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MEDICAL SURGICAL NURSING
Assessment of Central Nervous System and Low Back Pain
Dr Ibraheem Bashayreh, RN, PhD
4/1/2011
1
NERVOUS SYSTEM
Controls and integrates sensory, motor, and autonomic functions
Maintains internal homeostasis Enables connection and response to external
environment
NEURON
Working cell of the nervous system Carries impulses
Sensory (afferent) Motor (efferent)
Neurotransmitters (chemicals) Facilitate or hinder impulse transmission across
synapse
BRAIN
Cerebrum; sensation, movement Left hemisphere; speech, problem solving,
reasoning, calculations Right hemisphere; visual, spatial abilities
(relating to the position, area and size of things), Face recognition, Visual imagery and Music
BRAIN
Diencephalon Thalamus; sensory relay Hypothalamus; regulatory center
Brainstem: vital centers Cerebellum
Involuntary muscle activity; fine motor Balance and posture
PERIPHERAL NERVOUS SYSTEM
Cranial nerves Spinal nerves Somatic nervous system Autonomic nervous system
Sympathetic Parasympathetic
PERIPHERAL NERVOUS SYSTEM
Link between CNS and the body Spinal nerves
31 pairs Sensory and motor fibers Involved in reflexes/reflex arc
CRANIAL NERVES
Cell bodies in brain/brainstem Sensory function, motor function, or both Mainly control head and neck functions
AUTONOMIC NERVOUS SYSTEM
Maintains internal homeostasis Two divisions
Sympathetic: “flight or fight” Parasympathetic: “rest and digest”
NEUROLOGIC ASSESSMENT
LOC always assessed first Altered LOC leads to inaccuracies
Determine alternate sources of information Family, caregivers, health care professionals
ASSESSMENT
Subjective Past medical history
Actual neurologic disorders/family history Medication use Symptom history; include pain assessment Social/environmental data
ASSESSMENT
Subjective Motor: loss of movement; altered balance,
coordination Sensory: numbness, tingling, sight, touch Cognitive: memory, speech, intellect, mood
ASSESSMENT
Subjective Eye
PMH/family history related to the vision Changes in vision; use of corrective lenses; irritation
Ear PMH/family history related to hearing Changes in hearing; tinnitus drainage Use of hearing aids
ASSESSMENT
Objective General survey
Appearance, gait, balance, posture Vital signs Cranial nerve assessment
ASSESSMENT
Objective Cognitive functioning
LOC, mental status, mood Sensory functioning
Sight, sounds, touch Motor functioning
Muscle strength, tone symmetry Reflexes
ASSESSMENT
Objective Eye
Snellen, Rossenbaum charts Inspection
Ear Rinne, Webber, whisper tests Inspection
EXPECTED ALTERATIONS RELATED TO AGING
Slower movement and reflexes Forgetfulness Changes in sleep patterns Changes in motor skills
EXPECTED ALTERATIONS RELATED TO AGING
Ptosis Presbyopia Decreased tear production Changes in eyelids Hearing difficulties Increased production of cerumen
UNEXPECTED ALTERATIONS RELATED TO AGING
Significant changes in Long/short-term memory Mental status Coordination/motor skills Speech Pain perception Sleep
LABORATORY TEST
Electrolytes Complete blood count Liver function tests Renal panel Arterial blood gases Cultures Urinalysis
IMAGING STUDIES
All radiographic studies Allergy assessment—shellfish/iodine Hydration, renal function Pregnancy concerns Client teaching about procedure
IMAGING STUDIES
Skull/spine x-rays Client teaching/explanation
MRI Assess for implanted metal Client teaching: enclosed space; noise
The implants that are most prone to causing problems for patients with MRIs are the following:
* Pacemakers or heart valves * Metal implants in a patient's brain * Metal implants in a patient's eye or ears * Infusion catheters
IMAGING STUDIES
CT scan ID shellfish/iodine allergy Assess disorientation Medicate for agitation Teach: warm sensation with contrast
IMAGING STUDIES
Cerebral angiography NPO prior Flushing with contrast media Close neurologic/VS monitoring post Pressure dressing/ice Report bleeding/swelling at site STAT
IMAGING STUDIES
Myelography Post: elevate HOB, bed rest Close neurologic/VS monitoring Report leakage/bleeding at site STAT
IMAGING STUDIES
Positron emission tomography (PET): is a nuclear medicine imaging technique which produces a three-dimensional image or picture of functional processes in the body. NPO 4 hours prior IV start Post: hydration
Carotid duplex
ELECTROGRAPHIC STUDIES
EEG, evoked potentials Wash hair prior
Electromyography (EMG) :involves testing the electrical activity of muscles Discomfort with needle insertion
VISION TESTS
Fluorescein stain Potential stinging; staining not permanent
Visual fields Tiring
Facial x-rays/CT scan Explain procedure
Ultrasound Cornea anesthetized
HEARING TESTS
Audiometry Explain procedure
X-ray/CT scan Explain procedure
Caloric Testing (Electronystagmography) Post assessment; vomiting Aspiration precautions
EPIDEMIOLOGY 75% of adults will experience LBP at some
point in their lives 5th most common cause of all physician visits Peak incidence 20-40 years old; More severe in
older patients 85% of patients have no definitive anatomic
cause or imaging finding Most cases are self limited with serious
problems in < 5% Most common cause of work-related disability
for individuals < 45 years old
4/01/2011
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Rathmell, J. P. JAMA 2008;299:2066-2077.
Normal Anatomy of the Functional Spinal Unit (L4-5) and Associated Neural Structures
4/01/2011
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LBP: RISK FACTORS Heavy lifting and
twisting Obesity Poor physical
fitness/conditioning History of low back
trauma Psychiatric
history(chronic LBP)
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MECHANICAL LBP/LEG PAIN ETIOLOGIES (97%) usually attributable to musculoligamentous
injuries or age-related degenerative disease in intervertebral disks and facet joints Lumbar strain (70%)Degenerative disk and facets (10%)Herniated disk (4%)Spinal Stenosis (3%)Osteoporotic compression fracture (4%)Traumatic fracture (<1%)Congenital disease (<1%)
Kyphosis Scoliosis
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NON MECHANICAL LBP ETIOLOGIES (1%) Inflamatory, infectious our systemic disease
effecting vertebral musculoskeletal structures Neoplasia (0.7%)
Multiple myeloma Metastatic carcinoma Lymphoma / Leukemia Spinal cord tumors Primary vertebral tumors
Infection (<0.01%) Osteomyelits Septic diskitis Epidural abcess
Inflammatory arthritis (0.3%) Ankylosing spondylitis Psoriatic spondylitis Reiter’s syndrome Inflammatory bowel disease
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Ankylosing spondylitis is a chronic, inflammatory arthritis and autoimmune disease. It mainly affects joints in the spine eventual fusion of the spin
Reiter's syndrome is a chronic form of inflammatory arthritis three conditions are combined: arthritis; inflammation of the eyes (conjunctivitis); and inflammation of the genital, urinary or gastrointestinal systems.
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VISCERAL DISEASE INDUCED LBP:ETIOLOGIES (2%)
Process involving anatomic site other that vertebral musculoskeletal structures
Disease of pelvic organs Prostatitis Endometriosis Chronic Pelvic Inflammatory Disease
Renal disease Nephrolithiasis Pyelonephritis Perinephric abcess
Aortic aneurysm Gastrointestinal disease
Pancreatitis Cholecystitis Penetrating ulcer
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MECHANICAL LBP DIFFERENTIAL DIAGNOSIS :CLINICAL FEATURES
Herniated disk Usually occurs in adults aged 30 to 55 years Sciatica, often associated with leg numbness or paresthesias,
is a highly sensitive (95%) and specific (88%) finding for herniated
disk Exacerbation of pain may occur with
coughing sneezing Valsalva maneuvers : is performed by moderately forceful
attempted exhalation against a closed airway, usually done by closing one's mouth and pinching one's nose shut
Spinal Stenosis usually occurs in older adults characterized by neurogenic claudication (impairment in
walking, or a "painful, aching, cramping, uncomfortable, or tired feeling in the legs that occurs during walking and is relieved by rest) radiating back pain and lower extremity numbness exacerbated by walking and spinal extension improved by sitting
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LOW BACK PAIN CLASSIFICATION (TEMPORAL)
Acute Low Back Pain < 6 week duration
Chronic Low Back Pain > 6 week duration
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ACUTE LBP History
Time-course of onset (associated activity; time of day)
PainLocation (site, radiation)Nature (sharp, throbbing, dull, etc.)
SeverityAggravating/relieving factors
Prior injuriesAge
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ACUTE LOW BACK PAIN Three clinical groups of Acute LBP
Symptoms of potentially serious spinal condition (tumor, infection, fracture)
Sciatica (discomfort radiating to legs) Nonspecific back symptoms (most common is
strain of soft tissue elements)
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CLINICAL ASSESSMENT ACUTE LBP Physical Exam
Should be comprehensive, but focus on:Neurologic sensation, muscle strength(dorsiflexion of foot and great toe)
Peripheral pulsesStance and gaitFlexibilityFocal tendernessStraight leg raise
Non-physiologic symptoms consider depression, mental illness
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CLINICAL ASSESSMENT OF PERSISTENT (CHRONIC) LBP History
Additionally considerHistory of cancerAge > 50 (malignancy, osteoporotic fracture)
Recent unexplained weight loss (underlying malignancy)
Recent IV drug use (Osteomyelits, Septic diskitis,Paraspinous or Epidural abcess)
Presence of chronic infection (as above)Prior treatments and their effectiveness
Pain unrelieved with positional changesconsider infection, cancer (not specific, however)
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CLINICAL ASSESSMENT OF ETIOLOGYIs this likely to represent a serious illness?
Systemic Inflammatory Infectious Neoplastic Severe mechanical injury
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Risk factorsMajor trauma:
Possible fractureCorticosteroid use:
Greater risk for osteoporotic fractureAge >50 y:
Greater risk for malignancy, osteoporotic fractureHistory of cancer:
Greater risk for underlying malignancyUnexplained weight loss:
Greater risk for malignancy or infectionFever, immunosuppression, immunodeficiency,
injection drug use, or active infection: Risk for spinal infection
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Clinical Assessment of EtiologyClinical Assessment of Etiology
CLINICAL ASSESSMENT: PSYCHOSOCIAL
Are there complicating psychosocial factors that may impede treatment or prolong pain and predict poor outcomes? history of failed treatment, depression, and somatization (a psychiatric diagnosis
applied to patients who persistently complain of varied physical symptoms that have no identifiable physical origin).
Substance abuse, job dissatisfaction ongoing litigation or compensation claims
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WHEN TO USE RADIOLOGY? Age >50 years Recent significant trauma Neurologic deficits Systemic symptoms Fever Unexplained weight loss History of cancer, substance abuse, chronic
corticosteroid use
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TREATMENT Acute LBP
Superficial heat, deep heat, cold packsNSAIDs mainstay, narcotics only if severe pain
and only for short durationReevaluate treatment after 4 weeks90% get better within 4 weeksPhysical Therapy
Persistent LBP Intensive exercise (poor compliance)Treatment of concomitant mental illness if
presentPatient educationReferral to pain center (combination of
modalities)
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INTERVENTIONAL PAIN THERAPIES Epidural Corticosteriod Injection Facet injection Intrathecal Analgesia
Chronic refractory non-cancer pain Limited quality of evidence (observational) Should be reserved for patients refractory to other
interventions Intradiskal Electrothermal Therapy
39% of Chronic LBP diskogenic
Thermal sensory nerve ablation
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INDICATIONS FOR SURGERY Primary indication:
Severe or increasing neurologic deficit Sciatica and herniated disk Spinal stenosis Spondylolysthesis
Spinal stenosis symptoms Severe, persistent pain or sciatica for 12 months or
more
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PREVENTION STRATEGIES Exercise and
strengthening exercises
Weight loss? Smoking cessation? Improvement of
strenuous and stressful working conditions
Back braces are ineffective in prevention
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SITTING POSTUREWhen sitting in any
position, the three back curves need to be maintained.
If you cannot sit without slouching forward or backward, you need to support yourself with hands and arms or lean against a wall or chair back.
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LYING POSTURE: Avoid propping head or
upper body up on an arm and hand.
Head should remain relaxed. Legs should be together.
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