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Nursing Management PERIPHERAL NERVE and SPINAL CORD PROBLEMS

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Title: Nursing Management PERIPHERAL NERVE and SPINAL CORD PROBLEMS


1
Nursing ManagementPERIPHERAL NERVE andSPINAL
CORD PROBLEMS
  • Lewis Chapter 59

2
Explain the etiology, clinical manifestations,
collaborative care, and nursing management of
trigeminal neuralgia and Bells palsy.
  • Trigeminal Neuralgia (tic douloureux)
  • Etiology
  • Compression of the 5th cranial nerve (sensory)

3
  • Clinical manifestations
  • Pain (excruciating)
  • Lips, gums, eye, forehead, cheek
  • Tearing of the eye with blinking (tic)
  • Collaborative care
  • Diagnosis
  • CT, LP, MRI
  • R/O other causes
  • Drug therapy
  • Anti-seizure drugs
  • Conservative therapy
  • Nerve blocks
  • Surgical therapy
  • Focus is to decompress the nerve

4
  • Nursing Management
  • Assessment
  • Diagnosis
  • Pain
  • Altered nutrition
  • Anxiety
  • Altered mucosa membrane
  • Social anxiety
  • Implementation
  • Health Promotion
  • Awareness of triggers and reduction of events
  • Acute intervention
  • Pain relief
  • Lessening triggering stimuli
  • Adequate nutrition, oral care
  • Post op care
  • Ambulatory and home care
  • Chew on unaffected side
  • Avoid hot foods --- protect face from temp
    extremes

5
  • Bells palsy
  • Etiology
  • Unilateral disruption of the motor branches of CN
    VII (facial nerve) that may be caused by the
    reactivation of HSV
  • Clinical manifestations
  • Pain around the ear, fever, tinnitus, hearing
    deficit
  • Inability to close the eyelid, drooping of the
    mouth
  • Inability to smile, frown, whistle
  • Lower lid may turn out with tear overflow
  • Most recover within 6 weeks
  • Collaborative Care
  • Diagnosis
  • None specific
  • Drug therapy
  • Corticosteroids
  • Acyclovir(Zovirax)

6
  • Nursing Management
  • Assessment
  • HSV awareness
  • Nursing diagnosis
  • Pain
  • Altered nutrition
  • Risk for injury (corneal abrasion)
  • Body image disturbance
  • Implementation
  • Analgesics, hot packs
  • Avoid trapping food, Promote oral hygiene
  • Artificial tears, dark glasses, tape/patch
  • Facial sling

7
Explain the etiology, clinical manifestations,
collaborative care and nursing management of
Guillain-Barre syndrome, botulism, tetanus and
neurosyphilis
  • Guillain-Barre Syndrome
  • Etiology
  • Cell-mediated immunologic reaction directed at
    peripheral nerves preceded by a viral infection,
    trauma, surgery, viral immunization, HIV ? loss
    of myelin and ? neurotransmission
  • Clinical manifestations
  • Ascending bilateral weakness/paralysis that
    begins in the lower extremities occurs over hours
    to days to weeks and peaks at about 14 days
  • Autonomic dysfunction may cause respiratory
    problems, hypo/per tension, vagal stimulation
  • Pain
  • Return of function is descending
  • Complications
  • Respiratory failure

8
  • Collaborative Care
  • Diagnosis
  • History and clinical signs
  • CSF has ? protein after 7-10 days
  • Supportive Care
  • Drug therapy
  • Plasmapheresis
  • Immunoglobulin
  • Nutritional therapy
  • Careful feeding practices
  • Paralytic ileus
  • Tube feedings

9
  • Nursing Management
  • Assessment
  • Monitor paralysis
  • Respiratory function (ABGs) Vital capacity
  • Gag reflex
  • Corneal reflex
  • Autonomic dysfunction
  • Diagnosis
  • Inability to sustain spontaneous ventilation
  • Risk for aspiration
  • Pain
  • Impaired verbal communication
  • Fear
  • Self-care deficits
  • Implementation
  • Support body systems till patient recovers
  • Establish communication system
  • Indwelling vs intermittent catherization
  • Eye care

10
  • Botulism
  • Etiology
  • GI absorption of a neurotoxin produced by
    Clostridium botulinum (anerobic)
  • Clinical manifestation
  • Nausea, vomiting and cramps 6-48 hours after
    consumption of contaminated food
  • Neuro symptoms
  • Convergence of eyes, photophobia, ptosis,
    payalysis of extraocular muscles, blurred vision,
    dipolpia, dry mouth muscle weakness, respiratory
    failure and cardiac arrest
  • Symptoms are dose related with recovery to death
    in 4-8 days
  • Collaborative Care
  • Diagnosis
  • Stool contains organisms and toxins
  • EMG has characteristic spikes
  • Drug therapy
  • Antitoxin therapy
  • Enemas to assist in expelling remaining toxins

11
  • Nursing Care
  • Maximal monitoring, esp. respiratory function
  • PT with ROM and assisted ambulation as tolerated
  • Prevent decubiti
  • NG feedings as needed
  • Patient education
  • When preserving food at home cook at 176? F for
    30 min.
  • Toxin can be destroyed by boiling 10 minutes
  • Do not eat or taste anything from bulging cans
  • Avoid honey in 1st year of life
  • Full recovery may take months

12
  • Tetanus
  • Etiology
  • Neurotoxin produced by anerobic bacillus
    Clostridium tetani found in soil, garden mold and
    manure
  • Enters the body through a low O2 wound (puncture)
  • Incubation can range from 7-21 days
  • Clinical manifestations
  • Stiffness in the jaw or neck (trismus)
  • Generalized tonic spasms ---opisthotonos
  • Mortality 100 in severe form
  • Overall 45-50
  • Collaborative care
  • Diagnosis
  • Leukocytosis and positive culture
  • Drug therapy
  • Anticonvulsants
  • Diazepam
  • Pancuronium bromide plus ventilation
  • Tetanus toxoid in previously immunized patient
  • Tetanus immune globulin

13
  • Nursing Care
  • Health maintenance
  • Ensure tetanus prophylaxis every ten years in
    adults and appropriate childhood immunizations
  • Acute care
  • Intensive monitoring
  • Supportive care

14
  • Neurosyphilis (tertiary syphilis)
  • Etiology
  • Treponema pallidum untreated/inadequately treated
  • Lies dormant for years
  • Clinical manifestations
  • Meningitis, encephalitis, tabes dorsalis,
    dementia, Charcots joints
  • Management
  • Penicillin
  • Protection from physical injury

15
Spinal Cord Problems
  • Life expectancy for spinal cord injuries has
    increased from 10 years post injury to 5 years
    less than normal life expectancy
  • 11,000 Americans affected each year
  • 183,000 to 230,000 at any given time

16
Identify the population at risk for spinal cord
injuries
  • Males 15-30 YOA
  • Risk takers
  • Alcohol and drug abusers
  • Motorcycles, football players, sky divers
  • of elderly is increasing as population ages

17
  • Initial (primary) injury
  • Types
  • Cord compression by bone displacement
  • Interruption of blood supply to the cord
  • Traction resulting from pulling on the cord
  • Penetrating trauma
  • Tearing and transection
  • Secondary injury(24-72 hours post injury)
  • Cascade of events leading to
  • Ischemia
  • Hypoxia
  • Microhemorrhage
  • Edema

18
  • Injury
  • The spinal cord is wrapped in tough layers of
    dura and is rarely transected by direct trauma,
    penetrating wounds (gunshot, knife wounds,etc)
    are the exception.
  • Autodestruction---petechial hemorrhages, edema,
    and metabolites act together to produce ischemia
    which progresses to necrotic destruction of the
    cord
  • Edema 2? to inflammatory response ? permanent
    damage within 24 hours above and below the injury
  • Hemorrhagic necrosis completes in 48 hours
  • However continued necrotic necrosis and edema
    continue with complete destruction not evident
    for 72 hours to a week

19
  • Spinal shock
  • Temporary neurologic syndrome that may occur (50
    ) and lasts days to months
  • ? reflexes
  • Loss of sensation
  • Flaccid paralysis below the level of the injury
  • Neurogenic shock
  • Loss of vasomotor tone caused by ? sympathetic
    innervation
  • Hypotension (venous pooling)
  • Bradycardia (unopposed vegal stimulation)
  • Warm, dry extremities (no piloerection)

20
Describe the classification of spinal cord
injuries and associated clinical manifestations
  • Mechanism of injury
  • Flexion
  • Hyperextension
  • Flexion-rotation
  • Compression

21
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24
  • Level of injury
  • Cervical
  • Thoracic
  • Lumbar

25
  • Skeletal
  • Level of injury to bones and ligaments
  • Neurologic level
  • Lowest segment of spinal cord with normal sensory
    and motor function on both sides of the body
  • Tetraplegia (quadraplegia)
  • Paraplegia

26
  • Degree of injury
  • Complete
  • Flaccid paralysis and total loss of sensory and
    motor function below the level of the lesion
  • Incomplete
  • Mixed loss of voluntary motor activity and
    sensation that varies with the level of the
    lesion and those nerve tracts left intact
  • Six syndromes
  • Central cord
  • Anterior cord
  • Brown-Sequard
  • Posterior cord
  • Cauda equina
  • Conus medullaris
  • American Spinal Injury Association
  • Classification system p 1613

27
  • Clinical Manifestations - Related to the level of
    injury
  • (Incomplete lesion may demonstrate varied
    symptoms)
  • Respiratory System
  • Lesion above C4 ? total loss
  • Cardiovascular System
  • Lesion above T5 ? ? in sympathetic influence
  • Bradycardia
  • Vasodilation ? hypotension
  • Urinary System
  • Atonic to hyperexcitable
  • GI system
  • Above T5 ? Hypomobility, Stress ulcers

28
  • Integumentary
  • Denervation ? tissue breakdown
  • Flaccid paralysis ? muscle atrophy
  • Spastic paralysis ? contractures
  • Poikilothermism ? adjustment of body temperature
    to room temperature
  • No sweat below the lesion
  • Metabolic Needs
  • High protein diet helps prevent skin breakdown
    and muscle atrophy
  • Peripheral Vascular
  • DVTs

29
Describe the clinical manifestations,
collaborative care, and nursing management of
spinal cord shock.
  • Clinical manifestations of spinal and neurogenic
    shock
  • Failure of cord function below the lesion
  • Loss of all motor and sensory functions? ?
    reflexes and flaccid paralysis
  • Neurogenic shock
  • Loss of sympathetic innervation
  • Brady cardia ? ? cardiac output
  • Vasodilation ? ? hypotension
  • Loss of temperature control
  • Hypotonic bladder (urinary retention)
  • Indications of recovery ? readiness for rehab
  • Hyperreflexia
  • Spasticity --- hypereflexia
  • Reflex emptying of bladder

30
  • Nursing Management of spinal shock
  • Respiratory dysfunction
  • Mechanical ventilation above C4
  • Below C4
  • Phrenic nerve function ? diaphragmatic breathing
  • Decreased Vital capacity
  • Secretions
  • Effective cough
  • Quad-assist
  • Pulmonary edema
  • Neurogenic
  • Fluid overload

31
  • Cardiovascular
  • Unopposed vagal stimulation
  • Bradycardia
  • ? cardiac output
  • RX anticholinergic drugs (atropine)
  • Vasodilation
  • Hypotension
  • RX vasopressor (dopamine) and fluid replacement
  • Sluggish blood flow
  • DVTs
  • RX Compression stockings, routine assessment,
    passive ROM, anticoagulants

32
  • Fluid and nutritional balance
  • Paralytic ileus
  • NG tube
  • Bowel sound/flatus
  • High-protein/hi calorie diet
  • Hi fowlers with head flexed
  • ? roughage
  • Anorexia
  • Bowel and bladder
  • Urinary retention progresses to incontinence
  • Indwelling vs intermittent catherization
  • Fluid restriction
  • 1800-2000 ml/day
  • UTIs
  • Renal calculi
  • Prostatic hyperplasia
  • Constipation
  • Suppositories/laxatives/same time q other day

33
  • Temperature control
  • No vasoconstriction ? no piloerection or sweat
  • External environment must be maintained
    appropriately
  • Monitor body temperature regularly
  • Stress ulcers
  • Peak incidence 6 14 days
  • Guiac stool and gastric contents
  • H2 receptor blocker if using steroids
  • Sensory deprivation
  • Conversation, music, aromas, flavors
  • Prism glasses

34
  • Collaborative Care
  • Emergency Management (Table 59-4)
  • Diagnostic workup (Table 59-5)
  • Surgical therapy
  • Cord decompression
  • Laminectomy
  • Stabilization of spinal cord
  • Wires, fusion, rods
  • Drug therapy
  • Vasopressors
  • MAP 80-90 mm Hg
  • Methylprednisolone (Solu-Medrol)
  • Loading dose within 3 hours of injury followed by
    IV drip X 24 hours (Must be started within 8
    hours of injury)

35
  • Nursing Care Plan 59-1
  • Nursing Implementation
  • Health Promotion
  • Acute intervention
  • Immobilization
  • Backboards
  • Neutral or extension (prevent lateral rotation of
    cervical spine
  • Log rolling
  • Skull immobilizers (Crutchfield/Gardner-Wells
    tongs)
  • Stryker frames
  • Halo traction (Table 59-12 for care)
  • Thoracic brace

36
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37
  • Respiratory dysfunction
  • Monitor
  • Breath sounds
  • ABGs
  • PaO2 60 mm hg PaCO2
  • Tidal volume and vital capacity
  • Count to 10 out loud without breathing
  • Careful with prone position
  • Skin color
  • Breathing patterns
  • Subjective comments
  • Amount and color of sputum
  • Chest physiotherapy
  • Quad-assist coughing
  • Tracheal suctioning

38
  • Cardiovascular instability
  • Unopposed vagal stimulation
  • Vascular dilatation
  • Vasopressor (dopamine and fluid replacement)
  • Bradycardia
  • Anticholinergic (atropine), pacemaker
  • Sluggish blood flow/immobilization
  • Antiembolic hose
  • Anticoagulants

39
  • Fluid and nutritional maintenance
  • Paralytic ileus
  • NG tube, NPO
  • Progress to hi protein, high calorie diet, hi
    roughage
  • If unable to swallow (hi cervical injuries)
  • TPN to PEG tube
  • Bowel and Bladder
  • Loss of autonomic control ? no sensation of
    fullness, overdistention, reflux, renal failure
  • Indwelling catheter ASAP
  • Bladder retraining
  • Limit fluids (1800-2000 ml/day)
  • Intermittent catherizations
  • Problems
  • Infection
  • Calculi
  • Prostatic hyperplasia
  • Constipation
  • Suppositories/laxatives

40
  • Temperature control
  • Loss of sympathetic nervous system
  • No piloerection
  • No sweating
  • Stress ulcers
  • Peak incidence 6-14 days
  • H2 receptor blockers
  • Proton pump inhibitors
  • Sensory deprivation
  • Conversation, music, aromas
  • Reflexes
  • Return of inappropriate and excessive reflexes
    may complicate rehabilitation (spasticity)
  • Peaks in 2 years and may require cordotomy
    (destruction)
  • Skin Care
  • Table 59-11

41
  • Autonomic dysreflexia Table 59-7
  • Hyperreflexia that occurs in response to visceral
    stimulation once spinal shock is resolved in
    patients with spinal cord lesions at/above T 6
  • Manifestations
  • Hypertension
  • Blurred vision
  • Headache
  • Diaphoresis (above lesion)
  • Management
  • Prevention
  • Early recognition
  • Identify source of stimulation and remove
  • ? HOB, notify physician
  • Alpha adrenergic blockers

42
  • Ambulatory and Home Care
  • Neurogenic bladder Table 59-9
  • Abnormal/absent innervation
  • Atonic or spastic
  • Diagnosis (extensive)
  • RX
  • Drugs, Nutrition, Fluids, Urine drainage
  • Crede and Valsalva meneuvers
  • Intermittent caths (recommended)
  • Initially q 4 --- extend as indicated by
    urine drainage
  • 500 ?

43
  • Bowel Management Table 59-10
  • Hi fiber and adequate fluid intake
  • Stool softeners
  • Suppositories, digital stimulation
  • Routine q other day at same time
  • 30-60 minutes after 1st meal of day
  • Fecal incontinence
  • Too much stool softener
  • Impaction

44
  • Sexuality
  • Generally lack of perineal sensation
  • Reflex sexual capability with upper motor neuron
    lesion
  • Presence of tone in the external rectal sphincter
    indicates an upper motor neuron lesion
  • No tone ? possible psychogenic erection but not
    reflex
  • Table 59-13
  • Females
  • Remain fertile
  • Injury does not effect ability to become pregnant
    and deliver normally
  • Uterine contractions may not be felt

45
  • Grief (table 59-14)
  • Shock and denial
  • Anger
  • Depression
  • Adjustment

46
Correlate the clinical manifestations of spinal
cord injury with the level of disruption and
rehabilitation potential.
  • Table 59-3

47
Describe the nursing management of the major
physical and psychologic problems of a patient
with spinal cord injury.
48
Describe the effects of spinal cord injury on the
older adult population
  • ? number of older people with spinal cord injury
  • Bowel and bladder dysfunction ? with age
  • ? MS repetitive trauma injuries
  • Normal aging problems
  • ? sensation and inability to perceive pain

49
Explain the types, clinical manifestations,
collaborative care, and nursing management of
spinal cord tumors.
  • Spinal Cord Tumors
  • 0.5 to 1 of all neoplasms
  • Classifications
  • Primary or secondary
  • Extramedullary (outside the cord)
  • 90 of all spinal cord tumors
  • Visible on routine x-ray
  • Intramedullary (within the cord)
  • Require MRI or CT scan for detection
  • Clinical manifestations
  • Grow slowly
  • Radicular pain
  • Paresthesias (sensory)
  • Numbness, coldness, tingling
  • Motor
  • Ipsilateral weakness, paralysis, bladder
    dysfunction

50
  • Nursing and collaborative management
  • DX
  • Xray, CT, MRI, myelogram, CSF analysis
  • RX
  • 85 of primary lesions are benign and can be
    resected
  • Cord compression (loss of function)
  • surgery
  • Corticosteroids
  • Metastatic
  • radiation./chemo
  • Pain
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