chapter 45
Novantrone (Mitoxantrone)
+Antineoplastic agent effective for MS +Agent can cause CHF and life threatening dysrhythmias +A chemotherapy drug, has been shown to be effective in reducing neurologic disability. It also decreases the frequency of clinical relapses in patients with secondary progressive, progressive-relapses in patients with secondary progressive, progressive-relapsing, or worsening relapsing-remitting MS.
Pharmacologic Management for Clients with MS
+Corticosteroids - help decrease symptoms and induce remissions through anti-inflammatory effects +Prednisone (Orasone) +Solu-Medrol (Methylprednisolone drug of choice for acute exacerbations of MS
Cardiovascular/Respiratory
+Disruption of sympathetic fibers of the autonomic nervous system (above T6) +Bradycardia, hypotension, and hypothermia develop as a result of loss of sympathetic input, causing dysrhythmias +MUST teat BP <90 mm/Hg Systolic-lack of perfusion to spinal cord can worse condition +Lack of sympathetic and hypothermic control result in loss of thermoregulatory functions (thermostat is broken!) +Risk for breathing problems due to interruption of spinal innervation to respiratory muscles
Classification of SCI: Flexion Injury
+Forcefully accelerated, causing extreme flexion of neck +Posterior ligament tears, stretches or vertebrae fracture or dislocate causing hemorrhage, edema, and necrosis +Head on collision, diving accidents
Classification of SCI:Extension Injury
+Head is suddenly accelerated and then decelerated +Stretches or tears the anterior longitudinal ligament, fractures or subluxates the vertebrae, and could rupture a disc +Vehicle is struck from behind (whiplash), falls when chin is struck
Pathophysiology of MS
+Inflammatory response destroys myelin leading to axon dysfunction +Myelin sheaths of the spinal cord, brain and optic nerve are destroyed in patches, called plaques along the axon +Demyelination of nerve fibers slows and distorts conduction of nerve impulses or causes total absence of the impulse
Gastrointestinal/Genitourinary
+Look for internal bleeding-may result from trauma, stress ulcers, steroids +Monitor abdominal distention, pain and changes in bowel sounds-May develop and ileus from spinal shock +Neurogenic bladder (no reflex to contract bladder) develops due to autonomic dysfunction-puts patient at risk for UTI's (Foley catheter, bladder distention, stasis, overflow)
Long-Term complications
+Muscle wasting due to long term flaccid paralysis +Muscle spasticity which can lead to contractures +Pressure ulcers +Heterotopic ossification (Bony overgrowth, often into muscle)
Pathophysiology of MS
+Myelin sheaths are fatty, segmented wrappings that protect and insulate nerve fibers and increase the speed of transmission of nerve impulses +T cells which normally move in and out of the CNS remain in the CNS of clients with MS +T cells initiate an inflammatory response
Interventions for clients with ALS
+No specific treatment for the disease exists -Rilutek (Riluzole) antiglutamate --inhibits presynaptic release of glutamic acid in the CNS- protects neurons against excitotoxicity of glutamic acid
Amyotrophic Lateral Sclerosis: Charcteristics
+Progressive loss of motor neurons in both the cerebral cortex and the spinal cord until flaccid quadriplegia occurs +Atrophy of the hands, forearms and legs +Impairment of the respiratory muscles distinguishes it from MS +Results in paralysis and death
Assessments for clients with MS
+Vague and unrelated symptoms often dominate the early period of MS +Fatigue affects all clients with MS
Classification of SCI: compression injury
+Vertical compression +Vertebrae can shatter and pieces of bone can enter the spinal canal, damaging the cord +Diving accidents, falls on buttocks, extreme jump landing on their feet, blow to top of the head
Risk factors for back pain
+Younger than age 43 +Trauma-Acute back pain, the patient typically hyperflexes or twists the back during a vehicle crash, or the injury occurs when the patient lifts a heavy object. +Smoking-Linked to disk degeneration, possibly caused by contriction of blood vessels that supply the spine +Obesity-Increased stress on the back muscles +Congenital spinal conditions and scoliosis +Changes in support structures +Vascular changes +Osteoarthritis +Poor posture +Wearing high heeled shoes
Interventions for Back Pain-Muscle relaxants
+prescription of acetaminophen, muscle relaxants, and NSAIDs for acute LBP. +Flexeril
Typical clinical findings from assessment of the patients visual acuity, visual fields, and pupils include: 5
1. Blurred vision 2. Diplopia (double vision) 3. Decreased visual acuity 4. Scotomas (changes in peripheral vision) 5. Nystagmus (involuntary rapid eye movements)
Assessments for clients with MS :Brain lesions lead to CNS signs:
1. Emotional lability 2. Irritability 3. Changes in vision and coordination 4. Slurred speech 5. Ataxia 6. Diplopia 7. Nystagmus
Spinal Shock is characterized by 5 things
1. Flaccid paralysis 2. Loss of reflex activity below level of lesion 3. Bradycardia 4. Paralytic ileus 5. Hypotension
What is going on in autonomic Dysreflexia
1. Full bladder (urinary retention which may lead to UTI) 2. Nerve message blocked 3. Blood vessels constrict 4. Increased blood pressure 5. Brain senses increased blood pressure tells heart to slow down 6. Patient feels: nasal stuffiness, pounding headache, sweating above level of injury, flushing of the face and neck
4 primary mechanisms that may result in an SCI:
1. Hyper flexion 2. Hyperextension 3. Axial loading, or vertical compression 4. Excessive rotation
Emergency care of the patient experiencing autonomic dysreflexia: Immediate interventions
1. Place patient in sitting position (first priority) 2. Notify physician 3. Loosen tight clothing on the patient 4. Assess for and treat the cause 5. Check urinary catheter for kinks or obstructin 6. Check bladder distention for distention, and cath immediately if there is distention 7. Place anesthetic ointment on tip of catheter before insertion 8. Check the patient for fecal impaction; if present, disimpact immediately using anesthetic ointment. 9. Check the room temperature to ensure that it is not too cool or drafty. 10. Monitor blood pressure every 10 to 15 minutes 11. Give nitrates or hydralazine as prescribed
Early Clinical manifestations of Amyotrophic Lateral Sclerosis
1. Tongue atrophy 2. Weakness of the hands and arms 3. Beginning muscle atrophy of the arms 4. Fasciculations (twitching) of the face 5. Nasal quality of speech 6. Dysarthria (slurred speech) 7. Dysphagia (difficulty swallowing) 8 Fatigue while talking
Drugs to lessen muscle spasticity, 3
1. baclofen (Lioresal) 2. diazepam (Valium) 3. dantrolene sodium (Dantrium)
Interventions for Back Pain-Firm mattress
A firm mattress or a backboard placed under a soft matress may provide back support for some patients. A flat position is sometimes helpful for the patient with a muscle injury. However, a flat position may aggravate the pain caused by disk trauma or disease.
Dextran
A plasma expander, may be used to increase capillary blood flow within the spinal cord and to prevent or treat hypotension.
Glatiramer acetate (Copaxone)
A synthetic protein that is similar to myelin-based protein
Amyotrophic lateral sclerosis
ALS, aka Lou Gehrig's disease, is an adult-onset upper and lower motor neuron disease. IT is characterized by progressive weakness, muscle wasting, and spasticity that eventually leads to paralysis. Beginning in one area of the body, motor weakness and deterioration spread until the entire body is involved, including the ability to talk, swallow, and breathe. As a result of loss of lower motor neurons (LMNs) found in the spinal cord and brainstem, the muscles to which they connect weaken, atrophy, and die.
Amyotrophic Lateral Sclerosis; Amyotrophy, Lateral, Sclerosis
Amyotrophy-process of muscle atrophy Lateral- loss of nerves on each side of the spinal cord Sclerosis- hardened scar tissue when nerve cells die
Classification of Incomplete SCI
Anterior Cord Syndrome Motor, pain and temp are lost below the injury Touch, position, vibration are intact Patient can FEEL toes, but cannot MOVE toes
Drugs for bladder dysfunction (detrusor hyperreflexia)
Anticholinergic agents.
Assessment of Back Pain
Assess for pain and paresthesia and numbness (Tingling sensation) Inspect client's back for tenderness, swelling (Vertebral Alignment) Assess for loss of bowel/bladder control (Indicates sacral spinal nerve involvement) Check both extremities for sensation (May not be equal)
Initial assessment for SCI
Assessing the ABCs is priority, after an airway is established, assess the patients breathing pattern.
Autonomic Dysreflexia
Autonomic dysreflexia (hyperreflexia) Characterized by : Severe hypertension Bradycardia Severe headache Nasal stuffiness Flushing Caused by noxious stimuli Reflex vasoconstriction leading to hypertensive crisis
Other interventions for back pain
Avoid opioid analgesics, they are no more effective than NSAIDs +Heat/ice-Heat increases blood flow to affected are and promotes the healting of injuries. Applied for 20 to 30 minutes at least four times per day is often recommended. Hot showers or baths may also be beneficial. +Weight control
If demyelination of the spinal cord has occurred, findings include
Bowel and bladder dysfunctions. The patient may have an areflexic bladder or may experience frequency, urgency, or nocturia.
CRAB drugs for MS
C Copaxone R Rebif A Avonex B Betaserson Biologic Response Modifiers Delay disability and decrease the number of and severity of relapses Agents can cause thrombocytopenia, leukopenia,depression and injection site reactions
Natalizumab can also
Cause damage to hepatic cells. Carefully monitor liver enzymes and teach patients to have frequent laboratory tests to assess for changes.
Classification of Incomplete SCI
Central Cord Syndrome Loss of motor function in upper extremities
Sensory and motor assessment with a complete SCI
Changes include 1. Absence of tactie sensation 2. Flaccid paralysis (inability to move) of all voluntary muscles Use a cotton and pin
Penetrating injuries
Classified by the speed of the object causing the injury. Low-speed or low-impact injuries cause damage directly at the site or local damage to the spinal cord or spinal nerves. In contrast, high-speed injuries that occur from gunshot wounds cause both direct and indirect damage.
Pathophysiology of Spinal cord injury (SCI)-Complete and incomplete
Complete spinal cord injury-Is one in which the spinal cord has been severed or damaged in a way that eliminates all innervation below the level of the injury. Incomplete-Injuries that allow some function or movement below the level of the injury. They are more common.
Drug to improve walking ability and speed
Dalfampridine (Ampyra) a potassium channel blocker. It is not given to patients that have a history of seizures
Interventions for Back Pain (surgery)
Diskectomy-spinal nerve lifted to remove offending portion of disk
Axial loading injury
Driving accidents, falls on the buttocks, or a jump in which a person lands on the feet can cause many of the injuries. Vertical compression). Pieces of bone enter the spinal canal and damage the cord.
Teaching for self-management
Emphasize the importance of avoiding overexertion, stress, extremes of temperatures (fever, hot baths, overheating, and excessive chilling), humidity, and people with infections.
Treatment of diplopia and peripheral visual deficits
Eye patch for diplopia Teach scanning techniques by having the patient move his or her head from side to side.
Electromyography (EMG)
Findings may be grossly abnormal in people with advanced disease.
Clinical manifestations, fatigue
First, assess the patients ability to move. The patient often reports increased fatigue and stiffness of the extremities, particularly the legs. Fatigue is one of the most disabling manifestations, affecting almost all patients with MS. MS fatigue is associated with continuous sensitivity to temperature.
Clinical manifestations, Flexor spasms
Flexor spasms at night may awaken the patient from sleep. Further examination reveals increased or hyperactive deep tendon reflexes, positive Babinski's reflex, and absent abdominal reflexes. Gait may be unsteady because of leg weakness and spasticity due to cerebral motor strip damage.
Halo fixator
For spinal immobilization and stabilization. Is a static traction device.The metal halo ring may be attached to a plastic vest or cast when the spine is stable, allowing increased patient mobility. Fixed skeletal traction for immobilization of the cervical spine- in place for 8-12 weeks Common complications: Pin loosening Local infection Scarring Serious complications: Osteomyelitis Subdural abscess Instability Monitor vitals for indications of possible infection- fever, purulent drainage from pin sites and report changes immediately
Classification of SCI :Flexion-rotation Injury
Head is turned beyond normal range
Sensory findings
Hypalpesia (diminished sensitivity to pain), paresthesia, facial pain, and decreased temperature perception. The patient may report numbness, tingling, burning, or crawling sensations
Rehabilitation Medical and Nursing Care
Immobilization Respiratory dysfunction Cardiovascular instability Fluid and nutritional maintenance Bowel and bladder management Temperature control Sensory deprivation Impaired reflexes ------------------------------------------------------ Meticulous skin inspections to prevent pressure ulcers Autonomic loss results in orthostatic hypotension Need increased fluids and fiber Assume temp of environment due to vasoconstriction (need to control temp of the environment)
Fingolimod (Gylenya)
Immunomodulator. Capsule may be taken with or without food. +Teach patients to monitor their pulse every day because the drug can cause bradycardia, especially within the first 6 hours of taking it.
Interferon-beta (avonex, Betaseron, or Rebif)
Immunomodulators that modify the course of the disease and have antiviral effects.
Clinical manifestations, significant cerebellar findings
Include intention tremor (tremor when performing an activity), dysmetria (inability to direct or limit movement), and dysdiadochokinesia (inability to stop one motor impulse and substitute another). Motor movements are often clumsy. The patient may lose balance easily and may exhibit signs of poor coordination.
Incomplete Spinal Cord Injury
Incomplete: Results in mixed loss of voluntary motor activity and sensation below the level of injury
Spinal Cord Injury (SCI)
Initial injury Hemorrhage - microscopic bleeding into gray matter Edema - spreads along cord Vasospasm
Hyperextension
Injuries occur most often in car colisions in which the vehicle is struck from behind or during falls when the patients chin is truck. This stretches or tears the anterior longitudinal ligament, fractures or subluxates the vertebrae, and perhaps ruptures an intervertebral disk. As with flexion injuries, the spinal cord may easily be damaged.
Hyperflexion
Injury occurs when the head is suddenly and forcefully accelerated forward, causing extreme flexion of the neck. Either process may damage the spinal cord, causing hemorrhage, edema, and necrosis.
Treating bladder problems
Intermittent self-catheterization program, indwelling urinary catheter, or insertion of a bladder pacemaker, the bladder is stimulated and voiding is initiated. Remind the patient to drink plenty of water unless contraindicated.
Multiple sclerosis (MS)
Is a chronic autoimmune disease that affects the myelin sheath and conduction pathway of the central nervous system (CNS). It is characterized by periods of remission and exacerbation. PowerPoint-Chronic, progressive degenerative disease that affects the myelin sheath of the brain and spinal cord from viruses, allergies, or an autoimmune response.
Ziconotide (Prialt)
Is a drug used for severe chronic back pain. It is in the class called N-type calcium channel blockers. NCCBs seem to selectively block calcium channels on those nerves that usually transmit pain signals to the brain. +Should not be given to patients with severe mental health/behavioral health problems because it can cause psychosis.
Warning about Natalizumab
Is given IV infusion in physicians office. Patients receiving this drug are at a high risk for progressive multifocal leukoencephalopathy (PML). This opportunistic viral infection leads to death or severe disability. Monitor for neurologic changes, especially changes in mental state, such as disortientations or acute confusion. PML is confirmed by an MRI and examining the cerebrospinal fluid for the causative pathogen.
Riluzole (Rilutek)
Is the only dur gapproved by the FDA for use with ALS. IT is not a cure, but does extend survival time. Teach patients to take without food and when stomach is empty.
Spinal manipulative therapy
Is to promote alignment and prevent or treat pressure on nerve roots.
Drug therapy for severe hypotension
Is treated with inotropic and sympathomimetic agents such as dopamine hydrochloride (intropin) and isoproterenol
Atropine sulfate
Is used to treat bradycardia if the pulse rate falls below 50 to 60 beats per minute.
CT scan
May show an increased density in white matter and MS plaques.
Classification of Incomplete SCI: Posterior Cord Syndrome
Motor function is intact Loss of touch, position, vibration below level of injury Patient can MOVE toes, but can't FEEL toes
Classification of Incomplete SCI: Brown-Sequard Syndrome
Motor function, proprioception and deep touch lost on same side as injury Pain, temp and light touch are lost on opposite side
Rehabilitation Medical and Nursing 2
Neurogenic bladder- use valsalva maneuver and check post void residual, some need intermittent cath several times per day, some need indwelling catheter Risk for renal complications (hydronephrosis, renal failure, kidney stones, UTI's) These patients may not feel symptoms of infection (dysuria, urgency, back pain) Bowel schedule- include stool softeners and high fiber diet, increased fluids Digital stimulation ONLY if requested by healthcare provider- could cases vagal response (bradycardia, syncope)
Neurogenic Shock
Neurogenic shock May occur within the first 24 hours after injury Characterized by hypotension and bradycardia Associated with cervical spine injuries and caused by loss of autonomic function
NURSING SAFETY PRIORITY for Halo fixator
Never move or turn the patient by holding or pulling on the halo device. Do not adjust the screws holding it in place. Check the patients skin frequently to ensure that the jacket is not causing pressure. Pressure is avoided if one finger can be inserted easily between the jacket and the patients skin. Monitor the patients neurologic status for changes in movement or decreased strength.
Lab assessment
No single specific procedure is definitively diagnostic for MS. CSF shows elevated proteins, WBC cells and IgG bands due to the immune response CT scan shows atrophy and white matter lesions
TLSO Brace:
Nonsurgical treatment for thoracic and lumbosacral injuries +Custom fit, prevents prolonged periods of immobility
NURSING SAFETY PRIORITY, observing a patient with an upper SCI (above T6)
Observe for signs of autonomic dysreflexia (hyperreflexia). Although it does not occur frequently, autonomic dysreflexia is an excessive, uncontrolled sympathetic output. It is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause of this syndrome is a noxious stimulus--usually a distended bladder or constipation. This must be treated ASAP, to prevent stroke.
Rehabilitation Medical and Nursing
Ongoing Rehabilitation Neurogenic bladder Bowel management Sexuality and intimacy Grief Shock Anger Depression Adjustment
Level of injury: L1
Paraplegia
Level of injury: T6
Paraplegia
When a patient is sitting in a chair and paraplegic patients
Patient is repositioned or taught to reposition themselves more often than every hour. +Paraplegic patients usually perform frequent "wheel-chair push-ups" to relieve skin pressure. Special pressure-relief devices such as gel pads or cyclic pressure-relief devices may be used in the wheelchair or the bed, but these tools do not eliminate the need for regular turning or repositioning.
When giving antiepilpetics, what should we monitor for
Patients should be monitored very carefully for symptoms of hyponatremia, including generalized skeletal muscle weakness, headache, dizziness, and diarrhea.
Managing urinary and bowel elimination
Patients with SCIs have reflex or neurogenic loss of bowel and bladder control. Patients with flaccid bladders may achieve emptying of the bladder by performing a Valsalva maneuver or tightening the abdominal muscles. +Teach the patient that the essential elements of a bowel program include stool softeners, increased fluid intake, high-fiber diet, and a consistent time for elimination. +Rectal digital stimulation is done only if requested by the healthcare provider.
Flexion Exercises
Pelvic tilt: Lying on your back with your knees bent, tighten your abdominal muscles to push your lower back against the mat Semi-sit-ups: Lying on your back with your knees bent, raise your upper body at a 45-degree angle and hold this position for 5 to 10 seconds Knee to chest: Lying on your back with your knees bent, tighten your abdominal muscle sto push you lower back against the mat.
Pathophysiology of SCI
Petechial hemorrhage into the central gray matter and later into the white matter may result. Edema occurs when the cord is compressed by hemorrhage or body fragments. Hemorrhage and loss of blood vessel tone after severe cord injury may result In hypovolemia. Neurogenic shock may occur.
Physical therapy and MS
Plan an exercise program that includes ROM exercises and stretching and strengthening exercieses. Emphasize the importance of avoiding rigorous activities that increase body temperature.
Prevention of Back Pain
Proper body mechanics +Good posture +Avoid prolonged sitting or standing +Regular exercise +Keep weight within 10% of ideal body weight +Stop smoking +No high heels
Treatment of cerebellar ataxia (2 drugs)
Propranolol hydrochloride (Inderal) and clonazepam (Klonopin)
If the sciatic nerve is compressed
Severe pain occurs when the patients leg is held straight and lifted upward.
Extension Exercises
Stomach lying: Lie face down with a pillow under your chest; lift legs straight up Upper trunk extension: Lie face down with your arms at your sides, and lift your head and neck Prone push-ups: Lie face down on a mat and, keeping your body stiff, push up to extend your arms.
NURSING SAFETY PRIORITY for tricyclic antidepressants
Teach older adults and their families to monitor for side and adverse effects of tricyclic antidepressants, including urinary retention, constipation, dry mouth, drowsiness, and acute confusion. Instruct them to notify their health care provider to report these changes, but do not stop these drugs abruptly.
NURSING SAFETY PRIORITY, for interferon-beta and glatiramer acetate injections
Teach patients how to give and rotate the site of interferon-beta and glatiramer acetate injections because local injection site (skin) reactions are common. The first does of these drugs is given under medical supervision to monitor for allergic response, including anaphylactic shock. Teach patients receiving these drugs to avoid crowds and people with infections. Remind them to report any signs or symptom associated with infection immediately.
Level of Injury: C4
Tetraplegia
Level of injury: C6
Tetraplegia
What may occur in SCI
Tetraplegia (quadriplegia) paralysis and quadriparesis (weakness) involve all four extremities, as seen with cervical cord and upper thoracic injury. Paraplegia (paralysis) and paraparesis (weakness) involve only the lower extremities, as seen in lower thoracic and lumbosacral injuries or lesions.
Natalizumab (Tysabri)
The first monoclonal antibody approved for MS that binds to WBCs to prevent further damage to the myelin.
Interventions for Back Pain-Williams position
The paitent lies in the semi-fowlers position with a pillow under the knees to keep them flexed or sits in a recliner chair. This position relaxes the muscles of the lower back and relieves pressure on the spinal nerve root.
Rehabilitation Medical and Nursing Care
The patient with an SCI is especially at risk for pressure ulcers, contractures, venous thromboembolism (deep vein thrombosis and/or pulmonary embolus), and fractures related to osteoporosis. Patients with high SCIs are also at risk for orthostatic hypotension. ++Proper positioning not only helps prevent complications but also provides alignment to prevent further spinal cord injury or irritability.
Drug therapy-Methylprednisolone (Solu-Medrol)
This drug decreases inflammation, such as that caused by injury to spinal cord and nerve tissue. Monitor the patient receiving IV methylprednisolone closely for adverse drug events, including infection, elevated serum glucose, and stress ulcers. +In combination of cyclophosphamide (Cytoxan) and methylprednisolone may be used for some patients to stab
Amyotrophic Lateral Sclerosis: causes
Unknown May be related to increased levels of glutamate 10% have inherited form of the disease Viral infection creates a disturbance in motor neurons Autoimmune response
Upper motor neurons lower motor neurons
Upper motor neurons send messages from the brain to the spinal cord, and lower motor neurons send messages from the spinal cord to the muscles. Motor neurons are an important part of the body's neuromuscular system.
Chronic back pain interventions
Use antiepileptic such as Neurontin (gabapentin) or oxcarbazepine (Trileptal) to treat neuropathic (chronic nerve) pain. Start the patient on a low does, the does is gradually titrated until pain relief is achieved, the dose is not greater than the provider recommends, and the patient does not experience side effects.
Secondary injury, 4
Worsens the primary injury. They include: 1. Hemorrhage 2. Ischemia (lack of blood flow) 3. Hypovolemia (decreased circulating blood volume) 4. Neurogenic shock (a medical emergency)
Treatment of paresthesia
carbamazepine (Tegretol) or tricyclic antidepressants
MRI
demonstrates the presence of plaques and is considered diagnostic for MS
PET scan
measures brain activity. Shows changes in glucose metabolism in the brain
Spinal shock
occurs immediately as the cords response to the injury. The patient has complete but temporary loss of motor, sensory, reflex, and autonomic function that often lasts less than 48 hours but may continue for several weeks. Muscle spasticity, reflex activity, and bladder function begin in patients with cervical or high thoracic injuries when spinal shock is resolved. Occurs immediately after injury as a result of disruption in communication pathways between upper and lower motor neurons May last from days to months Reversal is indicated by return of reflex activity
Cause of ALS
unknown, but is likely due to interactions of genetic, viral, and environmental factors. -More common in men, death occurs 2-5 years after the onset -Age of onset is between 40 and 70 yrs
