Chapter 45
Care of Patients with Problems of
the Central Nervous System: The
Spinal Cord
Mrs. Marion Kreisel MSN, RN
NU230 Adult Health 2
Spinal Cord
Lumbosacral Back Pain (Low Back Pain)
• Herniated nucleus pulposus
Health Promotion and
Maintenance
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Good posture
Proper lifting
Exercise
Ergonomics
Mental Health Counseling for pain
and/or depression
Patient-Centered Collaborative
Care
• Assessment
• Diagnostic assessment
Nonsurgical Management
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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
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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
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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
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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; 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.
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
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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)
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Etiology
Genetic risk
Incidence
Prevalence
Major Types of Multiple Sclerosis
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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.
B.
C.
D.
Is experiencing a stroke
Has anterior cord syndrome
Has central cord syndrome
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.
B.
C.
D.
Fatigue
Seizures
Hallucinations
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.
B.
C.
D.
20%
40%
60%
80%