Care of Patients with Problems of the Central Nervous System: The Spinal Cord

Chapter 45

Mrs. Marion Kreisel MSN, RNNU230 Adult Health 2

Spinal Cord

Lumbosacral Back Pain (Low Back Pain)• Herniated nucleus pulposus

Health Promotion and Maintenance

• Good posture• Proper lifting• Exercise• Ergonomics • Mental Health Counseling for pain

and/or depression

Patient-Centered Collaborative Care

• Assessment• Diagnostic assessment

Nonsurgical Management

• Positioning• Drug therapy• Heat therapy• Physical therapy• Weight control• Complementary and alternative

therapies

Surgical Management

• Minimally invasive surgery:• Percutaneous lumbar diskectomy• Thermodiskectomy• Laser-assisted laparoscopic lumbar

diskectomy• Conventional open surgical procedures:

• Diskectomy• Laminectomy• Spinal fusion

Postoperative Care

• Prevention and assessment of complications• Neurologic assessment; vital signs• Patient’s ability to void• Pain control• Wound care• CSF check• Patient positioning and mobility

Community-Based Care

• Home care management• Health teaching• Health care resources

• KNOW CHART 45-6 on page 990

Cervical Neck Pain

• Conservative treatment is the same as described for back pain except that the exercises focus on shoulder and neck.

• If these treatments do not work, soft collar may be used at night for a period of no longer than 10 days.

• If conservative treatment is ineffective, surgery such as an anterior cervical diskectomy and fusion is commonly performed.

Spinal Cord Injuries

• Hyperflexion injury• Hyperextension injury• Axial loading injury or vertical compression such

as those that occur in jumping• Excessive rotation of the head beyond its range• Penetration injury, such as those wounds caused

by a bullet or a knife

Spinal Cord Injuries (Cont’d)

Spinal Cord Injuries (Cont’d)

Common Spinal Cord Syndromes

• Complete lesion • Anterior cord syndrome• Posterior cord lesion• Brown-Séquard syndrome: results from

penetrating injuries that cause hemisection of the spinal cord

• Central cord syndrome: motor loss more sever in upper section than lower section

Common Spinal Cord Syndromes (Cont’d)

Anterior Cord Syndrome

• Damage to the anterior portion of both gray and white matter of the spinal cord

• Usually a result of decreased blood supply• Motor function and pain and temperature lost

below the level of the injury• Sensations of touch, position, and vibration

remain intact

Posterior Cord Lesion

• Damage to the posterior gray and white matter of the spinal cord

• Motor function remains intact• Patient experiences loss of vibratory sense,

touch, and position sensation

Brown-Séquard Syndrome

• Results from penetrating injuries that cause hemisection of the spinal cord, or injuries that affect half of the spinal cord.

• Motor function, proprioception, vibration, deep touch sensations are lost on the same side (ipsilateral) of the body as the lesion.

• Opposite side (contralateral) of the body sensations of pain, temperature, light touch are affected.

Central Cord Syndrome

• Lesions of the central portion of the spinal cord.• Loss of motor function is more pronounced in the

upper extremities than in the lower extremities.• Varying degrees and patterns of sensation remain

intact.

SCI: Etiology

• Trauma is the leading cause• Incidence/prevalence

Patient with SCI: Initial Assessment

• First priority is assessment of the patient’s airway, breathing pattern, and circulation status

• Assessment for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around fracture sites

• Assessment of level of consciousness using Glasgow Coma Scale

Initial Assessment (Cont’d)

• Establishment of level of injury: tetraplegia/ quadriplegia: Paralysis

• Quadriparesis: weakness in all four extremities as seen in cervical cord and upper thoracic injuries.

• Paraplegia: paralysis and Paraparesis weakness lower extremities as seen in lower thoracic and lumboscaral injuries/lesions

Spinal Shock/Spinal Shock Syndrome

• This condition occurs immediately as a concussion response to the injury. The patient has:• Flaccid paralysis• Loss of reflex activity below the level of the

lesion• Usually resolves within 24 hours • Muscle spasticity begins in patients with cervical

or high thoracic injuries

Assessment of Sensory and Motor Ability

• Hypoesthesia (decreased sensation)• Hyperesthesia (increased sensation)

Cardiovascular and Respiratory Assessment

• Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous system especially if the injury is above the 6th thoracic vertebra.

• Cardiac dysrhythmias may result.• Systolic BP below 90 requires treatment because

lack of perfusion to the spinal cord could worsen the patient’s condition.

• Hypothermia.

Cardiovascular and Respiratory Assessment (Cont’d)

• Patients with cervical SCI are at risk for respiratory problems resulting from immobility or from an interruption of spinal innervations to the respiratory muscles.

• Continued respiratory assessment including vital capacity and minute volume.

Gastrointestinal and Genitourinary Assessment

• Assess abdomen for indications of hemorrhage, distention, or paralytic ileus.

• Assess for reflex or hypotonic bowel.• Assess for areflexic bladder, which later leads to

urinary retention.• Assess for neurogenic bladder.

Other Assessments

• Lower motor neuron assessment• Upper motor neuron assessment• Skin assessment• Heterotrophic ossification assessment (boney

growth into muscle)• Psychosocial assessment• Laboratory assessment• Imaging assessment

Nonsurgical Management

• Constant assessment• Assess for neurogenic shock. Neurogenic shock

is spinal shock with:• Bradycardia• Decreased or absent bowel sounds• Warm, dry skin• Hypothermia• Hypotension

Immobilization for Cervical Injuries

• Fixed skeletal traction to realign the vertebrae, facilitate bone healing, and prevent further injury

• Halo fixation and cervical tongs• Stryker frame, rotational bed, kinetic treatment

table• Pin site care and monitoring of traction ropes

Immobilization of Thoracic and Lumbosacral Injuries

• For patients with thoracic injuries—bedrest and possible immobilization with a fiberglass or plastic body cast

• For patients with lumbar and sacral injuries—immobilization of the spine with a brace or corset worn when the patient is out of bed; custom-fit thoracic lumbar sacral orthoses preferred

Drug Therapy

• Methylprednisolone 9Solu-Medrol) steroid decreases inflamation

• Dextran: A plasma expandar increase capilaary refill & blood flow back to the spinal column

• Atropine sulfate: prevent & treat hypotension r/t hypotension

• Dopamine hydrochloride: severe hypotension• Tizanidine: Central acting muscle relaxants

(Zanaflex, Sirdalud)• Intrathecal baclofen: pump goes into the CSP

Surgical Management

• Emergency surgery necessary for spinal cord decompression

• Decompressive laminectomy• Spinal fusion• Harrington rods to stabilize thoracic spinal injuries

Ineffective Airway Clearance and Breathing Pattern

• Interventions for the patient with spinal cord injury:• Airway management is the priority.• Patients with injuries at or above the 6th

thoracic vertebra are especially at risk for respiratory complications.

• Provide measures to maintain airway.

Ineffective Airway Clearance and Breathing Pattern (Cont’d)

• Assisted coughing, quad cough, cough assist• Use of incentive Spiro meter

Impaired Physical Mobility; Self-Care Deficit

• Interventions include:• In patients with spinal cord injury, monitor for

risk of pressure ulcers, contractures, and deep vein thrombosis or pulmonary emboli.

• Proper positioning, skin inspection, ROM exercises, heparin, and graduated compression stockings.

Impaired Physical Mobility; Self-Care Deficit (Cont’d)

• Prevent orthostatic hypotension.• Promote self-care.

Impaired Urinary Elimination;

Constipation

• Interventions include:• A bladder retraining program• Spastic bladder—manipulating external area• Flaccid bladder—Valsalva maneuver• Encouraging consumption of 2000 to 2500 mL

of fluid daily to prevent urinary tract infection

Impaired Urinary Elimination; Constipation (Cont’d)

• Long-term renal complication• Signs and symptoms of urinary tract infection not

perceived by the patient

Autonomic Dysreflexia

• Commonly seen in patients with upper spinal cord injury above T6. Hyper active sympathetic Nervouse system response

• Severe hypertension• Bradycardia• Severe headache• Nasal stuffiness• Flushing• Treatment • A MEDICAL EMERGENCY CAN LEAD TO A

CVA!

Establishing a Bowel Retraining Program

• Consistent time for bowel elimination• High fluid intake • High-fiber diet• Rectal stimulation (with or without suppositories)• Stool softener medications, as needed

Impaired Adjustment

• Interventions include:• Invite patients to ask questions about

significant life changes; reply openly and honestly.

• Encourage patients to discuss their perceptions of their situation and coping strategies that can be used.

• Begin a patient education program to clarify misconceptions.

Community-Based Care

• Home care management• Health teaching• Health care resources

Spinal Cord Tumors

• Primary spinal cord tumors• Intramedullary tumors: Gray matter• Extramedullary tumors: Spinal dura and more

common

Patient-Centered Collaborative Management

• Assessment• Diagnostic assessment• Surgical management—need for emergency

surgery• Nonsurgical management—radiation,

chemotherapy

Community-Based Care

• Home care management• Health teaching• Health care resources

Multiple Sclerosis

• Chronic autoimmune disease affecting the myelin sheath and conduction pathway of the CNS

• Characterized by periods of remission and exacerbation

• Inflammatory response resulting in random or patchy areas of plaque in the white matter of the CNS

Multiple Sclerosis (Cont’d)

• Etiology• Genetic risk• Incidence• Prevalence

Major Types of Multiple Sclerosis

• Relapsing-remitting• Primary progressive• Secondary progressive• Progressive-relapsing

Patient-Centered Collaborative Care

• Patient history• Physical assessment/clinical manifestations• Fatigue

Common Physical Assessment

• Findings include:• Flexor spasms at night• Intention tremor• Dysmetria• Blurred vision, diplopia, decreased visual

acuity, scotomas (change in perherial vision), nystagmus (involuntary rapid eye movement)

• Hypalgesia, numbness, tingling, or burning• Bowel and bladder dysfunction

Assessment

• Psychosocial assessment• Laboratory assessment• Other diagnostic tests

Drug Therapy

• Therapies include:• Interferon beta• Monoclonal antibodies• Copaxone• Novantrone• Immunosuppressive therapy• Methylprednisolone

Drug Therapy (Cont’d)

• Muscle relaxants• Treatment of paresthesia• Treatment of bladder dysfunction

Other Interventions

• Promoting mobility use adaptive devices• Managing symptoms• Complementary and alternative therapies

Community-Based Care

• Home care management• Health teaching• Health care resources

Amyotrophic Lateral Sclerosis

• Known as Lou Gehrig’s disease, an adult onset upper and lower motor neuron disease characterized by progressive weakness, muscle wasting, and spasticity eventually leading to paralysis

• Early symptoms—fatigue while talking, tongue atrophy, dysphagia, weakness of the hands and arms, fasciculations, nasal quality of speech, dysarthria

Interventions

• No known cure, no treatment, no preventive measures

• Riluzole, only drug approved by FDA to extend survival time

• Exercise and mobility program • Management of swallowing difficulties• Respiratory support

NCLEX TIME

Question 1

An important question to ask a patient with low back pain is:

A. “How does your back pain affect your activities of daily living?”

B. “Tell me about your pain and what interventions are helpful in managing your pain.”

C. “How long have you had back pain?” D. “Have you ever had magnetic resonance

imaging to find a cause for your back pain?”

Question 2

A 78-year-old patient complains of difficulty moving his upper extremities after a fall. Motor movement in his lower extremities is weak but stronger than his upper

extremities. The nurse suspects the patient:

A. Is experiencing a strokeB. Has anterior cord syndromeC. Has central cord syndromeD. Has an incomplete spinal cord injury

Question 3

What is an expected outcome for a patient with a spinal cord injury who is receiving intrathecal baclofen (Lioresal)?

A. FatigueB. Seizures C. Hallucinations D. Decreased muscle tone

Question 4

A patient with a spinal cord injury at C5-6 complains of a sudden severe headache. The patient is flushed. His blood pressure is 190/100 mm Hg, and heart rate is 52

beats/min. A nursing priority intervention is to:

A. Place the patient in a sitting position.B. Page/notify the health care provider. C. Check the urinary catheter tubing for kinks

or obstruction. D. Check the patient for fecal impaction.

Question 5

What percentage of the U.S. population are estimated to have lower back pain at any given time?

A. 20%B. 40% C. 60%D. 80%