Problems of the Central Nervous System

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Problems of the Central Nervous System
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Spinal Cord Injury

• Definition
• Fracture or displacement of one or more vertebrae
  causing damage to spinal cord and nerve roots
  with resulting neurological deficit and altered
  sensory perception or paralysis or both. There
  will be a total or partial absence of motor
  and/or sensory function below the level of injury

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Spinal Cord Injury (SCI)

• Effects of injury cannot be reversed
• Patient experiences loss of
• Motor function
• Sensation
• Reflex activity
• Bowel/bladder control
• Will cause behavior/emotions problems
• Changes in body image
• Role performance
• Self-concept

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SCI Autonomic Nervous System Syndromes

• Spinal (neurogenic) shock
• Occurs immediately after injury (at risk 1st 24
  hours)
• Result of disruption in pathways between
  upper/lower motor neurons
• Characterized by
• Flaccid paralysis
• Loss of reflex activity below level of lesion
• Bradycardia
• Paralytic ileus (occasionally)
• Hypotension

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SCI Autonomic Nervous System Syndromes

• Autonomic dysreflexia (hyperreflexia)
• Occurs in injuries above the 6th thoracic
  vertebra
• Occurs after period of spinal shock
• Results from uninhibited sympathetic discharges
• Life threatening complication
• Key features
• Severe, rapidly occurring hypertension
• Bradycardia
• Severe throbbing headache
• Nasal stuffiness
• Sweating
• Nausea
• Blurred vision

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Spinal Cord Injury

• Sources of force
• Injury to vertebral column (fracture,
  dislocation, subluxation)
• Penetrating trauma (gunshot or knife wound)
• Damage to cord results from
• Contusion
• Compression
• Concussion

• Mechanism of injury
• Hyperflexion
• Hyperextension
• Axial loading (vertical compression)
• Excessive rotation
• Penetrating injuries
• Extent of injury
• Complete
• Incomplete
• Pure syndrome may not be seen

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SCI Assessments and Clinical Manifestations

• 1st Priority assess respiratory function and
  maintain an adequate airway
• Assess for signs of hemorrhage (intraabdominal
  /or around fx sites)
• Assess LOC using GCS
• Assess motor and sensory function to determine
  level of injury
• Quadriplegia
• Quadriparesis
• Paraplegia
• Paraparesis

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SCI Assessments and Clinical Manifestations

• Sharp/dull test is used to test sensation,
  bilateral responses are compared
• Motor ability is tested and graded on a scale
• Cardiovascular (assess for bradycardia,
  hypotension, hypothermia)
• Dysrhythmias
• Autonomic dysreflexia
• Respiratory (continually assess status and for
  development of life threatening complications

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SCI Assessments and Clinical Manifestations

• Gastrointestinal
• Hemorrhage from trauma or stress ulcer
• distention
• Paralytic ileus
• Genitourinary
• Initially areflexic bladder (leads to urinary
  retention and neurogenic bladder
• Musculosckeletal
• Assess muscle tone and size
• LMN lesion muscle wasting due to flaccid
  paralysis
• UMN lesion muscle spasticity
• Assesses skin condition (esp. over bony
  prominences)
• Heterotopic ossification (bony overgrowth into
  muscle)

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SCI Assessments and Clinical Manifestations

• Psychosocial
• Assess pre-injury psychosocial status
• Usual methods of coping
• Assess support system(s)
• Assess family/significant others coping

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SCI Nursing Diagnoses

• Ineffective (spinal cord) tissue perfusion
• Ineffective airway clearance
• Impaired physical mobility
• Impaired urinary elimination
• Impaired adjustment
• Risk for impaired skin integrity
• Ineffective sexuality pattern
• Acute pain
• Risk for injury

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SCI Collaborative Problems

• Potential for DVT
• Potential of Sepsis
• Potential for Hypoxemia
• Potential for Atelectasis, Pneumonia

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SCI Ineffective Tissue Perfusion (spinal cord)--
Interventions

• Nonsurgical Management
• Assessment of vital signs and neurological status
  (resp. function, motor and sensory) at least
  every 4 hours
• Positioning
• Log roll
• Maintain optimal body alignment
• Immobilize head and spine
• Cervical injury usually fixed skeletal traction
• Thoracic injury bedrest, body cast
• Lumbar/sacral injury brace or corset

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SCI Ineffective Tissue Perfusion (spinal cord)--
Interventions

• Drug Therapy
• Solu-medrol (methylprednisolone) within 8 hours
  of injury is first course of treatment
• Dextran (plasma expander) to increase capillary
  blood flow within spinal cord and to prevent
  hypotension
• Atropine sulfate to treat bradycardia
• Dopamine and isoproterenol for severe hypotension
• Dantrolene (dantrium) and baclofen to control
  muscle spasticity in UMN injuries

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SCI Ineffective Tissue Perfusion (spinal cord)--
Interventions

• Surgical management
• Emergency surgery is needed for spinal cord
  compression from bone fragments, hemotoma or
  penetrating objects
• Decompressive laminectomy
• Additional surgical measures to support and
  stabilize the spine may be preformed

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SCI Health Teaching

• Physical mobility and activity skills
• Activities of daily living skills
• Bowel and bladder retraining program
• Skin care
• Medication regimen
• Sexuality education

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Spinal Cord Tumors

• Most frequently occur in thoracic area
• Signs/symptoms depend upon location and speed of
  growth
• Pathology
• Related to compression of cord or spinal nerve
  roots
• Displacement of the cord
• Disruption of vascular supply
• Obstruction of cerebrospinal fluid
• Spinal cord congestion and infarction

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Spinal Cord Tumors

• Primary tumors arise from epidural vessels,
  spinal meninges, or glial cells
• 20-30 are metastatic
• Intramedullary
• Extramedullary
• Majority of tumors are benign

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Spinal Cord Tumors Clinical Manifestations

• Depends on location and rate of growth
• Pain is the most frequent complaint
• Spinal cord compression
• Infiltration of spinal tracts
• Irritation of spinal roots
• Motor deficits
• Weakness, clumsiness, spasticity
• Hyperactive reflexex, ataxia, hypotonia
• Positive Babinskis sign
• Paralysis flaccid/spastic

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Spinal Cord Tumors Clinical Manifestations

• Sensory loss
• Numbness, tingling, pain
• Temperature loss
• Decreased appreciation of touch
• Inability to sense vibration
• Loss of position sense
• Tight bandlike feeling around trunk
• Brown-Séquard symptoms or central cord syndrome
• Loss of bladder/bowel control
• Sexual dysfunction

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Spinal Cord Tumors Interventions

• Monitor VS and neuro status frequently
• Surgical management
• Laminectomy
• Surgical decompression
• Total or partial resection of tumor
• Spinal fusion
• cordotomy

• Nonsurgical management
• Radiation
• Chemotherapy
• Pain control
• Prevention of complications
• Bowel/bladder program

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Multiple Sclerosis (MS)

• Progressive, degenerative disease affecting
• Myelin sheath
• Conduction pathway of CNS
• Leading cause of neurologic disability in 20-40
  year olds
• Periods of remission and exacerbation

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MS Pathophysiology

• Myelin sheath is damaged ? inflammatory response
• Inflammation reduces the thickness of the myelin
  sheath
• Impulses are not effectively transmitted
• Damaged myelin is removed by astrocytes
• Results in formation of scar tissue and plaques
  that interfere with normal impulse transmission
• White fiber tracts are affected
• Recovery of myelin occurs with remission, though
  with repeated exacerbations, damage becomes
  permanent.
• Six types

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MS Clinical Manifestations

• Motor Assessment
• Fatigue/stiffness of extremities
• Flexor spasms at noc
• Hyperactive, DTRs
• Clonus, Babinski
• Absent abdominal reflexes
• Unsteady gait

• Cerebellar findings
• Intention tremors, dysmetria
• Dysdiadochokinesia, clumsy motor movements
• Loss of balance, poor coordination

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MS Clinical Manifestations

• Crainial Nerves/ brainstem
• Tinnitus, vertigo, hearing loss
• Facial weakness, dysphagia
• Dysarthria, ataxia, slow scanning speech
• Blurred vision,diplopia, decreased visual acuity
• Scotomas, nystagmus

• Sensory
• Hypalgesia, paresthesia
• Facial pain, decreased temperature perception
• Numbness, tingling, burning, crawling sensations
• Bowel/bladder dysfunctions
• Alterations in sexuality

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MS Clinical Manifestations

• Cognitive
• ? short-term memory
• ? concentration
• ? ability to perform calculations
• Inattentiveness
• Impaired judgment

• Psychosocial
• Anxiety
• Apathy, emotional lability
• Depression
• euphoria

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MS Interventions

• Exercise program
• Drug therapy
• Steroid therapy
• Immunosuppressive therapy
• Adjunctive drug therapy
• Alternative drug therapy

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Amyotrophic Lateral Sclerosis

• Progressive and degenerative disease that
  involves the motor system (sensory and autonomic
  nervous system are not involved)
• Characterized by atrophy of hands, forearms and
  legs
• Results in paralysis and death (often within 2-5
  years)
• No known cause, no cure, no specific treatment,
  no standard pattern of progression and no method
  of prevention
• Can occur at any age (usually 40-70)

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ALS Clinical Manifestations

• Early symptoms
• Fatigue while talking
• Tongue atrophy
• Dysphagia
• Weakness of hands and arms
• Fasiculations of the face
• Nasal quality of speech
• dysarthria

• Progressive symptoms
• Muscle weakness and atrophy progressing to
  flaccid quadriplegia
• Involvement of respiratory muscles leading to
  respiratory compromise, pneumonia and death

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ALS Diagnosis and Interventions

• Diagnosis
• Based on clinical and diagnostic findings
• Increased CK
• EMG fibrillations and fasiculation of muscles
• BX small, angulated atrophic fibers
• Motor strength deficits
• Abnormal PFTs
• Dysphagia

• Interventions
• Interdisciplinary approach to maintaining optimal
  functioning
• Riluzole (monitor liver function)
• Nursing interventions directed toward preventing
  complications of immobility and promoting comfort
• Support and counseling