Spinal Cord Compress Ions

8/4/2019 Spinal Cord Compress Ions

http://slidepdf.com/reader/full/spinal-cord-compress-ions 1/24

Spinal Cord Compression:

A Case Study

Angie Angeles-Lo, SN,

Kathy Berliner, SNAnthony Bodestyne, SN

Lisa Warren, SN



Spinal Cord Compression:Patient History

Pt Demographics: 55 year old female, diagnosed 1

year prior with metastatic colon cancer. This

patient had a section of colon removed in 11/02;

she now has a permanent transverse colostomy.She was admitted to Kaiser South San Francisco

on 11/20/03 for Spinal Cord Compression with

paralysis of the lower extremities.



Spinal Cord Compression:Patient History

History of Present Hospitalization: In 9/03,

multiple retroperitoneal nodes were discovered on

CT. On the advice of the physician, the pt flew to

El Salvador to visit family. On 11/19, pt awokewith severe 10+/10 back pain accompanied by b/l

weakness of the lower extremities. She was seen

in the ER in El Salvador where she received

epidural analgesia in order to sit through the flight

back to the U.S. By the end of the flight, the pt

had no sensation or movement of the lower

extremities.



Spinal Cord Compression:Diagnostic Tests

CT Scan: A scan of the thoracic spine done on 11/20. The

impression showed probable metastatic disease to the

thoracic spine. Air was seen within the epidural space at

the lower thoracic level. Exact etiology is unknown.

MRI: A follow up MRI was done of the thoracic and lower

spine that same day. The impression showed extensive

metastatic tumor involving the cervical, thoracic, lumbar

and sacral vertebrae, with evidence or spinal cord

compression at T2 and T9.



Spinal Cord Compression:Pathophysiology

Definition: Spinal cord compression

damage occur when a tumor directly enters

the spinal cord or when the vertebralcolumn collapses from tumor entry. Tumors

may begin in the spinal cord but more

commonly spread from other areas of the

body such as the lung, prostate, breast,

colon.




Direct compression or distortion of the spinal cord may

result from neoplastic infiltration of the vertebral bodies or

paravertebral spaces.

Rarely, cancerous growths may originate from structures

within the epidural space.

Nerve tracts most vulnerable to mechanical pressure

include the corticospinal and spinocerebellar tracts and the

posterior spinal columns.




Spinal cord compression usually follows hematogenous

dissemination of a malignancy to the vertebral bodies, with

subsequent expansion of an epidural mass. Generally,

metastatic seeding appears in the thoracic spine 70% of with the lumbar spine being the next most involved

site.The cervical spine is affected in approximately 10% of

cases.Multiple spinal levels are affected in about 30% of

patients.

Systemic cancers with a tendency for spinal cord

metastasis include the following: breast, prostate, renal, or

lung neoplasms; lymphoma; sarcoma; and multiple

myeloma.




Spread into the epidural space may occur by

means of tumor extension through the

intervertebral foramina or hematogenous spread

by way of the Batson venous plexus. Additionally,gastrointestinal and pelvic malignancies tend to

affect the lumbosacral spine; lung and breast

cancers are more likely to affect the thoracic spine.




Leptomeningeal metastases spread by means of

diffuse or multifocal seeding of the meninges from

systemic cancer (eg, lung or breast cancer,

melanoma, lymphoma). Consequent signs andsymptoms are referable to the brain, cranial

nerves, or spine. Evidence of spinal compromise

includes lower extremity weakness, paresthesias,

reflex asymmetry, and spinal pain.



Spinal Cord Compression:Signs and Symptoms

Signs and Symptoms: Spinal cord compression causes

back pain, usually before neurologic deficits occur. Neurologic

deficits are related to the spinal level of compression and include the

following:

1. Numbness

2. T ingling

3. Loss of urethral, vaginal and rectal sensation

4. Muscle weakness

5. If paralysis occurs, it is usually permanent.

6. Valsalva maneuvers, such as coughing, sneezing, or straining, may

exacerbate radicular back pain.



Spinal Cord Compression:Treatment

Nurses caring for clients with spinal cord compression must recognize

the condition early. The nurses assesses the client for neurologic

changes consistent with spinal cord compression. The nurse also

teaches clients and families to recognize the symptoms of early spinal

cord compression and to seek medical assistance as soon as possible.

Treatment is largely palliative. High-doses radiation is usually

administered to reduce the size of the tumor in the area and relieve

compression. Radiation may be given in conjunction with

chemotherapy to treat the total disease. Surgery is occasionally

performed to remove the tumor from the area and rearrange the bonytissue so less pressure is placed on the spinal cord. External back or

neck braces may be prescribed to reduce the weight borne by the spinal

column and to reduce pressure on the spinal cord or spinal nerves.



Spinal Cord Compression:Patient Medications

Dexamethasone- Management of cerebral edema and spianal

compression .Potent, locally acting anti-inflammatory and immune

modifier.Action-suppresses inflammation and the normal immune

response. Dosage-0.75-9mg PO/IV/IM daily IM, IV (Adults):

Dexamethasone phosphate — 10 mg initially IV, 4 mg q 6 hr, may bedecreased to 2 mg q 8 – 12 hr, then change to PO. Adverse reaction-

nausea, dizziness, HA Serious reaction -anapyhaxis. Implication-

Assess patient for changes in level of consciousness and headache

throughout therapy.

Protonix- For hypersecretory condition, GERD Dosage 40-120mg PO BID Max:240 mg/d. Info:do not crush, cut

chew Action:Inhibits gastric parietal cell hydrogen-potassium ATPase

(proton pump inhibitr) Adverse RXN: HA, diarrhea Serious side

effect: Anaphylaxis Implication:monitor for and immediately report

S&S of angioedma or severe skin reaction




Fentanyl Patch: For Chronic Pain

Dosage: 25-100 mcg/hr patch q72h Action: Binds to various opiate

receptors, producing analgesia and sedation. Adverse reaction: dry

mouth, euphoria. Serious side effect: respiratory depression, severe

HTN. Implication:evaluate pain relief. Monitor VS, O2 Sat, bladderfunction.

Heparin-DVT Tx/prophylaxis

Dosage: 5000 U SC q8-12h Action: with antithrobin III and heparin

cofactor, inhibits thrombin and Factor Xa and inhibits conversion of

fibrinogen to fibrin Adverse reaction: Prolonged clotting time,bleeding Serious reaction: hemorrhage Implication:Monitor patient

for hypersensitivity reactions (chills, fever, urticaria). Report signs to

physician.Monitor platelet count every 2 – 3 days throughout therapy.




Insulin:Due to glucocorticoid administration.

Dosage: Sliding Scale before meals and bedtime Action:

Lower blood glucose by increasing transport into cells and

promoting the conversion of glucose to glycogen Adversereaction: rebound hyperglycemia (Somogyi effect),

hypoglycemia Serious reaction-anaphylaxis

Implications: Check type, species source, dose, and

expiration date with another licensed nurse. Do notinterchange insulins without consulting physician or other

health care professional.



Spinal Cord Compression:Radiation Therapy

Radiation treatment to areas of tumor compression should

be pursued after appropriate imaging and consultation.

Cord compression from an epidural tumor is consideredone of the few emergencies in radiation oncology.

Spinal cord tolerance to radiation depends on the fraction

size and cumulative dose.



Spinal Cord Compression:Radiation Therapy

Radiation treatment affects normal cells while damaging cancer cells.

Sometimes this effect on normal cells and tissues can cause pain and

discomfort.

Skin dryness, difficulty in swallowing or skin sores may occur. The

radiation therapy specialist can recommend a program to care for theskin to alleviate these side effects.

Fatigue can be a disabling side effect of cancer, cancer treatments and

dealing with pain. It restricts a person's ability to manage their usual

activities.

This patient was receiving external beam radiation for 8 days as

palliative treatment to shrink the tumor that invaded the spinal

column.



Spinal Cord Compression:Nursing Assessments and Interventions

Monitor and document vital signs. Rationale: Obtain info

on patient’s overall condition

Assess neurological status including limb strength, sensation, bladder and bowel function Rationale:

Establish patient’s level of consciousness. Ascertain any

evidence of increasing spinal cord compression as

indicated by motor dysfunction, weakness, ataxia, sensory loss, numbness, tingling, loss of sensation to pain

and temperature, constipation and urinary retention.



Spinal Cord CompressionNursing Assessment

Monitor blood chemistry and patient for signs of hypercalcemia, such

as confusion, drowsiness and lethargy. Rationale: Elevated calcium

levels may be associated with bone mets causing spinal cord

compression

Assess alterations in elimination of urine and feces in terns of urgency,

frequency, level of control over function, retention, constipation and

incontinence. Rationale: Early autonomic and nervous system

involvement results in constipation and urinary retention. Bowel

and bladder incontinence develop with advanced autonomic nervous system involvement.



Spinal Cord Compression:Nursing Assessment

Assess patient’s pain level. Assess for duration, location,

type, intensity and quality. Assess pain interventions.

Consider non-pharmacological interventions such as

relaxation, therapeutic massage and adjustment of patient’s position.

Assess patient’s skin as there are at risk for impaired skin

integrity. Rationale: Maintain good body alignment at all times to decrease the risk of further injury to spine.




Assess for signs and symptoms of deep venous thrombosis due to

activity. This can lead to pulmonary embolism, which can be a lethal

complication. Many die within one hour of onset of symptoms or

before it has been suspected.

For a DVT assess for calf and groin tenderness, pain, sudden onset of

unilateral swelling of leg and positive Homan’s sign. Symptoms of

pulmonary embolism include dyspnea, chest pain, restlessness, cough

and hemoptysis. Signs include tachypnea, crackles, pleural friction

rub, tachycardia, diaphoresis, fever and petechiae over chest and axilla.




Assess and monitor patient and family’s psychological

status and adaptation to diagnosis and implication onlifestyle. Feelings of helplessness, hopelessness and

depression are common. Bed bound patients become

withdrawn and lose motivation.



Spinal Cord Compression:Nursing Diagnoses and Interventions

Impaired physical mobility related to neuromuscular

impairment. Interventions include: maintain proper body

alignment, ROM exercises, adequate nutrition, teach

patient how to move in bed, monitor skin area overpressure areas.

Risk for falls related to decreased or absent lower

extremity sensation and strength. Interventions include:

bed in low position, side rails up, keep frequently used

items within patient’s reach, provide assistance with

ambulation.




Risk for impaired skin integrity related to physical

immobilization and loss of bladder and bowel control.

Interventions include: Active or passive range of motions,

ambulate to the extend possible, change positions every 2 hours,

reduce pressure using things like pillows, air mattresses and bedcradles, maintain good body hygiene, encourage adequate fluid

and nutritional intake.

Bowel incontinence related to loss of rectal sphincter

control. Interventions include: Keep area clean and dry.Monitor anal and genital skin integrity. Record each episode

including when it occurs, amount, color and consistency.

Provide emotional support for patient.




Ineffective Individual Coping related to inadequate

level of confidence in ability to cope. Interventions

include: maintain consistency in approach and teaching

whenever interacting with patient, monitor for andreinforce behavior suggesting effective coping

continuously, assist patient to identify and use available

support systems before discharge from hospital and help

patient evaluate which methods he or she have used that

have not been successful or have been only partiallysuccessful.

Date post:	07-Apr-2018
Category:	Documents
Upload:	freegie-racca
View:	222 times
Download:	0 times

Spinal Cord Compress Ions

Documents