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Spinal cord injury ❍ 185
◆Injury to the cord between the T1 and L1 to L2 levels causes paraplegia; voluntary motor function of the arms remains intact; loss of some intercostal muscle innervation may impede ventilation and secre- tion removal
◆Injury to the cauda equina causes mixed loss of motor, sensory, bowel, bladder, and sexual function and depends on which roots are damaged
◆Injury to the sacral spinal nerves causes loss of bowel, bladder, and sexual function Spinal shock
◆Spinal shock is caused by sudden, severe spinal cord damage and initially produces fl accid paralysis;
arefl exia below the level of the lesion and loss of cutaneous and proprioceptive sensations occur in the fi rst few hours and may last for weeks
◆Recovery occurs over time; refl ex activity returns in 3 to 6 weeks; fl exion spasms affect paralyzed limbs 6 to 16 weeks after injury; alternating fl exion and extension spasms affect paralyzed limbs about 6 months after injury; extension spasms predominate after 6 months
Autonomic dysrefl exia
◆Autonomic dysrefl exia is a complication of complete spinal cord injury
◆Injuries at or above T6 present the greatest risk, but autonomic dysrefl exia has been observed in inju- ries occurring at the T8 level
◆Autonomic dysrefl exia is a clinical emergency and is caused by stimulation of the autonomic refl exes below the level of the lesion
◆Autonomic dysrefl exia causes decreased heart rate, pallor, pilomotor spasm (goose bumps and hair erection), and severe, persistent hypertension
◆Other fi ndings include blotchy skin, diaphoresis, fl ushing, nasal congestion, pounding headache, and vasodilation above the lesion
◆Autonomic dysrefl exia can be precipitated by various sensory stimuli, including a full bladder or rectum, painful stimuli (such as pressure on the skin, pressure ulcers, and surgical incisions), other skin stimulation (such as pressure on the glans penis or perianal or periurethral area), and visceral contrac- tions (such as bladder spasms and uterine contractions of pregnancy)
◆Treatment aims to control blood pressure while locating and removing the sensory stimulus Diagnosis and treatment
◆Diagnosis is based on anterior and lateral X-rays of the spine, CT scan, and MRI
◆Emergency life support is required to maintain vital function and avoid further injury; priorities include maintaining a patent airway; ensuring adequate ventilation (spontaneous or mechanical); main- taining adequate circulation; and performing neurologic assessments
◆To prevent further injury, the spine is immobilized with a cervical collar, cervical traction or cervical tongs (such as Gardner-Wells, Crutchfi eld, Barton, Cone, and Vinke), kinetic bed with cervical tongs for skeletal traction, halo brace with vest (for long-term use), or surgery (by means of Harrington rods, Weiss springs, laminectomy, or spinal fusion)
◆Clots, fragments, and tumors are surgically decompressed
◆A steroid is administered for the fi rst 24 hours after the injury to reduce edema and infl ammatory response
◆An analgesic and an opioid may be administered to control pain
◆A muscle relaxant is given to reduce muscle spasm
◆An antacid and an antihistamine are given to prevent gastric ulcers (traumatic events, such as spinal cord injury, can precipitate gastric ulcer formation)
◆Anticoagulant therapy is initiated to prevent deep vein thrombosis; therapy may include low doses of heparin, thigh-high antiembolism stockings (which compress superfi cial veins and prevent periph- eral blood pooling), and sequential pneumatic compression devices (which massage the veins, mimic muscle action, and prevent peripheral blood pooling and thrombus formation)
◆Rehabilitative management includes surgical release of tendons for persistent muscle spasm of para- lyzed muscles and surgical correction for cervical support (laminectomy and spinal fusions)
◆Rehabilitation referrals include those for occupational and physical therapies, nutritional counseling, social services, and psychiatric evaluation and assistance
Nursing interventions
◆Provide respiratory support for a patient with a spinal cord injury above L1 to L2; support ranges from deep-breathing exercises to diaphragmatic coughing (exertion of abdominal pressure during coughing) to mechanical ventilation
◆Continuously monitor and assess neurologic function to detect early signs of deterioration
◆Modify the patient’s environment to decrease dependence on others and increase his feelings of self-worth; discuss modifi cations with the patient and his family before discharge; modifi cations may include manual or electric wheelchairs, ramps, widened doorways, structural changes to bathroom facilities, and home care aides
◆Provide frequent and proper positioning, skin care, and proper hydration and nutrition to prevent complications of immobility
◆Teach the patient and his family about the recovery process, therapeutic and adverse effects of pre- scribed drugs, possible drug interactions, nutritional needs, exercise, bowel and bladder training, ways to prevent constipation and urinary tract infection, self-catheterization techniques, skin care, proper positioning, ways to avoid infection (especially respiratory infection), symptoms to report to the practi- tioner, and local support groups
◆Provide emotional support to the patient and family; permanent physical disabilities can be devastat- ing to self-concept, relationships, and lifestyle; emotional support, particularly from others with similar experiences, can facilitate healing
❖ Stroke
Description
◆Stroke is a disruption in cerebral circulation, causing permanent neurologic defi cits
◆An embolic stroke may result from atherosclerotic plaque, an embolism, or vasospasm
◆A thrombotic ischemic stroke occurs when the occlusion evolves from partial to complete and may be heralded by a transient ischemic attack
◆A hemorrhagic stroke may result from a ruptured or leaking aneurysm, an arteriovenous malforma- tion, a bleeding disorder, trauma, or an arterial rupture (as caused by hypertension)
Signs and symptoms
◆Symptoms of stroke vary with the affected artery (see Signs and symptoms of stroke)
◆Symptoms also vary according to the severity of the damage and the extent of collateral circulation Diagnosis and treatment
◆CT scan, MRI, cerebral arteriography, lumbar puncture, Doppler fl ow studies, and EEG may be used to diagnose stroke
◆Carotid endarterectomy removes plaque to improve cerebral blood fl ow
◆Surgical evacuation of the clot or hematoma relieves increased ICP
◆Although anticoagulants are contraindicated in a patient with a hemorrhagic stroke, they may be useful in a patient with a nonhemorrhagic thrombolytic event
◆An anticonvulsant is used to prevent or treat seizures
◆Tissue plasminogen activator can improve neurologic function when given within 3 hours of the onset of symptoms in a patient with a thrombotic stroke
◆An analgesic is used to relieve discomfort such as headache
◆An antihypertensive is used to lower blood pressure and, thus, prevent additional bleeding
◆A diuretic is used to lower blood pressure and reduce cerebral edema
◆Physical therapy and occupational therapy help maintain muscle and joint function while teaching the patient needed home management techniques
Nursing interventions
◆Provide emergency care; the patient may require lifesaving measures because of cardiopulmonary arrest triggered by the injury; administer oxygen, if needed, to promote oxygenation within the cerebral tissue
◆Maintain a patent airway; the patient may be unable to protect his airway because of impaired cough and gag refl exes and inability to support his head; suction the patient as necessary
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Stroke ❍ 187
◆Make sure the patient maintains bed rest until the cause of the stroke is known because activity can cause bleeding to recur
◆Position the patient to prevent deformity; loss of muscle tone leads to fl exion contractures; turn and position him every 2 hours to prevent pressure ulcers
◆Implement physical therapy to maintain strength and prevent contractures; provide passive ROM exercises to prevent venous thrombosis and contractures
◆Speak slowly and simply; the patient may not be able to understand rapid speech and may become confused
◆Monitor vital signs at least hourly until the patient’s condition is stable; alterations can indicate fur- ther injury
◆Assess neurologic status hourly until the patient’s condition is stable; early identifi cation and treat- ment of increased ICP (signs include abnormal posturing, bradycardia, decreased LOC, decreased motor response, increased systolic blood pressure, and widened pulse pressure) may prevent further injury
◆Monitor fl uid input and output hourly to ensure hydration until the patient’s condition is stable
◆Ensure nutritional status by helping the patient to eat or by providing enteral or parenteral feedings Middle cerebral artery
When a stroke occurs in the middle cerebral artery, the pa- tient may experience:
● altered level of consciousness (LOC)
● aphasia
● contralateral hemiparesis (more severe in the face and arm than in the leg)
● contralateral sensory defi cit
● dysgraphia
● dysphagia
● dyslexia
● visual fi eld cuts
Carotid artery
When a stroke occurs in the carotid artery, the patient may experience:
● altered LOC
● aphasia
● bruits over the carotid artery
● headaches
● numbness, paralysis, sensory changes, transient vision loss, and weakness on the affected side
● ptosis
Vertebrobasilar artery
When a stroke occurs in the vertebrobasilar artery, the pa- tient may experience:
● amnesia
● ataxia
● diplopia
● dizziness
● dysphagia
● numbness around the lips and mouth
● poor coordination
● slurred speech
● visual fi eld cuts
● weakness on the affected side
Anterior cerebral artery
When a stroke occurs in the anterior cerebral artery, the pa- tient may experience:
● confusion
● impaired motor and sensory function
● incontinence
● loss of coordination
● numbness and weakness on the affected side
● personality changes
Posterior cerebral arteries
When a stroke occurs in the posterior cerebral arteries, paralysis is usually absent; however, the patient may experi- ence:
● coma
● cortical blindness
● dyslexia
● sensory impairment
● visual fi eld cuts