Nursing Management of the Adult Client with Neurologic Alterations Head and Spinal Cord Injury

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Nursing Management of the Adult Client with
Neurologic AlterationsHead and Spinal Cord
Injury

• NURS 228
• Janie Best, RN, MSN, APRN, BC

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Head Injuries
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Brain Injury

• Primary Injury
• Initial damage
• Secondary Injury
• Evolves over time

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Physiology / Pathophysiology
Brain suffers traumatic injury
Brain swelling or bleeding ? intracranial volume
Rigid cranium allows no room for expansion of
contents ? IICP
Pressure on blood vessels within brain ? Blood
flow to brain slows
Cerebral hypoxia and ischemia
Intracranial pressure continues to rise brain
may herniate
Cerebral blood flow ceases
Brunner, 10th ed. P 1912
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Scalp Injury

• Bleed profusely
• Avulsion of scalp
• Potentially life-threatening
• A true emergency
• Complications
• Infection
• Irrigate prior to suturing

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Skull Fractures

• With or without brain damage
• Coup / Contrecoup injury
• Classification
• Simple
• Comminuted
• Depressed
• Basilar

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Skull Fractures

• Symptoms
• Persistent, localized pain
• May not have edema in the area of fracture
• Battles sign
• Raccoon eyes

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Skull FracturesNursing Care

• Observe for
• Epistaxis
• Ecchymosis
• Otorrhea
• Rhinorrhea
• Halo ring on sheets or dressing

• Avoid blowing nose, coughing
• Sneeze through open mouth

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Skull FracturesNursing Care

• Assessment
• Radiologic x-rays
• MRI
• Cerebral angiography

• Patient / Family Education
• Neurologic changes
• CSF leakage
• Weakness in arm or leg
• Seizure

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Skull Fractures

• Medical management
• Assessment
• Surgery
• IV antibiotics
• HOB 300

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Brain Injury Clinical Manifestation

• Vital sign changes
• Vision / hearing impairment
• Sensory dysfunction
• Spasticity
• Headache
• Vertigo
• Movement disorders
• Seizures

• Altered LOC
• Confusion
• Abnormal pupils
• Altered or absent gag reflex
• Absent corneal reflex
• Sudden onset of neurological deficits

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Brain Injury

• Concussion
• Contusion
• Intracranial Hemorrhage

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Concussion

• Temporary loss of neurologic function with no
  apparent structural damage
• Assessment
• Difficulty in awakening
• Difficulty in speaking
• Confusion
• Severe headache
• Vomiting
• Weakness on one side of the body

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Concussion

• Treatment
• Observation
• Patient education
• Resume normal activities slowly
• Family post-concussion syndrome
• Headache
• Dizziness
• Lethargy
• Irritability
• Anxiety

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Contusion

• Brain is bruised, with possible surface
  hemorrhage
• Unconscious few minutes
• Faint pulse
• Shallow respirations
• Cool, pale skin
• Involuntary bowel / bladder evacuation
• Subnormal B/P and T
• May recover consciousness and become irritable

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Intracranial Hemorrhage

• Epidural Hematoma
• Subdural Hematoma
• Intracerebral Hematoma
• Intracerebral Hemorrhage

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Epidural Hematoma

• Between skull and dura - arterial
• Rapid Deterioration
• Symptoms related to IICP
• Deterioration of consciousness
• Ipsilateral dilation and fixation of pupil
• Contralateral paralysis of extremity
• Possible seizure

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Epidural Hematoma

• Loss of consciousness
• Arterial blood collects in epidural space and
  exerts pressure
• Regain consciousness
• CSF is reabsorbed to compensate for IICP
• Loss of consciousness
• Compensatory mechanism fails
• Rapid deterioriation of neurological signs

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Epidural Hematoma

• Treatment
• Burr holes to decrease ICP
• Craniotomy
• Removal of clot
• Control of bleeding
• Drain insertion

Brunner, 11th ed. ICP monitoring, p. 2180
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Epidural Hematoma
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Subdural Hematoma

• Blood collects between dura and brain
• Cause - venous
• Trauma
• Coagulopathies
• Rupture of aneurysm
• Acute, subacute, chronic

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Subdural HematomaAcute / Subacute

• Subacute
• 48 hr 2 week after injury
• s/s similar to acute injury

• Acute
• 24 -48 hr after injury
• ? LOC
• Pupillary changes
• Hemiparesis
• Emergent changes
• Coma
• ? B/P
• ? pulse
• Slowing respiratory rate

• Outcomes
• Control of ICP respiratory function
• High mortality due to brain damage

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Chronic Subdural Hematoma

• Symptoms
• Severe headache
• Focal neurologic signs
• Personality changes
• Mental deterioration
• Focal seizures
• May be misdiagnosed as neurotic or psychotic

• ? incidence with elderly
• Minor head trauma may shift the brain contents
  abnormally
• Time between injury and symptoms may be 3 weeks
  to months
• May mimic stroke

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Intracranial Hemorrhage
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Intracerebral Hemorrhage and Hematoma

• Bleeding into the brain tissue
• Etiology
• Force exerted to head over small area
• Systemic HTN
• Rupture of saccular aneurysm
• Vascular anomalies
• Intracranial tumors
• Bleeding disorders
• Complications of anticoagulant therapy

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Intracerebral Hemorrhage and Hematoma

• Symptoms
• Vary according to location of hematoma
• Incidious onset ? neurologic deficits ? headache
• Treatment
• Control of ICP
• Supportive care
• Antihypertensive meds nimodipine (Nimotop) ,
  fluids, electrolytes
• Craniotomy

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Brain Injury - Management

• Assessment/Diagnosis
• Presumed Cervical Spine Injury Until R/O
• Preservation of Homeostasis
• Prevention of Secondary Brain Injury
• Prevention / Treatment of IICP
• (barbituates propofol)
• Surgical Management

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Brain Injury - Management

• Supportive measures
• Ventilatory support
• Seizure prevention
• Fluid and electrolyte maintenance
• Temperature control
• Nutritional support
• NG tube
• Pain / anxiety management
• Benzodiazepines

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Brain Injury - Medications

• Corticosteroids
• Osmotic diuretics
• Anticonvulsants
• Barbituates
• Benzodiazepines

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Brain Death

• Potential organ donation
• Uniform Determination of Brain Death Act
• Cardinal Signs
• Coma
• Absence of brain-stem reflexes
• Apnea

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Brain Injury Nursing Diagnoses

• Ineffective Cerebral Tissue Perfusion
• Ineffective Airway Clearance
• Risk for Injury
• Risk for Imbalanced Body Temperature
• Interrupted Family Processes
• Deficient Knowledge
• PC
• ? Cerebral Perfusion, Cerebral Edema, Aspiration

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Brain Injury Goals

• Maintenance of
• Patent airway
• Adequate CPP
• Fluid/electrolyte balance
• Nutritional status
• Normal body temperature
• Skin integrity
• Improved cognitive function
• Prevention of sleep deprivation
• Effective family coping, Increased knowledge

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Brain Injury Nsg. Interventions

• Prevention and Health Promotion
• Interventions
• Monitoring for declining neuro function
• Maintaining the airway
• Monitoring fluid and electrolyte balance
• Promoting adequate nutrition

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Controlling ICP in Brain Injury

• Elevate HOB 30
• Maintain head / neck in neutral alignment
• Avoid Valsalva maneuvers
• Maintain normal body temperature

• PaO2 90 mm Hg
• Fluid balance
• Avoid excessive suctioning
• Sedate to ? agitation
• Cerebral perfusion pressure 70 mm Hg

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Brain Injury Nsg. Interventions

• Prevention and Health Promotion
• Interventions
• Risk for Infection
• Preventing injury
• Maintaining body temperature, skin integrity

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Brain Injury Nsg. Interventions

• Interventions
• Improving cognitive functioning
• Preventing sleep pattern disturbance
• Supporting family coping
• Monitoring for post-traumatic seizures
• Promoting home and community-based care

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Brain Injury Expected Outcomes

• Effective airway clearance, ventilation,
  oxygenation, normal body temperature
• Fluid and electrolyte balance
• Adequate nutritional status
• Avoid injury
• Intact skin integrity

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Brain Injury Expected Outcomes

• Improvements in cognitive function
• Absence of seizures
• Adaptive family processes
• Compliance with regimen
• Participates in rehab

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Spinal Cord Injury (SCI)

• Prevalence
• Risk Factors
• Incidence

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SCI

• Pathophysiology
• Transient concussion temporary loss of sensory
  and/or motor function
• Contusion bruising
• Laceration severing or tearing
• Compression pressure on spinal cord
• Incomplete / Complete transection

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Central Cord Injury

• Characteristics
• Motor deficits (in the upper extremities compared
  to the lower extremities sensory loss varies but
  is more pronounced in the upper extremities)
  bowel/bladder dysfunction is variable, or
  function may be completely preserved.

Brunner 10th ed. pp 1927
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Anterior Cord Injury

• Characteristics
• Loss of pain, temperature, and motor function is
  noted below the level of the lesion light touch,
  position, and vibration sensation remain intact.

Brunner 10th ed. pp 1927
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Lateral Cord Injury(Brown-Sequard Syndrome)
Characteristics Ipsilateral paralysis or
paresis is noted, together with ipsilateral loss
of touch, pressure, and vibration and
contralateral loss of pain and temperature.
Brunner 10th ed. pp 1927
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ASIA Impairment Scale
A Complete No motor or sensory function is
preserved in the sacral segments S4-S5. B
Incomplete Sensory but not motor function is
preserved below the neurologic level, and
includes the sacral segments S4S5. C
Incomplete Motor function is preserved below the
neurologic level, and more than half of key
muscles below the neurologic level have a
muscle grade less than 3. D Incomplete Motor
function is preserved below the neurologic
level, and at least half of key muscles below
the neurologic level have a muscle grade of 3
or greater. E Normal Motor and sensory
function are normal.
Brunner 11th Ed Used with permission of American
Spinal Injury Association. Chart 63-8 ASIA
Impairment Scale p. 2253
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SCI

• Pathophysiology
• Primary vs. Secondary
• Clinical Manifestations
• Lowest level at which sensory and motor function
  are normal
• Below the level
• Sensory and motor paralysis
• Loss of bladder and bowel control
• Loss of perspiration and vasomotor tome
• BP reduction

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SCI

• Emergency Management
• Scene of injury
• Rapid assessment
• Immobilization
• IV access
• Transportation

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SCI Medical Management

• Diagnostic
• Lateral C-spine, CT, MRI, Telemetry
• Assessment for Other Injuries
• Acute Phase
• Corticosteroids
• Respiratory support
• Skeletal traction
• Surgical management

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SCI Traction

• Crutchfield / Vinke / Gardner-Wells tongs
• Maintain traction at ALL times
• Assess
• Weights to ensure correct amount is in use
• Weights to ensure they are hanging freely
• Ropes and pulleys for integrity
• Pin care
• Roto-rest bed

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SCI TractionHalo Brace

• Alters balance
• Fatigue due to weight
• Assistance to rise from lying position
• Skin care
• Cut food into small pieces and use
  straw for liquids

Brunner 11ed p. 2255
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SCI Surgery

• Indicated if
• Cord compression
• Fragmented or unstable vertebral body
• Wound that penetrates the cord
• Bony fragments in spinal canal
• Neurologic status is deteriorating
• Fusion or fixation to create stable spinal column

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SCI Nursing Care

• Assessment
• Neurologic Exam
• Respirations
• Vital Signs
• Bladder
• Abdomen

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SCI Nsg. Diagnoses

• Ineffective breathing patterns
• Ineffective airway clearance
• Impaired mobility
• PC
• DVT
• Orthostatic hypotension
• Autonomic dysreflexia

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SCI - Nsg. Diagnoses

• Impaired physical mobility
• Spasticity
• Dantrolene (Dantrium)
• Baclofen (Lioresal)
• Contractures
• Foot drop
• Trochanter rolls

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Acute Complications

• Autonomic Dysreflexia
• Spinal Shock
• Neurogenic Shock

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SCI Complications- Autonomic Dysreflexia

• Autonomic Dysreflexia Lesions Above T6
• Emergency Severe HTN
• Can lead to cerebral vessel rupture and IICP
• Cause - Stimulus
• Usually tolerated in those without SCI
• Distended bladder (most common), Constipation or
  impaction, Skin stimulation (tactile, pain,
  ulcer, thermal)
• Creates excess responses from nervous system

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SCI Complications-Autonomic Dysreflexia -
Symptoms

• Pounding HA
• Profuse sweating (forehead)
• Flushing of the face and neck
• Nasal congestion
• Bradycardia
• HTN

• Nausea
• Restlessness
• Dilated pupils and blurred vision
• Piloerection

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SCI Complications-Autonomic Dysreflexia -
Interventions

• Rapid assessment
• Raise head to sitting position
• Identification and removal of cause / trigger
• Assess for
• bladder distention / kinked or occluded catheter
• Fecal impaction
• Pressure, irritation, or broken skin
• Loosen tight clothing
• Monitor VS, esp. B/P every 15 minutes
• Apresoline (if measures do not relieve HTN and
  HA)
• Label chart

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SCI Spinal Shock

• Immediately after SCI injury
• Sudden depression of reflex activity (areflexia)
  below level of injury
• Absence of sensation, reflexes
• Paralyzed and Flaccid
• Bladder and bowel function
• Treatment
• Intestinal decompression

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SCI Neurogenic Shock

• Loss of autonomic nervous system function below
  level of lesion (sympathetic innervation)
• Affects vital organs ? B/P and heart rate fall
• ? cardiac output
• Venous pooling in extremities
• Peripheral vasodilation
• Absence of perspiration on paralyzed areas
• May have abrupt onset of fever

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SCI Nursing Care

• Planning and Goals
• Interventions
• Promoting adequate breathing and airway clearance
• Improving mobility
• Promoting adaptation to sensory and perceptual
  alterations
• Maintaining skin integrity

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SCI Nursing Care

• Interventions
• Maintaining urinary elimination
• Improving bowel function
• Providing comfort measures
• Monitoring and Managing PCs
• Thrombophlebitis
• Orthostatic hypotension
• Autonomic dysreflexia

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SCI Nsg. Management

• Preventive Measures and Education
• Teaching Self-Care
• Ultimate Goal for Rehabilitation Process -
  Independence

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SCI- Expected Outcomes

• Improved gas exchange, clearance of secretions
• Moves within limits of dysfunction
• Adaptation to sensory and perceptual alterations
• Optimal skin integrity
• Urinary/Bladder function
• Absence of pain/discomfort
• Free of complications

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References

• DaDeppo, A. (2006). Decreased Adaptive
  Capacity closed-Head Injury. In. Wagner, K.D.,
  Johnson, K., Kidd, P.S. Eds. High Acuity Nursing.
  Upper Saddle River, N.J. pp. 448-458.
• Deglin, J.H., Vallerand, A.H. (2005). Daviss
  Drug Guide for Nurses, 10th Ed. Philadelphia.
  F.A. Davis. Pp. 739-741.
• Hogan, M., Madayag, T. (2004). Medical-Surgical
  Nursing Reviews and rationales. Pearson
  Education, Inc. Upper Saddle River, NJ. Pp. 167
  210.
• Hudak, C., Gallo, B, Morton, P. (1998). Patient
  Management Nervous System. In Critical Care
  Nursing A holistic approach, 7th ed.
  Lippincott. Philadelphia. Pp. 613-637.

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References

• Johnson, K.L., Hausman, K. (2006). Sensory
  Perceptual Disorders. In Wagner, K.D., Johnson,
  K., Kidd, P.S. Eds. High Acuity Nursing. Upper
  Saddle River, N.J. pp. 459-483.
• LeMone, P., Burke, K. (2008). Medical Surgical
  Nursing Critical thinking in client care.
  Pearson Education, Inc. Upper Saddle River, NJ.
  Pp. 1556-1559, 1595-1613.
• Smeltzer, S., Bare, B. (2004). Brunner
  Suddarths Textbook of Medical-Surgical Nursing.
  Lippincott, Williams, Wilkins. Philadelphia.
  Pp. 1910-1939.