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Nursing Care of Patients with CNS Disorders


Spinal Disorders & Spinal Cord Injuries * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Infection Individuals with cervical injuries are ... – PowerPoint PPT presentation

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Title: Nursing Care of Patients with CNS Disorders

Nursing Care of Patients with CNS Disorders
  • Spinal Disorders Spinal Cord Injuries

Nursing Care of Patients with CNS Disorders
  • Spinal Disorders Spinal Cord Injuries
  • Objectives
  • At the completion of this unit, the student will
    be able to
  • Discuss the pathophysiologies, signs symptoms,
    and diagnostic tests associated with spinal cord
    disorders and injuries
  • Explain the therapeutic interventions and nursing
    care associated with the care of clients with
    spinal cord disorders and injuries.

Spinal DisordersHerniated Disks
  • Common occurrence
  • Characterized by paresthesias pain
  • Key Terms
  • Inververtebral disk a fibrous elastic band
    found between two vertebrae band
  • Vertebra one of the 33 bones giving structure to
    the spinal cord.
  • Nucleous pulposus the soft inner or middle
    portion of a disk (p. 1156, figure 48.9)

Spinal DisordersHerniated Disks Pathophysiology
  • A disk between two vertebrae moves out of its
    correct position
  • When the outer tough portion of the disk is torn,
    the nucleus pulposus escapes
  • Displacement of the disk or nucleus pulposus
    compresses nerve roots
  • Causes
  • MVA
  • Lifting heavy Objects
  • Fall
  • Degenerative conditions

Spinal DisordersHerniated Disks Pathophysiology
Spinal DisordersHerniated Disks Signs Symptoms
  • SS are usually unilateral
  • Decreased ROM
  • Numbness tingling
  • Pain muscle spasm
  • Weakness
  • SS vary with location
  • Cervical
  • Thoracic
  • Lumbar

Spinal DisordersHerniated Disks Signs Symptoms
  • Herniated Lumbar Disk
  • Most common
  • Pain radiating down leg
  • Muscle spasms of leg
  • May affect gait
  • Deep Tendon reflexes
  • Incontinence

Spinal DisordersHerniated Disks Diagnosis
  • MRI is utilized to detect herniation of a disk
    and compression. Contrast is used when greater
    detail is needed.

Spinal DisordersHerniated Disks Treatment
  • Rest followed by slow and progressive activity
  • Physical Therapy
  • Increase muscle strength
  • Body mechanics instruction
  • Massage , ultrasound, heat/cool packs
  • Transcutaneous electrical nerve stimulator

Spinal DisordersHerniated Disks Treatment
  • Cervical Traction
  • Gently separates the vertebrae and allows the
    disk to return to its normal position
  • A series of ropes and pulleys are used
  • Devices available for laying, sitting, or
    standing traction

Spinal DisordersHerniated Disks Treatment
  • Medications
  • Muscle relaxants
  • Diazepam
  • NSAIDs
  • PO steroids
  • Epidural injections
  • Narcotics

Spinal DisordersHerniated Disks Treatment
  • Surgical Management
  • Diskectomy removal of an entire disk
  • Spinal fusion fuses to vertebrae together to
    stabile them. Donor bone usually taken from
    iliac crest
  • Laminectomy the removal of the bony arches of a
    vertebrae to relieve compression on a nerve or
    nerve root
  • Rods and screws may be utilized to stabilize the

Spinal DisordersHerniated Disks Treatment
  • Surgical Management
  • Cervical diskectomy may be performed via an
    anterior or posterior approach
  • Percutaneous diskectomy insertion of a large
    needle into the affected disk to aspirate the
    herniated material
  • Laser disk surgery disintegrate herniated

Spinal DisordersHerniated Disks Treatment
  • Surgical Management

Spinal DisordersHerniated Disks
  • Postoperative complications
  • Nerve root damage
  • Causes
  • SS
  • Reherniation
  • Risk of infection
  • Bleeding/hemorrhage

Spinal DisordersHerniated Disks
  • Postoperative Nursing Care
  • gt Assess for CMS changes
  • Assess sensation
  • Pain management
  • Assess for CSF leak or bleeding from surgical
  • Assess donor site
  • IO, voiding pattern
  • Activity encouragement/limitations

Spinal DisordersHerniated Disks Nursing
  • Pain related to surgical procedure
  • Risk for impaired urinary elimination related to
    effects of surgery
  • Risk for impaired physical mobility related to
    neuromuscular impairment

Spinal DisordersSpinal Stenosis
  • Etiology Pathophysiology
  • Usual Cause arthritis
  • Facet joints become inflamed enlarged ?
    narrowed diameter of spinal canal
  • Spinal canal compresses the spinal cord

Spinal DisordersSpinal Stenosis
  • Signs Symptoms
  • Vary depending on location
  • Back pain
  • Sciatica
  • Leg pain
  • Referred pain in arms
  • Heavy feeling in legs
  • Deterioration of motor skills
  • Treatment
  • Laminectomy

Spinal Cord InjuriesIntroduction
  • Characterized by decrease or loss of sensory and
    motor functions below the level of injury
  • Causes
  • MVAs
  • Falls sports related injuries
  • Assaults
  • Classified by location degree of injury
  • Complete VS. Incomplete spinal cord injury
  • Most injuries occur in the cervical and lumbar

Spinal Cord InjuriesPathophysiology
  • Damage to the spinal cord results in
    communication interferences between nerve fibers.
  • Communication between the brain and body is

Spinal Cord InjuriesSigns Symptoms
  • Depend on the level of cord damage (p. 1083
    figure 48.11)
  • Function is lost below the level of injury
  • Cervical injuries affect all four extremities and
    bowel bladder function
  • Quadriplegia
  • Quadriparesis
  • High cervical injuries (C1-C3) are usually fatal
  • C1-C5 injuries affect breathing and will require
    ventilatory support

Spinal Cord InjuriesSigns Symptoms
  • P. 1083, figure 48.11 Review
  • Thoracic and lumbar injuries affect lower
    extremities, bladder bowel.
  • Paraplegia
  • Paraparesis
  • Lower thoracic injuries (T7-T12) will have good
    function in wheel chair
  • Lumbar injured may walk with crutches or braces
  • Individuals with thoracic or lower injuries
    usually learn to perform ADLs independently

Spinal Cord InjuriesSigns Symptoms
Spinal Cord InjuriesSigns Symptoms
  • Flaccid paralysis and paresthesias
  • (Depending on level of spinal lesion)
  • Loss of reflex activity below the level of injury
  • Spinal shock initially
  • (up to the first four weeks following injury)
  • Risk for autonomic dysreflexia
  • (for injuries above the sixth thoracic

Spinal Cord InjuriesSpinal Shock
  • Immediately following a spinal cord injury,
    autonomic function ceases ? vasodilation,
    hypotension, bradycardia, hypothermia.
  • All reflexes below the level of injury are lost
  • Urinary and bowel retention occur
  • May last from one to four weeks.

Spinal Cord InjuriesEmergency Treatment
  • Respiratory/airway management
  • Spine immobilization/stabilization
  • Vasoactive drugs (Treatment of spinal
  • IV Steroids
  • Indwelling catheter
  • Identify fracture locations
  • Radiographs
  • CT Scan
  • MRI

Spinal Cord InjuriesEmergency Treatment
  • Cervical Spine Immobilization/Stabilization
  • (See P.1163 figure 48.13)
  • Crutchfield Gardner-Wells Tongs
  • Tongs

Spinal Cord InjuriesEmergency Treatment
  • Spine Immobilization/Stabilization
  • Halo Brace
  • Usually utilized post-operatively while fusion

Spinal Cord InjuriesSurgical Management
  • Surgical Goals Stabilization of the bones of
    the spine and relief of pressure on the spinal
  • Stabilization of spine ? earlier mobilization
  • Patients who were in cervical traction prior to
    surgery may be placed in a halo brace following
    surgery ? mobilization
  • Rods and other hardware devices mat be utilized
    to stabilize thoracic and lumbar spine fractures
  • Supportive corsets or rigid back braces are
    utilized to stabilize thoracic and lumbar FXs

Spinal Cord InjuriesSurgical Management
  • Corsets Braces Utilized to Stabilize Thoracic
    and Lumbar Spine Fractures

Spinal Cord InjuriesComplications
  • Orthostatic Hypotension
  • Loss of muscle pumps
  • Impaired vasoconstriction
  • Interventions
  • Elastic hose
  • Avoid sudden position changes and movements
  • Gradual elevation of the upper body
  • Use of recliner chairs

Spinal Cord InjuriesComplications
  • Skin Breakdown
  • Interventions
  • Frequent position changes
  • Use of alternating pressure mattresses and
  • Nutrition
  • Hydration

Spinal Cord InjuriesComplications
  • Infection
  • Individuals with cervical injuries are at
    greatest risk
  • Impaired respiratory effort
  • Impaired cough
  • Mechanical ventilation
  • Catheterization

Spinal Cord InjuriesComplications
  • Genitourinary complications
  • Urinary retention ? high incidence for UTIs
  • Urinary reflux ? renal damage
  • Ascending UTIs ? renal damage

Spinal Cord InjuriesComplications
  • Gastrointestinal Complications
  • Absent or decreased peristalsis is common
  • Constipation/impaction
  • Nutritional Concerns
  • Metabolic demands increase with work of breathing
    and during initial phase of injury
  • Metabolic demands decrease when condition is
  • Paralysis ? decreased metabolic demand

Spinal Cord InjuriesComplications
  • Deep Vein Thrombosis (DVT)
  • Paralysis and loss of muscle pumps ? blood
  • Interventions
  • Sequential compression devices
  • ROMs
  • Elevation of extremities
  • Subcutaneous heparin

Spinal Cord InjuriesComplications
  • Autonomic Dysreflexia
  • Life threatening
  • Injuries above the T6 level impairs equilibrium
    between the sympathetic and parasympathetic
    nervous systems.
  • Parasympathetic responses cannot descend past the
    level of injury
  • SS cool pale skin, marked HTN
    (vaso-constriction), goose flesh

Spinal Cord InjuriesComplications
  • Autonomic Dysreflexia (continued)
  • Parasympathetic response above the level of
    injury ? vasodilation, bradycardia, flushing,
  • Patient complains of headache nasal congestion
  • Cause noxious stimuli
  • Most common causes bladder distention, bowel
    impaction, UTI, ingrown toe nail, pressure
    ulcers, pain, labor

Spinal Cord InjuriesComplications
  • Depression Substance Abuse
  • Support groups
  • Self-medicating
  • Family stress

Spinal Cord InjuriesNursing Process
  • I. Impaired gas exchange related to lack of
    innervation to respiratory muscles
  • Frequent respiratory assessments
  • Interventions based on severity of situation
  • Phrenic nerve damage
  • Accessory muscle innervation
  • Diaphragm innervation

Spinal Cord InjuriesNursing Process
  • II. Ineffective airway clearance related to
    ineffective cough
  • Frequent respiratory assessments
  • Suction PRN
  • Liquefy/thin secretions
  • Cough, deep breathing, incentive spirometer

Spinal Cord InjuriesNursing Process
  • III. Risk for autonomic dysreflexia related to
    stimuli below the level of injury
  • Assess for SS of autonomic dysreflexia
  • If autonomic dysreflexia is suspected
  • Place in high-Fowlers position
  • Remove elastic hose compression devices
  • Assess for cause
  • Catheter patency (bladder distention)
  • Constipation
  • (never use high-volume enemas)

Spinal Cord InjuriesNursing Process
  • IV. Total urinary incontinence R/T spinal cord
    damage and no sensation to void and/or inability
    to control flow of urine
  • Assess urine characteristics
  • Utilize bladder scanner to assess bladder
  • Bladder training programs
  • Catheterization

Spinal Cord InjuriesNursing Process
  • V. Constipation R/T immobility and compromised GI
    track innervation
  • GI assessment and monitor BM frequency
  • Bowel management program
  • High fiber diet and adequate fluid intake

Spinal Cord InjuriesNursing Process
  • VI. Impaired physical mobility related to spinal
    cord injury, paresis, or paralysis
  • Interventions depend on patients ability to move,
    feel pressure, and feel pain
  • Frequent position changes
  • ROMs, physical therapy program
  • Support devices braces, splints, wheel chairs

Spinal Cord InjuriesNursing Process
  • VII. Self care deficit related to spinal cord
    injury or paralysis
  • Interventions as based upon the patients level of
    function and extent of injury
  • Assist with care as needed
  • Physical therapy and occupational programs
  • Assistive devices

Spinal Cord InjuriesReview / Closure
  • List the signs and symptoms of spinal shock
  • List the signs and symptoms of autonomic
  • When you have a patient with cervical traction,
    list important routine maintance considerations.
  • Following a spinal surgery procedure, what
    teaching will you provide to a patient in regard
    to mobility?
  • Discuss nutritional considerations as they apply
    to patients with quadraplegia or paraplegia

Spinal Cord InjuriesReview / Closure
  • What is the most common conservative treatment
    for a cervical disk herniation?
  • You find that a patient is experiencing autonomic
    dysreflexia explain the interventions that you
    will implement immediately.
  • Name common causes of disk herniation
  • List the signs symptoms of spinal stenosis
  • What is the usual cause of spinal stenosis?

Spinal Cord InjuriesReview / Closure
  • Work book exercises(pages 231-234)
  • Vocabulary
  • Drugs used for CNS disorders
  • Spinal Disorders
  • Review Questions (omit questions 7 10)
  • Text Book Review questions on pages 1187-1188