Spinal cord injury—Nursing process: The patient with acute spinal cord injury
-- S/S: Loss of movement/sensation, loss of bowel/bladder control, hyper/exaggerated reflex or spasms, changes in sexual function and fertility, pain or stinging sensation, difficulty breathing, coughing or clearing secretions -- Immobilize patient. Administer respiratory therapy to prevent progressive neurological deficits due to hypoxemia. -- Assess motor and sensory functions, signs of decreased neurological function, and spinal shock (complete loss of reflexes, motor, sensory, and autonomic activity). -- Palpate lower abdomen for signs of urinary retention and overdistention of the bladder. Assess for gastric dilation and paralytic ileus, as a result of autonomic disruptions. -- Patient may have periods of hyperthermia as a result of altered temp. Control. -- Orthostatic hypotension is common for the first 2 weeks after SCI because B/P is unstable and can be low. -- Nursing Goals: improve breathing pattern and airway clearance, improve mobility, prevent injury due to sensory impairment, maintain skin integrity, relieve urinary retention, improve bowel function, decrease pain, recognize signs of autonomic dysreflexia, and prevent/manage further complications such as muscle spasticity, and disuse syndrome. ** Autonomic dysreflexia- life-threatening emergency - occurs after spinal shock. S/S: severe pounding headache, HTN, diaphoresis (above spinal level lesion), nausea, nasal congestion, bradycardia. -Autonomic dysreflexia is typically caused by urinary retention/ distended bladder) -- Always check SCI patients for signs of urinary retention!!! Muscle spasticity is treated with Baclofen (most common), Valium, Botulinum toxin (Botox) -- Tumors cause inflammation, compression, and infiltration of tissue causing: increased ICP and cerebral edema, seizure activity, hydrocephalus, altered pituitary function. -- Primary tumors progress locally and rarely metastasize outside the CNS; Secondary or metastatic tumors, develop from structures outside the brain (more common than primary brain tumors). -- Elderly are more likely to develop primary brain tumors with an increase in malignancy. Often the s/s are overlooked as normal signs of aging. Brain Tumors
-- S/S: New onset of headaches, N/V, visual disturbances (papilledema - swelling of the optic nerve), seizures (occur in 60% of patients), language disturbances (aphasia), alteration in cognition, alterations in sensory or motor abnormalities, personality or behavior changes, and symptoms of ICP. -- Medical management: Radiation, chemo, surgery (post surgery do not give anything that could decrease neuro status (i.e. acetaminophen for pain), and pharmacology therapy - dexamethasone -- Assessment: neurologic exam, and address symptoms that decrease quality of life (pain, incontinence, impaired skin integrity, loss of vision and speech, impaired mobility, and temp regulation).