PNS Disorders & Spinal
Cord Injury
Megan McClintock, MS, RN
Fall 2011 – NRS 440
Trigeminal Neuralgia
(tic douloureux)
Dx/Treatment
CT & MRI
Tegretol (carbamazepine) or Trileptal (oxcarbazepine)
Nerve blocks
Biofeedback
Glycerol rhizotomy
Microvascular decompression
Gamma knife
Interventions
Strong opiods are usually avoided
Environmental management during attacks
Soft-bristled, small toothbrush
Foods high in protein/calories, easy to chew,
lukewarm
Bell’s Palsy
Treatment
Moist heat
Gentle massage
Electrical stimulation of the nerve
Facial exercises
Corticosteroids (prednisone)
Mild analgesics
Antivirals
Interventions
Prevention
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
Interventions
Careful 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
Botulism
Most 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
Shock
Spinal Shock
50% experience this
Neurogenic Shock
Decreased reflexes
Occurs due to loss of
vasomotor tone
Loss of sensation
Hypotension
Flaccid paralysis
Bradycardia
All below the level of the
injury
Peripheral vasodilation
Can last days to months
Decreased cardiac output
Still start active
rehabilitation
Usually associated with
cervical or high thoracic
injury
Venous pooling
Degree of Paralysis
Degree of Paralysis
Degree of Paralysis
Syndromes of Spinal Cord
Lesions
Central Cord Syndrome
Anterior Cord
Syndrome
Brown-Séquard
Syndrome
Posterior Cord
Syndrome
Signs/Symptoms
Respiratory
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
Cardiovascular
Above T6 decreases the activity of the SNS
Bradycardia, hypotension
Signs/Symptoms
Urinary
Urinary retention
Spinal shock causes retention, atonic bladder
Begin intermittent cath as soon as possible
GI
Above T5, problems are related to hypomobility
Stress ulcers
Intraabdominal bleeding (signs are masked)
Below T12 and spinal shock - neurogenic bowel
Signs/Symptoms
Skin
Potential for skin breakdown
Thermoregulation
Poikilothermism
Decreased ability to sweat/shiver below level of injury
Worse with high cervical injuries
Metabolic needs
Metabolic alkalosis, Na, K levels (from NG suctioning)
Acidosis (from decreased tissue perfusion)
High protein, high calorie diet
Peripheral vascular Problems
DVT & PE risk (harder to detect)
Dx/Treatment
CT
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
Drugs
High dose methylprednisolone w/in 8 hours of injury
Vasopressors (dopamine)
All drugs may be metabolized differently with SCI
Acute Interventions
Immobilization
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 Fixation
Pin Site care
Skin care under vest
Be 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
Respiratory
Critical to assess during first 48 hrs
Above C3 requires mechanical
ventilation
Assess carefully
Chest PT
Assisted coughing or incentive spirometry
Acute Interventions
Cardiovascular
Limit 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 & Nutrition
NG 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 & Bowel
Indwelling catheter
Lots of fluid intake
Watch for UTIs
Transition to intermittent catheterization as soon as
possible every 3-4 hours
Bowel program
Rectal stimulant followed by gentle digital stimulation
Temperature Control
Maintain environmental temp
Don’t overload with covers or expose too long (baths)
Cooling blanket for fevers
Acute Interventions
Stress Ulcers
Usually 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 Deprivation
Stimulate patient above the level of injury
Prism glasses, conversation, music, smells, flavors
Reflexes
Explain 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 Care
Respiratory
If ventilator-dependent can still be mobile
Assisted coughing, incentive spirometry
Neurogenic Bladder
Types – 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 Care
Neurogenic 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 Care
Neurogenic 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 Care
Sexuality
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 Care
Grief 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 Tumor
Rare
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
Treatment
Dx 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.
2.
3.
4.
return of reflexes.
bradycardia with hypoxemia.
effects of sensory deprivation.
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.
2.
3.
4.
breathe with respiratory support.
drive a vehicle with hand controls.
ambulate with long-leg braces and crutches.
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.
2.
3.
4.
A heart rate of 92
A reddened area over the patient’s coccyx
Marked perspiration on the patient’s face and arms
A light inspiratory wheeze on auscultation of the lungs