spinal cord injury, herniated disc & spinal cord tumors

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Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors Chris Puglia, MSN, RN, CEN

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Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors. Chris Puglia, MSN, RN, CEN. Objectives. Consider the risk factors, signs & symptoms, diagnostic tests, complications, and treatments of: Spinal cord injury Herniated disc Spinal cord tumors Prioritize nursing diagnoses - PowerPoint PPT Presentation

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Page 1: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Spinal Cord Injury, Herniated Disc &

Spinal Cord Tumors

Chris Puglia, MSN, RN, CEN

Page 2: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Objectives

• Consider the risk factors, signs & symptoms, diagnostic tests, complications, and treatments of:– Spinal cord injury– Herniated disc – Spinal cord tumors

• Prioritize nursing diagnoses• Discuss legal and ethical issues• Case study/questions

Page 3: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Spinal Cord ProtectionBones- vertebral column7 Cervical12 Thoracic5 Lumbar5 Sacral

Discs- between vertebra

Page 4: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nervous System and the Spinal Cord

• ANS can be affected by

Spinal Cord Injury (SCI)• Sympathetic chains on

both sides of the spinal column (T1-L2)

• Parasympathetic nervous system is the cranial-sacral branch (brainstem, S2-4)

• Reflex Arc

Page 5: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Etiology of Traumatic SCI

• MVC: most common cause• Other: falls, violence, sport injuries• SCI typically occurs from indirect injury from

vertebral bones compressing cord • SCI frequently occur with head injuries• Cord injury may be caused by direct trauma

from knives, bullets, etc

Page 6: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Spinal Cord Injury- SCI

• Compression• Interruption of blood supply• Traction• Penetrating Trauma

Page 7: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Spinal Cord Injury• Primary

– Initial mechanism of injury• Secondary

– Ongoing progressive damage• Ischemia• Hypoxia• Microhemorrhage• Edema

• Hemorrhage and edema occur in the cord post injury, causing more damage to cord

• Extension of the cord injury from cord edema can occur over the first few days– watch the phrenic nerve

Page 8: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Spinal Shock

– Decreased reflexes and loss of sensation below the level of injury

– Motor loss: flaccid paralysis below level injury– Sensory loss: loss touch, pressure, temperature

pain and proprioception perception below injury– Lasts days to months

Page 9: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Neurogenic ShockDue to loss of vasomotor tone

SNS loss results in parasympathetic dominance with vasomotor failure

Loss of SNS innervation causes peripheral pooling and decreased cardiac output

Hypotension and Bradycardia Orthostatic hypotension and poor temperature

control (poikilothermic)

Page 10: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors
Page 11: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classifications of SCI• Mechanism of Injury (MOI)• Skeletal and Neurologic Level• Completeness (degree) of Injury

Mechanism of Injury1. Flexion2. Hyperextension 3. Compression4. Flexion /Rotation

Page 12: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classifications of SCIMechanism of Injury

Flexion (hyperflexion)• Most common because of

natural protection position. • Generally cause neck to be

unstable because stretching of ligaments

Page 13: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classifications of SCIMechanism of Injury

Hyperextention• Caused by chin hitting a

surface area, such as dashboard or bathtub

• Usually causes central cord syndrome symptoms

Page 14: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classifications of SCIMechanism of Injury

Compression• Caused by force from above

– Such as hit on head– Or from below as landing on

butt

• Usually affects the lumbar region

Page 15: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors
Page 16: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classification of SCILevel of Injury

Spinal cord level

When referring to spinal cord injury, it is the reflex arc level (neurologic)not the vertebral or bone level

The thoracic, lumbar & sacral reflex arcs are higher than where the spinal nerves actually leave through the opening of vertebral bone

Page 17: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classifications of SCICompleteness (Degree) of Injury

• Complete• Incomplete– Central cord syndrome– Anterior cord syndrome– Brown-Sequard syndrome– Posterior cord syndrome– Cauda Equina and Conus Medullaris

Page 18: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classification of SCICompleteness (degree) of Injury

Complete (transection)• After spinal shock: • Motor deficits – Spastic paralysis below

level of injury• Sensory– Loss of all sensation

perception• Autonomic deficits– Vasomotor failure and

spastic bladder

Page 19: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classification of SCICompleteness (degree) of Injury

Incomplete

Central Cord Syndrome

• Injury to the center of the cord by edema and hemorrhage

• Motor weakness and sensory loss in all extremities

• Upper extremities affected more

Page 20: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classification of SCICompleteness (degree) of Injury

Incomplete Brown-Séquard Syndrome

• Hemisection of cord• Ipsilateral paralysis• Ipsilateral superficial

sensation, vibration and proprioception loss

• Contralateral loss of pain and temperature perception

Page 21: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classification of SCI Completeness (degree) of Injury

IncompleteAnterior Cord Syndrome

• Injury to anterior cord • Loss of voluntary motor,

pain and temperature perception below injury

• Retains posterior column function (sensations of touch, position, vibration, motion)

Page 22: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classification of SCICompleteness (degree) of Injury

IncompletePosterior Cord Syndrome

• Least frequent syndrome• Injury to the posterior

(dorsal) columns • Loss of proprioception• Pain, temperature,

sensation and motor function below the level of the lesion remain intact

Page 23: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classification of SCICompleteness (degree) of Injury

Incomplete

Conus MedullarisInjury to the sacral cord

(conus) and lumbar nerve roots

Cauda EquinaInjury to the lumbosacral

nerve roots Result = areflexic (flaccid)

bladder and bowel, flaccid lower limbs

Page 24: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Clinical Manifestations of SCI

• Skin: - pressure ulcers

• Neuro: - pain - sensory loss- upper/lower motor

deficits- autonomic dysreflexia

• Cardio: - dysrhythmias- spinal shock- loss of SNS control over

blood vessels- orthostatic hypotension, - poikilothermic

Page 25: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Clinical Manifestations of SCI

• Respiratory:– decrease chest

expansion, cough reflex & vital capacity

– diaphragm function-phrenic nerve

• GI:– stress ulcers– paralytic ileus– bowel- impaction &

incontinence

• GU:– upper/lower motor

bladder– impotence– sexual dysfunction

• Musculoskeletal:– joint contractures– bone demineralization– osteoporosis– muscle spasms– muscle atrophy– pathologic fractures– para/tetraplegia

Page 26: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors
Page 27: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestation/Complications

Upper and Lower Motor Deficits

• Upper motor deficits result in spastic paralysis

• Lower motor deficits result in flaccid paralysis and muscle atrophy

Page 28: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestations/Complications• Spinal cord injuries are described by the level of the injury – the cord segment or dermatome level– such as C6; L4 spinal cord injury

• Terms used to describe motor deficits– Prefix: • para- meaning two extremities• tetra- or quadra- all four extremities

– Suffix:• -paresis meaning weakness • -plegia meaning paralysis

Quadraparesis means what?

Page 29: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestations/Complications

• C1-3 = usually fatal• Loss of phrenic innervation

= ventilator dependent• No B/B control• Spastic paralysis• Electric w/c with

chin/mouth control

Page 30: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestations/Complications

• C6 = weak grasp• Has shoulder/biceps to

transfer & push w/c• No bowel/bladder control • Consider level of

independence

Page 31: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestations/Complications

• T1-6 = full use of upper extremity

• Transfer self• Drive car with hand controls

and do ADL’s• No bowel/bladder control

Page 32: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Immediate Care

Emergency Care at Scene, ED & ICU

• MOI• Transport with cervical

collar (LOG ROLL)• Assess ABC’s

– Suction PRN/Airway– O2

– BVM/Intubate

• IV x2 large bore• Foley• CMS

Page 33: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Diagnostic Studies for SCI

• X-ray of spinal column• CT with and/or without

contrast (depends on MOI)• MRI• Lab work• Blood gases

Page 34: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Therapeutic Interventions

• Medications• IV methylprednisolone (Solu-Medrol) within 8 hrs to

decrease cord edema• Controversial!!

Page 35: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Therapeutic Interventions

• Medications • To control or to prevent complications of SCI and

immobility:– Vasopressors to maintain perfusion– Histamine H2 blockers to prevent stress ulcers

– Anticoagulants– Stool softeners– Antispasmodics

Page 36: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Therapeutic Interventions

Stabilization/Immobilization

TractionGardner-wells tongsHalo

CastsSplintsCollarsBraces

Page 37: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Therapeutic Interventions

Surgery for SCI

• Manipulation to correct dislocation or to unlock vertebrae

• Decompression laminectomy

• Spinal fusion• Wiring or rods to hold

vertebrae together

Page 38: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing ManagementAssessment

• HEALTH HISTORY (SAMPLE)• Description of how and when injury occurred (MOI)• Other illnesses or disease processes• Ability to move, breathe, and associated injury such

as a head injury, fractures

Page 39: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Management Assessment

PHYSICAL EXAM

• LOC and pupils– may have indirect SCI from head injury

• Respiratory status– phrenic nerve (diaphragm) and intercostals; lung

sounds• Vital signs• Motor• Sensory• Bowel and bladder function

Page 40: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing ManagementAssessment

Motor Assessment Upper Extremity

Movement, strength and symmetry

Hand grips

Flex and extend arm at elbowwith and without resistance

Page 41: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Management Assessment

Motor Assessment Lower Extremity

• Flex and extend leg at knee – with and without resistance

• Planter and dorsi flexion of foot

• Assess for Clonus

Page 42: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Management Assessment

Sensory assessment

• With the sharp and dull ends of a paperclip have the individual, with their eyes closed identify

• Use the dermatome as reference to identify level

• C6 thumb; T4 nipple; T10 naval

Page 43: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Problems/Interventions

• 1.Impaired mobility• 2.Impaired gas exchange• 3. Impaired skin integrity• 4. Constipation• 5. Impaired urinary elimination• 6. Risk for autonomic dysreflexia• 7. Ineffective coping

Page 44: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

1. Impaired Physical Mobility

• Log roll as a single unit; provide assistance as needed to keep alignment; teach patient

• Care traction, collars, splints, braces, assistive devices for ADL’s

• Flaccid paralysis- use high top tennis shoes or splints to prevent contractures. Remove at least every 2 hrs for ROM (active ROM best)

Page 45: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

1. Impaired Physical Mobility

• Spastic Paralysis– Prevent spasms by avoiding: sudden movements

or jarring of the bed; internal stimulus (full bladder/skin breakdown; use of footboard; staying in one position too long; fatigue)

– Treat spasms by decreasing causes; hot or cold packs; passive stretching; antispasmodic medications

• Assess skin breakdown & thrombophlebitis; remove TED hose at least every shift

Page 46: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

1. Impaired Physical Mobility• Prevent/treat orthostatic hypotension – Abdominal binder, calf compressors, TED hose

when individual gets up– Assess BP, especially when rising

– Teach use of transfer board– Assist Physical Therapy with tilt table as individual

gradually gets use to being in an upright position

Page 47: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

2. Impaired Gas Exchange

• Phrenic nerve (C3-5) controls the diaphragm bilaterally. If nerve is nonfunctioning then individual is ventilator dependent.

• Thoracic nerves control the intercostals muscles for breathing and abdominal muscles aide in breathing and coughing

Page 48: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

2. Impaired Gas Exchange

• Respiratory rate, rhythm, depth, breath sounds, respiratory effort, ABG’s, O2 saturation

• Signs of impending extension of SCI up cord to phrenic nerve level (C3-5)

• Need for ventilatory assistance (tracheotomy, ventilator )

• Quad cough (assistive cough) as needed

Page 49: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

3. Impaired Skin Integrity

• Change position frequently• Protection from extremes in temperature• Inspect skin at least 2x/day especially over boney

prominences• Avoid shearing and friction to soft tissue with

transfers• Removal of TED hose every 8 hours/SCDs• Nutritional status

Page 50: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

4. Constipation

• Bowels rely more on bulk than on nerves• Stimulate bowels at the same time each

day. Best after a meal when normal peristalsis occurs

• Individual may progress from Dulcolax suppository to glycerin then to gloved finger for digital stimulation

• Assess bowel sounds prior to giving food for the first time– paralytic ileus!

Page 51: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

5. Impaired Urinary Elimination

Flaccid bladder (lower motor neuron lesion) - No reflex from S2,3,4- Automatic empting of bladder - Urine fills the bladder and dribbles out- Need Foley or freq intermittent self catheterization

Spastic bladder (upper motor neuron lesion) - Reflex arc but no connection to or from brain - Reflex fires at will - Bladder training- trigger points to stimulate empting; self

catheterization

Page 52: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

5. Impaired Urinary Elimination

• Use bladder scan to see amount of urine in bladder • Goal = residual <100ml/20% bladder capacity• Some individuals may need suprapubic catheter• Assess effectiveness of medication – Urecholine to stimulate bladder contraction– Urinary antiseptic

Page 53: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

6. Risk for Autonomic Dysreflexia

• SCI above T6 • Results in loss of normal compensatory

mechanisms when sympathetic nervous system is stimulated

• Life threatening! • If goes unchecked BP can result in cerebral

hemorrhage

• Vasodilatation symptoms above SCI• Vasoconstriction symptoms below SCI

Page 54: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors
Page 55: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

7. Ineffective Coping/Grief and Depression

• Assess thoughts on ‘quality of life’; body image; role changes

• Physical and psychological support• Most common SCI is 15-30 year old males and

generally risk takers– This greatly affects their perception of life and

rehabilitation

Page 56: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

7. Ineffective Coping/Sexuality

Male• UMN lesion

– reflexogenic (S2,3,4) erections

• LMN lesion – psychogenic erections

(psychological stimulation)

• Ejaculation/fertility may be affected

Female• Hormones more than

nerves regarding fertility • C-section because of chance

for autonomic dysreflexia during labor

• Lack of sensation/movement affects sexual performance

Page 57: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

7. Ineffective Coping/Sexuality

• Assess readiness/knowledge/your ability to teach• Use proper terminology• Suggestions: – empty bladder before sex– withhold fluids and antispasmodics– certain positions may increase spasms– explore new erogenous zones– penile implants

• Refer to specially trained counselor

Page 58: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Home Care

• Assess psychological & physiological resources• Need for rehabilitation (in-house or out

patient)• Need for community resources

• Home assessment

Page 59: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

What’s new in SCI treatment?

Superman breather Superman BreatherSuperman Breather

• Kevin EverettHypothermia for SCI

Travis Roy11 SecondsTravis Roy B.U.

Stem Cell treatment for SCI Lipitor for SCI

Page 60: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

CASE STUDY

• Patient Profile– Mr. Porter is a 19-year-old man with a spinal cord

injury (paraplegic), status post gunshot wound to the lumbar spine. His accident was 4 months ago, and he is in the rehabilitation unit.

Page 61: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

• Subjective Data– States he is depressed and “is getting used to the idea of not walking

again”• Objective Data• Physical Examination • Vital signs: supine blood pressure 120/68, sitting blood pressure 114/62,

pulse 68, temperature 99º F, respirations 16 • Apical pulse: 69• Slight edema bilateral lower extremities • Urine dark yellow in drainage bag • Last bowel movement yesterday• Coccyx with 2 cm red area• Right heel with 1 cm red area• Full passive range of motion in the bilateral lower extremities without

crepitation• Full active range of motion in the bilateral upper extremities without

crepitation • No sensation in bilateral lower extremities, normal sensation bilateral

upper extremities

Page 62: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

• Diagnostic Studies • White blood cells: 9500/µl• Hemoglobin: 16 g/dl• Hematocrit: 45%

Page 63: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Critical Thinking Questions

– What is the primary nursing concern for this patient?

– What nursing interventions are appropriate for impaired skin integrity?

– Based on all of the assessment data, what are other nursing priorities?

– What are appropriate nursing diagnoses for a patient with paraplegia?

Page 64: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Herniated Discs

Page 65: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Herniated Disc

Herniated nucleus pulposus, (HNP) slipped disc, ruptured disc

HNP- annulus becomes weakened/torn and the nucleus pulposus herniates through it

Risk FactorsStanding erectAging changesPoor body mechanicsOverweightTrauma

Page 66: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestations/Complications

• HNP compresses– Spinal nerve (sensory or

motor component) as it leaves the spinal cord

– Or the cord itself (the white tracts within the cord) • rare

Page 67: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestations/Complications

Sensory root or nerve usually affected pain, parenthesis, or loss of sensation

Motor root or nerve may be affected paresis or paralysis

Manifestations depend on what nerve root, spinal nerve is being

compressed– which dermatomesRadiculopathy

pathology of the nerve root

Page 68: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestations/Complications Lumbar HNP

Most common site for HNPL4-5 disc- the 5th lumbar nerve rootposterior sensory nerve or root compressed

Classic symptomslow back / sciatica painpain increases with increase in intrathoracic pressure

Herniated disc L4-L5

Page 69: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Other Symptoms Lumbar HNP

• Postural changes• Urinary/male sexual function changes• Paresis or paralysis• Foot drop• Paresthesias• Numbness• Muscle spasms• Absent cord reflexes

Page 70: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestations/Complications Cervical HNP

C5-C6 disc- affects the 6th cervical nerve root

• Pain- neck, shoulder, anterior upper arm to thumb

• Absent/diminished reflexes to the arm• Motor changes- paresis or paralysis• Sensory- paresthesias or pain• Muscle spasms

Page 71: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Therapeutic Interventions Diagnostic Tests

• X-ray – identify deformities

and narrowing of disk space

• CT• MRI• Myelogram• Nerve conduction

studies (EMG) – detect electrical

activity of skeletal muscles

Page 72: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Treatment: Conservative

Bed rest with firm mattress log roll side lying position with knees bent and pillow

between legs to support legsAvoid flexion of the spine

brace/corset, cervical collar to provide supportMedications

non-narcotic analgesics, anti-inflammatory, muscle relaxants, antispasmodics and tranquilizers

Page 73: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Treatment: Conservative

Heat/cold therapy to decrease muscle spasmsBreak the pain-spasm-pain cycleUltrasound, massage, relaxation techniquesProgressive mobilization with approved exercise

program –includes abdominal/thigh strengtheningTeaching good body mechanicsWeight lossTENS unit

Page 74: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Treatment: Surgery• Laminectomy

– removal of a portion of the lamina to relieve pressure and to get to the herniated nucleus pulposus that is protruding out

• Herniated disc repair• Foraminotomy

– enlargement of the bony overgrowth at the opening which is compressing the nerve

• Microdiskectomy – Use of electron microscope through a small incision to

remove a portion of the HNP that is displaced • Anterior cervical fusion

– If cervical HNP, usually use the anterior approach in the neck

Page 75: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Treatment: Surgery

• Spinal fusion • removes most of the disc and replaces it with

bone usually from the patient iliac crest• fusion also with rods, pins, synthetic protein• flexibility is lost at the site- requires longer

hospital stay• Artificial Disc• combination of metal and plastic• attached to vertebrae above and below

Page 76: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Prevention of HNP

• Back school approach– Causes of HNP– Learn how to prevent – Good body mechanics– Exercises to strengthen leg and abdominal

muscles

• Change in life-style or occupation

Page 77: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Assessment Specific to HNP Health History

• Assess for risk factors• The cumulative effect of standing erect and daily

stress • Aging changes in disc/ligaments • Poor body mechanics • Overweight• Trauma• Employment • History of pain and other neuro changes

Page 78: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Assessment Specific to HNP Physical Exam

• Use similar methods to assess as utilized SCI

• Muscle strength and coordination• Sensation– sharp/dull of paperclip using dermatome as

reference• Pain evaluation- pain scale• Pre/Post-op assessment

Page 79: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Post-Op Assessment for HNP

• Sensory/motor assessment– be careful not to injure op site

• Assess for CSF drainage or bleeding from op site• Encourage turn (log roll, cough, deep breath) • Assess for postural hypotension– especially if patient was on bed rest for

several days/weeks prior to surgery

Page 80: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Post-op Assessment for HNP

• If Anterior Cervical – Assess injury to the carotid, esophagus, trachea,

laryngeal nerve (speech- hoarseness)– Assess respiration, neck size, swallowing and

speech

• If Post-Op Lumbar – Assess bowels sounds, voiding– Minimize stress of post-op site- flat with pillow

between knees, log roll, etc

Page 81: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Problems/Interventions 1. Acute Pain

Post surgery the individual may have similar pain as pre-op due to lack of resiliency of the spinal nerves to ‘bounce’ back quickly

Donor site (illiac crest) may cause more pain than laminectomy

Individual may be in a pain-spasm-pain cycle, therefore may need both antispasmodic as well as analgesic

Page 82: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

2. Chronic Pain

• Surgery may not relieve pain

• Consider nonpharmalogical methods to control pain

• Pain clinic

Page 83: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Spinal Cord Tumors

Page 84: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Spinal Cord Tumors

• CNS is made up of neural tissue and support tissue

• These tissues undergo changes and result in spinal cord tumors

• Blood vessels and bone also can be part of the tumor

Page 85: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Classification by origin

Primary originating in the spinal cord or meninges

Secondarymetastases from other parts of the body

Most spinal cord tumors are found in the thoracic region

Spinal cord tumors can compress (benign), invade the neural tissue, or cause ischemia to the area because of vascular obstruction

Page 86: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestations/Complications

• Symptoms depend on the anatomical level of the spinal column, the anatomical location, the type of tumor and the spinal nerves affected

• Pain that is not relieved by bed rest is the most common presenting symptom

• Other symptoms are similar to those found with HNP or spinal cord injury- sensory or motor

Page 87: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Common Manifestations/Complications

• Manifestations of thoracic cord tumor– Paresis & spasticity of one leg then the other– Pain back & chest, not relieved by bed rest– Sensory changes – Babinski reflex– Bowel (ileus); bladder dysfunction (UMN in type)

Page 88: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Therapeutic Interventions

• Diagnostic tests include– X-ray of the spinal column– Myelogram– Lumbar puncture with CSF analysis

Page 89: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Therapeutic Interventions

• Medications for spinal tumors– Control pain• narcotic analgesics, epidural catheter, PCA, NSAID’s

– Reduce cord edema and tumor size • steroids- high dose Dexamethasone

Page 90: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Therapeutic Interventions

• Surgery for spinal cord tumors– Laminectomy to remove or to decrease the size

(decompression laminectomy) of the spinal cord tumor

– Spinal fusion or the insertion of rods if several vertebra involved and the column is unstable

• Radiation to reduce size and control pain

Page 91: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Assessment

• Health history– Pain, motor and sensory changes, bowel and

bladder changes, Babinski reflex

• Physical exam– Similar to physical assessment for HNP

Page 92: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Problems/Interventions

• 1. Anxiety– Metatastic tumor vs benign spinal cord tumor– Education and support system

• 2. Risk for constipation– From spinal cord compression, narcotics, bed rest– Adjust fluid and diet

Page 93: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Problems/Interventions

3. Impaired physical mobility–From bed rest and motor involvement–Basic nursing- ROM, etc

4. Acute pain–From compression or invasion of tumor–Assess and treat

5. Sexual dysfunction–Male sacral reflex arc (S 2,3,4) interference–Similar care as discussed with SCI

Page 94: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Nursing Problems/Interventions

• 6. Urinary retention– Reflex arc (S2,3,4) interference can cause

neurogenic bladder as discussed with SCI

• 7. Home care– Rehabilitation– Home evaluation– Support groups

Page 95: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?

1. Bladder distension2. Neurological deficit3. Pulse ox readings4. The patient’s feelings about the injury

Page 96: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

While in the ED, a patient with a C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?

1. Autonomic dysreflexia2. Hemorrhagic shock3. Neurogenic shock4. Pulmonary embolism

Page 97: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

A 22-year-old patient with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?

1. Place the client flat in bed2. Assess patency of the indwelling urinary catheter3. Give one SL nitroglycerin tablet4. Raise the head of the bed immediately to 45-90 degrees

Page 98: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

A patient with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?

1. To hasten wound healing2. To immobilize the surgical spine3. To prevent autonomic dysreflexia4. To hold bony fragments of the skull together

Page 99: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

A patient has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?

1. Absent corneal reflex2. Decerebrate posturing3. Movement of only the right or left half of the body4. The need for mechanical ventilation

Page 100: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

The nurse is evaluating neurological signs of the male patient in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?

1. Positive reflexes2. Hyperreflexia3. Inability to elicit a Babinski’s reflex4. Reflex emptying of the bladder

Page 101: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Your T1 spinal cord injured patient complains of a headache. You should

1. Give him prn Tylenol2. Disimpact his bowels3. Call the doctor4. Take his blood pressure

Page 102: Spinal Cord Injury, Herniated Disc & Spinal Cord Tumors

Your patient has a malignant metastatic lesion at T8 and is in for palliative radiation. What is your main goal with this patient?

1. Teach patient self catheterization2. Ensure patient receives pain medication as needed3. Encourage patient to discuss fears4. Ambulate twice a shift