Chapter #43

Immediate Emergency Care of the Patient Experiencing Autonomic Dysreflexia

1. Sitting (or safe) Position. 2. Notify the PHCP or RRT. 3. Assess for urinary retention, catheter blockage (ex. kinks or blockage), or distention. 4. Anesthetic Catheterization. 5. Is a UTI or Bladder Calculi contributing to the genitourinary infection? 6. Fecal Impaction or Colorectal Irritation? 7. Examine for New or Worsened Pressure Injuries. 8. Monitor BP (every 10-15 minutes). Administer Nifedipine or Nitrate. recurrence = prophylactic Alpha-Blocker

Multiple Sclerosis & Patient History

ask the patient about their vision, ROM (mobility), fatigue, incontinence, stress, personality changes, temperature increase, disease progression, intermittent symptoms which become progressive, aggravating factors, and family history or history of autoimmune disease

MS Psychosocial Assessment

assess decreased short-term memory, concentration, calculations, inattentiveness, impaired judgment, sexuality, bowel/bladder issues, and coping strategies for self-management

GI/GU Assessment

assess patient abdomen for indications of hemorrhage, abdominal distention, pain, or paralytic ileus, establishment of bowel/bladder programs for dysfunction (NO defecation), reflex or hypotonic bowel, and urinary retention with a bladder scanner or indwelling catheter

Cardiovascular SCI Assessment

assess the patient for cardiovascular dysfunction as the result of ANS disruption (ex. dysthymia), bradycardia, SBP < 90 mmHg can cause a secondary SCI, hypothermia, and hypotension

Other Nursing Considerations

consider VTE, skin integrity, nutritional status, bony overgrowth into muscle manifested as pain (heterotrophic ossification), desire for pain control resulting in manipulation, and CT/MRI/X-Ray LAB = urinalysis, ABGs, WBC, H & H

Drug Therapy for Multiple Sclerosis- Monoclonal Antibodies

controversial as it may cause adverse effects such as severe patient disability or death due to opportunistic infections (ex. Progressive Multifocal LeukoEncephalopathy)

Use of a Halo Device

discharge teaching related to management includes that device weight alters balance especially when leaning backward/forward, wear loose clothing, use a tub or sponge bath for bathing (provider preference), wash underneath the best liner, use powders or lotions sparingly, change the liner if odorous, use a small pillow to support the head when sleeping, resume normal activities BUT avoid contact activities, do NOT drive because vision is impaired, keep straws available for drinking, cut food into small pieces, wrap the pins with cloth before going outside in cold temperatures, observe pin sites daily for infection, prevent constipation, and use a position of comfort during sexual activity

Low Back Pain & Injury Drug Therapy (ex. Ziconotide)

do NOT give to patients with mental health issues as psychosis may result

Anterior Cervical Diskectomy/Fusion Discharge Teaching

ensure that the patient is accompanied for the first few days after surgery, review drug therapy, teach incision care, walk every day, NO lifting or strenuous activities, driving requires surgeon permission, wear a brace or collar if prescribed, and alert the surgeon if any symptoms worsen (ex. pain, numbness, tingling, swallowing)

ACTION ALERT & Cognitive Impairment

for the patient with MS, assist with orientation by using a single-date calendar, give or encourage the patient to use written lists or recorded messages, maintain an organized environment, encourage keeping frequently used items in familiar places, and the use of phone apps may be useful for re-orientation or reminders/behavioral cues

Spinal Shock Syndrome

immediately follows trauma as the cord's response to injury including complete (but temporary) loss of motor, sensory, reflex, and autonomic function; usually lasts less than 48 hours but can take several weeks to resolve may be Hypoesthesia v. Hyperesthesia

Physical Assessment of MS: Dysmetria

inability to direct or limit movements, difficulty starting starting or stopping movements

Management of Neurogenic Shock

include MAP maintained at 65 mmHg (< 60 required notification), drop in SpO2, decrease in HR or UOP, hypotension, changing LOC from inadequate perfusion, maintaining adequate hydration, spinal alignment, foot orthotics, and NEVER removing a stabilization device without an order hypovolemia/hypotension = plasma expanders (ex. Dextran or Dopamine) bradycardia = atropine

MS Diagnostics

include an elevated protein, WBC, and IgG in CSF + MRI to assess plaques

Anterior Cervical Diskectomy/Fusion Post-Op Interventions

includes ABCs, bleeding + drainage at the incision site, frequent monitoring of vitals as well as neurologic status, checking for swallowing ability, I & O, voiding ability (consider effect of opiates/anesthesia), pain management, and early ambulation assistance COMPLICATIONS = hoarseness from laryngeal injury, temporary dysphagia, arterial injury, infection, spinal cord or nerve root injury, Dura Mater tear with CSF leakage, pseudoarthrosis, or graft/screw loosening

Initial Assessment of Spinal Cord Injury

includes ABCs, vital signs, neurological + neuromuscular checks, and an injury to C3-C5 can cause partial/complete diaphragmatic paralysis (concern for patient airway); further assessment includes level of sensation such as comparison of both dermatome sides of the body (ex. pen or cold alcohol wipe)

Complications of Lumbar Spinal Surgery

includes CSF leakage, fluid volume deficit, acute urinary retention, paralytic ileus, Fat Embolism Syndrome, persistent or progressive lumbar radiculopathy, and infection

Impaired Physical Mobility & Self-Care Deficit of SCI Patients

includes VTE prophylaxis and risk for orthostatic hypotension, pressure ulcers, contractors, DVT (daily measurement of calves/thighs), or PE

Physical Assessment of Lumbosacral Back Pain

includes a pain assessment with consideration of normal aging changes, paresthesias, touch discrimination while patients are usually complaining of continuous pain aggravated by coughing, straining, sneezing, and driving EMG = distinguishes motor neuron disease from peripheral neuropathy + radiculopathy, observing for spinal root involvement

Multiple Sclerosis Patient Education

includes avoiding rigorous exercise which increases body temperature and lead to fatigue, diminished motor ability, and decreased visual acuity (ex. hot baths, overheating, humidity, excessive chilling)

MS Risk Factors

includes changes in immunity or environment (ex. colder climate), common within families, and occurs more in women

Extension Exercises for Chronic or Post-Op Low Back Pain

includes laying face down with a pillow underneath the chest while alternating leg lifting, arms at sides with lifting the head + neck, or on a mat to push up extending the arms (keeping the body stiff)

Flexion Exercises for Chronic or Post-Op Low Back Pain

includes laying on the back with the knees bent while tightening abdominal muscles to push the lower back against the mat, raising the upper body at 45 degrees (holding for 5-10 seconds), or tightening the abdominal muscles to push against the mat then bringing both knees to the chest for 5-10 seconds

Key Features of Multiple Sclerosis

includes muscle weakness + spasticity, fatigue, intention tremors, inability to direct or limit movement (dysmetria), paresthesias, decreased sensitivity to pain (hypalgesia), ataxia, slurred speech (dysarthria), diplopia, nystagmus, changes in peripheral vision (scotomas), decreased visual + hearing acuity, tinnitus, vertigo, incontinence, alterations in sexual function (ex. impotence), depression, and cognitive changes COGNITIVE = memory loss, impaired judgment, decreased ability to solve problems or perform calculations

Immobilization of Thoracic & Lumbosacral Injuries

interventions include surgery, immobilization, custom-fit orthoses (prevents prolonged immobility periods), knowing instructions to correspond with the brace, and obtaining a brace that keeps the patient as mobile as possible

Complications of Lumbar Spinal Surgery: Acute Urinary Retention

interventions involve assisting the patient to the bathroom/bedside commode ASAP and helping male patients stand at the bedside ASAP after the procedure

Complications of Lumbar Spinal Surgery: Fluid Volume Deficit

interventions involve monitoring I & O (drain output > 250 mL in eight hours during the first day), and monitoring vital signs for hypotension or tachycardia

Complications of Lumbar Spinal Surgery: Fat Embolism Syndrome (FES)

interventions involve reporting any chest pain, dyspnea, anxiety, or mental status changes (especially in older adults) while noting petechiae around the neck, upper chest, buccal membrane, and conjunctiva; monitor ABGs for a decreased PaO2 more common in patients with Spinal Fusion

Complications of Lumbar Spinal Surgery: CSF Leakage

interventions involve the assessment for clear fluid on or around the dresses, placing the patient FLAT, and reporting leakage immediately to the surgeon

CRITICAL RESCUE & Autonomic Dysreflexia

management includes raising the head of the bed to reduce BP, notify the PHCP for drug therapy, determine the cause (ex. catheterize any bladder distention), check room temperature + bed coverings for comfort, and remember that a lack of sensory perception may prevent the patient form noticing temperature variations

SCI Surgical Management- Cervical

management with wiring and fusion (stabilization)

Physical Assessment of MS

manifestations include a decreased ability to move, fatigue, extremity stiffness, sensitivity to temperature, leg spasticity at night, dysarthria (slurred speed), bladder issues, HYPERactive DTRs, + Babinski, unsteady gait, intention tremor, dysmetria, blurred vision, diplopia, and nerve pain or diminished pain sensitivity

Percutaneous Endoscopic Diskectomy

minimally invasive surgery which removes disk pieces that are compressing the nerve root

Complications of Lumbar Spinal Surgery: Infection (ex. wound, diskitis, hematoma)

monitor an increase or spike in patient temperature (expect a slight elevation which is normal), report increased pain or swelling at the wound site (or legs), administer antibiotics if infection is confirmed, and use clean technique for any dressing changes

CRITICAL RESCUE & Acute Spinal Cord Injury

monitor for decreased sensory perception from patient baseline (especially in a proximal/downward dermatome) or new loss of motor function & mobility which is considered an emergency and requires immediate report to the PHCP; document these findings = loss of sensation moving UPWARD

Complications of Lumbar Spinal Surgery: Paralytic Ileus

monitor for flatus or stool and assess for abdominal distention or any N/V

Monitoring the Patient with an Acute Spinal Cord Injury

monitoring hourly for SpO2 < 95% or symptoms of aspiration, symptomatic bradycardia, reduced LO, decreased UOP, hypotension with SBP < 90 mmHg, or MAP < 65 mmHg which would require notification of the PHCP

SCI Drug Therapy: Tizanidine

muscle spasm control

Low Back Pain & Injury Drug Therapy (ex. Tramadol/Ultram)

narcotic to reduce risk of opioid addiction

Epidural Spinal Cord Stimulator

neurologic status should be assess below the level of insertion frequently especially for early changes in sensory perception, movement, and muscle strength; ensure that the patient can void WITHOUT difficulty while documenting + reporting any changes

Spinal Cord Injury: Hyperextension Injury

occurs from a MVA (accident from behind)

Spinal Cord Injury: Hyperflexion Injury

occurs from a diving accident or MVA (head on accident)

Cervical Injury Immobilization

one of the first interventions performed to prevent secondary SCI including fixed skeletal traction for vertebral realignment or facilitation of bone healing (prevent further injury), halo fixation, cervical tongs, or Strker Frame (rotational bed); document + assess neurovascular status plus ensure adequate documentation to allow other staff members to be able to recognize any deterioration in neurological status

SCI Drug Therapy: Ca++ & Biphosphonates

osteoporosis prevention

Paraplegia

paralysis in ONLY the lower extremities

Tetra/Quadriplegia

paralysis of all four extremities

Multiple Sclerosis Types: Progressive-Relapsing

partial recovery but with frequent relapses, without return to baseline as recovery is only partial

Prevention of Low Back Pain & Injury: Williams Position

patient in Semi-Fowler's with a pillow under the knees or sitting in a recliner to assist patients with lower back pain become more comfortable

T6+ Injury

patient is at risk for respiratory distress AND pulmonary embolism during the FIRST FIVE DAYS of injury so assess breath sounds every 2-4 hours and manage secretions;

Prevention of Low Back Pain & Injury

prevention involves the use of safe manual holding practices with specific attention to body mechanics (when sitting too), assessing the need for assistance, regular exercise programs that strengthen the back (ex. swimming + walking), avoiding high-heeled shoes, use of good posture, NO prolonged sitting or standing (ex. foot stools), keep weight within 10% healthy range, ensure adequate Ca++ with Vitamin D supplementation, and STOP smoking plus tobacco use

Cervical Injury Immobilization: Halo Fixation

requires pin care with NS, skin assessment, use for 8-12 weeks, and NO adjustment; wrench needs to be taped to the vest in case it needs to be removed quickly (ex. CPR)

Post-Op Monitoring: Failed Back Surgery Syndrome (FBSS)

requires the placement of an implantable spinal cord stimulator; assess the patient below level of insertion, ensure voiding ability, and monitor for any changes in sensation, movement, or strength (REPORT ANY CHANGES)

Autonomic Dysreflexia Signs & Symptoms

signs & symptoms include severe hypertension, bradycardia, severe headache, nasal stuffiness, and sweating/flushing above the injury goos bumps

Multiple Sclerosis Types: Secondary Progressive

starts with Relapse-Remitting (#1), then becoming steadily progressive

ACDF Critical Rescue

the priority intervention for patients after this procedure includes maintaining an airway and ensuring that the patient has NO problem with breathing; swelling from the surgery can narrow the trachea (partial obstruction) or interfere with cranial innervation for swallowing (compromised airway or aspiration) --> open the patient's airway, sit the patient upright, suction PRN, provide supplement O2, notify the surgeon or RRT, and document assessment + interventions

DRUG ALERT with Interferons + Glatiramer Acetate

these SubQ injections can be self-administered, so patients should be taught how to give and rotate injection sites since local injection site reactions are common; the FIRST DOSE should be administered under medical supervision in oder to monitor for allergic responses (ex. anaphylactic shock) patients are also at risk for infection, so they also needed to be educated on staying away from crowds and report any signs/symptoms of infection

SCI Drug Therapy: Celebrex

treat Heterotopic Ossification (HO), but puts patients at risk for MI + stroke

Physical Assessment of MS: Intention Tremor

tremor when trying to perform activity (ex. holding onto a syringe while focusing on that activity increases the tremor)

Lumbosacral Back Pain (Low Back Pain)

usually occurs with issues between L4-L5, creating the importance of ergonomics

Quadriparesis

weakness of all four extremities

Drug Therapy for Multiple Sclerosis- Muscle Relaxers

works to improve mobility (ex. Zanaflex & Baclofen)

Secondary Spinal Cord Injury

an injury which worsens the primary injury such as hemorrhage, ischemia, hypovolemia (impaired perfusion), or local edema

Drug Therapy for Multiple Sclerosis

designed to treat a secondary infection due to impaired immunity (Relapsing MS) including Interferon Beta 1A & 1B, Novantrone, Monoclonal Antibodies, and muscle relaxers ALL of these medications impact the immune system, so patient education includes infection prevention

The nurse is preparing a plan of care for a client with a diagnosis of amyotrophic lateral sclerosis (ALS). On assessment, the nurse notes that the client is severely dysphagic. Which intervention should be included in the care plan for this client? Select all that apply. A. Provide oral hygiene after each meal. B. Assess swallowing ability frequently. C. Allow the client sufficient time to eat. D. Maintain a suction machine at the bedside. E. Provide a full liquid diet for ease in swallowing.

A. Provide oral hygiene after each meal. B. Assess swallowing ability frequently. C. Allow the client sufficient time to eat. D. Maintain a suction machine at the bedside.

Multiple Sclerosis Types

A. Relapsing-Remitting B. Primary Progressive C. Secondary Progressive D. Progressive-Relapsing

Ten days later the patient is to be discharged to a rehabilitation facility. The nurse understand which to be realistic initial priorities of care during rehabilitation? Select all that apply. A. Teaching self-care skills B. Working on mobility skills C. Bowel and bladder retraining D. Returning to pre-injury status E. Training caregivers to take over patient's care

A. Teaching self-care skills B. Working on mobility skills C. Bowel and bladder retraining

Pre-Operative Care for Surgical Management

brace fitting worn for 4-6 weeks after, vital signs, fever, hypotension, neurological checks, ROM, log rolling, voiding ability, pain control wound care, CSF check, VTE, exercise program immediately after discharge, pain relief right after surgery, JP emptying, and PCA pump education Sacral Spinal Nerve = NO urination in six hours after discharge

Multiple Sclerosis

chronic disease caused by immune, genetic, or infectious factors which affect the myelin nerve fibers of the brain & spinal cord with periods of remission + exacerbation; diagnosed by random/patchy areas of plaque in CNS White Matter

Common Complications of the Halo Device

common complications includes pin loosening, local infection, scarring, osteomyelitis, subdural abscess, and instability; implement pin-care, monitor vital signs for indication of infection, and report any changes to the PHCP

Multiple Sclerosis Types: Relapsing-Remitting

"classic MS" including symptoms that develop then resolve within a few weeks to months, and then following with a return to baseline

Respiratory SCI Assessment

concern especially for patients with a Cervical SCI resulting in immobility or spinal disruption to respiratory muscles; consult RT, C3-C4 may require intubation or a trach, and assess for SpO2 92% or less with adventitious breath sounds such as crackles which can indicate Pneumonia or atelectasis

The nurse is administering mouth care to an unconscious client. The nurse should perform which actions in the care of this person? Select all that apply. A. Position the client on his or her side. B. Use products that contain alcohol. C. Brush the teeth with a small, soft toothbrush. D. Cleanse the mucous membranes with soft sponges. E. Use lemon glycerin swabs when performing mouth care.

A. Position the client on his or her side. C. Brush the teeth with a small, soft toothbrush. D. Cleanse the mucous membranes with soft sponges.

Neurogenic Shock

defined as Spinal Shock with bradycardia, decreased or absent bowel sounds, warm/dry skin, hypothermia, and hypotension (hypovolemic shock) = EMERGENCY occurs from a disruption between Upper v. Lower motor neurons

Multiple Sclerosis Types: Primary Progressive

defined as a steady, gradual deterioration without remission or acute attacks (progressive disability)

Impaired Physical Mobility & Self-Care Deficit of SCI Patients (DVT)

SCI patients are at high risk due to pressure on their calf muscles, loss of skeletal muscle pump, and blood hypercoagulability (ex. Liquid/Xarelto)

Surgical Spinal Fusion

after the procedure, assess the patient's neurologic status and vital signs at least EVERY HOUR for 4-6 hours, and then every four hours as the patient becomes stable complications = worsening of motor/sensory function at or above surgical site

Management of Diplopia in MS

alternating eye patches can be used for relief

While the patient is monitored in the ED, which finding will the nurse immediately report to the provider? A. Unresolved headache B. Blood pressure of 90/70 mm Hg C. Neck pain of "5" on a 0-to-10 scale D. Increase in the Glasgow Coma Scale score

B. Blood pressure of 90/70 mm Hg can indicate a decrease in perfusion to the spinal cord

A patient with a spinal cord injury at C5-C6 reports a sudden severe headache. The patient is flushed. Vital signs include a blood pressure of 190/100 mm Hg and heart rate of 52 beats/min. What is the priority nursing intervention? A. Notify the health care provider. B. Place the patient in a sitting position. C. Check the patient for fecal impaction. D. Check the urinary catheter for kinks or obstruction.

B. Place the patient in a sitting position. (Autonomic Dysreflexia)

In assessing a patient with low back pain, which priority assessment question or statement will the nurse provide? A. "How long have you had back pain?" B. "How does your back pain affect your activities of daily living?" C. "Tell me about your pain and what interventions are helpful in managing your pain." D. "Have you ever had magnetic resonance imaging to find a cause for your back pain?"

C. "Tell me about your pain and what interventions are helpful in managing your pain." the priority assessment question helps the nurse more fully understand the patient's experience with pain and how the patient has attempted to address it

The nurse understands which of the following is a risk factor associated with the development of multiple sclerosis? A. Smoking B. High-fat diet C. Age greater than 70 D. Gender

D. Gender MS affects women 2-3 times more often than men, suggesting a possible hormonal role in disease development

Post-Op Monitoring

ambulation, back to work in 4-6 weeks, lifting maintained at five pounds, steri-strips until they fall off, moist heat, weight control, NSAIDS, assessment of Failed Back Surgery Syndrome, showering POD #3 or #4

SCI Surgical Management- Thoracic/Lumbar

management with steel and metal rods for immobilization (plus stabilization)

Management of Autonomic Dysreflexia

priorities for a patient with Autonomic Dysreflexia includes sitting them down while elevating the head of the bed as high as possible, putting legs down, medication administration to improve BP, checking bowel + bladder noxious stimuli

Paraparesis

weakness in ONLY the lower extremitie

Spinal Cord Injury: Axial Loading Injury

injury caused by force

Spinal Cord Injury

most commonly caused by C5 trauma

Complications of Lumbar Spinal Surgery: Persistent/Progressive Lumbar Radiculopathy

= nerve root pain interventions include reporting pain which does NOT respond to opioids, documenting nature + location of pain, and administering analgesics as prescribed

CASE STUDY: A 19-year-old man who was involved in a motor vehicle accident is brought to the ED. The patient was stopped at a red light when he was hit from behind by another vehicle traveling at 15 mph. The patient was placed in a cervical immobilizer by the paramedics. He is alert and oriented, states that his neck hurts, and is in no apparent distress. He currently rates his neck pain as a "5" on a 0-to-10 scale. Which assessment will the nurse perform first? A. Airway B. Circulation C. Sensory-motor D. Level of consciousness

A. Airway

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. A. Keeping the linens wrinkle-free under the client B. Preventing unnecessary pressure on the lower limbs C. Limiting bladder catheterization to once every 12 hours D. Turning and repositioning the client at least every 2 hours E. Ensuring that the client has a bowel movement at least once a week

A. Keeping the linens wrinkle-free under the client B. Preventing unnecessary pressure on the lower limbs D. Turning and repositioning the client at least every 2 hours

The next morning, the nurse notes that the patient's heart rate is 48/min and blood pressure is 78/66. His skin is warm and dry. What is the nurse's best first action? A. Notify the provider immediately. B. Raise the head of the bed to 45 degrees. C. Apply oxygen at 2 L per nasal cannula. D. Increase the IV rate from 50 to 75 mL/hr.

A. Notify the provider immediately. physician should be notified immediately because neurogenic shock is an emergency

T6+ Injury (Cough Assist/Quad Cough)

as the patient exhales, our hands are placed on the upper abdomen over the diaphragm below the ribs, pushing upward + inward to help expand the lungs --> cough

Conventional Open-Back Surgery

patient turned to work within 4-6 weeks with a lifting restricting and exercise plan

ACTION ALERT & Halo Devices

patients should NEVER be moved or turned by this device or have the screws adjusted; frequently check skin to ensure that the jacket is NOT causing pressure, monitor neurologic status for changes in movement or decreased strength, use a special wrench to loosen the vest during emergencies, tape the wrench to the vest for easy access, and sharp objects should NOT be used to relieve itching due to the risk of skin damage + infection

SCI Surgical Management

performed within the first 24 hours to prevent secondary complications, especially needed for decompression Decompressive Laminectomy = allows for cord expansion from edema

Autonomic Dysreflexia

potentially life-threatening condition which is the body's response to noxious visceral or cutaneous stimuli (ex. epididymitis, scrotal compression, hemorrhoids, temperature changes, restrictive clothing, SCDs, TED Hose wrinkles, ingrown toe nails) to cause a sudden, massive, and inhabited reflex sympathetic discharge; common in upper SCI injuries

Drug Therapy for Multiple Sclerosis- Interferon Beta 1A & 1B (ex. Fingolimod)

prescribed for antiviral effects while monitoring for bradycardia, flushing, GI disturbances, and a decreased WBC

Drug Therapy for Multiple Sclerosis- Novantone

prescribed to resolve relapse(s) BUT increases the patient's risk for Leukemia and cardiac issues due to cardiotoxicity

SCI Drug Therapy: Intrathecal Baclofen

programmable pump for spasticity, implanted to deliver into CSF with a SubQ pouch in the lower abdomen can cause SEIZURES OR HALLUCINATIONS if suddenly withdrawn also sedation, fatigue, dizziness