composed of water, glucose, sodium
chloride, and protein
Acts as a shock absorber for the brain and
spinal cord
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Figure 27-2
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Extends from the border of the first cervical
vertebra (C1) to the level of the second
lumbar vertebra (L2)
Thirty-one pairs of spinal nerve roots exit
the spinal cord, each consisting of a
posterior sensory (afferent) root and
anterior motor (efferent) root
These roots, along with the 12 cranial
nerves, make up the peripheral nervous
system
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Controls the involuntary activities of the
viscera, including smooth muscle, cardiac
muscle, and glands
Two major subdivisions: sympathetic
nervous system and the parasympathetic
nervous system
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The number of nerve cells decreases
Brain weight is reduced; ventricles increase in size
Lipofuscin: aging pigment deposited in nerve cells
with amyloid, a type of protein
Increased plaques and tangled fibers in nerve tissue
Eye pupil often smaller; may respond to light more
slowly
Reflexes intact except for Achilles tendon jerk, which
is often absent
Reaction time increases, especially complex reactions
Tremors in the head, face, and hands are common
Some develop dizziness and problems with balance
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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
◦ If patient has pain, note the onset, severity, location, and
duration
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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, drainage from
ears or nose, dysphagia, neck pain or stiffness,
vomiting, bladder or bowel function, sexual
dysfunction, fainting, blackouts, tremors,
paralysis, incoordination, 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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Advanced neurologic examination
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Cranial nerves
Coordination and balance
Neuromuscular function
Sensory function
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Pain
Temperature
Light touch
Vibration
Position
Tactile discrimination
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Figure 27-5
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Figure 27-6
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Figure 27-7
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Lumbar puncture
Electroencephalography
Electromyography
Radiologic studies
◦ Brain scan
◦ Cerebral angiography and digital subtraction
angiography
◦ Computed tomography
◦ Magnetic resonance imaging
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Figure 27-8
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Figure 27-9
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Figure 27-10
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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
◦ Craniotomy
 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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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
Tearing and nausea and vomiting may occur
Hypersensitive to light and sound; prefers dark,
quiet environment
Mild migraines treated with acetaminophen or
aspirin; severe ones with ergotamine (Cafergot) or
sumatriptan (Imitrex) tablet or autoinjector for
self-injection
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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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Result from prolonged muscle contraction
from anxiety, stress, or stimuli from other
sources, such as a brain tumor or an
abscessed tooth
Pain location may vary; may have nausea
and vomiting, dizziness, tinnitus, or tearing
Treatment: correction of known causes,
psychotherapy, massage, heat application,
and relaxation techniques
Analgesics, usually nonopioid, may be
prescribed to reduce anxiety
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Electrical impulses in the brain are
conducted in a highly chaotic pattern that
yields abnormal activity and behavior
Related to trauma, reduced cerebral
perfusion, infection, electrolyte disturbances,
poisoning, or tumors
Medical diagnosis
◦ Accurate history of the seizure disorder
◦ Electroencephalogram (EEG)
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Partial seizures
◦ Simple
 Part of one cerebral hemisphere; consciousness not
impaired
◦ Complex
 Consciousness impaired; may exhibit bizarre
behavior
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Generalized seizures
◦ Involve the entire brain from the onset
◦ Consciousness lost during the ictal (seizure)
period
◦ Types: tonic-clonic, absence, myoclonic, and
atonic
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Status epilepticus
◦ Medical emergency: continuous seizures or
repeated seizures in rapid succession for 30
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
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Surgical treatment
◦ Removal of seizure foci in the temporal lobe and
pallidotomy or vagal nerve stimulator
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Assessment
◦ Describe the seizure episode, including the
postictal period (following the seizure), and
document drug therapy
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Risk for Injury
◦ Side rails of bed up and padded, suction machine
readily available, bed maintained in the low
position
◦ Quickly move objects away from the patient
◦ Do not attempt to restrain the patient
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Ineffective Coping and Deficient Knowledge
◦ Teach family and patient about the seizure
disorder and the therapy
◦ Teaching must be directed toward helping the
patient and family adjust to a chronic condition
◦ Encourage questions and concerns
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Scalp injuries
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Concussion
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Contusion
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Hematoma
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Intracerebral hemorrhage
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Penetrating injuries
◦ Lacerations, contusions, abrasions, and
hematomas
◦ Trauma with no visible injury to the skull or brain
◦ Bruising and bleeding in the brain tissue
◦ Subdural hematoma or epidural hematoma
◦ 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 and débriding
damaged tissue
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Interventions
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Ineffective Tissue Perfusion
Ineffective Breathing Pattern
Risk for Injury
Risk for Infection
Impaired Physical Mobility
Disturbed Body Image and Ineffective Role
Performance
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Etiology and risk factors
◦ Some congenital; others 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
Medical treatment
◦ Surgery often followed by radiation with or without
chemotherapy
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Interventions
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Acute Pain
Disturbed Thought Processes
Disturbed Sensory Perception
Impaired Physical Mobility and 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, nuchal rigidity (stiffness of the back of
the neck), irritability, diminished level of
consciousness, photophobia (sensitivity to light),
hypersensitivity, and seizure activity
◦ Positive Kernig’s sign and Brudzinski’s sign
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Medical diagnosis
◦ Lumbar puncture to obtain CSF for lab analysis
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Figure 27-16A
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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 vital signs and neurologic status frequently
to determine further deterioration or onset of
complications
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Interventions
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Ineffective Tissue Perfusion
Ineffective Breathing Pattern
Acute Pain
Risk for Injury
Deficient Fluid Volume
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Etiology and risk factors
◦ Inflammation of brain tissue caused by virus
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Signs and symptoms
◦ Fever, nuchal rigidity (stiff neck), headache,
confusion, delirium, agitation, and restlessness
commonly seen
◦ 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 viral infection
◦ Patients often report some recent viral infection or
vaccination
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Initial phase
◦ Symmetric 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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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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Medical 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
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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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Interventions
Ineffective Breathing Pattern
Decreased Cardiac Output
Risk for Disuse Syndrome
Imbalanced Nutrition: Less Than Body
Requirements
◦ Anxiety
◦ Deficient Knowledge
◦ Rehabilitation
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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
◦ Depression common; dementia may develop
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Figure 27-17
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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 pramipexole (Mirapex)
or ropinirole (Requip); L-dopa (Ldihydroxyphenylalanine); carbidopa/levodopa
(Sinemet); anticholinergic drugs such as
trihexyphenidyl (Artane) and benztropine (Cogentin)
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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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Interventions
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Impaired Physical Mobility
Risk for Injury
Imbalanced Nutrition: Less Than Body Requirements
Ineffective Coping
Deficient Knowledge
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Etiology
◦ Chronic, progressive degenerative disease
◦ Attacks the protective myelin sheath 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
◦ 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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Figure 27-18
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Medical diagnosis
◦ Based on the physical examination and history of
cyclic remission-exacerbation periods
◦ Magnetic resonance imaging of the brain and
spinal cord may reveal plaques characteristic of
MS
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Medical treatment
◦ Corticosteroids (ACTH, prednisone,
methylprednisolone)
◦ Interferon  1b (Betaseron) and interferon 1a
(Avonex)
◦ Glatiramer acetate (Copaxone)
◦ Immunosuppressants: mitoxantrone (Novantrone)
◦ Amantadine (Symmetrel)
◦ Urinary retention treated with cholinergics, such
as bethanechol (Urecholine) or neostigmine
(Prostigmine)
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Assessment
◦ Onset and progression of symptoms, especially
those that affect mobility, vision, eating, and
elimination
◦ Range of motion and strength, gait abnormalities,
tremors, and muscle spasms
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Interventions
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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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Signs and symptoms
◦ Weakness of voluntary muscles of the upper
extremities, particularly the hands
◦ Difficulty swallowing and speaking
◦ Eventually, respirations shallow; difficulty clearing
airway of pulmonary secretions
◦ Death results from aspiration, respiratory
infection, or respiratory failure
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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
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Interventions
◦ 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
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Medical treatment
◦ Anticholinesterase drugs
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 Neostigmine and pyridostigmine (Mestinon)
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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Interventions
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Ineffective Breathing Pattern
Impaired Physical Mobility and Self-Care Deficit
Impaired Swallowing
Deficient Knowledge
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Cerebrovascular
Accident
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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 right hemisphere controls the left side
of the body, and the left hemisphere controls the
right side of the body
◦ The cortex of each is divided into the parietal,
frontal, temporal, and occipital lobes; each has a
different area of function
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Figure 28-1
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Brainstem
◦ Includes midbrain, pons, medulla, and part of the
reticular activating system
◦ Controls vital, basic functions, including
respiration, heart rate, and consciousness
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Uses information received from the cerebrum,
muscles, joints, and inner ear to coordinate
movement, balance, and posture
Unlike the cerebrum, the right side of the
cerebellum controls the right side of the body,
and the left side of the cerebellum controls the
left side of the body
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
Carotid system
◦ Begins as one common artery; later divides into
the external and internal carotid arteries
 The external carotid arteries divide to 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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
Vertebral 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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Figure 28-2
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
Nonmodifiable factors
◦ Risk factors that cannot be changed
 Age, race, gender, 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, dysphagia, drooping mouth,
weakness, and tingling or numbness on one side
of the body

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), or clopidogrel bisulfate
(Plavix) decrease platelet clumping
◦ Warfarin (Coumadin) and heparin
◦ Carotid endarterectomy and transluminal
angioplasty
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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
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
Hemorrhagic stroke
◦ Blood vessel in brain ruptures; bleeding into the
brain occurs

Ischemic 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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Figure 28-4
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

Different signs and symptoms, depending
on the type, location, and extent of brain
injury
Hemorrhagic stroke
◦ Occurs suddenly; may include severe headache
described as “the worst headache of my life”
◦ Other symptoms: stiff neck, loss of consciousness,
vomiting, and seizures
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
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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Figure 28-5
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
Aphasia
◦ A defect in the use of language; speech, reading, writing,
or word comprehension

Dysarthria
◦ The inability to speak clearly

Dysphagia
◦ 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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Figure 28-8
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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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


Constipation, dehydration, contractures,
urinary tract infections, thrombophlebitis,
decubitus ulcers, and pneumonia
Sensory losses put patient at risk for
traumatic and thermal injuries
Swallowing difficulties place patient at risk
for pulmonary complications, such as
choking and aspiration pneumonia
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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
Many 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




Hypertension
Oxygenation
Hyperthermia
Hyperglycemia
◦ Drug therapy
 Tissue plasminogen activator (rt-PA, alteplase,
Activase)
 Given to dissolve clots in acute ischemic strokes
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
Other medications




Mannitol
Nimodipine (Nimotop)
Phenytoin (Dilantin) and phenobarbital
Acetylsalicylic acid (aspirin), ticlopidine
hydrochloride (Ticlid), Aggrenox, and
clopidogrel (Plavix)
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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

Health history
◦
◦
◦
◦
◦
Chief complaint and history of present illness
Medical history
Family history
Review of systems
Functional assessment
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
Physical examination
◦ Assess patient’s general appearance,
responsiveness, and behavior
◦ Record restlessness or agitation
◦ Measure vital signs; weight and height if possible
◦ Inspect the face for symmetry; mouth for moisture
and drooling
◦ Evaluate the alert patient’s ability to swallow
◦ Inspect pupils for size, equality, and reaction to
light
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
Physical examination
◦ Conduct a gross vision assessment
◦ Inspect skin color and palpate for moisture and turgor
◦ Assess extremities for muscle tone and strength,
sensation, and voluntary movement
◦ Record evidence of incontinence or bladder distention
◦ Frequently repeat neurologic checks: evaluating level of
consciousness, pupil appearance and response to light,
the patient’s ability to follow commands, and the
movement and sensation of extremities
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
Interventions
◦ Ineffective Airway Clearance and Ineffective
Breathing Patterns
◦ Risk for Injury
◦ Deficient Fluid Volume or Excess Fluid Volume
◦ Imbalanced Nutrition
◦ Disturbed Sensory Perception
◦ Ineffective Thermoregulation
◦ Disturbed Thought Processes
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
Interventions
◦
◦
◦
◦
◦
◦
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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
Assessment
◦ Reassess patient’s abilities, expectations,
knowledge, motivation, and resources
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
Interventions
◦
◦
◦
◦
◦
◦
◦
◦
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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Figure 28-6
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Figure 28-7
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Figure 28-9
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



Patients may be discharged to home or go
to specialized rehabilitation centers for
continued therapy
Outpatient therapy is an option for some
patients
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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

During and after the rehabilitation phase,
patients and families need to be made
aware of resources to help them deal with
continuing disabilities
In rehabilitation, the patient is respectfully
challenged to return to the highest level of
function possible
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Spinal Cord Injury
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
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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Figure 29-1
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



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 mobility and
flexibility
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

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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Figure 29-2
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

Extends from the brainstem to L2 in 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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Figure 29-3
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
Gray matter
◦ Consists of the bodies of nerve cells that control
motor and sensory activities

White 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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Figure 29-4
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
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
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
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
◦ Computed tomography (CT)
 Noninvasive examination of the specific levels of the
spinal cord to be visualized, bony vertebrae, and the
spinal nerves
◦ Magnetic resonance imaging (MRI)
 Produces precise, clear images of internal structures
◦ Myelogram
 Visualizes the spinal cord and vertebrae
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
Location
◦ Cervical, thoracic, or lumbar

Open or closed
◦ Closed: trauma in which 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 spinal cord injury occurs when the cord
has been completely severed, whereas an
incomplete injury results from 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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Figure 29-6
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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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

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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
An immediate, transient response to injury
in which reflex activity below the level of the
injury temporarily ceases
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


Exaggerated response of autonomic nervous
system to noxious (painful) stimuli
With injury at or above the level of T6
The sympathetic 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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
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
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
Muscle spasms may be incapacitating for
these patients, hampering efforts at
rehabilitation
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

Impaired motor function can affect the
patient’s mobility and self-care and thus
result 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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

During spinal shock, all bladder and bowel
function ceases
Once spinal shock resolves, reflex activity
returns
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
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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
May lose these regulatory mechanisms and
be unable to adapt to temperature extremes
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

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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

Because immobile patient can’t change
positions, skin in sacral area and across
bony prominences may break down
Loss of tone results in vasodilation and
pooling of blood in the periphery; impedes
perfusion of the skin; and encourages the
development of pressure sores
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
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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



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
Jaw-thrust method of opening the airway is
preferred for these patients
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


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
 Secured just above the ears; doesn’t actually penetrate
skull
 Crutchfield tongs
 Applied directly to the skull just behind the hairline
◦ 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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Figure 29-7
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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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Figure 29-9
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
Drug therapy
◦ Methylprednisolone
 Reduces the damage to the cellular membrane
 Administered within the first 8 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 24 hours is most desirable

Laminectomy

Spinal fusion
◦ Involves removing all or part of the posterior arch
of the vertebra
◦ 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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Figure 29-10
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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
◦ Physician, nurse, physical therapist, occupational
therapist, speech therapist, dietitian, social
worker, psychologist, and counselor
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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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Interventions
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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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