202spinalppt
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Interferences to Rest and Activity Needs Due to Trauma and Degenerative Disorders, Spinal Cord Injuries/Developmental Alterations, Amputations Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. Lumbosacral Back Pain (Low Back Pain) Herniated nucleus pulposus Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 2 Health Promotion and Maintenance Good posture Proper lifting Exercise Ergonomics Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 3 Patient-Centered Collaborative Care Assessment Diagnostic assessment Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 4 Nonsurgical Management Positioning Drug therapy Heat therapy Physical therapy Weight control Complementary and alternative therapies Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 5 Surgical Management Minimally invasive surgery: Percutaneous lumbar diskectomy Thermodiskectomy Laser-assisted laparoscopic lumbar diskectomy Conventional open surgical procedures: Diskectomy Laminectomy Spinal fusion Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 6 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 7 Community-Based Care Home care management Health teaching Health care resources Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 8 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. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 9 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 10 Spinal Cord Injuries (Cont’d) Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 11 Spinal Cord Injuries (Cont’d) Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 12 Common Spinal Cord Syndromes Complete lesion Anterior cord syndrome Posterior cord lesion Brown-Séquard syndrome Central cord syndrome Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 13 Common Spinal Cord Syndromes (Cont’d) Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 14 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 15 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 16 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. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 17 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. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 18 SCI: Etiology Trauma is the leading cause Incidence/prevalence Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 19 Patient with SCI: Initial Assessment First priority is assessment of the patient’s airway, breathing pattern, and circulation status Assessment for indications of intraabdominal hemorrhage or hemorrhage or bleeding around fracture sites Assessment of level of consciousness using Glasgow Coma Scale Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 20 Initial Assessment (Cont’d) Establishment of level of injury: tetraplegia, quadriplegia, quadriparesis, paraplegia, and paraparesis Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 21 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 22 Assessment of Sensory and Motor Ability Hypoesthesia Hyperesthesia Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 23 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. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 24 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. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 25 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. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 26 Other Assessments Lower motor neuron assessment Upper motor neuron assessment Skin assessment Heterotrophic ossification assessment Psychosocial assessment Laboratory assessment Imaging assessment Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 27 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 28 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 29 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 30 Drug Therapy Methylprednisolone (controversial) Dextran Atropine sulfate Dopamine hydrochloride Tizanidine Intrathecal baclofen Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 31 Surgical Management Emergency surgery necessary for spinal cord decompression Decompressive laminectomy Spinal fusion Harrington rods to stabilize thoracic spinal injuries Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 32 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. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 33 Ineffective Airway Clearance and Breathing Pattern (Cont’d) Assisted coughing, quad cough, cough assist Use of incentive Spiro meter Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 34 Impaired Physical Mobility; SelfCare 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. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 35 Impaired Physical Mobility; Self-Care Deficit (Cont’d) Prevent orthostatic hypotension. Promote self-care. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 36 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 37 Impaired Urinary Elimination; Constipation (Cont’d) Long-term renal complication Signs and symptoms of urinary tract infection not perceived by the patient Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 38 Autonomic Dysreflexia Commonly seen in patients with upper spinal cord injury Severe hypertension Bradycardia Severe headache Nasal stuffiness Flushing Treatment Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 39 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 40 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. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 41 Community-Based Care Home care management Health teaching Health care resources Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 42 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 Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 43 Multiple Sclerosis (Cont’d) Etiology Genetic risk Incidence Prevalence Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 44 Major Types of Multiple Sclerosis Relapsing-remitting Primary progressive Secondary progressive Progressive-relapsing Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 45 Patient-Centered Collaborative Care Patient history Physical assessment/clinical manifestations Fatigue Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 46 Common Physical Assessment Findings include: Flexor spasms at night Intention tremor Dysmetria Blurred vision, diplopia, decreased visual acuity, scotomas, nystagmus Hypalgesia, numbness, tingling, or burning Bowel and bladder dysfunction Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 47 Assessment Psychosocial assessment Laboratory assessment Other diagnostic tests Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 48 Drug Therapy Therapies include: Interferon beta Monoclonal antibodies Copaxone Novantrone Immunosuppressive therapy Methylprednisolone Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 49 Drug Therapy (Cont’d) Muscle relaxants Treatment of paresthesia Treatment of bladder dysfunction Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 50 Other Interventions Promoting mobility Managing symptoms Complementary and alternative therapies Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 51 Community-Based Care Home care management Health teaching Health care resources Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 52 Guillain-Barré Syndrome Demyelination of the peripheral nerves, progressive motor weakness and sensory abnormalities Ascending paralysis Result of a variety of related immunemediated pathologic processes Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 53 Clinical Manifestations Muscle weakness and pain have abrupt onset; cause remains obscure. Cerebral function or pupillary signs are not affected. Cranial nerve involvement. Autonomic dysfunction. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 54 Clinical Manifestations (Cont’d) Weakness and paresthesia begin in the lower extremities and progress upward toward the trunk, arms, and cranial nerves in ascending GBS. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 55 Interventions Drug therapy Plasmapheresis Monitoring respiratory status and managing the airway Managing cardiac dysfunction Improving mobility and preventing complications of immobility Managing pain Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 56 Interventions (Cont’d) Promoting communication Providing emotional support Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 57 Plasmapheresis Plasmapheresis removes the circulating antibodies assumed to cause the disease. Plasma is selectively separated from whole blood; the blood cells are returned to the patient without the plasma. Plasma usually replaces itself, or the patient is transfused with albumin. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 58 Myasthenia Gravis Chronic disease characterized by weakness primarily in muscles innervated by cranial nerves, as well as in skeletal and respiratory muscles Thymoma—encapsulated thymus gland tumor Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 59 Myasthenia Gravis (Cont’d) Progressive paresis of affected muscle groups that is partially resolved by resting Most common symptoms—involvement of eye muscles, such as ocular palsies, ptosis, diplopia, weak or incomplete eye closure Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 60 Tensilon Testing Within 30 to 60 sec after injection of Tensilon, most myasthenic patients show marked improvement in muscle tone that lasts 4 to 5 minutes. Prostigmin is also used. Cholinergic crisis is due to overmedication. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 61 Tensilon Testing (Cont’d) Myasthenic crisis is due to undermedication. Atropine sulfate is the antidote for Tensilon complications. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 62 Nonsurgical Management Respiratory support Promoting mobility Drug therapy: Cholinesterase inhibitor drugs Immunosuppression Plasmapheresis Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 63 Cholinesterase Inhibitor Drugs Drugs include anticholinesterase and antimyasthenics. Enhance neuromuscular impulse transmission by preventing decrease of ACh by the enzyme ChE. Administer with food. Observe drug interactions. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 64 Emergency Crises Myasthenic crisis—an exacerbation of the myasthenic symptoms caused by undermedication with anticholinesterases Cholinergic crisis—an acute exacerbation of muscle weakness caused by overmedication with cholinergic (anticholinesterase) drugs Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 65 Myasthenic Emergency Crisis Tensilon test is performed. Priority for nursing management is to maintain adequate respiratory function. Cholinesterase-inhibiting drugs are withheld because they increase respiratory secretions and are usually ineffective for the first few days after the crisis begins. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 66 Cholinergic Emergency Crisis Anticholinergic drugs are withheld while the patient is maintained on a ventilator. Atropine may be given and repeated, if necessary. Observe for thickened secretions due to the drugs. Improvement is usually rapid after appropriate drugs have been given. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 67 Management Immunosuppression Plasmapheresis Respiratory support Promoting self-care guidelines Assisting with communication Nutritional support Eye protection Surgical management usually involving thymectomy Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 68 Health Teaching Factors in exacerbation include infection, stress, surgery, hard physical exercise, sedatives, enemas, and strong cathartics. Avoid overheating, crowds, overeating, erratic changes in sleeping habits, and emotional extremes. Teach warning signs. Teach importance of compliance. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 69 Trigeminal Neuralgia Affects trigeminal or fifth cranial nerve Nonsurgical management of facial pain— drug therapy Surgical management—microvascular decompression, radiofrequency thermal coagulation, percutaneous balloon microcompression Postoperative care—monitoring for complications Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 70 Trigeminal Nerve Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 71 Facial Paralysis or Bell’s Palsy Acute paralysis of seventh cranial nerve Medical management—prednisone, analgesics, acyclovir Protection of the eye Nutrition Massage; warm, moist heat; facial exercises Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 72 Amputations Surgical amputation Traumatic amputation Levels of amputation Complications of amputations— hemorrhage, infection, phantom limb pain, neuroma, flexion contracture Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 73 Common Levels of Amputation Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 74 Phantom Limb Pain Phantom limb pain is a frequent complication of amputation. Patient complains of pain at the site of the removed body part, most often shortly after surgery. Pain is intense burning feeling, crushing sensation, or cramping. Some patients feel that the removed body part is in a distorted position. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 75 Management of Pain Phantom limb pain must be distinguished from stump pain because they are managed differently. Recognize that this pain is real and interferes with the amputee’s ADLs. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 76 Management of Pain (Cont’d) Opioids are not as effective for phantom limb pain as they are for residual limb pain. Other drugs include beta blockers, antiepileptic drugs, antispasmodics, and IV infusion of calcitonin. Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 77 Exercise After Amputation ROM to prevent flexion contractures, particularly of the hip and knee Trapeze and overhead frame Firm mattress Prone position every 3 to 4 hours Elevation of lower-leg residual limb controversial Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 78 Stump Care Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 79 Prostheses Devices to help shape and shrink the residual limb and help patient adapt Wrapping of elastic bandages Individual fitting of the prosthesis; special care Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 80 Complex Regional Pain Syndrome A poorly understood complex disorder that includes debilitating pain, atrophy, autonomic dysfunction, and motor impairment Collaborative management—pain relief, maintaining ROM, endoscopic thoracic sympathectomy, and psychotherapy Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 81 Cerebral Palsy Copy and past the URL below to see a video ppt presentation on CP http://www.authorstream.com/Presentation /laqueitaowens23-388993-cerebral-palsypower-point-presentation-education-pptpowerpoint/ Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 82 Spina Bifida The most common, permanent and disabling birth defect in the United States Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 83 What are the effects of Spina Bifida? Ongoing medical challenges Full or partial paralysis Nervous system complications Bladder and bowel control difficulties Learning disabilities Depression Social and sexual issues Latex allergy Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 84 Latex allergy 70% of children and adolescents with Spina Bifida are sensitive to latex Items made with latex include: • Promotional items like stress balls • Balloons • Rubber bands • Rubber erasers Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 85 How does Spina Bifida happen? First month of pregnancy Before most women know they are pregnant The spine does not close Causes an opening or lesion Damaged nerves may result in varying degrees of paralysis Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 86 What happens after birth? Surgery Reduces risk of infection Further damage to the spinal cord Life-long treatment and care Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 87 Can Spina Bifida be prevented? Exact cause is not known Medical research confirms link between folic acid and Spina Bifida* Women who take 400 mcg of folic acid every day reduce the risk by up to 70%. BEFORE becoming pregnant During first three months of pregnancy * (and other birth defects) Elsevier items and derived items © 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc. 88 What is folic acid? B-vitamin that builds healthy cells In most multivitamins Foods Leafy green vegetables (broccoli and spinach) Fruits and juices (orange juice) Folic acid-fortified breakfast cereals and other bread and grain products The surest way to get enough folic acid every day is to take a vitamin with folic acid. 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