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1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc.
NURS 1130 Unit 4
Neurologic Disorders
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Anatomy and Physiology of the Nervous System
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Neuron (Nerve Cell)
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
Motor neurons ◦ Carry motor information from the CNS to the
periphery
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Axons and Dendrites
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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Myelin
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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Central Nervous System (CNS) Made up of the brain and spinal cord
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Peripheral Nervous System Comprises all the nerves of the peripheral
parts of the body, including spinal and cranial nerves
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Brain
Divided into the cerebrum, cerebellum, and brainstem
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Cerebrospinal Fluid (CSF)
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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Spinal Cord
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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Autonomic Nervous System 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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Age-Related Changes 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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Pathophysiology of Neurologic Diseases
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Types of Disorders
Developmental and genetic Trauma Infections and inflammation Neoplasms Degenerative processes Vascular disorders Metabolic and endocrine disorders
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Nursing Assessment of Neurologic Function Health history
◦ Note speech, behavior, coordination, alertness, comprehension
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 Past medical history
◦ Head injury, seizures, diabetes mellitus, hypertension, heart disease, and cancer
◦ Record dates and types of immunizations
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Nursing Assessment of Neurologic Function Family history
◦ Have immediate family members had heart disease, stroke, diabetes mellitus, cancer, seizure disorders, muscular dystrophy, or Huntington’s disease?
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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Nursing Assessment of Neurologic Function
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
Physical examination◦ Level of consciousness, pupillary evaluation,
neuromuscular response, and vital signs
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Diagnostic Tests and Procedures
Advanced neurologic examination◦ Cranial nerves◦ Coordination and balance◦ Neuromuscular function◦ Sensory function
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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Diagnostic Tests and Procedures
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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Common Therapeutic Measures
Drug therapy◦ Antimicrobials ◦ Analgesics ◦ Anti-inflammatory ◦ Corticosteroids ◦ Anticonvulsants ◦ Diuretics◦ Chemotherapeutic agents◦ Dopaminergics ◦ Anticholinergics ◦ Cholinergics◦ Antihistamines
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Common Therapeutic Measures
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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Disorders of the Nervous System
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Migraine Headache
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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Cluster Headache
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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Tension Headache
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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Seizure Disorder
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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Seizure Disorder: Classification
Partial seizures◦ Simple
Part of one cerebral hemisphere; consciousness not impaired
◦ Complex Consciousness impaired; may exhibit bizarre
behavior 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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Seizure Disorder
Status epilepticus ◦ Medical emergency: continuous seizures or
repeated seizures in rapid succession for 30 minutes or more
Aura ◦ Dizziness, numbness, visual or hearing
disturbance, noting an offensive odor, or pain may precede a seizure
Medical treatment◦ Resolution of the underlying condition◦ Anticonvulsant drug therapy
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Seizure Disorder
Surgical treatment◦ Removal of seizure foci in the temporal lobe and
pallidotomy or vagal nerve stimulator
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Seizure Disorder: Nursing Care
Assessment◦ Describe the seizure episode, including the
postictal period (following the seizure), and document drug therapy
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Seizure Disorder: Nursing Care 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
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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Head Injury: Types
Scalp injuries◦ Lacerations, contusions, abrasions, and
hematomas Concussion
◦ Trauma with no visible injury to the skull or brain Contusion
◦ Bruising and bleeding in the brain tissue Hematoma
◦ Subdural hematoma or epidural hematoma Intracerebral hemorrhage
◦ From lesions within the tissue of the brain itself Penetrating injuries
◦ Sharp objects penetrate the skull and brain tissue
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Head Injury
Surgical treatment◦ Directed at evacuating hematomas and
débriding damaged tissue
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Head Injury: Nursing Care
Interventions◦ 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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Brain Tumors
Etiology and risk factors◦ Some congenital; others may be related to heredity◦ Drug/environmental factors may play a role in
development Signs and symptoms
◦ 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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Brain Tumors: Nursing Care Interventions
◦ Acute Pain◦ Disturbed Thought Processes◦ Disturbed Sensory Perception◦ Impaired Physical Mobility and Self-Care Deficit◦ Ineffective Coping
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Meningitis
Etiology and risk factors◦ Inflammation of the meningeal coverings of the
brain and spinal cord caused by either viruses or bacteria
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 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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Meningitis
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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Meningitis: Nursing Care
Assessment◦ Assess vital signs and neurologic status
frequently to determine further deterioration or onset of complications
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Meningitis: Nursing Care
Interventions◦ Ineffective Tissue Perfusion◦ Ineffective Breathing Pattern◦ Acute Pain ◦ Risk for Injury◦ Deficient Fluid Volume
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Encephalitis Etiology and risk factors
◦ Inflammation of brain tissue caused by virus 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
Medical treatment◦ Enhance patient comfort and increase strength ◦ Because seizure activity is a potential problem,
take appropriate safety precautions
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Encephalitis: Nursing Care
The nursing plan of care parallels that of the patient with meningitis
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Guillain-Barré Syndrome
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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Guillain-Barré Syndrome
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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Guillain-Barré Syndrome
Plateau phase◦ Remains essentially unchanged◦ No further neurologic deterioration, but no
improvement either Recovery phase
◦ Remyelinization; muscle strength returns in a proximal-to-distal pattern (head to toes)
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Guillain-Barré Syndrome
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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Guillain-Barré Syndrome
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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Guillain-Barré Syndrome: Nursing Care
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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Guillain-Barré Syndrome: Nursing Care 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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Parkinson’s Syndrome
Etiology and risk factors◦ Progressive degenerative disorder of the basal
ganglia: an eventual loss of coordination and control over involuntary motor movement
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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Parkinson’s Syndrome
Medical diagnosis◦ From health history and physical examination◦ MRI to rule out other causes of the symptoms
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 (L-dihydroxyphenylalanine); carbidopa/levodopa (Sinemet); anticholinergic drugs such as trihexyphenidyl (Artane) and benztropine (Cogentin)
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Parkinson’s Syndrome: Nursing Care 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
Interventions◦ Impaired Physical Mobility ◦ Risk for Injury◦ Imbalanced Nutrition: Less Than Body Requirements◦ Ineffective Coping ◦ Deficient Knowledge
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Multiple Sclerosis
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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Multiple Sclerosis
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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Multiple Sclerosis
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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Multiple Sclerosis
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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Multiple Sclerosis: Nursing Care
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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Multiple Sclerosis: Nursing Care
Interventions◦ Impaired Physical Mobility◦ Disturbed Sensory Perception◦ Self-Care Deficit◦ Functional Urinary Incontinence◦ Risk for Infection◦ Ineffective Coping ◦ Deficient Knowledge
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Amyotrophic Lateral Sclerosis (ALS) Etiology
◦ Also known as Lou Gehrig’s disease; a degenerative neurologic disease
◦ Virus suspected, but exact cause unknown Pathophysiology
◦ Degeneration of the anterior horn cells and the corticospinal tracts, so patient exhibits upper and lower motor neuron symptoms
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ALS
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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ALS
Medical diagnosis◦ History and physical examination findings ◦ Electromyography
Medical treatment◦ Because no known cure or treatment, therapy is
supportive; focuses on preventing complications and maintaining maximum function
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ALS: Nursing Care
Assessment◦ Dyspnea, dysphagia, muscle cramps, weakness,
twitching, joint stiffness, muscle atrophy, abnormal reflexes and gait, and paralysis
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ALS: Nursing Care
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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Huntington’s Disease
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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Myasthenia Gravis
Etiology◦ May have an autoimmune basis
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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Myasthenia Gravis
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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Myasthenia Gravis
Medical diagnosis◦ Administering edrophonium (Tensilon)
Muscle tone is markedly improved within 1 minute of injection; persists for 4 to 5 minutes
Medical treatment◦ Anticholinesterase drugs
Neostigmine and pyridostigmine (Mestinon) ◦ Corticosteroids◦ Cytotoxic therapies◦ Thymectomy◦ Plasmapheresis
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Myasthenia Gravis: Nursing Care
Assessment◦ Health history describes the onset of symptoms:
muscle weakness, diplopia, dysphagia, slurred speech, breathing difficulties, and loss of balance
Interventions◦ Ineffective Breathing Pattern◦ Impaired Physical Mobility and Self-Care Deficit◦ Impaired Swallowing◦ Deficient Knowledge
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NURS 1130 Unit 4
Cerebrovascular Accident
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Cerebrum
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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Cerebrum
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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Cerebellum
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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Circulation
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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Circulation
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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Cerebrovascular Accidents
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Risk Factors for Stroke
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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Transient Ischemic Attack
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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Transient Ischemic Attack
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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Transient Ischemic Attack
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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Stroke
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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Stroke: Pathophysiology
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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Stroke: Signs and Symptoms 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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Stroke: Signs and Symptoms 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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Stroke: Signs and Symptoms 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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Stroke: Signs and Symptoms 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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Medical Diagnosis
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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Complications
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
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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Medical Treatment in the Acute Phase 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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Medical Treatment in the Acute Phase
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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Medical Treatment in the Acute Phase
Other medications Mannitol Nimodipine (Nimotop) Phenytoin (Dilantin) and phenobarbital Acetylsalicylic acid (aspirin), ticlopidine
hydrochloride (Ticlid), Aggrenox, and clopidogrel (Plavix)
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Medical Treatment in the Acute Phase
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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Medical Treatment in the Acute Phase
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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Medical Treatment in the Acute Phase
Urine elimination ◦ Indwelling catheter to manage urinary
incontinence ◦ Intermittent catheterization: controlling
incontinence caused by a flaccid bladder
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Nursing Care in the Acute Phase
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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Nursing Care in the Acute Phase
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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Nursing Care in the Acute Phase
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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Nursing Care in the Acute Phase
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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Nursing Care in the Acute Phase
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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Nursing Care in the Rehabilitation Phase Assessment
◦ Reassess patient’s abilities, expectations, knowledge, motivation, and resources
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Nursing Care in the Rehabilitation Phase 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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Discharge
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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Discharge
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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NURS 1130 Unit 4
Spinal Cord Injury
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Anatomy and Physiology of the Spinal Cord
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Vertebral Column
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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Vertebral Column
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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Disks
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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Spinal Cord
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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Spinal Cord
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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Spinal Cord
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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Spinal Cord
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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Diagnostic Tests and Procedures
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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Diagnostic Tests and Procedures
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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Pathophysiology of Spinal Cord Injury
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Types of Injuries
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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Effects of Spinal Cord Injury 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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Effects of Spinal Cord Injury 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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Respiratory Impairment
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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Spinal Shock
An immediate, transient response to injury in which reflex activity below the level of the injury temporarily ceases
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Autonomic Dysreflexia
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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Autonomic Dysreflexia
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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Spasticity
Muscle spasms may be incapacitating for these patients, hampering efforts at rehabilitation
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Impaired Sensory and Motor Function
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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Impaired Bladder Function
During spinal shock, all bladder and bowel function ceases
Once spinal shock resolves, reflex activity returns
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Impaired Bowel Function
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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Impaired Temperature Regulations May lose these regulatory mechanisms
and be unable to adapt to temperature extremes
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Impaired Sexual Function
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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Impaired Skin Integrity
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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Altered Self-Concept and Body Image
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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Medical Treatment in the Acute Phase
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Saving the Patient’s Life:Establish Airway 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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Saving the Patient’s Life: Establish Airway
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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Preventing Further Cord Injury 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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Preventing Further Cord Injury 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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Preventing Further Cord Injury 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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Preserving Cord Function
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 ◦ Involves removing all or part of the posterior
arch of the vertebra Spinal fusion
◦ If multiple vertebrae are involved◦ Placing a piece of donor bone into area between
the involved vertebrae
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Assessment
Monitor the patient’s level of consciousness, vital signs, respiratory status, motor and sensory function, and intake and output
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Health History
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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Past Medical History
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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Family History
Routine family history taken but not considered specifically relevant to a diagnosis of spinal cord injury resulting from trauma
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Review of Systems
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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Functional Assessment
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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Physical Examination
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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Physical Examination
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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Interventions
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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Interventions
Risk for Infection Ineffective Thermoregulation Feeding/Dressing/Grooming Self-Care
Deficit Sexual Dysfunction Ineffective Coping Ineffective Therapeutic Regimen
Management
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Rehabilitation
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
Patient and family must be emotionally and physically prepared to make adjustments
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Rehabilitation
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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Nursing Care of the Laminectomy Patient
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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Nursing Care of the Laminectomy Patient
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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Nursing Care of the Laminectomy Patient
Interventions◦ Risk for Injury ◦ Ineffective Tissue Perfusion ◦ Acute Pain ◦ Impaired Urinary Elimination ◦ Constipation ◦ Impaired Physical Mobility ◦ Deficient Knowledge