Title: Nursing Management PERIPHERAL NERVE and SPINAL CORD PROBLEMS
1Nursing ManagementPERIPHERAL NERVE andSPINAL
CORD PROBLEMS
2Explain 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
7Explain 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
15Spinal 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
16Identify 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)
20Describe the classification of spinal cord
injuries and associated clinical manifestations
- Mechanism of injury
- Flexion
- Hyperextension
- Flexion-rotation
- Compression
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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
29Describe 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
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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
46Correlate the clinical manifestations of spinal
cord injury with the level of disruption and
rehabilitation potential.
47Describe the nursing management of the major
physical and psychologic problems of a patient
with spinal cord injury.
48Describe 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
49Explain 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