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Concept Map: Selected Topics in Neurological Nursing
ASSESSMENT
Physical Assessment
Inspection
Palpation
Percussion
Auscultation
ICP Monitoring
“Neuro Checks”
Lab Monitoring
PATHOPHYSIOLOGY
PHARMACOLOGY
Traumatic Brain Injury
Spinal Cord Injury
Specific Disease Entities:
Amyotropic Lateral Sclerosis
Multiple Sclerosis
Huntington’s Disease
Alzheimer’s Disease
Huntington’s Disease
Myasthenia Gravis
Guillian-Barre’ Syndrome
Meningitis
Parkinson’s Disease
Care Planning
Plan for client adl’s,
Monitoring, med admin.,
Patient education, Discharge
Planning, more…based
On Nursing Process: A_D_P_I_E
--Decrease ICP
--Disease /
Condition
Specific Meds
Nursing Interventions & Evaluation
Execute the care plan, evaluate for
Efficacy, revise as necessary
Objectives
 Explain pathophysiology of various SCIs and related
conditions
 Detail signs & symptoms and functionality of
different level SCIs
 Differentiate between Neurogenic Shock and Spinal
Shock
 Explain Autonomic Dysreflexia / Hyperreflexia and
list appropriate nursing interventions
 Discuss overall medical & nursing management of
SCIs
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SCI Goals of Care
 There's no way to reverse damage
 Treatment focuses on:
1. Preventing further injury
2. Enabling people to return to an active and
productive life within the limits of their disability
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Treatment
 Spinal Immobilization / Traction
 High doses of corticosteroid drug
Methylprednisolone (Medrol) STAT !
must be within eight hours of injury
 A few days after injury medical reassessment and
repeat of diagnostic tests will help determine the
severity of the injury and likely extent of recovery
 Surgery as indicated
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Tong Care to
Prevent
Infection
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Stryker Frame Traction Bed
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Log Rolling Technique
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SCI Meds
 Glucocorticoids (Decadron – suppress immune response)
 Vasopressors (treat hypotension)
 Plasma extenders (treat shock)
 Atropine (treat bradycardia)
 Muscle relaxants
 Anti-Spasmodics (Dantrium)
 Analgesics
 Antidepressants
 Zantac, Ranitidine (prevent gastric ulcers)
 Stool Softeners
 Vasodilaters (Hydralazine, nitroglycerin to treat HTN such as AD)
 Anti-Seizure (gabapentin, phenytoin)
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Neurogenic Shock
 Occurs in acute stage of SCI (first hour per ATI)
 Usually in injuries ABOVE T6
 D/T interruption of the CNS …
…causing disruption of sympathetic outflow from T1 to L2
…with unopposed vagal tone
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Neurogenic Shock: S & S’s
 Warm and DRY skin… does not perspire on the paralyzed parts of
body d/t blocked sympathetic activity
 Hypotension + Bradycardia + Hypothermia
(d/t vascular dilation …therefore blood pooling )
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Spinal Shock
 D/t concussive effect of the primary SCI on the nervous system
 Can last days or months
 Interferes with definitive diagnosis of permanent deficit
 Effect causes temporary (transient) depression of all reflexes =
- paralysis (flaccid)
- loss of sensation
- loss of autonomic function
- loss of B & B control (Sometimes priapism)
 Spasticity or hyperreflexia signals end of this shock
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Autonomic Dysreflexia ( Hyperreflexia )
 SCI acute syndrome of excessive uncontrolled
sympathetic output
 Occurs ONLY after spinal shock has resolved
 SCI above T6
 Life-threatening HTN emergency
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A. D. (Hyperreflexia)
Below T6 intact sensory nerves transmit noxious
impulses up the spinal cord…
…. BUT …
Sympathetic inhibitory impulses above T6
are blocked
THEREFORE
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Sympathetic outflow continues…
causing release of norepinephhrine and dopamine
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Result…
Severe Vasoconstriction
H/A + Sudden HTN
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Result above the SCI…
Sweating + Flushing
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Other Distinctive S & S
 Bradycardia
 Blotching of the Skin
 Restlessness
 Goose bumps
 Stuffy nose (nasal congestion)
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A.D. / Hyperreflexia
 Clients with spinal cord injuries at Thoracic 6 – 10
(T6 -T10) may be susceptible
 Patients with Thoracic 10 (T-10) and below are usually
not susceptible
 The older the injury the less likely the person will
experience autonomic dysreflexia
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Common Causes
 The most common cause of noxious stimuli is
distension of the hollow viscera (80%), such as the
urinary bladder or bowel
1. Urinary Retention
2. Constipation
 Simple kinks in the tubing or plugs in the urinary
catheter can trigger autonomic dysreflexia
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Crede’s Method
 Credé's method is a manual suprapubic pressure exerted with a clenched fist or fingers,
used to initiate micturition, in patients with spinal cord injury (SCI) who have
neurovesical dysfunction.
 However, it is currently NOT recommended practice because of the risk of bladder
rupture.
Sources:
Hockenberry, M.J. (2003). Wong’s Nursing Care of Infants and Children. (7th ed.). St. Louis: Mosby, pp.
1326-1328.
Reinberg Y., Fleming T., & Gozalez, R. (1994). Renal Rupture After the Crede Maneuver. Journal
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Treatment…
 Assist to sitting position to lower the BP through lowerextremity vascular pooling
 Loosen restrictive garments (shirts, belts, slacks, straps and
even shoes)
 Monitor Vitals
 Look for Cause & Eliminate!
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Treatment…
 Ensure catheter patency (make sure catheter not kinked or pulled too
tight, and is actually draining urine)
 Catheterize to decompress bladder
 Assess for signs of urinary tract infection, such as dark, cloudy urine or
sediment in catheter tubing
 If bowel is distended, disimpact after inserting anesthetic jelly or
ointment per rectum
Hypertension should be treated medically if it persists
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Still Can’t Find Cause ? !!!
 Cause may not be readily found…
 Careful physical exam is imperative during this crisis
 Other causative agents usually not considered in medical
emergencies include skin irritations, wounds, pressure sores,
burns, broken bones, pregnancy, ingrown toenails, appendicitis,
and other medical complications
Still cannot find cause? ….
focus on decreasing the blood pressure!
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Antihypertensive Meds
 Nifedipine (Adalat) 10 mg orally - instruct the patient to
bite the capsule, then swallow it
 Nitroglycerin sublingual or topical paste (1/2 inch)
 Prazosin (Minipress)
 Clonidine (Catapres) 0.1- 0.2 mg PO
 Hydralazine (Apresoline) 10 - 20 mg IM/IV
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Client Teaching
• Provide education about early recognition and treatment of
A.D.
• Encourage the client to carry some type of medic alert
identification
(It is estimated that approximately 85% of spinal cord injury patients at level T-6 will
suffer at least one episode of autonomic dysreflexia)
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Client Teaching
Prevention:

Frequent pressure relief in bed/chair

Avoid sun burn/scalds (avoid overexposure, use of #15 sunscreen,
watch water temperatures)

Faithful adherence to bowel program

Keep catheters clean and remain faithful to catheterization schedule

Well balanced diet and adequate fluid intake

Compliance with medications
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SCI Recovery
 Recovery typically starts between a week and six
months after injury, if it occurs, with the majority of
recovery taking place within one year
 Doctors generally regard any impairment remaining
after 12 to 24 months as likely to be permanent
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SCI Nursing Interventions
 Bowel retraining program
 ROM
 Sexual function adaptive strategies
 PT
 OT
 Assistive devices
 Q2H turns – skin care
 Nutrition
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SCI Nursing Interventions
Referrals:



Social Services
Support Groups
Appropriate specialists
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SCI Rehabilitation
 Initial rehabilitation emphasizes regaining leg and arm strength,
redeveloping fine-motor skills and learning adaptive techniques to
accomplish day-to-day tasks
 Then long-term rehab typically includes exercise and training with:
Modern wheelchairs - Improved, lighter weight wheelchairs are
more mobile and more comfortable. The Food and Drug
Administration has even approved a wheelchair that can climb stairs
and elevate a seated passenger to eye level to reach high places without
help
Computer devices - Computer-driven tools and gadgets can
help with daily routines. Voice-activated computer technologies to
answer and dial a phone, or to use a computer and pay bills. Computercontrolled technologies can also help with bathing, dressing,
grooming, cleaning and reading
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Complications
Urinary tract problems - urinary incontinence increases risk of
urinary tract infections, kidney infection, kidney or bladder stones. d/t
ongoing catheterizations
Bowel management difficulties – Reduced peristalsis and fecal
incontinence
Pressure sores - particularly susceptible to pressure sores because the
injury reduces or eliminates sensations, making it difficult to know when a
sore is developing
Deep vein thrombosis and pulmonary embolism
Lung and breathing problems - Difficult to breathe and cough
with weakened abdominal and chest muscles, so people with cervical and
thoracic spinal cord injury may develop pneumonia, asthma or other lung
problems
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Complications…
Spasticity – some people develop muscle spasms and
jumping of their arms and legs because some of the nerves
in the lower spinal cord become more sensitive after injury
and cause muscle contractions. However, because of the
spinal cord injury, the brain can no longer send signals to
the lower nerves to regulate the contractions
Weight control issues - Weight loss and muscle atrophy
are common. But the change in lifestyle and activities may
eventually cause weight gain, which can make it difficult
for the pt lift themselves — or be lifted — from place to
place
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Concerns
Pain
- It's possible to feel pain in areas where there's little or no
sensation
- May also experience pain from overusing muscles in one part
of the body. Many people develop shoulder tendinitis from
manually operating a wheelchair for a long period of time
- Any kind of pain can have a negative impact on daily living
.
New Injuries
- Susceptible to injury of any part of the body that has impaired
sensation
- May even receive a burn or cut without realizing it
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Male Concerns…
Sexual Dysfunction
 Still have erections, even with little sensation in the genital area
 But erections may not be firm enough or last long enough for sexual
activity
 Fertility also can be affected:
- 99% aren't able to ejaculate during intercourse
- Low sperm counts
- Poor sperm motility
***** However, men can be sexually active and father a child
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Female Concerns…
Sexual Dysfunction
• Most have no physical change that inhibits sexual intercourse
or pregnancy
• But may lose ability to produce vaginal lubrication or control
vaginal muscles
• Many experience changes in body image that affect sexuality
• Any pregnancy will likely be considered high risk
• There may be amenorrhea for about 6 months after SCI
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Coping
Grieving
Healthy part of recovery. It's natural and important to grieve the loss of the way the
person was before. Then…necessary to set new goals and find a way to move forward
with life
*** Depression and alcohol abuse***
Taking control
Education about injury and options for reclaiming an independent life
Because the costs can be overwhelming, find out about economic assistance or
support services from the state or federal government or from charitable
organizations
Talking
Friends and family may respond in different ways
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Continued…
 Dealing with intimacy
 Self - Care
 Looking ahead …
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