MEDICAL SURGICAL NURSING

Assessment of Central Nervous System and Low Back Pain

Dr Ibraheem Bashayreh, RN, PhD

4/1/2011

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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

A NEURON.

CENTRAL NERVOUS SYSTEM

Brain Spinal cord

BRAIN

Control center of the nervous system

THE FOUR MAJOR REGIONS OF THE BRAIN WITH AN ILLUSTRATION OF THE MENINGES.

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

SPINAL CORD

Spinal tracts Sensory and motor messages White matter and gray matter

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

DISTRIBUTION OF SPINAL NERVES.

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

UNEXPECTED ALTERATIONS RELATED TO AGING

Significant changes in Orientation Psychologic status

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

LOW BACK PAIN

Dr Ibraheem Bashayreh, RN, PhD

4/01/2011

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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

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ANATOMY REVIEW4/01/2011

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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

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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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LBP CLASSIFICATION Etiologic

Mechanical Non-Mechanical Visceral

Temporal Acute Chronic

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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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SITTING POSTURE

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SITTING POSTURE:

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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