Neurological Disorders

1
Neurological Disorders

• Sherry Burrell, RN, MSN
• Rutgers University
• Nursing III
• Lecture One 11/11 / 05

2
Review of Anatomy Physiology

• The function of the nervous system is to control
  all motor, sensory autonomic functions of the
  body.
• Divided Into
• Central Nervous System (CNS)
• Consisting of the brain and spinal cord.
• Peripheral Nervous System (PNS)
• Cranial nerves (12) and spinal nerves (31)
• Autonomic Nervous System
• Sympathetic Division fight or flight response
• Parasympathetic Division rest digest
  response

See Smeltzer Bare pp. 1830 Table 60-3
3
Cells of the Nervous System

• The Neuron
• Functional unit of the nervous system transmits
  impulses
• Cell Body Controls metabolic activity
• Dendrite Transmits impulses to the cell body
• Axon Transmits impulse away from the cell body
• Many myelinated (white matter)
• Insulation speeds transmission of impulses
• Some non-myelinated (gray matter)
• Neuroglial Cells
• Provide support, nourishment, protection to the
  neuron
• Four Types
• Astroglia, oligodendroglia, ependyma microglia

4
The Neuron Cellular Impulses

• Action Potentials
• Based on ion shifts, which create electrical
  charges
• Synapses
• Connects the neuron to another neuron or target
  tissue (muscle, organ or gland)
• Neurotransmitters
• Chemical substances that enhance or inhibit nerve
  impulses across synapses.
• i.e. Acetylcholine and Dopamine

See Smeltzer Bare pp. 1822 Table 60-1
5
CNS The Brain

• The brain controls, initiates and integrates all
  body functions.
• Composed of both gray matter and white matter.
• Protective Mechanisms
• Skull (cranium) Bony container surrounding the
  brain
• Meninges Three additional layers of protection
• Dura mater, arachnoid mater pia mater
• Potential Actual Spaces
• Epidural Space
• Subdural Space
• Subarachnoid Space

6
Cerebrum

• Divided into two hemispheres
• Right Hemisphere
• The right side of the brain controls receives
  information from the left side of
  the body.
• Left Hemisphere
• The left side of the brain controls receives
  information from the right side of the body.
• Dominant hemisphere in most people

7
Lobes of the Cerebrum

• Frontal Lobe
• Primary motor area
• Brocas area for motor speech
• Memory, abstraction, affect,
  judgment,
  personality inhibitions.
• Parietal Lobe
• Primary sensory area
• i.e. Interpretation of pain, touch, temperature
  pressure
• Awareness of body parts and body part position
  sense

8
Lobes of the Cerebrum Cont.,

• Temporal Lobe
• Wernickes area for interpretative speech
• Auditory Center
• Limbic Lobe
• Anatomically part of the temporal lobe
• Moods, behaviors, emotions and visceral
  processes needed for
  survival
• Interpretation of smell
• Learning and memory
• Occipital Lobe
• Primary visual area

9
The Diencephalon Cerebellum

• Diencephalon
• Thalamus Relay Station
• Hypothalamus Regulates ANS, appetite,
  temperature, fluid balance emotions
• Pituitary Gland Master gland controlling
  numerous hormonal functions (i.e. posterior
  pituitary releases ADH)
• Cerebellum
• Coordinates smooth muscle
  movements posture,
  equilibrium,
  muscle tone position sense.

10
The Brainstem

• Brainstem
• Reticular Activating System (RAS)
• Controls level of consciousness (awareness
  alertness)
• Cranial Nerves
• Structures of the Brainstem
• Midbrain
• Aqueduct of Sylvius
• Pons
• Cardiac Respiratory Centers (rate length)
• Medulla Oblongata
• Auditory, Cardiac Respiratory Center (basic
  rhythm)
• Location where motor fiber cross

11
Cerebral Circulation

• Arterial Circulation
• Internal carotid arteries ? anterior cerebral
  artery (ACA) middle cerebral artery (MCA)
  anterior cerebral circulation.
• Posterior vertebral arteries ? basilar artery ?
  two posterior cerebral arteries (PCA) posterior
  cerebral circulation.

12
Cerebral Circulation Cont.,

• Arterial Circulation Cont.,
• Circle of Willis
• Internal carotid, basilar artery the anterior,
  middle posterior arteries join together via
  small communicating arteries to form a ring at
  the base of the brain.
• Venous Circulation
• Cerebral veins ? dural venous sinuses ? internal
  jugular veins ? superior vena cava back to
  right atrium.

13
Central Nervous System Other Considerations

• Blood-Brain Barrier (BBB)
• Selective Permeability
• Substances that can pass include oxygen, glucose,
  carbon dioxide, alcohol, anesthetics water
• Substances that can not pass include medications
  such as many antibiotics systemic
  chemotherapy agents.
• Cerebrospinal Fluid (CSF)
• Ventricular system CSF-filled core of the brain
• Two lateral, third fourth ventricles
• Subarachnoid Space
• CSF surrounds the brain spinal cord
• Protective Role Shock absorber
• Role in nutrient waste exchange.

14
The Spinal Cord

• Controls body movement regulates visceral
  function processes sensory information
  transmits information to and from the brain.
• A continuation of the brain stem.
• Exits the skull through the foramen magnum, an
  opening in the base of the skull.
• Spinal cord itself ends at L1 or L2, yet the
  vertebral column continues to the coccyx.
• Protection
• Vertebral Column
• Intervertebral Disks
• Meninges

15
Peripheral Nervous System (PNS)

• Spinal Nerves (31 pairs)
• Mixed Nerve Fibers Exiting the spinal cord to
  receive information and to transmit information
  to the cord ? brain.
• Posterior Root Sensory
• Anterior Root Motor
• Reflex Arc
• Interneurons connecting sensory motor fibers.
• Dermatomes
• Sensory depiction of the corresponding spinal
  nerves

See Smeltzer Bare pp. 1829 Figure 60-11
16
PNS Cranial Nerves

• There are 12 pair of cranial nerves.
• Sensory CN I, II VIII
• Motor CN III, IV, VI, XI XII
• Mixed CN V, VII, IX X

See Handout Smeltzer Bare pp. 1837 Table
60-5
17
Neurological Assessment

• Health History
• General Signs Symptoms
• Physical Examination Considerations
• Level of Consciousness
• Motor Function
• Pupillary Function / Eye Movements
• Vital Signs
• Respiratory Patterns
• Laboratory Diagnostic Testing

18
Neurological Health History

• Explore Presenting Compliant (s) ? OLD CART
• Precipitating Events
• Traumatic Event Data
• Type of force and direction of force
• / - loss of consciousness (if duration too).
• Progression of signs / symptoms
• Client Information
• Allergies
• Past Medical Surgical History
• Medications
• Habits / Lifestyle Changes
• Familial History of Neurologic Disorders

19
General Signs / Symptoms

• Memory Loss
• Disorientation
• Changes in level of consciousness
• Seizures
• Speech or Swallowing Difficulties
• Vision Pupillary Changes
• Dizziness

• Headache / Pain
• Weakness
• Loss of Coordination
• Tremors
• Numbness / Tingling
• Paralysis
• Nausea / Vomiting
• Bowel or Bladder Difficulties

20
Physical Examination Considerations

• Level of Consciousness
• Most important aspect of neurologic examination
• Level of consciousness first to deteriorate
  changes often subtle, therefore requiring careful
  monitoring.
• Consciousness
• Composed of Two Components
• Arousal (Alertness)
• Awareness (Content)
• Assessment Orientation vs. Disorientation
• Person, Place Time
• Varying sequence of questions is important !!

21
Categories of Consciousness

• Alert
• Responds immediately to minimal external (visual,
  tactile or auditory) stimuli.
• Lethargic
• A state of drowsiness client needs increased
  external stimuli to be awakened but, remains
  easily arousable verbal, mental motor
  responses are slow or sluggish.
• Obtunded
• Very drowsy, when not stimulated, but can follow
  simple commands when stimulated (i.e. shaking or
  shouting) verbal responses include one or two
  words, but will drift back to sleep without
  stimulation.

22
Categories of Consciousness

• Stuporous
• Awakens only to vigorous and continuous noxious
  (painful) stimulation minimal spontaneous
  movement motor responses to pain are appropriate
  but, verbal responses are minimal and
  incomprehensible (i.e. moaning).
• Comatose
• Vigorous external stimulation fails to produce
  any verbal response both arousal and awareness
  are lacking no spontaneous movements but, motor
  responses to noxious stimuli maybe be purposeful
  (light coma) or non-purposeful or absent (deep
  coma).

23
LOC Assessment Tools
Thalen Table 24-1 pp.647

• Glasgow Coma Scale (GCS)
• Three Categories
• Eye opening
• Best motor response
• Best verbal response
• Scoring
• Highest or best possible score 15
• A score of
• Lowest or worst possible score 3
• Not appropriate for use in
• Children, intoxicated clients or spinal cord
  injuries

24
Motor Assessment Techniques

• Steps of Examination
• Observe for spontaneous movement
• Elicit motor movement in response to stimuli
• Types of Stimuli
• Verbal
• Simple and direct statements no visual or
  tactile stimuli
• Reduce environmental stimuli or distractions
• Noxious (painful)
• When no response to verbal stimuli
• Acceptable methods nail bed pressure, trapezius
  pinch supraorbital pressure (not used with head
  injury).

25
Motor Responses

• Abnormal Motor Responses
• In the unconscious client noxious stimuli may
  elicit abnormal posturing
• Decorticate (abnormal flexion)
• Decerebrate (abnormal extension)
• Flaccidity

? Decorticate
? Decerebrate
26
Motor Assessment Cont.,

• Motor Movements Strength
• Evaluate each extremity and compare with opposite
  side record each extremity separately.
• Graded 0 to 5
• (O Paralysis ? 3 ROM / Gravity ? 5 ROM /
  Full Resistance)
• Deep Tendon Reflexes (DTR)
• Tap appropriate tendon with percussion or reflex
  hammer
• Achilles, quadriceps, brachioradialis, biceps and
  triceps
• Graded 0 to 4
• ( 0 Absent? 2 Normal ? 4 Hyperactive)

27
Motor Assessment Cont.,

• Superficial Reflexes
• Normal Adult Reflexes
• Corneal
• Gag
• Swallowing
• Abnormal Adult Reflexes
• Babinski

28
Ocular Responses

• Evaluate both pupils for equality
• Size (mm)
• Shape
• Reactivity to Light
• Extraocular Movements (EOM)
• CN III, CN IV and CN VI

29
Ocular Responses Cont.,

• Ocular Reflexes (unconscious client)
• Oculocephalic (Dolls Eye) Reflex
• While the eyes are held open the head is briskly
  turned from side-to-side.
• Oculovestibular (Cold Caloric) Reflex
• With HOB elevated 30 degrees 20-100 ml of iced
  water is injected into the external auditory
  canal.

See Thalen pp. 653-654, Figures 24-4 24-5
30
Vital Signs Abnormal Respiratory Patterns

• Cheyne-Stokes
• Rhythmic crescendo decrescendo rate and depth
  of respiration brief periods of apnea
• Central Neurogenic Hyperventilation
• Very deep, very rapid respirations no apnea
• Apneustic
• 2-3 second inspiratory and / or expiratory pause
• Cluster Breathing
• Groupings of irregular, gasping respirations
  separated by long periods of apnea
• Ataxic Respirations
• Irregular, random pattern deep and shallow
  respirations with periods of apnea (irregular
  too).

See Thalen Figure 24-6 Table 24-2 pp. 655
31
Diagnostic Testing

• Imaging Studies of the Skull Spine
• X-rays
• MRI
• CT Scans
• Position Emissions Tomography (PET) Scans
• A radioactive substance is either inhaled or
  injected to provide images of the brains
  function.
• Used to assess blood flow, tissue composition
  brain metabolism, therefore it indirectly
  measures brain function.

32
Diagnostic Testing

• Cerebral Angiography
• Involves artery access (usually femoral), then a
  contrast medium is injected to visualize cerebral
  circulation.
• Used to detect aneurysms, traumatic injuries,
  vascular occlusions, tumors or arteriovenous
  malformations.
• Nursing Considerations
• Prior to the procedure
• Maintain NPO status
• Assess for allergies to iodine, shellfish or IV
  dye

33
Diagnostic Testing

• Cerebral Angiography
• Nursing Considerations Cont.,
• Procedural Education
• Requires the client to remain still and lie a
  hard, cold table.
• Injection of contrast medium may cause a burning
  or flushing sensation
• Post Procedure
• Maintain bedrest with HOB elevated and the puncture site extremity straight as
  prescribed
• Neurovascular puncture site assessments
  regularly
• Encourage fluids (unless contraindicated)

34
Diagnostic Testing

• Lumbar Puncture (Spinal Tap)
• A needle is inserted into the subarachnoid space
  between the third and fifth lumbar vertebrae.
• Used to obtain CSF, measure CSF fluid or pressure
  or to inject a contrast medium or a medication.
• Contraindicated with increased intracranial
  pressure !!
• Nursing Considerations
• Post Procedure
• Activity as prescribed often bedrest with lying
  flat
• Encourage fluids (if not contraindicated)
• Complications
• Spinal headache

35
Diagnostic Testing

• Myelography
• Allows for visualization of the vertebral column,
  intervertebral disks, spinal nerve roots blood
  vessels.
• Requires a lumbar puncture to inject the contrast
  medium into the subarachnoid space of the spine.
  
• Nursing Considerations
• Assess for allergies to iodine, shellfish or IV
  dye
• Post-Procedure
• Maintain the head of bed elevated 15-30 degrees
• Encourage fluids (if not contraindicated)

36
Diagnostic Testing

• Electroencephalogram (EEG)
• Records the electrical activity of the brain
  through a series of electrodes on the scalp.
• Used to diagnose and evaluate seizures disorders,
  identify tumors, brain abscesses or infections
  and to confirm of brain death.
• Evoked Potentials (EPs)
• A series of electrodes on the scalp and an
  external stimulus is applied to the peripheral
  sensory receptors to elicit change in brain
  waves.
• Stimulus maybe be visual, auditory or electrical.

37
Laboratory Testing

• Cerebrospinal Fluid (CSF) Analyses
• Normal Findings
• pH 7.35-7.45
• Specific Gravity 1.007
• Appearance Clear, colorless and odorless
• Cells minimal number of WBCs and no RBCs
• Positive Protein
• Positive Glucose (2/3 blood sugar value)

38
Intracranial Pressures (ICP)

• Brain contained within the skull (closed
  container)
• Intracranial space is occupied by three
  components
• Blood (10)
• Cerebral Spinal Fluid (CSF) (10)
• Brain Tissue (80)
• Normal physiologic conditions ICP
• An ICP value of 20 mmHg (sustained) requires
  immediate medical intervention.

39
Intracranial Pressures (ICP) Cont.,

• Monro-Kellie Hypothesis
• Increase in one intracranial component must be
  compensated by a decrease in one or more of the
  other components.
• The body has a limited ability to compensate in
  response to increases in ICP.
• Displacing CSF
• Increasing Absorption of CSF
• Decreasing Cerebral Blood Volume

40
Increased Intracranial Pressures

• Compensatory mechanisms will eventually be
  exhausted and clinical manifestations of
  increased ICP will occur.
• Causes of Increased ICP
• Traumatic Brain Injuries
• Brain Tumors
• Other Causes
• Meningitis or Encephalitis
• Brain Abscesses
• Hydrocephalus

41
Cerebral Perfusion Pressure

• Cerebral perfusion pressure (CPP) represents the
  pressure gradient driving cerebral blood flow
  (CBF) and hence oxygen and metabolite delivery
• CPP MAP - ICP
• CPP Normal Limits 80-100mmHg
• CPP of 80 mmHg is needed to ensure adequate blood
  supply to the brain
• CPP irreversible neurologic damage.
• Clinically - CPP is maintained by either
  increasing MAP or decreasing ICP.

42
Clinical ManifestationsStages of Increased ICP

• Stage I (Full Compensatory)
• Alert Orientated
• History of head injury
• Vital signs / pupillary responses normal
• May complain of a headache
• Stage II (Partial Compensatory)
• Mental Status Changes
• Confusion and restlessness
• Decreased Level of Consciousness
• Lethargy
• Vital signs / pupillary responses normal

43
Clinical ManifestationsStages of Increased ICP

• Stage III (Beginning Decompensation)
• Further decrease in level of consciousness
• Obtunded ? Stupor
• Cushings Triad
• Systolic HTN (widening pulse pressure)
• Bradypnea
• Bradycardia (bounding, slow pulse)
• Small pupils (
• Vomiting (maybe projectile)

44
Clinical ManifestationsStages of Increased ICP

• Stage IV (Herniation)
• Comatose
• Pupillary dilation fixation (ipsilateral ?
  bilateral)
• Abnormal Posturing
• Decorticate ? Decerebrate ? Flaccidity
• Cushings Triad Progresses To
• Narrowing pulse pressure
• Weak, thready pulse
• Respirations Cheyne-Stokes ? Ataxic Respirations
• Stage V (Death)

45
ICP Monitoring

• Four Methods of ICP Monitoring
• Intraventricular
• A small catheter is placed within the ventricular
  system (ventriculostomy) allows for CSF
  drainage.
• Subarachnoid
• Hollow bolt or screw into the subarachnoid space
• Epidural
• Small fiberoptic sensor into epidural space
  (between skull dura)
• Intraparechymal
• Small fiberoptic catheter into the white matter
  of brain tissue (parenchyma)

46
Increased ICP Medical Management

• Control of Cerebral Edema
• Osmotic Diuretics (i.e. Mannitol)
• Monitor urinary output carefully !!
• Cortiocsteriods (i.e. dexamethasone)
• Monitor blood glucose levels carefully
• Often accompanied by a proton-pump inhibitor or
  H2 blocker
• Control of Intracranial Volume
• Draining CSF (i.e. ventriculostomy)
• Must be done slowly to prevent collapse of the
  ventricles.
• Controlled Hyperventilation
• PaCO2 low end of normal current trend (35 mmHg)

47
Increased ICP Medical Management

• Control of Metabolic Demand
• Sedatives
• Benzodiazepines i.e. lorazepam (Ativan)
• Neuromuscular Blockade / Paralyzing Agents
• i.e. vecuronium (Norcuron)
• Must still provide sedation and / or pain
  management !!
• Barbiturate Therapy (Induced Coma)
• i.e. pentobarbital or thiopental used when
  conventional medical interventions fail to reduce
  ICP controversial.

48
Increased ICP Medical Management

• Other Medical Interventions
• Temperature Regulation
• Prevent Hyperthermia (i.e. antipyretics, ice
  packs cooling blankets)
• Blood Pressure Regulation
• Delicate balance in the client with increased
  ICP often maintained on the high end of normal
  to ensure adequate cerebral perfusion!!
• Sedatives often enough, if not antihypertensive
  agents used
• Seizure Control / Prevention
• Antiseizure Agents i.e. phenytoin (Dilantin)

49
Increased ICP Nursing Considerations

• Nursing Assessment / Monitoring
• Frequent Vital Signs Neurological Exams
• Trends in signs and symptoms are paramount !!
• Report deterioration of neurologic status
  promptly
• Maintain ICP monitoring device
• Document amount appearance of CSF drainage
• Aseptic technique with dressing changes
• Strict I O and Daily Weights
• Laboratory Values
• i.e. CBC, SMA 7, Electrolytes ABGs

50
Increased ICP Nursing Considerations

• Nursing Activities
• HOB elevated to 30 degrees
• Trendelenburg, prone positions should be avoided
  / limited
• Head should be maintained neutral position
  (midline)
• Avoid extreme neck angulation and hip flexion
• Identify daily care activities that increase ICP
• Provide rest periods
• Avoid Valsalva Maneuver turning or straining
  with BM
• Reduce noxious environmental stimuli
• Manage pain with alternative and pharmacologic
  therapies

51
Increased ICP Nursing Considerations

• Nursing Activities Cont.,
• Respiratory / Ventilator Considerations
• Deep Suctioning
• Hyperoxygenate with each pass
• Limit the number of passes pass
• Ensure tracheostomy ties are not too tight
• Limit / avoid unnecessary coughing or gagging
• Prevention of Infection
• Ensure aseptic techniques with invasive line care
  
• Prevention of Injury
• Maintain seizure precautions (i.e. padded
  side-rails)

52
Increased ICP Nursing Considerations

• Nursing Activities Cont.,
• Administer medications as prescribed
• Maintain Nutritional Support
• High-protein high-fiber diet
• Total Parenteral Nutrition (TPN)
• Dietary Supplements
• Maintain Therapeutic Environment
• Encourage contact from significant others
• Provide emotional support and education

53
Increased ICP Surgical Management

• Craniotomy
• Involves opening the skull to gain access to
  intracranial structures.
• Indicated for relief of Increased ICP by tumor
  removal, hematoma or abscess evacuation or
  controlling hemorrhage.
• Surgical Approaches
• Transcranial
• Transsphenoidal

54
Craniotomy Considerations

• Preoperative Nursing Care
• Assessment
• Frequent vital signs and neurological exams
• Documentation of neurological baseline
• Diagnostic / Laboratory Tests
• Blood tests / blood type and cross match
• Chest x-ray and 12 lead EKG
• Education
• Avoid activities known to increase ICP
• Surgery specific instructions
• Provide Emotional Support

55
Craniotomy Considerations

• Postoperative Nursing Management
• Frequent Monitoring of Neurologic Status Vital
  Signs
• Maintain ICP Monitoring Device
• Prevent Increased ICP
• Client positioning
• Prompt management of vomiting, fever pain
• Administer anti-seizure medications as ordered
• Maintain Fluid / Electrolyte Balances
• IOs and daily weights
• Prevent / Monitor for Infection
• Aseptic technique for dressings ICP monitoring
  device
• Pulmonary Care

56
Craniotomy Considerations

• Postoperative Nursing Management Cont.,
• Prevent Injury
• Seizure / Falls Precautions
• Eye Care / Skin Care
• Providing Emotional Support
• Patient Education
• Signs symptoms of increased ICP
• Signs symptoms of infection
• Incisional care
• Medications
• Neurologic Rehabilitation
• Stress importance PT / OT consults helpful .

57
Craniotomy Considerations

• Complications
• Increased ICP
• Surgical Hemorrhage
• Fluid / Electrolyte Imbalance
• CSF Leak
• DVT
• Gastric Ulcers
• Pneumonia
• Seizures

58
Complications of Increased ICP

• Diabetes Insipidus
• SIADH (Syndrome of Inappropriate Antidiuretic
  Hormone)
• Herniation
• Brain Death

59
Diabetes Insipidus

• Decreased secretion of antidiuretic hormone (ADH)
• Clinical Manifestations
• Hypernatremia (serum)
• Excessive water losses via urine (? UO)
• Client may experience volume depletion !!
• Management
• Fluid Volume Replacements
• Encourage oral intake of fluids (if possible)
• I.V. fluids careful monitoring laboratory
  results and BP
• Electrolyte Replacements
• Vasopressin therapy
• Pitressin or Desmopression DDAVP

60
SIADH

• Increased secretion of antidiuretic hormone (ADH)
• Clinical Manifestations
• Hyponatremia (serum)
• Decreased water losses via urine (? UO)
• Volume overload (i.e. weight gain)
• Management
• Fluid restriction usually sufficient

61
Herniation Brain Death

• Herniation
• Result of excessive ICP downward displacement of
  brain tissue resulting in the cessation of CBF.
• Leads to irreversible brain anoxia and brain
  death
• Brain Death
• Complete, irreversible cessation of function of
  the entire brain and brain stem.
• Mechanical support sustaining life
• Nursing Considerations
• Emotional support to significant others
• Organ donation

62
Neurological DisordersExploring Causes of
Increased ICP

• Sherry Burrell, RN, MSN
• Rutgers University
• Nursing III
• Lecture Two 11/18/05

63
Head Injury

• Broad term to classify sudden trauma to head,
  which includes injuries sustained to the scalp,
  skull or brain.
• Most common causes
• MVA motor vehicle collisions (50)
• Falls (21)
• Violence (12)
• Sports related-injuries (10)
• The most serious type of head injury is traumatic
  brain injury (TBI)

64
TBI Pathophysiology

• Primary Injury
• Initial damage to the brain that results from the
  traumatic event.
• Secondary Injury
• Additional damage to the brain tissue occurring
  minutes to hours after the initial traumatic
  event.
• As a result of the cellular changes that occur
  with cerebral edema, ischemia and hemorrhage.

65
TBI Clinical Manifestations

• Neurological Deficits
• Altered Level of Consciousness
• Confusion
• Pupillary Abnormalities
• Vital sign Changes
• Altered Reflexes
• Gag
• Corneal

• Headache
• Dizziness
• Impaired Hearing or Vision
• Sensory or Motor Dysfunction
• Seizures

66
TBI Mechanisms of Injury

• Penetrating / Missile Injuries
• Object forcefully enters the cranial vault
  causing damage to the meningeal layers, blood
  vessels the brain tissue.
• Associated with an increase risk of infection
• Communication of intracranial contents with
  external environment Dura mater no longer intact
  !!
• Causes
• Gunshot Wounds (most common)
• Stab Wounds

67
TBI Mechanisms of Injury Cont.,

• Blunt, Non-Missile Injuries
• Deformation Injuries
• Occurs when an object strikes the head
• Often resulting in skull fractures, concussion,
  contusion or intracranial hemorrhage.
• Causes baseball bat or bottle

68
TBI Mechanisms of Injury Cont.,

• Blunt, Non-Missile Injuries
• Acceleration-Deceleration Injuries
• Also, called Coup-Contrecoup Injuries
• When the brain rapidly accelerates
  and decelerates
  within the skull.
• Two areas of brain injury
• Site of impact
• Opposite side of the brain
• Often resulting in contusions intracranial
  hemorrhage
• Cause Motor vehicle collision (MVC)

69
Scalp Injuries

• Isolated scalp injuries usually classified as
  minor head injuries.
• The scalp is highly vascular with poor
  constrictive abilities bleeding is often profuse
• Infection is a major concern, which must be
  prevented!!

70
Skull Fractures

• Actual break in continuity of skull
• Cause can be blunt force trauma or penetrating
  injury
• Brain injury may or may not occur
• Skull fractures considered closed if dura mater
  is intact open if dura mater is torn.
• Types of Skull Fractures
• Linear
• Non-displaced fracture of the skull
• Depressed
• Fracture involving the downward depression of
  bone into brain tissue
• Comminuted
• Fragmentation and downward displacement of bone
  into brain tissue
• Basilar
• Fracture occurring at the base of skull.

71
Skull Fractures Cont.,

• Basilar Skull Fractures
• Fracture at base of skull usually temporal or
  frontal areas
• Often an open head injury
• Bleeding from nose, pharynx, ears or into
  conjunctiva
• Bruising
• Battles sign ecchymosis over mastoid
• Raccoon (eyes) sign bilateral periorbital
  ecchymosis
• Monitor For A CSF Leak !!
• Observe nose or ears
• Halo Sign
• Prevent Infection !!

72
Cerebral Concussion

• Head injury with temporary loss of neurological
  function with no structural damage.
• Cause jarring of the brain results in temporary
  disruption of synaptic activity often occurs
  with acceleration-deceleration injuries.
• Clinical Manifestations
• Loss of consciousness usually brief
• Amnesia regarding events immediately prior to
  injury
• Postconcussion Syndrome
• Usually occurs within 24 to 48 hours after injury
  and may present up to several months later, but
  will subside in time.
• S/Sx HA, lethargy, irritability, memory
  deficits, dizziness insomnia

73
Cerebral Contusion

• Bruising of the brain tissue actual structural
  damage visible on diagnostic testing (i.e. CT
  scan).
• Often caused by deformation or acceleration-decele
  ration injuries (often two focal areas of
  bruising)
• Clinical Manifestations
• Loss of consciousness (more than brief)
• Vary depending on the location size of
  contusion
• Secondary injury is possible (i.e. hemorrhage or
  cerebral edema) the client must be monitored
  closely for increased ICP.

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Diffuse Axonal Injury (DAI)

• Wide spread brain injury causing direct damage to
  the axons or disruption of axonal
  processes.
• Caused by high-velocity shearing, rotational and
  acceleration-deceleration forces.
• Microscopic hemorrhaging throughout the brain
  tissue not usually visible on diagnostic
  testing, unless severe them small hemorrhages
  maybe seen.
• Clinical Manifestations
• Most present in a comatose state
  and often require
  long-term care.

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Intracranial Hemorrhage (ICH)

• Trauma can cause bleeding within the brain tissue
  or within the spaces surrounding the brain.
• The result is hematomas or collections of blood
  within cranial vault most serious of brain
  injuries
• Classified according to location
• Epidural hematoma
• Subdural hematoma
• Intracerebral hematoma

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Epidural Hematoma (EDH)

• Blood collects between the dura mater the skull
  
• Most often arise from arterial hemorrhage
• Cause usually is injury of middle meningeal
  artery resulting in rapid accumulation of blood.
• Clinical Manifestations
• LOC after initial trauma usually at the
  location of injury
• Lucid interval (30-50 experience)
• Rapid deterioration in neurologic status S/Sx of
  ? ICP
• Management
• Medical emergency requiring immediate medical and
  surgical intervention (i.e. craniotomy).

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Subdural Hematoma (SDH)

• Blood collects between the dura mater the
  arachnoid mater
• Often originating from venous hemorrhage
• Cause is usually injury to bridging veins venous
  blood tends to accumulate more slowly than
  arterial blood, therefore signs/symptoms of ? ICP
  tend not occur as quickly.
• Two Main Types of SDH
• Acute (less than 48 hours after injury)
• Requires immediate medical and /or surgical
  intervention
• Chronic (over 2 weeks after injury)
• Often forget actual injury common in elderly
• S/Sx of ? ICP fluctuate or come and go
• Management Burr hole clot evacuation or
  craniotomy

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Intracerebral Hematoma (ICH)

• Blood collects within the brain tissue
  (parenchyma)
• Bleeding causes displacement of brain tissue
  even small bleeds can cause significant
  neurological alterations.
• Destroys brain tissue
• Causes cerebral edema
• Increases ICP
• S/Sx of ? ICP maybe be immediate or develop
  overtime
• Management
• Depends on location of the bleed and size of the
  bleed
• Small ICH will be absorbed overtime
• Surgical management only if anatomically
  appropriate if not will be managed medically.

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TBI Management Considerations

• Medical / Surgical Management
• Supportive Interventions
• Prevention or Management of Increased ICP
• Airway
• Ventilation
• Nutrition
• Pain and anxiety management
• Prevention of seizures agitation
• See previous discussion of medical / surgical
  management of increased ICP

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TBI Management Considerations

• Nursing Considerations
• Frequent neurologic assessments / vital signs
• Fluid and electrolyte balances
• I O and daily weights
• Increased ICP (see previous discussion)
• Client positioning Care
• Nursing Activities
• Maintain skin integrity
• Protection from injury
• Prevent infection
• Provide rest
• Provide support education to client and/or
  significant others

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Brain Tumors

• Space-occupying intracranial lesions
• Benign or malignant.
• Clinical manifestations differ according to area
  of lesion and rate of growth
• Common Signs / Symptoms
• Alterations in consciousness
• Neurologic deficits
• Motor Visual Disturbances
• Headaches
• Seizures
• Vomiting (maybe sudden and projectile)

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Types of Brain Tumors

• Brain tumors within the brain tissue
• Gliomas Most common type of brain tumor
• Astrocytomas
• Most common type of Glioma
• Slow growing benign but may become malignant
• Invasive (difficult to surgically remove entire
  tumor)
• Glioblastomas Mulitforme
• Is a advanced stage of Astrocytomas
• Rapid growing malignant invasive
• Poorest prognosis

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Types of Brain Tumors Cont.,

• Brain tumors arising from supporting structures
• Meningiomas
• Encapsulated, non-invasive usually benign
• Slow growing well defined
• Compresses rather than invades
• Acoustic Neuromas
• Non- malignant slow growing
• CN VIII affected HA, tinnitus, hearing loss,
  impaired balance, unsteady gait facial pain /
  numbness on the side of tumor
• Developmental Tumors
• Angiomas
• A benign mass of abnormal blood vessels with thin
  walls prone to rupture

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Brain Tumor Management Considerations

• Increased Intracranial Pressure
• Pharmacologic Agents
• Corticosteroids (dexamethasone and prednisone)
• H2 blocker or proton pump inhibiter must
  accompany
• Osmotic Diuretics
• Antiseizure, antiemetic analgesic medications
• See previous discussion of ? ICP management
  nursing considerations
• Tumor Removal / Destruction
• Surgical Interventions
• Craniotomy
• ICP monitoring

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Brain Tumor Management Considerations

• Tumor Removal / Destruction Cont.,
• Medical Interventions
• Chemotherapy (often a combination of agents
  utilized)
• Routes of Administration
• Intrathecal Route
• Intracranial Route
• Disk-shaped drug wafers (Gliadel wafers) maybe
  implanted for some tumors (i.e. glioblastomas
  multiforme or recurrent tumors) during a
  craniotomy.
• Systemic / Venous Route
• Most agents poorly penetrate the blood-brain
  barrier
• Temodar (temozolomide) can penetrate widely used
  today

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Brain Tumor Management Considerations

• Radiation Therapy
• External radiation therapy
• Gamma Knife (stereotactic radiosurgery)
• Single dose of high ionized radiation
  to
  selectively destroy the tumor.
• Requires the use of a helmet device
  
  therapy usually takes about a hour
• The client usually will stay over-night
  at the
  hospital for observation.
• Internal radiation therapy (Brachytherapy)
• A catheter is inserted in or just next to a tumor
  to deliver radiation by means of radioactive
  capsules seeds
• The radioactive source will then be left in place
  from several hours to several days to kill the
  tumor cells Client hospitalized during
  treatment.

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Increased ICP Nursing Diagnoses

• Ineffective cerebral tissue perfusion related to
  increased ICP and decreased CPP.
• Potential for impaired skin integrity related to
  bedrest or immobility.
• Knowledge deficit related to increased ICP or its
  treatments.
• Decreased sensory perception related to
  neurological impairment.
• Risk for injury related to altered level of
  consciousness or seizures.

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Increased ICP Nursing Diagnoses

• Ineffective airway clearance related to
  diminished protective reflexes (i.e. cough or
  gag).
• Interrupted family processes related to health
  crisis.
• Risk for infection related to ICP monitoring
  device.
• Fluid volume deficit related to decreased level
  of consciousness or hormonal imbalance (DI).
• Imbalanced nutrition, less then body requirements
  related to inadequate intake.
• Potential for sleep disturbances related to
  frequent neurological status monitoring.