Chapter 46 Interventions for Clients with Problems of

Back Pain • Low back • Herniated nucleus pulposus • Physical assessment: continuous acute pain, altered gait, vertebral alignment, paresthesia • Diagnostic assessment using MRI, CT, and electromyography Elsevier items and derived items © 2006 by Elsevier Inc.

Nonsurgical Management • Williams position, firm mattress or backboard under soft mattress • Exercise • Drug therapy • Heat and ice therapy • Diet therapy (Continued) Elsevier items and derived items © 2006 by Elsevier Inc.

Nonsurgical Management (Continued) • Other pain relief measures • Complementary and alternative therapies • Percutaneous laser disk decompression Elsevier items and derived items © 2006 by Elsevier Inc.

Surgical Management • Diskectomy • Laminectomy • Spinal fusion (arthrodesis) • Minimally invasive lumbar procedures, such as percutaneous lumbar diskectomy, microdiskectomy, laser-assisted laparoscopic lumbar diskectomy Elsevier items and derived items © 2006 by Elsevier Inc.

Postoperative Care • Prevention and assessment of complications • Neurologic assessment; vital signs • Client’s ability to void • Pain control • Wound care • Client positioning and mobility Elsevier items and derived items © 2006 by Elsevier Inc.

Cervical Neck Pain • Conservative treatment is the same as described for back pain except that the exercises focus on shoulder and neck. • If these treatments do not work, soft collar may be used at night for a period of no longer than 10 days. • If conservative treatment is ineffective, surgery such as an anterior cervical diskectomy and fusion is commonly performed. Elsevier items and derived items © 2006 by Elsevier Inc.

Spinal Cord Injury • Hyperflexion injury • Hyperextension injury • Axial loading injury such as those that occur in jumping • Rotation of the head beyond its range • Penetration injury, such as those wounds caused by a bullet or a knife Elsevier items and derived items © 2006 by Elsevier Inc.

Cervical Injuries • Anterior cord syndrome • Posterior cord lesion • Brown-Séquard syndrome •

Initial Assessment • Assessment of the respiratory pattern and ensuring an adequate airway • Assessment for indications of intra-abdominal hemorrhage or bleeding around fracture sites • Assessment of level of consciousness using Glasgow Coma Scale (Continued) Elsevier items and derived items © 2006 by Elsevier Inc.

Initial Assessment (Continued) • Establishment of level of injury: tetraplegia, quadriparesis, paraplegia, and paraparesis

Spinal Shock • This condition is characterized by the following: – Flaccid paralysis – Loss of reflex activity below the level of the lesion – Bradycardia – Paralytic ileus – Hypotension Elsevier items and derived items © 2006 by Elsevier Inc.

Cardiovascular Assessment • Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous system. • Bradycardia, hypotension, and hypothermia result from a loss of sympathetic input and may lead to cardiac dysrhythmias. (Continued) Elsevier items and derived items © 2006 by Elsevier Inc.

Cardiovascular Assessment (Continued) • Systolic blood pressure lower than 90 mm Hg requires treatment because lack of perfusion to the spinal cord worsens the condition. Elsevier items and derived items © 2006 by Elsevier Inc.

Autonomic Dysreflexia • Commonly seen in clients with upper spinal cord injury • Severe hypertension • Bradycardia • Severe headache • Nasal stuffiness • Flushing • Treatment Elsevier items and derived items © 2006 by Elsevier Inc.

Assessments • Respiratory assessment • Gastrointestinal and genitourinary assessment • Musculoskeletal assessment • Psychosocial assessment • Laboratory assessment • Radiographic and other diagnostic assessments Elsevier items and derived items © 2006 by Elsevier Inc.

$Ineffective Tissue Perfusion • Interventions include: – Reduction and immobilization of the fracture to$

Ineffective Tissue Perfusion • Interventions include: – Reduction and immobilization of the fracture to prevent further damage to the spinal cord from bone fragments – Nonsurgical techniques, such as traction or external fixation, but surgery may be necessary as well Elsevier items and derived items © 2006 by Elsevier Inc.

Immobilization for Cervical Injuries • Fixed skeletal traction to realign the vertebrae, facilitate bone healing, and prevent further injury • Halo fixation and cervical tongs • Stryker frame, rotational bed, kinetic treatment table • Pin site care and monitoring of traction ropes Elsevier items and derived items © 2006 by Elsevier Inc.

Immobilization of Thoracic and Lumbosacral Injuries • For clients with thoracic injuries: bedrest and possible immobilization with a fiberglass or plastic body cast • For clients with lumbar and sacral injuries: immobilization of the spine with a brace or corset worn when the client is out of bed; custom-fit thoracic lumbar sacral orthoses preferred Elsevier items and derived items © 2006 by Elsevier Inc.

Drug Therapy • Methylprednisolone (controversial) • Dextran • Atropine sulfate • Dopamine hydrochloride •

Drug Therapy (Continued) • 4 -AP potassium channel blocker • Dantrolene • Baclofen •

Surgical Management • Emergency surgery necessary for spinal cord decompression • Decompressive laminectomy • Spinal fusion • Harrington rods to stabilize thoracic spinal injuries Elsevier items and derived items © 2006 by Elsevier Inc.

Ineffective Airway Clearance and Breathing Pattern • Interventions for the client with spinal cord injury: – Airway management is the priority. – Clients with injuries at or above the sixth thoracic vertebra are especially at risk for respiratory complications. – Provide measures to maintain airway. (Continued) Elsevier items and derived items © 2006 by Elsevier Inc.

Ineffective Airway Clearance and Breathing Pattern (Continued) – Assisted coughing, quad cough, cough assist

Impaired Physical Mobility; Self-Care Deficit • Interventions include: – In clients with spinal cord injury, monitor for risk of pressure ulcers, contractures, and deep vein thrombosis or pulmonary emboli. – Proper positioning, skin inspection, ROM exercises, heparin, and graduated compression stockings. (Continued) Elsevier items and derived items © 2006 by Elsevier Inc.

Impaired Physical Mobility; Self-Care Deficit (Continued) – Prevent orthostatic hypotension. – Promote self-care. Elsevier

Impaired Urinary Elimination; Constipation • Interventions include: – A bladder retraining program – Spastic bladder: manipulating external area – Flaccid bladder: Valsalva maneuver – Encouraging consumption of 2000 to 2500 m. L of fluid daily to prevent urinary tract infection (Continued) Elsevier items and derived items © 2006 by Elsevier Inc.

Impaired Urinary Elimination; Constipation (Continued) • Long-term renal complication • Signs and symptoms of urinary tract infection not perceived by the client Elsevier items and derived items © 2006 by Elsevier Inc.

Establishing a Bowel Retraining Program • Consistent time for bowel elimination • High fluid intake for at least 200 m. L/day • High-fiber diet • Rectal stimulation (with or without suppositories) • Stool softener medications, as needed Elsevier items and derived items © 2006 by Elsevier Inc.

Impaired Adjustment • Interventions include: – Invite clients to ask questions about significant life changes; reply openly and honestly. – Encourage clients to discuss their perceptions of their situation and coping strategies that can be used. – Begin a client education program to clarify misconceptions. Elsevier items and derived items © 2006 by Elsevier Inc.

Spinal Cord Tumors • Surgical management: goal of removing as much of the tumor as possible • Nonsurgical management: radiation therapy, chemotherapy, pain control Elsevier items and derived items © 2006 by Elsevier Inc.

Multiple Sclerosis • Chronic autoimmune disease affecting the myelin sheath and conduction pathway of the CNS • Characterized by periods of remission and exacerbation • Inflammatory response resulting in random or patchy areas of plaque in the white matter of the CNS Elsevier items and derived items © 2006 by Elsevier Inc.

Major Types of Multiple Sclerosis • Relapsing-remitting • Progressive-relapsing • Primary progressive • Secondary

Common Physical Assessment • Findings include: – Flexor spasms at night – Intention tremor – Dysmetria – Blurred vision, diplopia, decreased visual acuity, scotomas, nystagmus – Hypalgesia, numbness, tingling or burning – Bowel and bladder dysfunction Elsevier items and derived items © 2006 by Elsevier Inc.

Drug Therapy • Therapies include: – Biological response modifiers – Immunosuppressives – Steroids –

Management • Promoting mobility and self-care • Managing cognitive problems • Adapting to changes in sexual functioning • Managing bladder and bowel problems • Treating visual disturbances • Complementary and alternative therapies Elsevier items and derived items © 2006 by Elsevier Inc.

Amyotrophic Lateral Sclerosis • Known as Lou Gehrig’s disease, a progressive and degenerative disease that involves the motor system • Early symptoms: fatigue while talking, tongue atrophy, dysphagia, weakness of the hands and arms, fasciculations, nasal quality of speech, dysarthria Elsevier items and derived items © 2006 by Elsevier Inc.

Interventions • No known cure, no treatment, no preventive measures • Riluzole, only drug approved by FDA to extend survival time • Exercise and mobility program • Management of swallowing difficulties • Respiratory support Elsevier items and derived items © 2006 by Elsevier Inc.