Med Surg 2 (Neuro) Ch. 39

Skull fractures

-A break in the continuity of the cranium -Results from a blow to the head; can be associated with open head injury (scalp, cranium & dura mater are exposed) or a closed head injury (intact layer of scalp covers fractured skull) -Open head injuries create potential for infection

Spinal Shock (areflexia)

-A loss of sympathetic reflex activity below the level of injury within 30-60 minutes of a spinal injury -In addition to paralysis, pronounced hypotension, bradycardia, & warm dry skin occur -If level of injury is in cervical or upper thoracic region, respiratory failure can occur -Bowel & bladder distension develop & pt does not perspire below level of injury (which impairs temperature control) -Poikilothermia: pt assumes body temp of environment -May persist for 1 week to months until body adjusts to damage imposed by injury

Autonomic dysreflexia (hyperreflexia)

-An exaggerated sympathetic nervous system response in people with spinal cord injuries above T6 -Can occur suddenly at any time after spinal shock subsides -Characteristics of this acute emergency; Severe hypertension, slow heart rate, pounding headache, nausea, blurred vision, flushed skin, sweating, goosebumps, nasal stuffiness, anxiety -Uncontrolled, this can lead to seizures, stroke & death -Prevention is best treatment

Concussion assessment findings

-At the time of concussion occurs, the pt may experience a brief lapse of consciousness -Headache, N&V, loss of memory -Watch for increased ICP

Cerebral hematoma

-Bleeding within the skull -Most result from heard trauma or cerebral vascular disorders

When concussions occur repetitively, even though blows to the head may appear initially to have subclinical effects, they can result in...

-Chronic traumatic encephalopathy (a form of neurodegeneration) -Cumulative and sustained concussions, such as those that are sports related can result in long-term effects such as dementia, depression, Parkinson's, and early onset Alzheimer's

Spinal Nerve Root Compression: Medical Management

-Conservative treatment first; hot, moist packs are used to treat muscle spasm -Skeletal muscle relaxants; diazepam (valium) to reduce anxiety associated with the pain of a herniated disk and to relax the skeletal muscle

Nursing Management Cerebral Hematoma

-Consider all head injuries an emergency -Assess, prepare, prevent -Neurochecks (pupillary response, facial nerve damage, A&O, hand grasps, push pulls) -Check for rhinnorea (leakage from nose, may be CSF) -Are they on blood thinners?

Spinal Nerve Root Compression: Surgical Management

-Diskectomy: removal of disk -Laminectomy: removal of posterior arch of a vertebra -Diskectomy with spinal fusion: removal of ruptured disk followed by grafting a piece of bone taken from another area onto the vertebra to fuse the vertebral spinal process -Chemonucleolysis: injection of enzyme chymopapain into the nucleus pulposus to shrink or dissolve the disk which relieves the pressure

Basilar skull fractures

-Located at the base of the skull -Trauma in this location is especially dangerous because it can cause edema of the brain near the origin of the spinal cord, interfere with circulation of CSF, injure nerves that pass into the spinal cord, or create a pathway for infection between the brain & middle ear which can result in meningitis

Contusion Pathophysiology & Etiology

-More serious than a concussion and leads to gross structural injury to the brain -Result in bruising and sometimes hemorrhage of superficial cerebral tissue -When the head is struck directly, injury to the brain is called a coup injury -Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull (contrecoup)

Spinal Nerve Root Compression: Pathophysiology & Etiology

-Pressure on spinal nerve roots results from trauma, herniated (ruptured) intervererbal disks, and tumors of the spinal cord & surrounding structures -Stress caused by poor body mechanics, age, or disease weakens an area in the vertebra -This condition is commonly caused a slipped disk (displacement puts pressure on nearby nerves) -Pain along the distribution of the nerve root is common; actions the increase pressure intensify the pain

Complications of spinal cord injury

-Respiratory arrest & spinal shock (areflexia) are immediate complications -Autonomic dysreflexia (hyperreflexia) -Respiratory infections -Urinary and fecal impairment -Spasticity & contractures -Weight change -Calcium depletion -Urinary calculi -Sexual dysfunction -Pain

Pathophysiology & Etiology Concussion

-Results from a blow to the head that jars the brain -Usually the consequence of falling, striking the head against a hard surface -Results in diffuse & microscopic injury to the brain; force of the blow causes temporary neurologic impairment but no immediate evidence of serious damage to cerebral tissue

Spinal Cord Injuries

-Serious & sometimes fatal -Cervical and lumbar vertebrae most common injured -Correct emergency management at time of injury is crucial because moving pt incorrectly cause permanent damage

A cerebral hematoma increases ICP & unrelieved increased ICP cause brain to...

-Shift to lateral side (uncal herniation) or hernate downward through foramen magnum -These developments affect the vital center for respirations, HR, and BP as well as cranial nerve function -Death occurs if symptoms are not recognized and bleeding is not controlled

Contusion Assessment Findings

-Signs and symptoms vary depending on severity of blow and degree of head velocity -Watch for increased ICP

Signs and Symptoms: Skull Fractures

-Simple fx's produce few, if any, symptoms & heal without complication -Symptoms depend on area of brain that has been injured -Because basilar skull fx tend to be near dura, rhinorrhea (leaking of CSF from nose) or otorrhea (leaking of CSF from ear) may occur -Periorbital ecchymosis (raccoon eyes) or Battle's sign (bruising of mastoid processes behind ear) -Conjuctival hemorrhages

Medical & Surgical Management of Skull Fractures

-Simple fx's require bed rest and close observation for signs of increased ICP -Depressed skull fx's require a craniotomy -Additional treatment includes antibiotics to control infections, an osmotic diuretic to prevent or treat cerebral edema, and an anticonvulsant to prevent or treat seizures

Tetraplegia

-Term that replaces quadriplegia -Refers to weakness, paralysis, and sensory impairment of all extremities and the trunk when there is a spinal injury at or above the first throacic (T1) vertebrae

Spinal Nerve Root Compression

-There are 2 basic types: intramedullary lesions (involve spinal cord) and extramedullary lesions (involve tissues surrounding spinal cord) -The most common site of nerve root compression is at the level of the three lower lumbar disks; however it also occurs in the cervical spine

Spinal Nerve Root Compression: Assessment Findings

-Vary depending on the cause of compression and level involved -Usually include weakness, paralysis, pain and paresthesia (numbness, tingling) -DX: PE, hx, radiographs, EMG

Subdural hematoma

-Venous bleeding, with blood gradually filling space below dura -Can be acute, sub-acute, or chronic depending on rate of neurologic changes -Symptoms progressively worsen in acute within 1st 24 hours of injury; sub-acute & chronic show up after 24 hours and up to 1 week later

Which of the following is the most important reason for the nurse to monitor a pt's body temp after intracranial surgery? Hyperthermia increases the risk for... 1. Tetraplegia 2. Cerebral edema 3. Immobility 4. Brain damage

4. Brain damage

Common causes of autonomic dysreflexia

Full bladder, abdominal distention, impacted feces, skin pressure or breakdown, overstretched muscles, sex, labor and delivery, sunburn below cord injury, infected ingrown toenail, exposure to hot or cold environmental temp, taking OTC decongestants

When the tracts of the spinal nerves are completely severed...

No effective nerve regeneration occurs

After the initial period of therapeutic care for a spinal cord injury pt, the focus of treatment turns to...

Rehabilitative and restorative measures

Epidural hematoma

Stems from arterial bleeding (bleeds more than venous); characterized by rapidly progressive neurologic deterioration

Nursing Management of a Skull Fracture

To detect any CSF drainage, nurse looks for a halo sign (a blood stain collected on gauze that is surrounded by a clear or yellowish stain) -If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice -Qh neurochecks; Q15 minutes VS

Paraplegia

Weakness or paralysis & compromised sensory function of both legs & lower pelvis, occurs with injuries below the T1 level