Lab Day 1
Autonomic Dysreflexia
1. Describe the pathophysiology of the disease process. (Spinal cord injury, stroke,
syncope)
Autonomic dysreflexia is a complications of a spinal cord injury (occurs after the shock
has subsides in the rehab faze). It occurs above the T-5 T-6, T-12 level (between the two
paraplegia with trunk and leg involvement normal arm and hand movement. Paraplegia
with fair ability to control balance and trunk, little or no voluntary bowel or bladder
control.) A strong sensory input such as pain, distended bladder, rapid temperature
changes infection or a full rectum is carried into the spinal cord via intact peripheral
nerves. This input travel up the spinal cord and evokes a massive sympathetic surge from
the hypothalamus (thermostat of the body). Which cause vasoconstriction and that leads
to hypertension.
2. What are the signs and symptoms of the disease process?
Severe headache, hypertension, bradycardia, tachycardia, diaphoresis, flushing above and
pallor below the injury level
Most common cause of this condition is A FULL BLADDER OR FULL BOWEL. Others
could be tight clothing, GI disturbances, DVT, pressure ulcer, bladder and kidney
infection, temp extremes, shoes, lying or sitting on hard object or a minor injury.
3. What are the nursing interventions for this disease process?
Monitor BP if an increase of 20-40mm above patients’ baseline is a concern
Administer antihypertensive medications as ordered HOB at 45 or sit the patient up.
Loosen restrictive clothing remove braces, antiembolism stocking or shoes look for
sources of pain (helps blood pool into the extremities which will help lower bp)
Check the bladder/ patency of catheter/ collect UA for possible UTI
Check for bowel impaction
Check body for other sources like pressure ulcer, wounds, bites, scratches etc.
4. What education would you provide to a patient with this disease process?
I would tell the patient to make sure he informs us of a headache or if he notices he hasn’t
had a bowel movement in a while.
Educate the family that they need to inspect the catheter for kinks and insure he has a
high fiber diet. Ensure normal care is given as if he could feel his legs.
Educate family on S/S of this condition. Also look for skin breakdown.
Spinal Cord Injury
1. Describe the pathophysiology of the disease process. (Spinal cord injury, stroke,
syncope) damage to the spinal cord with the resulting functional loss of mobility and or
sensation. Spinal cord injurers result form concussion, contusion, compression, tearing,
laceration, transection, or ischemia of the spinal cord. Normally the blood brain barrier
keeps immune system cells from entering the brain or spinal cord. After spinal cord
injury the barrier is broken, and WBCs can invade the surroundings tissue and trigger an
inflammatory response characterized by fluid buildup and the arrival of immune cells. A
complete injury results in total loss of motor and sensory function below the level of
injury. In an incomplete injury there is incomplete structural damage with some function
preserved below the primary injury level.
, 2. What are the signs and symptoms of the disease process?
Level of injury corresponds to the body parts that are affected. Cervical injury can result
in inability to breath above C4 and quadriplegic. Thoracic injuries often result in
paraplegia and can include poor trunk control. Lumbar and sacral injuries result in
decreasing control of legs bowel and bladder function and sexual function.C1-C8, T1-
T12, below L1-L5, S1-S5.
Cervical cord injury- difficulty breathing, loss of bowel and bladder control, numbness,
weakness and paralysis, pain, sensory change, spasticity. Bp control issues and body
temp control, constant sweating may be an issue.
Thoracic injury at chest level- loss of normal bowel and bladder control numbness,
sensory changes spasticity (increased muscle tone)
Lumbar sacral injury- loss of normal bowel and bladder, numbness, pain, sensory
changes, spasticity (increased muscle tone), weakness and paralysis.
3. What are the nursing interventions for this disease process?
Respiratory function C4 loses complete function
Vital signs depending on the level of injury because of loss of sympathetic input the
patient my experience spinal shock/neurogenic shock, cardiac/respiratory arrest,
autonomic dysreflexia. Patients are unable to regulate temp so hypothermia may result
because of loss of blood vessel function.
Pain due to the level of damage to the nerve roots above level of injury
I’s and O’s for perfusion
Surgical sites observe for signs of infection or CSF, bleeding.
Actions- maintain suction for airway, (pt has decreased ability to cough well)
Encourage cough effectiveness
Maintain spinal immobilization and stabilization
Passive ROM
Reposition and maintain in good alignment
Perform pin cite cleaning
4. What education would you provide to a patient with this disease process?
S/S of autonomic dysreflexia to family and caregiver
Skin care management, skin breakdown, teach to not sit in one position for too long.
S/S of respiratory distress [(Hypoxemia below 95 %, dyspnea (difficulty breathing),
pulmonary edema (fluid buildup), breathing rate greater than 20 breaths per min,
decreased breath sounds, anxiety, rales crackles, wheezing, restlessness, cyanosis,
retraction of the ribs].
Test- thorough Physical and neurological exam, X-ray, CT scan or MRI to show the extent of
damage
Guillain- Barre Syndrome
1. Describe the pathophysiology of the disease process. (Spinal cord injury, stroke,
syncope)
This is an acute, progressive autoimmune condition that affects the peripheral nerves. The
myelin surrounding the axon are damaged from autoimmune effect. The disease usually
follows a viral infection, surgery other acute illness or immunization by a couple of
weeks. Ascending GBS exhibits muscle weakness and or paralysis that begins in the
, distal lower extremities and travel upwards descending also occurs (respiratory
compromise may occur). Axon repair can occur over several months.
2. What are the signs and symptoms of the disease process?
Burning or tickling feeling due to the demyelination of the nerve axons.
Symmetrical weakness or flaccid paralysis, typically ascending in pattern. Absence of
deep tendon reflexes due to changes within the nerves—reflexes are a sensory-motor
response that happens at the spinal level, not the brain Recent infection or other acute
illness Facial weakness, dysphagia, visual changes in descending disease
3. What are the nursing interventions for this disease process?
Monitor for progression of change of sensation.
Monitor respiratory status for change in effort or rate, use of accessory muscles, cyanosis, change
in breath sounds, breathlessness when talking, irritability, and decreased cognitive awareness. Call
physician if there are respiratory changes or decrease in pulse oximeter reading.
Monitor gag reflex.
Monitor for visual changes.
Monitor for communication ability; the patient may need special method to communicate with
staff if not able to use call bell system.
Turn and reposition.
Consult with social worker or chaplain for support services available to patient.
4. What education would you provide to a patient with this disease process?
Importance of turning and positioning.
Care of the plasmapheresis access site.
Importance of planning for home care needs.
Depending on how long the condition stay the patient may need some form of rehab.
INTERPRETING TEST RESULTS
Lumbar puncture will show cerebrospinal fluid (CSF) with increased protein; may not be present
initially.
Nerve conduction studies show slowed velocity.
Pulmonary function tests show diminished tidal volume and vital capacity .
TREATMENT
Monitor respirations and support ventilation if necessary.
Plasmapheresis for plasma exchange to remove the antibodies in the circulation.
Administer immunoglobulin intravenously after drawing labs for serum IgA.
Autonomic Dysreflexia
1. Describe the pathophysiology of the disease process. (Spinal cord injury, stroke,
syncope)
Autonomic dysreflexia is a complications of a spinal cord injury (occurs after the shock
has subsides in the rehab faze). It occurs above the T-5 T-6, T-12 level (between the two
paraplegia with trunk and leg involvement normal arm and hand movement. Paraplegia
with fair ability to control balance and trunk, little or no voluntary bowel or bladder
control.) A strong sensory input such as pain, distended bladder, rapid temperature
changes infection or a full rectum is carried into the spinal cord via intact peripheral
nerves. This input travel up the spinal cord and evokes a massive sympathetic surge from
the hypothalamus (thermostat of the body). Which cause vasoconstriction and that leads
to hypertension.
2. What are the signs and symptoms of the disease process?
Severe headache, hypertension, bradycardia, tachycardia, diaphoresis, flushing above and
pallor below the injury level
Most common cause of this condition is A FULL BLADDER OR FULL BOWEL. Others
could be tight clothing, GI disturbances, DVT, pressure ulcer, bladder and kidney
infection, temp extremes, shoes, lying or sitting on hard object or a minor injury.
3. What are the nursing interventions for this disease process?
Monitor BP if an increase of 20-40mm above patients’ baseline is a concern
Administer antihypertensive medications as ordered HOB at 45 or sit the patient up.
Loosen restrictive clothing remove braces, antiembolism stocking or shoes look for
sources of pain (helps blood pool into the extremities which will help lower bp)
Check the bladder/ patency of catheter/ collect UA for possible UTI
Check for bowel impaction
Check body for other sources like pressure ulcer, wounds, bites, scratches etc.
4. What education would you provide to a patient with this disease process?
I would tell the patient to make sure he informs us of a headache or if he notices he hasn’t
had a bowel movement in a while.
Educate the family that they need to inspect the catheter for kinks and insure he has a
high fiber diet. Ensure normal care is given as if he could feel his legs.
Educate family on S/S of this condition. Also look for skin breakdown.
Spinal Cord Injury
1. Describe the pathophysiology of the disease process. (Spinal cord injury, stroke,
syncope) damage to the spinal cord with the resulting functional loss of mobility and or
sensation. Spinal cord injurers result form concussion, contusion, compression, tearing,
laceration, transection, or ischemia of the spinal cord. Normally the blood brain barrier
keeps immune system cells from entering the brain or spinal cord. After spinal cord
injury the barrier is broken, and WBCs can invade the surroundings tissue and trigger an
inflammatory response characterized by fluid buildup and the arrival of immune cells. A
complete injury results in total loss of motor and sensory function below the level of
injury. In an incomplete injury there is incomplete structural damage with some function
preserved below the primary injury level.
, 2. What are the signs and symptoms of the disease process?
Level of injury corresponds to the body parts that are affected. Cervical injury can result
in inability to breath above C4 and quadriplegic. Thoracic injuries often result in
paraplegia and can include poor trunk control. Lumbar and sacral injuries result in
decreasing control of legs bowel and bladder function and sexual function.C1-C8, T1-
T12, below L1-L5, S1-S5.
Cervical cord injury- difficulty breathing, loss of bowel and bladder control, numbness,
weakness and paralysis, pain, sensory change, spasticity. Bp control issues and body
temp control, constant sweating may be an issue.
Thoracic injury at chest level- loss of normal bowel and bladder control numbness,
sensory changes spasticity (increased muscle tone)
Lumbar sacral injury- loss of normal bowel and bladder, numbness, pain, sensory
changes, spasticity (increased muscle tone), weakness and paralysis.
3. What are the nursing interventions for this disease process?
Respiratory function C4 loses complete function
Vital signs depending on the level of injury because of loss of sympathetic input the
patient my experience spinal shock/neurogenic shock, cardiac/respiratory arrest,
autonomic dysreflexia. Patients are unable to regulate temp so hypothermia may result
because of loss of blood vessel function.
Pain due to the level of damage to the nerve roots above level of injury
I’s and O’s for perfusion
Surgical sites observe for signs of infection or CSF, bleeding.
Actions- maintain suction for airway, (pt has decreased ability to cough well)
Encourage cough effectiveness
Maintain spinal immobilization and stabilization
Passive ROM
Reposition and maintain in good alignment
Perform pin cite cleaning
4. What education would you provide to a patient with this disease process?
S/S of autonomic dysreflexia to family and caregiver
Skin care management, skin breakdown, teach to not sit in one position for too long.
S/S of respiratory distress [(Hypoxemia below 95 %, dyspnea (difficulty breathing),
pulmonary edema (fluid buildup), breathing rate greater than 20 breaths per min,
decreased breath sounds, anxiety, rales crackles, wheezing, restlessness, cyanosis,
retraction of the ribs].
Test- thorough Physical and neurological exam, X-ray, CT scan or MRI to show the extent of
damage
Guillain- Barre Syndrome
1. Describe the pathophysiology of the disease process. (Spinal cord injury, stroke,
syncope)
This is an acute, progressive autoimmune condition that affects the peripheral nerves. The
myelin surrounding the axon are damaged from autoimmune effect. The disease usually
follows a viral infection, surgery other acute illness or immunization by a couple of
weeks. Ascending GBS exhibits muscle weakness and or paralysis that begins in the
, distal lower extremities and travel upwards descending also occurs (respiratory
compromise may occur). Axon repair can occur over several months.
2. What are the signs and symptoms of the disease process?
Burning or tickling feeling due to the demyelination of the nerve axons.
Symmetrical weakness or flaccid paralysis, typically ascending in pattern. Absence of
deep tendon reflexes due to changes within the nerves—reflexes are a sensory-motor
response that happens at the spinal level, not the brain Recent infection or other acute
illness Facial weakness, dysphagia, visual changes in descending disease
3. What are the nursing interventions for this disease process?
Monitor for progression of change of sensation.
Monitor respiratory status for change in effort or rate, use of accessory muscles, cyanosis, change
in breath sounds, breathlessness when talking, irritability, and decreased cognitive awareness. Call
physician if there are respiratory changes or decrease in pulse oximeter reading.
Monitor gag reflex.
Monitor for visual changes.
Monitor for communication ability; the patient may need special method to communicate with
staff if not able to use call bell system.
Turn and reposition.
Consult with social worker or chaplain for support services available to patient.
4. What education would you provide to a patient with this disease process?
Importance of turning and positioning.
Care of the plasmapheresis access site.
Importance of planning for home care needs.
Depending on how long the condition stay the patient may need some form of rehab.
INTERPRETING TEST RESULTS
Lumbar puncture will show cerebrospinal fluid (CSF) with increased protein; may not be present
initially.
Nerve conduction studies show slowed velocity.
Pulmonary function tests show diminished tidal volume and vital capacity .
TREATMENT
Monitor respirations and support ventilation if necessary.
Plasmapheresis for plasma exchange to remove the antibodies in the circulation.
Administer immunoglobulin intravenously after drawing labs for serum IgA.
