PNS Disorders & Spinal Cord Injury

Megan McClintock, MS, RNFall 2011 – NRS 440

Trigeminal Neuralgia (tic douloureux)

Dx/TreatmentCT & MRI

Tegretol (carbamazepine) or Trileptal (oxcarbazepine)

Nerve blocks

Biofeedback

Glycerol rhizotomy

Microvascular decompression

Gamma knife

InterventionsStrong opiods are usually avoided

Environmental management during attacks

Soft-bristled, small toothbrush

Foods high in protein/calories, easy to chew, lukewarm

Bell’s Palsy

TreatmentMoist heat

Gentle massage

Electrical stimulation of the nerve

Facial exercises

Corticosteroids (prednisone)

Mild analgesics

Antivirals

InterventionsPrevention

Hot, moist packs

Protect the face from cold and drafts

Good nutrition (chew on unaffected side)

Meticulous oral hygiene

Dark glasses

Artificial tears

Taping eyelid closed or protective shield

Facial sling

Gentle massage

Facial exercises

Guillian-Barré Syndrome

Dx/Treatment• Diagnosis based on history, s/s

• Supportive care

• Ventilatory support in acute phase

• Plasmapheresis

• IV high-dose immunoglobulin (Sandoglobulin)

• Nutritional support

InterventionsCareful assessment

Prepare for intubation if vital capacity less than 800 mL

Careful prevention of infection

Establish a communication system early

Catheterization

ROM

Meticulous eye care

Nutrition (risk of aspiration)

F&E balance

Prevention of constipation

BotulismMost serious type of food poisoning

Thought that the neurotoxin prevents Ach from working

Sx – n/v, diarrhea, abdominal cramping, afebrile, no mental deficits, decscending paralysis with cranial nerve deficits

Death can occur from circulatory failure, resp paralysis, or resp complications

Tx – IV botulinum antitoxin, purge of GI tract

Prevention is key

Nursing care is like for Guillian-Barre

Tetanus (Lockjaw)

Spinal Cord Injury

Spinal Cord Injury

ShockSpinal Shock

50% experience this

Decreased reflexes

Loss of sensation

Flaccid paralysis

All below the level of the injury

Can last days to months

Still start active rehabilitation

Neurogenic ShockOccurs due to loss of vasomotor tone

Hypotension

Bradycardia

Peripheral vasodilation

Venous pooling

Decreased cardiac output

Usually associated with cervical or high thoracic injury

Degree of Paralysis

Degree of Paralysis

Degree of Paralysis

Syndromes of Spinal Cord LesionsCentral Cord Syndrome

Anterior Cord Syndrome

Brown-Séquard Syndrome

Posterior Cord Syndrome

Signs/SymptomsRespiratory

Above C4 have total loss of resp muscle function

Below C4 can have problems with the phrenic nerve

Cervical/thoracic injuries cause paralysis of abdominal/intercostal muscles

Ma have a tracheostomy

Neurogenic pulmonary edema

CardiovascularAbove T6 decreases the activity of the SNS

Bradycardia, hypotension

Signs/SymptomsUrinary

Urinary retention

Spinal shock causes retention, atonic bladder

Begin intermittent cath as soon as possible

GIAbove T5, problems are related to hypomobility

Stress ulcers

Intraabdominal bleeding (signs are masked)

Below T12 and spinal shock - neurogenic bowel

Signs/SymptomsSkin

Potential for skin breakdown

ThermoregulationPoikilothermism

Decreased ability to sweat/shiver below level of injury

Worse with high cervical injuries

Metabolic needsMetabolic alkalosis, Na, K levels (from NG suctioning)

Acidosis (from decreased tissue perfusion)

High protein, high calorie diet

Peripheral vascular ProblemsDVT & PE risk (harder to detect)

Dx/TreatmentCT

Treat systemic and neurogenic shock

If cervical injury, must maintain all body systems (pg 1552)

Assess muscle groups, sensory status, brain injury, musculoskeletal injuries, internal injuries

Logroll during transfers/repositioning

Stabilization of injury – traction, realignment, surgery

DrugsHigh dose methylprednisolone w/in 8 hours of injury

Vasopressors (dopamine)

All drugs may be metabolized differently with SCI

Acute InterventionsImmobilization

Stabilize the neck to prevent lateral rotation

Keep body correctly aligned

Logroll when turning

If traction is used, it must be maintained at all times

Kinetic therapy bed

Halo FixationPin Site care

Skin care under vestBe able to insert 1 finger under vest

Do not hold onto halo to move

Weights must hang freely

Don’t release traction

Keep a set of wrenches close

Keep sheepskin pad under vest, wash

weekly

Acute Interventions

RespiratoryCritical to assess during first 48 hrs

Above C3 requires mechanical

ventilation

Assess carefully

Chest PT

Assisted coughing or incentive spirometry

Acute Interventions

CardiovascularLimit vagal stimulation (turning, suctioning)

Assess VS frequently

Give anticholinergics (atropine) for bradycardia

Give vasopressors (dopamne) for hypotension

Sequential compression devices

ROM and stretching exercises

Prophylactic heparin (Lovenox)

Watch closely for signs of hypovolemic shock

Acute Interventions

Fluid & NutritionNG tube

Gradually start food/fluids will bowel sounds are active or flatus is passed

High protein, high calorie diet

Evaluate swallowing before starting oral feeding

Enteral or parenteral nutrition may be needed

Creative ways to encourage eating

Dietary supplements as needed

Acute Interventions

Bladder & BowelIndwelling catheter

Lots of fluid intake

Watch for UTIs

Transition to intermittent catheterization as soon as possible every 3-4 hours

Bowel programRectal stimulant followed by gentle digital stimulation

Temperature ControlMaintain environmental temp

Don’t overload with covers or expose too long (baths)

Cooling blanket for fevers

Acute Interventions

Stress UlcersUsually occur 6-14 days after injury

Test stool/gastric contents for blood

Give steroids with antacids or food

Histamine receptor blockers (Zantac, Pepcid) or proton pump inhibitors (Protonix, Prilosec)

Sensory DeprivationStimulate patient above the level of injury

Prism glasses, conversation, music, smells, flavors

ReflexesExplain that this is not always a return to function

Antispasmodic drugs (baclofen, Dantrium, Zanaflex)

Autonomic Dysreflexia

Life threatening emergency!!!

Massive uncompensated cardiovascular reaction caused by the SNS

Occurs in response to visceral stimulation

Sx – HTN (up to 300), throbbing headache, sweating above the level of the lesion, bradycardia, piloerection, flushing of skin above the level of the lesion, blurred vision/spots, nasal congestion, anxiety, nausea

Tx – elevate HOB to 45 degrees or sit upright, call dr, assess for cause, cath (lidocaine jelly), ensure cath is not kinked, digital rectal exam (anesthetic ointment), remove constrictive clothing, monitor BP closely, give Procardia, teach the patient

Home CareRespiratory

If ventilator-dependent can still be mobile

Assisted coughing, incentive spirometry

Neurogenic BladderTypes – reflexic, areflexic, sensory

Identify appropriate drainage method

Surgical options

Anticholinergic drugs, adrenergic blockers, antispasmodic drugs

Avoid long-term use of indwelling catheters if possible

Home CareNeurogenic Bowel

High fiber diet, adequate fluid intake

Suppositories (dulcolax, glycerin) or small-volume enemas with digital stimulation 20-30 minutes later

Stool softener (Colace)

Valsalva and manual stimulation (for lower motor neuron lesions)

Time BM for 30-60 minutes after breakfast

Upright position with feet flat on floor or on stepstool if possible

Exercise

Home CareNeurogenic Skin

Twice daily comprehensive visual and tactile exam

Carefully watch ischia, trochanters, heels, sacrum

Reposition every 2 hours

Pressure relieving cushions, special mattresses

Adequate intake of protein

Protection from thermal injury

Use pillows to protect bony prominences

In a wheelchair, lift self up and shift weight every 15-30 min

Home CareSexuality

See table 61-13 (pg 1562)

If upper motor neuron lesion, can have reflex sexual function

If lower motor neuron lesion, may be capable of psychogenic erection (ejaculation may retrograde into bladder)

Tx – drugs, vacuum devices, surgical procedures

Fertility a problem with men

Women have problems with lubrication

Open communication is important

Sexual activity may be less spontaneous

May have incontinence during sexual activity

Home CareGrief and Depression

Can feel an overwhelming sense of loss

Believe they are useless and a burden to their family

May have regression

Expect a wide fluctuation of emotions

Table 61-14 (pg 1563) Mourning Process

Counseling for caregiver and family

Sympathy is not helpful, insist that care be performed

Spinal Cord TumorRare

Can be primary or secondary

Can be extradural, intradural extramedullary, or intradural intramedullary

Most are slow-growing and don’t cause secondary injury

May have sensory and motor problems

Early sx – back pain with radicular pain causing intercostal pain, angina or herpes zoster; pain worsens with activity, coughing, straining, lying down

TreatmentDx with spinal xray, MRI, CT

Surgical Treatment: tumor removal

Radiation Therapy (may also do chemo)

Compression of the cord is an emergency!!!!

Give high-dose corticosteroids

1. A patient is just admitted to the hospital following a spinal cord injury at the level of T4. A priority of nursing care for the patient is monitoring for

1. return of reflexes.2. bradycardia with hypoxemia.3. effects of sensory deprivation.4. fluctuations in body temperature.

2.A young adult is hospitalized after an accident that resulted in a complete transection of the spinal cord at the level of C7. The nurse informs the patient that after rehabilitation, the level of function that is most likely to occur is the ability to

1.breathe with respiratory support.2.drive a vehicle with hand controls.3.ambulate with long-leg braces and crutches.4.use a powered device to handle eating utensils.

3. During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which of the following findings would concern the nurse the most?

1. A heart rate of 922. A reddened area over the patient’s coccyx3. Marked perspiration on the patient’s face and

arms4. A light inspiratory wheeze on auscultation of

the lungs