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109 Cards in this Set
- Front
- Back
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What should the nurse assess initially in a patient with spinal cord injury?
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*Assess respiratory pattern
*Ensure adequate airway *Assess for intra-abdominal hemorrhage or bleeding around fracture site (hypotension, tachycardia & weak thready pulse can also indicate hemorrhage) *Determine Glasgow Coma Scale *Detailed assessment of motor and sensory status |
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What level of spinal cord injury is at high risk for respiratory compromise?
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Cervical (C3 - C5)
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Why are C3 - C5 injuries at increased risk for respiratory problems?
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Because the cervical spinal nerves innervate the phrenic nerve, which controls the diaphragm
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What is often needed to prevent respiratory arrest in C3 - C5 injury patients?
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Endotracheal intubation
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What does the Glasgow Coma Scale determine?
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The patient's level of consciousness (LOC)
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What is the significance of a detailed assessment of motor and sensory status (for patients with SCI)?
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*Assists in determining the level of injury
*Serves as baseline data for future comparison |
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What is "the level of injury?"
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The lowest neurologic segment with intact or normal motor/sensory function
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What dermatome level is the top of the foot and the calf of the leg?
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*L3
*L4 *L5 |
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What dermatome level is the umbilicus?
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*T10
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What dermatome level is the clavicle?
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*C3 or C4
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Finger sensation is considered to be which dermatome level?
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*C7 and C8
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What is meant by the term hypoesthesia?
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Decreased sensation
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What is meant by the term hyperesthesia?
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Increased sensation
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How would a nurse assess for C4-C5 injury?
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Apply downward pressure while the patient shrugs shoulders upward
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How would a nurse assess for C5-C6 injury?
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Apply resistance while the client pulls up his or her arms
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How would a nurse assess for C7 injury?
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Apply resistance while the patient straightens his or her flexed arms
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How would a nurse assess for C8 injury?
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Assess the patient's ability to grasp an object and form a fist
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How would a nurse assess for L2-L4 injury?
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Apply resistance while the patient lifts his or her legs from the bed
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How would a nurse assess for L5 injury?
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Apply resistance while the client dorsiflexes his or her feet
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How would a nurse assess for S1 injury?
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Apply resistance while the client plantar flexes his or her feet
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What are the signs/symptoms of autonomic dysreflexia?
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*Severe, rapidly occurring hypertension
*Bradycardia *Flushing above the level of the lesion *Severe, throbbing headache *Nasal stuffiness *Sweating *Nausea *Blurred vision |
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What is included in emergency care of autonomic dysreflexia?
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*Raise the HOB to high Fowler's
*Call the physician to notify him/her of the emergency *Loosen tight clothing on patient *Check the Foley catheter tubing (if present) for kinks or obstruction *If a Foley is not present, check for bladder distention and catheterize immediately *Check the client for fecal impaction; if present, disimpact immediately using anesthetic ointment *Check the room temperature to ensure that it is not too cool or drafty *Monitor blood pressures every 10-15 minutes *Give nitrates, hydralazine (apresoline), or Procardia as ordered |
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What is the cause of autonomic dysreflexia?
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Noxious stimulus, most often a distended bladder or constipation
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What will likely happen if autonomic dysreflexia is not treated promptly?
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Hypertensive stroke
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What are the signs/symptoms of spinal shock?
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*Absent deep tendon reflexes
*Absence of all motor function *Absence of all sensation *Decreased peristalsis *Absent bowel sounds *Gastric distention |
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What are the effects of an upper motor nueron (UMN) lesion on the bladder?
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Bladder spasms/difficulty in urination
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What might a nurse teach a client with UMN lesion to do to stimulate urination?
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*Stroke the inner thigh
*Pull on pubic hair and hair of the upper thigh *Pour warm water over the perineum *Tap the bladder area to stimulate the detrusor muscle |
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What effect does a lower motor neuron (LMN) injury have on bowel elimination?
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The resulting flaccid large bowel may require the client to perform or undergo manual disimpaction
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What effect does an upper motor neuron injury have on bowel elimination?
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Spasms: difficulty in eliminating
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What is usually included in a bowel retraining program?
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*Consistent time for bowel elimination
*High fluid intake (at least 2000 mL/day), unless fluid intake is restricted *High fiber diet *Rectal stimulation with or without suppositories *Stool softeners, if needed |
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How long does spinal shock usually last?
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72 hours to several months
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What happens after spinal shock subsides?
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Hyperreflexia of muscles and deep tendon reflexes
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What is an appropriate intervention for paralytic ileus as a result of spinal shock?
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NG tube with low suction
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What is an appropriate intervention for hemodynamic instability as a result of spinal shock?
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*Monitor vital signs closely
*Change positions slowly to avoid orthostatic hypotension |
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What is hemodynamic instability?
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Decrease in blood pressure and pulse
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What is a key nursing intervention for spinal shock patients with regards to skin care?
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*Monitor pressure areas (poor blood perfusion to the skin)
*Blanching test |
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With what type of SCI does autonomic dysreflexia most often occur?
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Injuries at or above T6
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What are some potential long-term SCI complications?
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*DVT's
*Decubiti *Renal calculi (non weight-bearing) *Osteoporosis *UTI's if urinary tract care not stringent *Pneumonia *Possible contractures and/or dislocations |
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Why do SCI patients have an increased risk for pneumonia?
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Due to compromised respiratory function and decreased activity of supporting muscles
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What is the leading cause of death in SCI patients, in long-term management of this condition?
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Pneumonia
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What drugs might help to control severe muscle spasticity in patients with UMN injuries?
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*Dantrolene (Dantrium)
*Baclofen (Lioresal) |
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20 - 30% of spinal cord tumors are secondary mets from what?
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*Lung cancer
*Breast cancer *Colon cancer *Prostate cancer *Uterine cancer |
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List some clinical manifestations of spinal cord tumor:
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*Pain from cord compression/infiltration of cancer cells
*Motor deficit: weakness, clumsiness, ataxia, hyperreflexia *Spastic paralysis *Flaccid paralysis *Sensory loss: numbness, tingling, temperature loss, loss of touch *Gradual loss of bladder control, and then loss of bowel control |
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What tests are usually done to diagnose a spinal cord tumor?
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*Myelogram
*CT Scan *MRI |
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What are the signs/symptoms of spinal cord compression?
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*Back pain (usually occurs before any neurologic deficits occur)
*Numbness *Tingling *Loss of urethral, vaginal, rectal sensation *Muscle weakness *Sometimes paralysis occurs |
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If spinal cord compression causes paralysis, can this be reversed?
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No; if paralysis occurs due to spinal cord compression, it is usually permanent
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What is the nurse's responsibility in regards to skeletal traction?
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*Maintaining the correct balance between traction pull and counteraction force
*Make sure weights are not removed, unless ordered *Make sure the weights are freely hanging at all times *Inspect skin at least Q 8hrs. for signs of irritation/inflammation *Remove the boot or belt when possible to inspect skin under it *Perform pin care every day *Observe pin sites at least every 8 hours for drainage, color, odor, and severe redness *Check traction equipment to ensure proper functioning *Inspect all ropes, knots and pulleys at least every 8 hours for loosening, fraying and positioning *Check weight for consistency with health care provider's order *Assess the neurovascular status of the affected body part to detect circulatory compromise and subsequent tissue damage |
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What is included in the assessment of neurovascular status for a client in traction?
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*Skin color
*Skin temperature *Movement *Sensation *Pulses *Capillary refill *Pain |
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Decreased dopamine levels cause Parkinson's patients to lose what ability?
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The ability to refine voluntary movement, (result=jerky movements)
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A decrease in epinephrine levels cause what to occur in Parkinson's patients?
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Orthostatic hypotension
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What causes Parkinson's disease?
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*Depigmentation/degeneration of Substantia Nigra
*Depletion of dopamine |
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Parkinson's can possibly be associated with what conditions?
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*Aging
*Head trauma *Basal ganglia infarct *Environment |
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What muscles are affected by Parkinson's?
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All skeletal muscle
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What are the cardinal symptoms of Parkinson's?
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*Muscle rigidity
*Bradykinesia (slow movement) *Poor posture *Tremor |
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What is must be present in order to diagnose Parkinson's?
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At least 2 of the cardinal symptoms
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List some other signs/symptoms of Parkinson's:
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*Resting tremor
*"Pill-rolling" *Muscular weakness with rigidity *Inability to maintain balance *Mask-like face *Drooling *Slowed, monotonous speech *Shuffling gait *Dementia *Cognitive function impairment *Emotional lability *Paranoia *Depression |
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What is the purpose of "drug holidays" from Parkinson's medications?
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After 3-5 years of taking the medicine, there is a loss of response to the med. Drug holidays attempt to improve effectiveness of the drugs.
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What type of medications are used for Parkinson's patients?
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Dopaminergics (precursor to dopamine)
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What specific drugs are used most often for Parkinson's?
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*Levodopa
*Carbidopa/Levodopa (Sinemet) |
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What is the goal of drug treatment for Parkinson's?
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To achieve a balance between dopamine and acetylcholine in the basal ganglia
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What should Parkinson's patients know about the side-effects of Sinemet?
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The following can result from long-term use:
*Dyskinesia/tardive dyskinesia *Hallucinations *Orthostatic hypotension: change positions slowly *Fasciculations of tongue *Tics/twitches |
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What is significant of Levodopa?
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Converts to dopamine in the CNS
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Patients taking dopaminergics should be instructed to take medication with what to avoid interactions with vit. B6 in food?
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Juice and a low-protein snack
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What should be included in patient teaching for a patient who is taking anticholinergic drugs?
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*Take drug with meals to decrease GI distress
*Change positions slowly *Effectiveness of drug is evaluated by decreased muscle rigidity/ tremors |
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What type of drug is selegiline (Eldepryl)?
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MAO inhibitor
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What condition should patients beware of when taking selegiline (Eldepryl)?
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Hypertension
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What foods should patients taking selegiline (Eldepryl) avoid?
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*Cheese
*Red wine *Beer *Yogurt |
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What is COMT?
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An enzyme that inactivates dopamine
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What does a COMT inhibitor do?
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Increases the effect of Levodopa
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What is the end result of a Pallidotomy?
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Stops tremors, but causes permanent motor loss
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What are some signs of levodopa toxicity?
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*Mental status changes
*Personality changes *Increased twitching *Grimacing *Tongue protrusion |
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What is included in the management of an acute exacerbation of MS?
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*Solu-Medrol (methylprednisolone): administer 1 g IV for 3-14 days, depending on provider and pts symptoms
*Prednisone (PO) 60 mg may be given after Solu-Medrol for 5-7 days *Adrenocorticotropic (ACTH) 25-60 international Units IV or IM may be given instead of Solu-Medrol and tapered gradually over 2-4 weeks |
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What is the purpose of giving corticosteroids / ACTH in an acute exacerbation of MS?
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To reduce edema and inflammatory response
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What are the major types of MS?
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*Relapsing-remitting type
*Primary progressive type |
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What is involved in relapsing-remitting MS?
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characterized by relapses that develop over 1-2 wks and resolve over 4-8 months. Pt returns to baseline.
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What is significant of Primary Progressive MS?
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Involves a steady and gradual neurologic deterioration w/out remission of symptoms
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What is the diagnosis method for MS?
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Usually diagnosed by obtaining a thorough history from the patient
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What are some bladder control options for older children with myelomeningocele?
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*Clean intermittent catherization taught to older children
*Medication (Ditropan or Detrol) used to improve bladder storage & continence *Vesicotomy (stoma on abdominal wall for urinary drainage) *Regular bladder emptying |
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What is the most common cause of neuropathic bladder dysfunction?
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Myelomeningocele
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What should be included in parent teaching upon discharge of a myelomeningocele patient?
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*Passive range-of-motion exercises, positioning, & stretching exercises may help prevent muscle contractures
*Watch for skin breakdown since decrease sensitivity in lower extremities *Bladder training *Catherization, medicines *Bowel control with diet modification reg. toilet habits, prevention of constipation & impaction *Prone position *Infants held to promote bonding or touch, stroke, talked to |
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What is used to diagnose myelomeningocele (antepartum)?
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*Elevated alpha-fetoprotein (AFP): AFP performed between 16-18 wks
*Ultrasound *If positive diagnosis, C-section will be done |
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What can women of child-bearing age take to prevent myelomeningocele?
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Folic Acid 0.4 mg/day
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What is included in care of a myelomeningocele patient prior to surgery?
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*Prevention of myelomeningocele from drying out by applying sterile, moist nonadherent dressing (changed q 2-4 hr)
*Inspect sac for leaks, abrasions, irritation or signs of infection *Keep infant in prone position *No rectal temps *Measure head circumference & examine fontanels (ICP) |
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What type of allergies are very common in Cerebral Palsy patients?
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Latex allergies
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What should a nurse consider in regards to latex allergies?
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*Allergic reaction- urticaria, wheezing, watery eyes, rashes, anaphylactic shock
*Most severe reaction occurs when latex comes in contact with mucous membranes, wet skin, bloodstream or airway *Food cross-reactions: banana, avocado, kiwi, chestnuts, milk |
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What are the signs/symptoms of Cerebral Palsy?
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*Increased muscle tone
*Increased DTR and clonus *Difficulty with fine and gross motor skills *Heelcord contracture (most common) *Visual deficits *Drooling *Feeding problems *Language deficits *Intellectual impairments |
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What should a nurse assess in a cerebral palsy patient, in relation to association with hydrocephalus?
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*Measure head circumference daily (predominant sign of hydrocephalus)
*Bulging fontanels (esp. anterior) that are tense & nonpulsatile |
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What are the signs/symptoms of hydrocephalus?
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*Increased head circumference
*Bulging fontanels *Lethargy *Vomiting *High-pitched cry *Pupils sluggish *Depressed eyes |
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What interventions can be done to promote communication with a cerebral palsy patient?
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*Enlist speech therapist to promote good habits of communication
*Talk to child slowly to give child time to understand speech *Use articles and pictures to reinforce speech and encourage understanding *Use feeding techniques that help facilitate speech, such as using lips, teeth, and various tongue movements *Teach and use of nonverbal communication methods for children with severe dysarthria *Help family acquire electronic equipment to facilitate nonverbal communication (computer with voice synthesizer) |
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What is Dorsal Rhizomoty?
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A procedure that involves selectively cutting the dorsal column sensory rootlets that have an abnormal response to electrical stimulation
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What is the expected outcome of Dorsal Rhizomoty?
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*Flaccid muscles
*Improve function rather than for cosmetic purposes |
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What should parents be taught about Dorsal Rhizomoty?
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*Surgery done when child doesn’t respond to more conservative measures
*Child needs intensive PT, they must be retaught to sit, stand, and walk |
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What should parents be taught regarding feeding a child with cerebral palsy?
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*Feed in normal eating position (flexed sitting position with arms brought forward to decrease the tendency toward back and neck extension)
*Manual jaw control to help with stability of jaw *Provide extra calories to meet energy demands *Provide vitamin, mineral, and protein supplements to meet caloric requirements *Feeding techniques- place food at side of tongue, make them use lips to get food off spoon |
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What should be included in discharge teaching for a patient with Myasthenia Gravis?
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*Explain signs and symptoms of myasthenic and cholinergic crises and need to contact Dr. when in crises
*Teach family to use resuscititation equipment *Keep medication and water at bedside so can take med. Even when too weak to get out of bed *Take meds on time *Plan strenuous activities when meds peaks *Don’t take OTC meds without checking with Dr. *Factors that predispose client to exacerbation are infection, stress, surgery, hard physical exercise, sedatives, enemas *Lifestyle adaptation- avoid heat, crowds, overeating, erratic changes in sleep habits, stress |
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What is significant of the activity level of a Myasthenia Gravis patient?
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*Generalized weakness that increases as the day progresses
*Weakness increases with activity, improves with rest *Limb weakness is more often proximal. Client may have difficulty climbing stairs, lifting heavy objects, or raising arms overhead |
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What should the nurse do to avoid complications of a thyectomy?
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*Observe for signs of pneumothorax or hemothorax, such as chest pain & sudden SOB
*Maintain adequate respiratory function |
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What is a myasthenic crisis?
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An exacerbation of MG symptoms caused by undermedication with anticholenesterase drugs
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What are the signs/symptoms of myasthenic crisis?
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*Increased pulse and respiration
*Increase BP *Anoxia *Cyanosis *Bowel and bladder incontinence *Decreased urine output *Absence of cough and swallow reflex |
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What is involved in treatment of myasthenic crisis?
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*Maintain ventilatory function
*Tensilon test: if muscle activity returns (+ tensilon test) give Tensilon |
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What is a cholinergic crisis?
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An acute exacerbation of muscle weakness caused by overmedication with cholinergic drugs (Tensilon)
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What are the symptoms of a cholinergic crisis?
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*Nausea, vomiting, diarrhea
*Abdominal cramps *Blurred vision *Pallor *Hypotension *Facial muscle twitching |
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What is involved in treatment of cholinergic crisis?
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Hold anticholinergic drugs (Tensilon) and give Atropine (which will thicken secretions so watch airway)
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What is the antidote for Tensilon?
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Atropine
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What should a nurse teach a patient regarding the drug Mestinon?
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*Take with milk/crackers 30-60 min a.c.
*Maintain steady blood levels (Take same time each day) *Take drugs before any activity *Avoid muscle relaxants, aminoglyocides, magnesium (these increase muscle weakness) |
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What is important to know regarding nutrition/feeding with clients who have myasthenia gravis?
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*Small, frequent meals and high calorie snacks
*Record client’s calorie counts, serum albumin levels, daily weights, I & O *Assess client’s gag reflex and ability to chew and swallow *Frequent oral hygiene *Keep head of bed elevated during and after meals (30-60 min) *Avoid liquids *Administer anticholinesterase drugs (Tensilon or Prostigmin) 45-60 min prior to meals |
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What is involved in Tensilon testing?
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Tensilon is injected IV and within 30 -60 seconds, most MG clients show a marked improvement in muscle tone that last 4-5 mins. (+ Test)
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What are the dangers of Tensilon testing?
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*Ventricular fibrillatino
*Cardiac arrest |
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What is Guillain Barre Syndrome?
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*Cell-mediated immunologic reaction
*Patients have history of acute illness, surgery, immunization, trauma, respiratory infection, Epstein-Barr virus, CMV (which causes T-cells to attack myelin) *Acute autoimmune disorder *Mortality is usually from complications of resp. compromise-emboli or respiratory arrest *Immune system destroy the myelin sheath around axons resulting in slow conduction of impulses *Self limiting disease, paralysis temporary *Ascending GBS is most common form |
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What is important to know regarding the care of a patient with Guillain Barre Syndrome?
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*Assess respiratory function
*Pain control *ROM and change position q 2 hr *Plasmopheresis: removal of antibody *Put on cardiac monitor *Hypertension: treat with beta blockers or nitroprusside *Hypotension: treat with IV fluids and pt is supine *Atropine for bradycardia *If urinary retention: insert foley and strict I & O’s |
