Complex Health and Sensory Lecture Notes

SPINAL CORD INJURIES

200,000 live with a spinal cord disability in the US Motor Vehicle accidents 35% of SC injuries Violence 24% of SC injuries (being hit with 2x4, baseball bat, lamp stand, PVC pipes, crowbars, lead pipe, getting knocked down, falling and hitting head.) Falls 22% of SC injuries (tree stands when hunting, down stairs) The longer it takes to get these people to the ER to get medical attention, the worse the outcome. These people out in the woods get delays medical attention and have a worse prognosis. Teach hunters to wear a harness when in the tree stand Sports injuries 8% of SC injuries ( FOOBALL, cheerleading, rugby) Our athletes are getting bigger, stronger, and faster. They do not do form tackling anymore, they lower their head and hit) There are usually medics on standby at high school and college football games.

After a concussion, the player should NOT go back into the game. EDUCATE
82% of SC injuries are males Ages 16-30 account for over of the SC injuries Diving accidents Physical abuse Spinal Cord Injury Any traumatic injury causing spinal cord compression, ischemia, edema, and possible SC transsection. Types Concussion a blow with temporary loss of function in the SC that quickly resolves. May be caused by a simple blow to the back. Contusion BRUISE. The SC bruises and swells. When it swells it can create pressure, and the nerves cannot travel like normal. Lacerations Spinal Cord is cut. Usually caused by stabbing wound, a broken bone, and explosives. The laceration is NOT cut all the way through. Compression 2 vertebrae get collapsed. (Diving accident, lowering head in football, jumping off an ob\ject, etc) Transsection completely cut through

Complex Health and Sensory Lecture Notes

Primary Injury initial injury and usually permanent (transsection) Secondary Injury what occurs after the injury. Usually reversible if treated quickly.
(contusion, edema)

Pg. 2252 Cord Syndromes Chart 63-7. Memorize!!!

Hyperflexion/Hyperextension injuries usually affect C spine. C-spine is the weakest part of the spine and a lot of pressure from carrying the head on top of it. The C-Spine is at the greatest risk for injury. C1-C7 T1-T12 L1-L5 Respiratory issues @ C3-C4

Chart on page 2253 Table 63-3 Hyperflexion a sudden deceleration of the head chin to chest involuntary can snap the
vertebrae. When you have a head injury, rule out spinal cord injury as well as part of protocol. Immobilize patient!!! Hyperextension head gets thrown back

Diagnostic Test for Spinal Cord Injuries CT, X-Ray, MRI, EMG, evoke potential
studies When a pt comes in on a back board on a C-collar, do not take them off the board until the C-spine, L-spine, and T-spine is cleared from injury. The patient will want off the board and will say they have to pee. If so, offer to put a catheter in them. Autonomic dysreflexia - Pt. with T6 injuries T6 and above (numerically) T6 and

below (anatomically) caused by distended bladder, fecal impactions, pressure ulcers on lower
extremities, and pressure from sitting against something putting pressure on legs. Works b/c the pain nerves spreads from the site of the pain up through the spinal cord to the brain. If you have to go pee, the impulse travels from the bladder, through the spinal cord to the brain. With autonomic dysreflexia, there is a blockage in the spinal cord, and the impulses cant travel up to the brain. This causes the nervous system to go haywire and it pretty much short circuits. (Example: 6-30 and 430. Everybody goes 4-30 to get to Benton/Bryant. If you blow it up the cars cant go that way so they overload the side roads. The same happens with autonomic dysreflexia. The nerves cant get

Complex Health and Sensory Lecture Notes

through the spinal cord, so they try to go a different route through the body and causes a lot of problems.

Signs and symptoms of Autonomic dysreflexia

Pounding headache Nasal congestion Sudden/severe hypertension (hypertensive crisis 220/160) can cause a hemorrhagic stroke because the brain cannot handle the pressure. HR bottoms out Profuse sweating above the lesion (T6 and up) Cyanosis below the lesion (below T6) Severe anxiety (Feeling of impending doom)

Nursing interventions for autonomic dysreflexia Sitting position (in a wheelchair, elevate HOB). The sitting position will cause
gravity to pull some blood out of the brain reducing pressure. Identify the cause (kink in foley, if we need to put a foley in use viscous lidocaine to reduce pain which will make the problem worse. We want to avoid all pain! Only put catheter in for a distended bladder. Fecal impaction before removing the impaction, use a topical anesthetic to reduce pain. Do they have pressure? Are they in an uncomfortable position? Clothing too tight? Socks too tight? Treat hypertension with IV Apresoline usually if we treat the underlying cause the blood pressure will resolve itself, but if it goes on for an extended period of time the BP must be treated with the IV Apresoline.

A Pt. with autonomic dysreflexia needs to have a sign on their door that says they are at risk for autonomic dysreflexia.
These pts. Will be at risk for autonomic dysreflexia throughout their entire lifespan. When a pt. comes in the emergency room with a spinal cord injury, they must be immobilized until the s/s of the initial injury has been resolved (no more edema, etc)

Teaching for these pts. And their care givers should include bowel and bladder care, skin care, knowing when to catheterize themselves, how to prevent pressure.

Complex Health and Sensory Lecture Notes

Halo Devices pg. 2255 figure 63-9
Must keep pin sites clean Use sterile technique Assess regularly monitoring for s/s on infection (the screws are close to the brain and puts them at risk for an infection in the brain. It is hard to get rid of an infection in the brain b/c a lot of drugs do not cross the blood/brain barrier. If you walk into a room and there is a screw loose on the halo device, call the neurosurgeon. The nurse DOES NOT tighten the screw. The drill they use to tighten it will be at the bedside, but the nurse does not do it. The nurses job is to immobilize the neck where they cannot move it until the neurosurgeon can get there to tighten it.

Education for the patient with a spinal cord injury

In the beginning, education consists of why they are immobilized, why they have the C-collar on, why they cannot feel their feet, etc what to expect, surgery, being in the hospital for an extended period of time.

Major goals for Spinal Cord Injury patients

Improve breathing Assess lungs, breathing effort, suction, oxygen administration Airway clearance Skin integrity Teach bowel and bladder care Comfort Sexual activity A big deal for patients. Paralyzed patients can still have sex and have children

There will be a LOT of emotional issues with these patient r/t being active their whole life and now they are bound to a wheelchair
These patients will be very angry and often lash out at the RN. The RN cant take it personally. We are the only ones who they can lash out at b/c if they lash out at their family the family may leave and not come back for a while. They may hit, spit, kick, and call bad names, so we set boundaries, but listen and be there for them.

Complex Health and Sensory Lecture Notes

Know for the test: lab values up to this point, priority interventions, expected orders, assessment findings Disherniation generally C5-C6 or C6-C7. Lower lumbar is next most common. Thoracic
disherniation is VERY RARE. May be genetic, weight lifting, generally b/t age 25-45yrs old Two main causes Injury Degenerative changes With these patients we expect back pain

Assessment in a patient with disherniation

Movement trouble Numbness/tingling The pain can be caused by direct pressure Rituculopathy - numbness in extremities Extreme pain, nothing decreases it

Management of disherniation
Relief of pressure Surgery Steroid shots Kyphoplasty inject with cement to fuse the vertebrae and relive pain. A lot of time when you relieve one, the next one messes up Discectomy takes the whole disk out and fuses them together There is cartridge between the two disks, when there is pressure it will eventually rupture causing compression. It is very painful. The compression can cause the bone to fracture causing a compression fracture. The disc problems are usually chronic. The spinal column can narrow causing spinal stenosis. They can do a lamenectomy to open it up and relieve pressure off the spine

Diagnostics
MRI (most common) X-Ray (shows visual alignment only) Lamenectomy relieves pressure from spinal cord

Medications
NSAIDS tordal/kotoralac (GI bleeds)

Complex Health and Sensory Lecture Notes

Opioids oxycodone, Vicodin, vicoprofen Local anesthetic (lidocaine/steroid cocktail) Muscle relaxants (Soma, flexaril, Scalaxin) Robaxin (IM injection)

Management
Rest Reduce inflammation Surgical management Posterior worse for patients Anterior approach better but bigger risk for airway obstruction due to edema. There are major arteries that are at risk for nicking and causing bleeding. o Hoarseness may occur due to hitting the vocal cords.

KNOW POST OP COMPLICATIONS Once they are better from surgery:

PT No lifting for 2 weeks No more then 5-10 lbs after 2 weeks

Pre-op teaching:
Time line to expect Recovery takes time May be hoarse May be hard to swallow Breathing problems NOT expected Do they take aspirin? Plavix? Heparin? Coumadin? Naproxen Know any allergies Stop smoking

Post op teaching for lumbar surgery:

Weight restrictions They will feel better but not good as new, so do not overdo it with your activities Teach upper body and lifting mechanics (keep knees bent) Strengthening exercises

Complex Health and Sensory Lecture Notes

ROM exercises

ALS LOU GERIHGS DISEASE

An autoimmune disease we dont know what causes. There is no cure for ALS)
Characterized by progressive weakness and atrophy of the trunk (causes breathing issues) Will have weakness of bulbar muscles (swallowing and talking problems) Clinical manifestation pain, weakness, severe cramps, twitching Interventions Riluzole may help slow the disease but will not cure it.

Vailuim potent muscle relaxer for cramps Baclofen Dantrium spasticity problems
Eventual death will occur so coping is a major issue with the family and patient. The patient will usually deal with it better than the family will Support the family Support the patient Provide resources and counseling Prepare for what is going to happen (2 years is average prognosis) Home health care in the end stages of the disease

HEAD INJURIES / ICP

Review strokes!!! Need to know the different kinds of strokes, layers of the brain and the anatomy of the brain, (the lobes, where is the temperature control = hypothalamus, etc) Increased Intracranial Pressure Monroe Kelley hypothesis The skull is solid and cannot expand. The hypothesis
says, because there is limited space for expansion of the skull, an increase in any of the components causes a change in the volume of the others. Components in the skull

Complex Health and Sensory Lecture Notes

CFS (cerebral spinal fluid) Brain tissue Any problem in the brain can cause an increase in CSF and result in pressure building up and putting pressure on the brain. Encephalopathy Hydrocephalus Increase in blood from hemorrhagic strokes Brain injury Contusion Concussion Tumors grow bigger and bigger and put pressure on the brain and forces the Cerebral Spinal Fluid (CSF) out. When the brain swells, the CSF displaces causing big time complications Normal ICP = 10-20 mmHg (Intracranial Pressure is measured in the lateral ventricles of the brain.) when monitoring ICP they are at risk for infection b/c you have to drill a hole in the brain to get the monitoring device in. When you have a lot of pressure in the skull, the brain tissue will be forces out the foramen and into where the spinal cord comes in. This is called a brain stem herniation. A VERY BAD problem.

Reasons for Increased ICP

A decrease in cerebral blood flow when you have decreased cerebral blood flow, the brain tissue starts dying. The body responds by sending more blood flow to fix and increases ICP

Cushings response (reflex)

Slow bounding pulse Respiratory irregularities Blood pressure changes and increase in systolic pressure (the body trying to increase cerebral perfusion.) Will

Complex Health and Sensory Lecture Notes

have a widening pulse pressure (BP 150/50 for example.) They have a reflex slowing of the heart. y Cushings response is the first sign of increased ICP and must be dealt with immediately. After Cushings response comes Cushings triad.

Cushings triad is a grave sign and means the patient is about to

die. Bradycardia (20s to 30s) Hypertension (everything shoots up. No wide pulse pressure) B radypnea Changes in CO2 levels when there is a rise in CO2, the brain tries to get rid of it by vasodilation. The vasodilation increased the blood flow and increases the ICP. If there is a drop in CO2 it will vasoconstrict which makes it impossible for the blood in the brain to get out and increases ICP as well. Must maintain an adequate balance. Intubated pts. Must have frequent blood gases monitored. (ABGs) Edema (via a brain injury concussion, contusion, etc)

Signs and symptoms of ICP:

Change in LOC/mental status most important sign to pick up on. (LOC= alert, and able to respond appropriately. LOC= a continuum from alert to coma.) Usually a result of something else. Altered level of consciousness is not a primary problem. LOC should be the first thing that should be charted about the client b/c it is the first thing you will pick up on during an assessment Slowing of speech Delay in response

Complex Health and Sensory Lecture Notes

Early signs
LOC changes Restlessness Headache that is constant Agitation/ combative Increased respiratory effort Bp changes Drowsiness Pupil changes Extraoccular movement Loss of coordination/ muscle movement

Late signs
Coma Posturing Decorticate/ Decerabate - GRAVE physician immediately Seizures (these patients are always on seizure precautions) Pulse and RR decrease and become erratic Temperature (pressure is being put on the hypothalamus) may have 104106 degree temps. Must use cooling blankets and ice to prevent frying the brain. BP increases Cheyne-Stokes breathing periods of apnea with periods of breathing Loose ALL reflexes(gag, corneal, swallowing) To check the gag reflex, take a long cotton swab and brush the uvula. Pupil may be blown Projectile vomiting

SIGNS!!! Notify

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Assessments
Neuro assessment SMC (sensory, motor, coordination) Can they tough their nose? Grip strength (shake their hand) Pupils Can they puff both cheeks out? Tongue movement Push against and pull hands and feet Glasgow coma scale

Look up and know the criteria for the test!!! Pg. 2240
Pupil checks Assess intracranial nerves (look up for NCLEX/ EVOLVE) Frequent vitals

Diagnostics
CT, MRI, PET scans Doppler scans carotid artery dopplers for blockage AVOID lumbar punctures b/c they increase ICP and can cause pain/headaches)

Medical Treatment
Dobutamine increases cardiac output to maintain cerebral perfusion pressure greater than 70. Burr holes drilled into skull to drain blood Ventriculostomy holes drilled into skull to drain blood Treat fever cooling blankets, rectal Tylenol (they are NPO) Shivering increased metabolic demands, not good Maintain oxygenation and keep CO2 levels balanced Decrease metabolic demands sedation and intubation will be needed to reduce demands of the brain. They will be on total control vent b/c

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breathing causes work on the brain. They will probably be put into a medically induced coma.

Drugs used for sedation/intubation:

Paralytic Barbiturates Versed Diprivan (may be avoided due to risk for hypotension)

Drug to decrease cerebral edema

Mannitol osmotic diuretic Steroids dexamethasone / reduces swelling

Nursing interventions
Maintain patent airway Achieve adequate breathing pattern Maintain adequate cerebral perfusion Maintain negative fluid balance r/t edema Prevent infection

Complications
Brain stem herniation DI - diabetes insipidus SIADH Infection

Burr Holes educate patient what to expect and what has happened. The
patient will come out with dressings on the screws. Benzos need to be used selectively because it can mask symptoms of ICP

Nursing Management
Careful frequent monitoring Bleeding from burr holes Vitals frequently

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Maintain cerebral perfusion Regulate temperature

Nursing Diagnosis
Knowledge deficit Self image Risk for infection

HEAD INJURIES
Usually with severe head injuries, the patient will not be the same from then on. They may end up on a vent and not come off. May end up with family and friends drifting away and leave the care up to the staff. Everything has to be done for these patients.

Head Injuries injuries of the scalp, cranium, or brain

The outward appearance of the head injury does not reflect the extent of the injury The brain is not anchored. It is only attached to the spinal cord and nothing is there to keep it from shifting in a severe impact. Vessels tear easily causing injury. With severe impact, the brain will go back and forth like a pinball.

Factors influencing the extent of the head injury:

Force of impact Point of impact Surface area involved in impact Status of head during impact Location and direction of impact Did they fall head first? Where they sitting still? Head on? 1.5 million Americans suffer from head injuries annually

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Major cause of death in ages 1-35 b/c they are more risky, they play sports, their skull is more pliable, etc Elderly are also at risk due to falls and being on Coumadin, plavix, and aspirin

Types of skull fractures Linear a simple fracture or crack in the skull with no movement of the bone
Generally these are okay. They may have a concussion. Usually do not require surgery.

Comminuted may have displacement of bones. Bone pieces get shifted into the
brain Usually caused by a projectile! (Bullets, puncture wounds

Depressed the bone is broken into a lot of small pieces.

Falling object, blunt trauma to top of head

Basilar Occur at the base of the skull. These can be serious because the
respiratory and motor centers are in that part of the brain. There are 3 signs of a Basilar skull fracture:

Battle Sign - Bruising behind the ear (Ecchymosis on the

mastoid process)

Raccoon eyes periorbital ecchymosis Bleeding from the nose and ears, and may contain cerebral
spinal fluid. To check for CSF, perform a halo test or check for glucose.

Halo Test hold the sample on gauze up to the light

and look for a halo around it. Do not stop the bleeding by shoving gauze into the nose because it can cause infection. Loosely place gaze over the place that is bleeding.

Primary Injury contusions, lacerations, damage to vessels, acceleration or deceleration of the

brain, or foreign object penetration.

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Secondary Injury complications that occur r/t the primary injury. Due to cerebral edema,
ischemia, or chemical changes associated with the trauma.

Types of brain injuries: Closed injuries Concussions temporary loss of consciousness possible. There is no apparent
structural damage. May be minor (recover in a few days with no lasting effects), to severe (last weeks with severe headaches, vomiting, ringing in the ears). When they exhibit vomiting and ringing in the ears, they need to be put in the hospital for closer observation. Concussions generally do not cause any long term damage, but the repeated injury as seen in football players can cause a problem with sensory deficits, inability to remember things, slurred speech, possible Alzheimers Disease, Parkinsons, ALS Pts. Need to be observed afterward D/C instructions for the pt. with a concussion no bright lights, avoid sensory stimulation, wake pt. up q 2 hrs. and note the difficulty of arousing from sleep. If they have ringing in the ears, vomiting, or blurred vision they should return to the ER for further evaluation.

Contusions Bruise of the brain. Possible surface hemorrhage. Symptoms and

recovery depend on the amount of damage and how much swelling there is. PRIMARY injury. The edema that follows is the secondary injury. They pts. May have longer periods of unconsciousness with more damage and may exhibit some vital sign changes.

ContraCoup Injury an injury to the brain located on the opposite

side of the primary injury. (The patient gets hit on the back of the head, but the injury is on the frontal lobe r/t the impact shoving the brain into the front of the skull. Still considered a primary

s/s of cerebral contusions:

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altered LOC stupor pupil changes incontinence cerebral edema

patients usually recover from contusions. Difuse axal injuries dont recover from. The pts. Suffers severe axon damage in the
brain. The pt. has NO lucid moments, and instantly begins posturing and goes into a coma. The injury happens, and the pt. immediately has the brain shut down and they die. This could be caused by mild trauma. It just depends on where the injury is.

Axon how the nerve impulses travel through the body Review strokes, acute and chronic subdural hematomas, epidural hematomas Medications
Osmotic diruetics Mannitol Corticosterioids SoluMedrol, decadron Anti convulsants Dilantan, neurontin, phospaphenatona IV Barbituates, Sedatives, Opiates use cautiously. May mask s/s of altered LOC. Antibiotics especially with open skull fractures (depressed, convanutied?????

Treatment
Depends of the severity of the head injury surgery, bleed, eliminate swelling via craniotomy, intubation The more serious the head injury is, the more likely we will have to intubate the patient.

Signs and Symptoms of head injuries (Same and increased ICP)

Decreased LOC

More combative More agitated More seizures

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It is easier to care for a patient that is sedated and intubated so these patients will be intubated and sedated to provide better care for them.

Medications Same as with Increased ICP

The best way to reduce intracranial pressure is to SIT THE PATIENT UP!!! Elevate the HOB first b/c it increased venous outflow.
Management of Head Injury Patients
Always assume a cervical spine injury when there is a head injury Prevent secondary damage (ischemia, edema) must act quickly b/c the longer it takes to get treatment, the more damage will occur. Get a health history focused upon immediate injury. It will tell about the head injury. It is the nurses job to ask questions to the family or paramedic. The doctor will want to know everything that had happened in regards to that injury. It is also important to know because a chronic subdural hematoma may happen a week or two after the injury. Baseline assessment using Glasgow Coma Scale pg. 2240 Frequent Neurologic Assessments look up neurologic assessments in book and

know what all is involved. Nursing Diagnosis for Brain Injuries

Ineffective Airway Clearance Ineffective Gas Exchange Ineffective Cerebral Perfusion Imbalanced Fluid Volume Imbalanced Nutrition Risk for Injury Imbalanced Body Temperature

Interventions for Increased ICP are same as those for head injuries Collaborative Problems and Complications

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Decreased cerebral perfusion Herniation Fluid/Electrolyte and Nutritional Imbalances Post-traumatic Seizures Do not start shoving things in their mouth during a seizure b/c they will bite through your fingers. If your patient is at risk for seizures, you must have the following at the bedside: Pillows Ambu-bag Bite blocks OPAs oropharangeal airway (keeps them from biting down and keeps the tongue pressed and prevents the tongue from rolling back in the throat. Pt should be on seizure precautions and everybody should know it.

Goals for Head Injuries

Maintain a patent airway Maintain Fluid/Electrolyte balance Maintain adequate nutrition

Interventions
Get baseline data to know if there are changes in pts. LOC

Hourly neuro assessments!!!

Daily weights Prevent injury Padded side rails Mattress on the floor Place patient closest to the nurses station Decrease sensory stimulation Raise HOB 30 degrees

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Suction cautiously b/c suctioning increased ICP. A lot of nurses like to
hyperventilate the patient before suctioning, but if its a head injury patient that will decrease the ICP. You have to suction NO MORE than 3-4 seconds

at a time
Monitor ABGs At risk for ARDS b/c they are on a vent. Too much FiO2 can increase the

risk for ARDS so monitor for it!

Avoid restraints b/c they fight and get agitated which causes the ICP to increase. If the patient is pulling at tubes and things, we can use mittens to prevent it. Also Posey vests work. Support cognitive function and families head injuries are hard to deal with because they go from completely normal to completely dependent. Let the patient have to opportunity to use the capabilities they have left. Do not do everything for them if they are able to do it themselves. Pictures may be used to jog their memory.

Read over strokes, epidural and subdural hemorrhages

Nutrition is often achieved through TPN or a PEG tube.

HEADACHES
Primary generally a non-organic cause. No tumors, aneurism, etc Usually an outside
stressor, substance, or stimulus.

Secondary usually caused by pressure in the brain tumors, aneurism

Types of headaches

Cluster hangover
usually last about 3 hours. Most common in men Caused by alcohol usually Other symptoms that go along with it are:

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Nasal congestion Ptosis drooping eyelids Lacremation Flushed feeling

Migraine nobody knows exactly why they are caused.

Generally hereditary Vasodilation More common in females may be caused by decrease in hormones

Signs and Symptoms

Pupillary response pupils are really big so they are photosensitive Nausea/vomiting are very common

Management
Treat the symptoms only (secondary care) Neurologist consult

Phases of a migraine Prodrom phase feel headache coming on. They have an auora 13-30
minutes before a migraine. This is when they must start treating it with medication to prevent progressing. In the ER we treat with narcotics and send them home to sleep it off

Headache cocktail: Ativan muscle relaxant/sedative Benadryl histamine response/sleep Compazine - antiemetic
If it is a true migraine, this cocktail will treat it. It is given IV Push. Medications LOOK UP MIGRAINE MEDS

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Teach preventative measures, refer to neurologist, dont just keep giving narcotics, and treat the underlying cause. Teach to avoid caffeine, chocolate

Tension most popular

Caused by stress, anxiety Feels like a tightness up the back of your neck and can feel in your temples

GUILLIAN BARRE
Chapter 64
Autoimmune disorder (like ALS, MS) some part of the body attacks itself Guillian Barre attacks the peripheral nerve myland. The rapid demylanization can cause respiratory failure.

Retrograde paralysis starts at the feet and paralyzes and works its way up. When it gets to
the chest region, you cant breathe on your own. There is no way to know how fast it will progress and how long it will last. The patient will be on a ventilator when it affects the chest. The patient will recover completely we just dont know when they will recover

Nursing interventions
Provide resources to make sure the patient gets everything in a row before the disease progresses because it can last for a while. Must provide quality nursing care b/c the patient will be on a ventilator for a long time. We must prevent pneumonia, teach the patient to expect a trach and that the trach will be reversed eventually. Teach that they WILL RECOVER!!!

MULTIPLE SCLEROSIS

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Demilanization involving the CNS. Characterized by remissions and exacerbations. Autoimmune disease. Occurs between 15-30 years of age. Not sure why it is caused.

Exacerbations may be caused by

Extreme temperature changes Fatigue Emotional stress Infections (UTI, bad skin care)

Treatment for the patient

Cluster care to promote FREQUENT rest Do not get too fatigued Keep a constant temperature (do not go outside in extreme temperatures).

Avoid hot tubs, and hot baths and showers.

Most of the patients are in a relapsing /remitting stage. They usually recover with most of their functioning at the beginning. After a while residual problems will occur during relapses. When they get to progressive relapsing it snowballs. We want to PREVENT exacerbations Assessment data in Multiple Sclerosis

Double vision is often the first sign

Diplopia double vision. Fixed by an eye-patch Stagnis one eye twitches constantly Numbness/tingling Altered temperature Muscle spasms FATIGUE Bulbar muscle weakness (swallowing/vocals) DEPRESSION as they keep having more frequent exacerbations Sexual dysfunction

Diagnosis

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There is no definitive diagnosis May do CT or lumbar puncture

Medications Interferon can slow down relapses but do not cure

Side effects seizures

NSAIDS Steroids Baclofen muscle spacticity Valuim/Xanaflex

Multiple Sclerosis is more debilitating than fatal. It will cause problems for life.

MYASTHENIA GRAVIS
Nerve involvement. Affects acetylcholine/cholinergic sites. It is a motor disorder

Initial symptoms involve:

Occular muscles (double vision, drooping eyes) Weakness of facial muscles Generalized weakness Bulbar muscle weakness Atropine is an anticholenergic

Medications Mestadon See chart 64-4 pg. 2286 Plasmaferesis plasma is pulled out, cleansed and put back into the body. It is
very $$$, slows down the disease but does not cure

Thyectomy removal of thymus

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Myasthenic Crisis
Caused by a respiratory infection Avoid public places in winter

Cholenergic Crisis
Too much Mestadon Severe muscle weakness with bulbar weakness, respiratory weakness. Respiratory comprimise

Get generalized weakness with bulbar and respiratory Weakness. At risk for Respiratory Failure. Respiratory Effort is decreased. Possible respiratory Failure

There is a balancing act with the treatment b/c the s/s of the disease are the same and the s/s of an OD of the medication. A lot of education!!

Management of crisis
Anticipate ventilation and intubation Insure respiratory support (ABGs F/E, ) Nasogastric feedings may be needed.

SHOCK
Organs are not getting oxygen. There is a state of hypoperfusion. There is not enough oxygen in the cells. It doesnt matter what kind of shock, they all lead to a lack of oxygen and nutrients in the cells, and when there is not enough oxygen in the cells they become ischemic and die. All body systems are affected by shock.

Three types Hypovolemic Circulatory/Distributive

Septic Anaphylactic Neurogenic

Cardiogenic

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Three Stages of shock Compensatory Stage (Stage #1) the body is trying to compensate.
Signs and symptoms of the compensatory stage of shock The body vasoconstricts HR and contractility increases Blood Pressure will stay normal r/t the vasoconstriction. Cardiac output remains the same. Perfusion to the tissues is still inadequate. The body is only worried about the heart, lungs, brain. The rest of the tissues may not have adequate perfusion. Acidosis may occur r/t cell death LOC will be altered may be slightly confused. Early alkalosis, then becomes acidic (when the cells die, they liase and dump K into the blood stream. When K levels increase you end up with acidosis.

Progressive Stage (Stage # 2) Shock continues to worsen. Mechanisms that regulate

the blood pressure can no longer compensate. This is the point at which the body is starting to shut down. Everything the brain is trying to do to fix things is not working. All organs, including the brain begin to suffer from hypo perfusion. If the cardiac output and BP continue to decrease you will see Signs and symptoms: Cyanosis SOB Mental changes Arrhythmias r/t increased K levels in the blood (V-tach, V-Fib can lead to an infarction whether it me cardiac, brain, kidney, etc) Increased K Acidodic Oliguric urine output will decrease r/t the bodies response to shock. During shock, the body wants to hold on to fluids to try and increase the

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circulating volume which would provide the organs with oxygen. Because of this response and the lack of oxygen, the patients urine output will decrease to little if none. Lungs fail Liver and GI function fail In the progressive phase, the patient is at risk for multi-organ failure, and DIC

Irreversible Stage (Stage #3) You dont realize it until its too late. Organ damage is
so severe any treatments will not work Multisystem organ failure Patient will eventually die Treatment Identify it early and fix the problem PREVENTION Time frames of the shocks vary from patient to patient Early identification and treatment is the best treatment

Management of Shock
Administer fluids Crystalloids 0.9% NS, LR Volume expanders Dextram, Albumin (pulls and retains fluids in the intravascular space. We are not worried about Na levels with shock) these meds are very $$$. Albumin requires donors. And Dextran interferes with platelet aggregation If we get a patient with shock and we administer 0.9% NS and albumin and suddenly the patient exhibits JVD and breathing difficulties, the first thing to do is to STOP the albumin! The albumin is pulling too much fluid in and the body can circulate it in this case Vasoactive Meds for the treatment Dobutamine increased cardiac output Dopamine vasopressor (especially is distributive type shock)

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Levophed septic shock Neosynephrine Vasopressin Nitro/Nipride helps the blood circulate and dilates the cardiac muscles (cardiogenic shock All medication dosages are titrated to effects desired (depend on vital signs)

Hypovolemic Shock Everything is working fine, except there is not enough circulating volume
Causes of hypovolemic shock Hemorrhage - pancreatitis Dehydration burns, third-spacing, ascites, vomiting/diarrhea, pancreatitis Fistula new ostomies Diabetes insipidus polyuria DKA Polyuria Pelvic fractures can hold 2 liters of blood before showing symptoms Large bone fractures are very vascular

Changes in vital signs that can cue to Hypovolemia

Increased HR (110-120bpm)

Management of Hypovolemic Shock

Start 2 large bore 18G IVs. If a major trauma, may need 2 16G IVs Usually hypovolemic shock can be cured and sent home. The problems come when it is not treated in a timely manner.

Cardiogenic Shock There is a pump problem in the heart. The volume and vascular bed are
fine. The cardiac output in decreased resulting in less oxygen to tissues. During cardiogenic shock, the cardiac tissues are dying and worsening an MI.

Causes of Cardiogenic Shock

Heart attack (MI)- the greater the damage to the heart, the greater the risk of cardiogenic shock.

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Complex Health and Sensory Lecture Notes

Cardiomyopathy the heart is enlarged, so it is not as strong and not as efficient Valvular heart disease it is not opening and closing correctly Cardiac Tamponade stretched out and not pumping effectively Arrhythmias - not pumping effectively They all have decrease cardiac output

Management of Cardiogenic Shock

Find the cause and treat usually an MI MONA (Morphine, oxygen, nitro, aspirin) Treat the pain Dobutamine to improve cardiac output Nitrates to improve pressure. They will dilate the coronary arteries and improve oxygen flow back to them. Do not put on Dopamine b/c it vasoconstricts and drives the heart; increases the workload on the heart. Levophed and Dopamine may be hung together to increase the BP without increasing the workload on the heart. It is a balancing act. If Dopamine is up and levophed is down and the HR is high, you can drop the Dopamine and up the levophed. There will be titration orders and the nurse will be autonomous. Improve the pump Balloon pump takes the workload off the heart Must have a 1:1 care nurse and the nurse must be specifically trained on balloon pumps. Heart transplant

Nursing Interventions for Cardiogenic Shock

Cluster care Administer supplemental oxygen Monitor hemodynamic status Relieve angina immediately!!!

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Complex Health and Sensory Lecture Notes

Distributive/Circulatory Shock This is a vascular bed problem. The vascular bed spreads
out, but the heart and volume is fine.

Neurogenic shock Anaphylactic shock not anaphylaxis. Occurs because the body responds to the
allergen with a huge histamine response.

Three drugs to solve anything

Benadryl H1 antagonist. Stops the release of the histamine Ibuprofen - anti-inflammatory Pepcid H2 antagonist. Stops the release of the histamine

Signs and symptoms

Flushed skin Nausea/vomiting Respiratory problems

Interventions for Anaphylactic Shock

Identify and Remove the source of the anaphylaxis. If it is a medication, have them stop the medication and report to their physician

Septic Shock seeing more and more and is being identified earlier. Caused by a
systemic inflammatory response from the body and is usually cause by some gram (-) or gram (+) bacteria. It is a bacterial infection. It is the bodys response to the bacteria that causes the body to go haywire. UTIs are the most common cause of septic shock. (from foley catheters) May be from an infection from a bed sore or an unclean dressing Pulmonary, GI 4 primary changes occur: Myocardial depression the cardiac output decreases and ventricular contraction decreases. Massive vasodilation the blood is not getting back to the heart effectively

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Complex Health and Sensory Lecture Notes

Maldistribution of myocardial volume micro-emboli form from the spread of the vascular bed. The pt. is at risk for PEs, infarction, etc which leads to cell death.)

There are 2 types of septic shock:

Hyperdynamic phase Normal or elevated temperature Chills Restlessness Change in LOC (anxiety, confusion, restlessness) Tachycardia Widening pulse pressures Decrease in urine output

Hypodynamic phase worse.

Subnormal temperature r/t the brain/hypothalamus not getting enough oxygen Disorientation Hypotension decrease in ventricular contraction and blood back to heart Tachycardia with ventricular dysrhythmias Weak, thready pulses Cool, clammy skin Complete lack of urine output We need to find our patient in the hyperdynamic phase and fix the problem before the hypodynamic

Treatment of septic shock

Treat the infection Draw a CBC, blood cultures (before antibiotic), urine cultures, culture/sensitivity, order a lactate (can be drawn on ABGs, just have to request it)

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Complex Health and Sensory Lecture Notes

Normal lactate 2-20 or 3-23 (lactate is important because when there is a lack of perfusion to the cells they will produce lactate as they die.) Hang antibiotics (start with a broad spectrum until the C/S returns. Rocefin (ceftryaxone) in common Restore the volume to get cardiac output back Levophed

Nursing Interventions for Septic Shock

Control body temperature/ treat fever Monitor safety with confusion and decreased LOC Nutritional support if nutritional intake is decreased, the body will not be able to effectively fight infection Help family anxiety, support, end of life issues, coping, resources Must perform constant assessments of our patients

EMERGENCY NURSING
Car Wrecks, hemorrhage, chest pain, hypothermia, hyperthermia, fractures, amputation, lacerations, blunt/penetrating/crush injuries, CVAs, neurological problems, rape, sexual assault. Triage the pit

Triage nurse assess patients and gets them to the back based on urgency. Emergent triage life threatening. These patients go straight back to the room.
airway obstructions stridor circulatory problem chest pain, partial amputation, breathing with accessory muscles gunshot/stab wounds to the chest impaled with something

Urgent should see within 15-30 minutes. Not immediately life threatening.
They may sit for a period of time without treatment. The triage nurse must

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constantly watch these patients to make sure their condition does not progress to Emergent.

Non-Urgent can be safely addressed within 24 hours. Probably can be seen

at the PCP office

ABCs of Trauma Assessment (Primary)

A airway B Breathing C Circulation D Disability (neuro-checks, deformities) you must fully expose the patient.
The nurses role in the ER is to get the history and report on the trauma when they come in whether it is from the family or EMT/Paramedic. Know the mechanism of injury, how it happened.

Car wrecks
A driver that gets hit on the drivers side is at risk for a spleen injury or kidney A passenger that gets hit on the passenger side is at risk for a liver injury Lateral impact (T-bone) the harder the impact, the worse the injury Frontal impact usually have crush injuries in the lower extremities r/t everything moving forwards. Can also have head and Hyperflexion injuries r/t the airbags Rollovers teach seatbelts save lives!

Extrication Jaws of Life Can be very scary for the patient and they may
have emotional issues These patients are at risk for hemorrhage. Start 2 large bore 18G IVs with NS, LR If external, put a pressure dressing (microphone tape, gauze, koban, anything we can get tight around the wound. Tourniquet is a last resort (tourniquet cuts off all blood flow) If internal, treatment depends of vital signs

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Complex Health and Sensory Lecture Notes

Chest pain/MI Hypothermia/Hyperthermia Cold, wet, fever, heat exhaustion Treatment includes cool fluids, cooling blankets, warm blankets, warming fluids. Fractures/amputations Lawnmowers, kid riding bike with flip-flops Missed fractures, fingers, hands, jaw Fights beer bottles Fireworks can lose part of their hands and fingers Lacerations altercations or gunshot wounds can range from mild to severe.

Assessments for Trauma Patients

The patient must be rolled!! The front and back must be assessed. With gunshot wounds, there must be an entrance and exit wound. The exit wound will be larger than the entrance wound. Pooling blood is cold to the touch, and it can drop the body temperature. Animal bites (animal will be quarantined for 7 days if not put down) snakes, spiders, dogs, cats Fachiotomy for snake bites to handle the swelling With bites, we circle the area involved so we can track if the area is getting bigger or smaller. If anti-venom is used, the physician pushes it. Prior to giving, a little bit of the anti-venom is placed under the skin to test for a reaction.

ARORA are the ones that has to approach family members about organ donation. They do
not approach until the family has had a chance to deal with the death. ARORA and the coroner must be notified of every death in the E.D.

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Complex Health and Sensory Lecture Notes

In the event of a death, the family should be brought back ASAP, but they must be cleaned up before hand. If it is a coroner case, nothing can be removed from the patient (ET tubes, IV, Foley, etc) until the coroner clears them. After the coroner has cleared and has been cleaned up, get the family back as soon as possible. Never deny a family to see the deceased patient in the ED.

Non-traumatic patient ask the patient if they are having suicidal or homicidal thoughts.
Suicidal patients are often sent to the ICU for close observation because they must have 1:1 care. They may not be left alone. If the patient has suicidal or homicidal ideation, they will be held in the hospital for at least 72 business hours. When taking care of these patients, do not take anything into the room (stethoscopes, hemostats, tape, pens, etc leave it at the desk. Always know where your exit is and Always stay between them and the door. Strip these patients down when they get there and remove any weapons from them.

Staff safety
Patients will be violent. The police should be our friends and we should use them if we need help. (armed patients entering the ER, if somebody comes to finish the job, get out of the way b/c there is nothing you can do to stop it.)

The ER nurses safety is the priority. If in doubt, call the police department, not
security. It is a federal crime to threaten a health care worker

BURNS
1.1 million people per year are treated from burns from sunburn to 3rd degree 4500 people die per year r/t burns and inhalation injuries Most burs occur in the home Child burns are in large part to child abuse. As a nurse it is or responsibility to report child abuse. Bring it to the physician attention, go and assess the child together, and if it is determined to be child abuse, report to the authorities.

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Complex Health and Sensory Lecture Notes

PREVENTION is a huge part of the nurses role. We should teach prevention of burns.
(eg turn the handles towards the back of the stove, metal vents in the floor of old houses, curling irons, CHI Irons, light sockets

Factors that affect the burn Exposure to the agent length of time exposed Depth of the burn 1st 4th degree Temperature of the agent and flame, flash, electrical, chemical What is the size of the burn (Rule of Nines) Location (back of hand vs. neck) Age and past medical history (a young healthy person will handle better than an older
person with co morbidities)

Thickness of the skin that was burned

What other injuries occurred with the burn?

Types of burns Flame and Flash Second most common type of burn. Often associated with inhalation
injuries.

Chemical and Radiation burns accidents at home, or staying in the tanning bed too
long.

Thermal scald (hot water)

Contact

Review pg. 1997 Table differentiates 1st, 2nd,& 3rd degree burns First degree burns (Superficial Burns) involve the epidermis (top
layer of the skin) Due to a minor sunburn Pink or red appearance Small blisters possible Moderate pain

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Complex Health and Sensory Lecture Notes

Spontaneous healing (it will heal on its own) Ibuprofen is a good medicine to recommend for the sunburn because it stops the inflammation

Second degree burn (Partial Thickness Burn) involves the epidermis

and gets into the dermis Blistering occurs Severe pain Scarring Caused by: scalding, contact with hot liquids or solids, chemicals, UV light, direct flames

Third degree burn (Full Thickness Burn) involves all layers of the
skin. May extend into the muscle No pain r/t all the nerves damaged White, gray, black, dry appearance. charring Edema

Eschar black. Forms b/c tissue gets burned and all the
elasticity is destroyed and the skin cant spread. The eschar is a hard crusty surface Skin grafting may be needed Everything is destroyed tissue, bone, muscle

Emotional issues are huge in regard to burns. Circumfrential burns become concern when they start effecting blood flow and
neurovascular status because limbs can be lost. When the eschar gets tight, the edema starts pushing but cant expand due to the eschar. The blood flow cant get to the limb

Escharotomy strategic cuts to allow room for edema Rule of Nines BSAB Body Surface Area Burned

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Complex Health and Sensory Lecture Notes

Prognosis is determined by BSAB. And area burned Head and neck 9% Arms 9% Leg 18% Chest 18% Back 18% Anything >25% Body Surface Area is a major burn Anything <25% Body Surface Area is a local response

Effects of Major burns Fluid/electrolyte shifts

K increased r/t cell death Third-spacing leads to hemoconcentration of K At risk for fluid volume deficit or hypovolemic shock

Cardiovascular effects
Increased HR due to the pain which makes the heart work harder. Eventually the heart will get tired and at risk for an MI

Pulmonary injuries
Inhalation injuries S/s Decreased pulse ox Singed facial hair, eyebrows gone Soot in nose, eyes, ears Dark sooty sputum These injuries dont always show up immediately. May be 24-48 hours before showing symptoms.

Renal/GI complications
Paralytic ileus Will put a NG tube down

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Complex Health and Sensory Lecture Notes

Stress ulcers

Risk for infection Risk for thermoregulation problems r/t skin gone Three phases of burn injury Phase # 1 - Emergent/resuscitative phase onset of injury to completion of
fluid resuscitation. Do not put anything on the burn prior to going to the hospital b/c once they get to the burn center they will have to scrub it off. Do not pop blisters r/t increased risk for infection

Interventions outside the hospital setting. First Responder:

#1 stop the burning process Prevent injury to the rescuer ABCs Remove rings and other jewelry from the patient to avoid having to amputate a finger r/t swelling. Take earrings, necklaces, remove clothing unless it is burned to the patient and cut around it. Cover the patient with a clean dry sheet Treat for a cervical spine injury No ointments (silvadine, Neosporin, etc) It will have to be scrubbed off once they get to the burn center.

Interventions at the Emergency Room

Foley catheter NG tube Place on 100% oxygen with a non-rebreather Fluid resuscitation begins in this phase. Need 2 large bore 18G IVs bilaterally. They dont have to be in the arms they may in the EJ, IJ, SC Fluid amount depends on patients weight

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Complex Health and Sensory Lecture Notes

Cardiac monitoring with electrical burns (they may have neuro deficits, arrhythmias, etc Address Pain use IV medications only (IM puts them at risk for infection, and the pt is NPO. The only IM medication that will be given in Tetanus.) NPO status you can wet their mouth, but nothing to eat or drink at all!!!

Assessment data for the burn patient

Expect a 15%-20% weight gain within the first 72 hour. The weight gain is due to the fact that the patients fluids will thirdspace out of the vascular space, and we will be pumping fluids into the vascular space. Expect absent bowel sounds Generalized dehydration Hemoconcentration Urine output is next to nothing because the body shuts the kidneys down to retain fluid which stops dieresis in the body. Metabolic acidosis

Indicators of adequate fluid replacement in burn patients

Urine output increases Heart rate decreases (HR < 120) BP maintains above 100 systolic CVP between 2-6

Parklands Formula (How we determine how much fluid we are going to give them.

4cc x kg x BSAB = mL to be administers/24hrs

Ex wt. 150lbs, BSAB 50% 4cc x 68kg x 50 = 13,600mL in 24 hrs.

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Complex Health and Sensory Lecture Notes

Give 50% in the 1
st

8 hours 8 hours 8 hours

Give 25% in the 2 Give 25% in the 3

nd

rd

1st 8 hr 6400mL (800ml/hr) 2nd 8hr 3400mL (425ml/hr) 3rd 8 hr 3400mL (425ml/hr)

Nursing Diagnosis for Emergent Phase of Burns

Acute Pain Risk for infection Impaired Skin Integrity Ineffective airway Fluid Volume Deficit Tissue perfusion inadequate

Phase # 2 Acute Phase expected to occur 48-72 hrs after the injury.
Continue assessment, maintain respiratory and circulatory support. DIURESIS occurs in this stage. The fluid starts moving back from the third-space and into the vascular area. This puts the patient at risk for fluid volume overload. (heart failure, pulmonary edema, respiratory difficulties, a huge increase in urine output

Signs and Symptoms of the Acute Phase of Burns

Pulmonary edema Respiratory difficulties Significant increase in urine output Vital signs start returning back to normal

Fluid Replacement is guided by serum electrolytes and urine output. (the patient will be at risk for hypokalemia and hyponatremia
r/t hemodilutional.

Nursing Diagnosis for the Acute Phase of Burns

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Complex Health and Sensory Lecture Notes

Impaired Skin Integrity Risk for infection Acute pain
Background or resting pain Procedural pain (debridement, dressing changes) Drug of choice Morphine, Oxycodone, OxyContin y Morphine is good because it can be given very frequently. Give pain medications before treatments(30-45min) If the pain meds dont work, we will paralyze, sedate, and intubate them so they dont feel the pain

Altered Nutritional status

Metabolic rate rises rapidly and peaks 7-14 days after burns b/c they body is trying to heal itself. This will increase the metabolism. We will give double calories to these patients which may exceed 5000 calories per day. The diet should be high in protein (2-3 times normal.) TPN/Enteral feedings watch glucose and sepsis

Phase # 3 - Rehabilitation Phase starts from admission, but really moves

forward when the patients burn is less than 20%, and the patient is capable of resuming some of their normal activities. The focus is on wound healing, psychosocial support, self image, lifestyle, and maximum functioning ability. DO NOT give them false hope. We need to let them do things for themselves. They may be going through reconstructive surgery to fix looks or functioning. Get the patient vocational support. Depression is the worst thing for the patient to have while healing.

Nursing Diagnosis for the Rehabilitation Phase of Burns

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Complex Health and Sensory Lecture Notes

Body Image Disturbance Ineffective Coping Knowledge Deficit Self Care Deficit Chronic Pain

Interventions for the Rehabilitation Phase of Burns

Promote Mobility exercises, splints Promote skin integrity roll pts, etc

Wound Care pg. 20-18 table 57-5 and 57-6. Also, read over and be familiar with the wound care. Review shocks!!! And interventions for them.

MASS CASUALTY AND TERRORISM

Pg. 2562 Chart 72-1 - Triage Categories in Mass Casualty See Attached
With mass casualty triage, we take the patients that are most likely to survive. There will be limited resources, so we must not spend our time trying to resuscitate a patient that will probably not live.

If the emergency system is activated, the nurse must make sure their family is safe and report to work.
As a nursing student, we can assist with moving patients and be the gofer but we cannot step out of our role as a student and do anything invasive or triage In Arkansas we are at risk for Earthquakes Tornadoes Pine Bluff arsenal Nuclear one in Russellville Military Bases Plane crashes

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Complex Health and Sensory Lecture Notes

Pg. 2569 Common Chemical Agents See attached
We should suspect a terrorist attack when we see a lot of people come into the ER with the same symptoms from the same place

Radiation dirty bombs could be set off anywhere. Patients at risk for burns Bioterrorism Anthrax the problems comes from the spores. The patient will not be on isolation
precautions b/c we wont be in contact with the spores.

Small Pox like chickenpox times 100. Develop vesicles on the face Botulism affects the food supply Hemorrhagic fever Bubonic Plague De Dsa Dsa Dsa

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