ACI 6

autonomic hyperreflexia ppt

-Medical Emergency which must be recognized immediately (most common in SCI) -Hyperactivity of Autonomic Nervous System from a trigger »Distended bladder (blocked catheter) »Constipation -Sympathetic response: hypertension, bradycardia, severe headache, diaphoresis -If pt. complains of headache, check VS! (esp. BP) -HOB up, call MD, assess cause, anti-hypertensives -If left untreated could lead to seizures, MI, cerebral hemorrhage pg 1414 »Table 60-7

nursing Mx: SCI

-Rehabilitation: team approach, goal to get highest level of functioning •Respiratory rehabilitation •Neurogenic bladder: Flaccid, spastic, or sensory loss table 60.8 p 1416 -Management based on upper extremity function, caregivers, lifestyle -Anticholinergics- (see med list) -Intermittent catheterization with pre and post-void residual checks •Neurogenic bowel: 60-10 pg 1416

SCI Clinical Manifestations

-Respiratory system: Priority •Above C4: respiratory failure (ventilation) -Think about intubation pitfalls with a Cervical injury! •Diaphragmatic impairment (poor cough, atelectasis) •Assess swallow -Cardiovascular system: Vasodilation • bradycardia (atropine), hypotension (vasopressors) -Hypotension could also be due to internal hemorrhage! -Urinary system: retention • Bladder program -Gastrointestinal system: •paralytic ileus: place an NG, metoclopramide, H2 blockers, What will you see and hear? •Neurogenic bowel: bowel program -Integumentary system: pressure ulcers -Thermoregulation: loss of ability to regulate temp. -Metabolic needs: electrolyte imbalances, weight loss (high calorie/protein) -Peripheral vascular problems: DVT, PE -Reflexes (check for bulbocavernosus, anal wink) •Hyperactivity (Baclofen, Botox injections)

The client's cervical injury has been immobilized with cervical tongs and traction to realign the vertebrae, facilitate bone healing, and prevent further injury. Which occurrence necessitates your immediate intervention? 1. The traction weights are resting on the floor after the client is repositioned 2. The traction ropes are located within the pulley and are hanging freely 3. The insertion sites for the cervical tongs are cleaned with hydrogen peroxide 4. The client is repositioned every 2 hours by using the logrolling technique

1

surgical management: SCI

1st goal relieve pressure -2nd goal to stabilize spine •Decompression laminectomy, fusion •Harrington rods *Surgeries may not reverse spinal cord damage

Mr. M is a 32 y/o male brought to the ER by paramedics after a fall from the second story roof of his home. He was placed on a spinal board w/ a cervical collar to immobilize his spine. After spinal radiographs were obtained, the dr's determined that he has a vertebral compression injury at the c4-c5 level. What is your priority concern at this time? 1. Spinal immobilization 2. Airway 3. Potential for injuries r/t the client's decreased sensation 4. Dysrhythmias c/b disruption of the autonomic nervous system

2

Mr. M is to be transferred to a rehab facility. Which statement indicates the client needs more teaching? 1. After rehab, i may be able to achieve control of my bladder. 2. With rehab, i will gain all of my motor functions 3. Rehab wil help me to become as independent as possible 4. After rehab, i hope to return to a gainful employment

2

Mr. M is stabilized and moved to the neurologic ICU w/ a diagnosis of SCI at level c4-c5. You are the admitting nurse, working with an experienced UAP. When frequent respiratory assessments are performed, which can you delegate to the UAP? (Select all that apply) 1. Auscultate breath sounds every hour to detect decreased or absent ventilation 2. Ensuring that oxygen is flowing at 5 L/ min via the NC 3. Teach the client to breathe slowly and deeply using the IS 4. Check the client's oxygen saturation by pulse oximetry every 2 hours. 5. Assessing the client's chest wall movement during respirations

2 and 4

MAP

2DBP plus SBP divided by 3 higher than 70 for brain perfusion/head injury

An hour later, Mr. M's oxygen saturation drops to 88% and his respirations are rapid and shallow. On auscultation, he has decreased breath sounds bilaterally. What is your best action at this time? 1. Increase o2 to 10 L/min 2. Suction the client's airway 3. Notify the HCP immediately 4. Call the respiratory therapist

3

Mr. M's condition has stabilized and he has been removed from the ventilator. His cervical injury is now immobilized with a halo fixation device with jacket. He has regained the use of his arms and has some movement in his legs. Which instruction would you give the UAP providing help to Mr. M in ADLs? 1. Feed, bathe, and dress the client so he doesn't get too tired. 2. Encourage the patient to perform all of his own care 3. Allow the client to do what he can and then assist him with what he cant

3

The nursing student asks you how best to assess Mr. M's motor function. What is your best response? 1. Apply resistance while the client lifts his legs from the bed 2. Apply resistance while the client lifts his legs from the bed 3. Apply downward pressure while the client shrugs his shoulders upward 4. Make sure the client is able to grasp objects firmly and forms a fist

3

incomplete spinal cord injury

5 types 1)Central Cord Syndrome 2)Anterior Cord Syndrome 3)Brown-Séquard Syndrome 4)Posterior Cord Syndrome 5)Conus Medullaris or Cauda Equina Syndrome

specific Mx of increased ICP

A- airway Monitor airway patency. • Intubation, if needed, to prevent hypoxemia and hypercapnia B- blood pressure Monitor cerebral perfusion pressure (CPP). • Maintain adequate blood pressure to optimize CPP. C- calm Decrease stimulation by providing a calm, quiet environment. • Minimize nursing interventions and space them out as able. • Provide intravenous (IV) sedatives as needed. D- decompression • Insert a nasal* or oral gastric tube to decompress the stomach E- edema, eyes, elevate HOB • Monitor intracranial pressure if a catheter has been placed. • Monitor for changes in the neurologic exam. • Administer osmotic diuretics or hypertonic saline as ordered. Monitor pupillary responses to light and corneal reflexes. • Raise the head of the bed to 30 degrees to facilitate jugular venous outflow. F- fluids and electrolytes, food, and family Monitor for fluid and electrolyte imbalances that might indicate abnormal anti-diuretic hormone (ADH) levels. • Administer IV fluids and electrolytes. • Provide enteral nutrition either through a feeding tube or orally if cleared by a speech pathologist. • Provide family education and support. Participate in advanced care planning. G- GCS Monitor GCS hourly and report changes to a provider. H- hip flexion, hyperventilation, hyperthermia, herniation Avoid hip flexion which increases intra-abdominal and intrathoracic pressure. • Hyperventilation is used to lower carbon dioxide levels if other measures to lower ICP are ineffective. • Prevent hyperthermia to lower the metabolic requirements of the brain. • Monitor for impending herniation: unilateral or bilateral pupil dilation, coma, posturing, Cushing's reflex (hypertension, bradycardia, bradypnea) I- ICP monitoring and infection • Monitor ICP and inform provider of sustained ICP>20. • Monitor the effect of nursing care on ICP and minimize treatments or stimuli which increase it. • Strict aseptic technique when applying or changing dressings to ICP monitoring devices or ventricular drainage systems. *Note: Nasogastric tubes are contraindicated with basilar skull fractures.

Acute intracranial hypertension (AIH)

Acute intracranial hypertension (AIH) is a clinical syndrome in which homeostatic mechanisms are overwhelmed causing a rapid increase in intracranial pressure (ICP). AIH is a medical emergency requiring immediate treatment to prevent irreversible neurologic damage or death. Patients at risk for AIH should be monitored in a critical care setting.

dermatome

Area of skin supplied by a single spinal nerve

Nursing Mx: SCI pt. 2

Careful management of bowel evacuation is necessary in the patient with SCI because voluntary control may be lost. Usual measures for preventing constipation include high-fiber diet and adequate fluid intake (see Table 42.10). Patient and caregiver teaching is needed to promote successful independent bowel management. Guidelines related to bowel management are outlined in Table 60.10. These measures may not be adequate to stimulate evacuation. Suppositories (e.g., bisacodyl [Dulcolax], glycerin) or small-volume enemas and digital stimulation (done 20 to 30 minutes after suppository insertion) by the nurse or patient may be needed. In the patient with an upper motor neuron injury, digital stimulation can relax the external sphincter to promote defecation. A stool softener, such as docusate sodium (Colace), can help regulate stool consistency. Oral stimulant laxatives should be used only if absolutely necessary and not on a regular basis. Valsalva maneuver and manual stimulation are useful in patients with lower motor neuron injuries. Because the Valsalva maneuver requires intact abdominal muscles, it is used in patients with injuries below T12. In general, a bowel movement every other day is considered adequate. However, consider preinjury patterns. Fecal incontinence can result from too much stool softener or a fecal impaction. Timing of defecation is important. Planning bowel evacuation for 30 to 60 minutes after the first meal of the day may enhance success by taking advantage of the gastrocolic reflex induced by eating. This reflex may also be stimulated by drinking a warm beverage right after the meal. Discuss timing of the bowel program among the interprofessional team so there are no interruptions when the patient is doing therapy (e.g., swimming pool therapy).

neurogenic shock

Circulatory failure caused by paralysis of the nerves that control the size of the blood vessels, leading to widespread dilation; seen in patients with spinal cord injuries. § A complete but temporary loss of motor, sensory, reflex, and autonomic function that occurs immediately after injury as the cord's response to the injury. It usually lasts less than 48 hours but can continue for several weeks § ■ Hypotension § ■ Bradycardia

s/s of increased ICP

Conditions associated with chronically increased ICP may first present insidiously. Headaches may be the only symptom of chronic intracranial hypertension. Chronic intracranial hypertension can cause vision loss due to pressure on the optic nerve. Intracranial volume may increase steadily over months with minimal symptoms and no change in the level of consciousness, and yet present dramatically with an acute deterioration of consciousness when compensatory mechanisms are exceeded. There should be a high clinical suspicion of increased ICP for patients presenting with acute headache, papilledema, and vomiting. The patient may describe the headache as throbbing pain which worsens with actions that further increase ICP such as coughing, sneezing, recumbency or exertion. Other initial signs and symptoms of increased ICP include nausea, blurred vision, restlessness, irritability, and confusion. The clinical presentation of AIH can be mistaken for other problems, such as drug or alcohol intoxication, migraine headache, infection, or post-ictal state

more head injury

Diffuse axonal injury (DAI) •Widespread axonal damage •Decreased LOC •Increased ICP •Decortication, decerebration •Global cerebral edema Focal (localized) •Minor (GCS 13 to 15) •Moderate (GCS 9 to 12) •Severe (GCS 3 to 8) •Lacerations •Contusions •Hematomas •Cranial nerve injuries

drug metabolism in SCI

Drug metabolism is altered in patients with an SCI. Therefore drug interactions may occur. The differences in drug metabolism correlate with level and completeness of injury, with greater change apparent in people with cervical cord injury than in those with injury at lower spinal levels.

GCS

Glasgow Coma Exam, used to assess level of consciousness in trauma patients eyes (4) verbal (5) Motor (6)

traumatic head injury

Head injury is trauma to the skull, resulting in mild to extensive damage to the brain. § 2. Immediate complications include cerebral bleeding, hematomas, uncontrolled increased ICP, infections, and seizures. § 3. Changes in personality or behavior, cranial nerve deficits, and any other residual deficits depend on the area of the brain damage and the extent of the damage. Types of head injuries (Box 66-9) § Open § a. Scalp lacerations § b. Fractures in the skull § c. Interruption of the dura mater § Closed § a. Concussions § b. Contusions § c. Fractures

s/s of increased ICP part 2

Level of consciousness will decrease progressively as ICP gets worse. The Glasgow Coma Scale (GCS) is the most common scoring system used to objectively describe the patient's level of consciousness. The GCS is composed of three objective tests: eye, verbal, and motor responses. The lowest possible total GCS is 3, indicative of deep coma, while the highest is 15. GCS scores help facilitate communication among healthcare providers and provide guidance for diagnostic workup and therapeutic intervention. Increased ICP may cause protrusion or herniation of brain tissue through one of the rigid intracranial barriers. Signs of brain herniation include pupillary dilatation, hemiplegia, impaired oculocephalic movements, increased motor tone, flexion or extension to pain (posturing), and respirations containing sighs, deep yawns, or pauses. The Cushing reflex, which consists of hypertension, bradycardia, and diminished respiratory effort, is a preterminal condition indicating impending brainstem herniation. Emergency treatment is warranted.

CPP

MAP-ICP 60-100

LICOX catheter

Measures brain oxygenation (PbtO2) and temperature Placed in healthy white brain matter •Measures brain oxygenation (PbtO2) & temperature •Placed in healthy white brain matter •https://www.youtube.com/watch?v=LRyCvkxipBc

neurogenic shock ppt

Neurogenic shock- life threatening! •Due to loss of sympathetic nervous system •Bradycardia, hypotension, and paralytic ileus •Risk is in first hour after injury Generally associated with a cervical or high thoracic injury (T6 or higher) In contrast to spinal shock, neurogenic (vasogenic) shock can occur in cervical or high thoracic injury (T6 or higher). It occurs from unopposed parasympathetic response due to loss of sympathetic nervous system (SNS) innervation. It causes peripheral vasodilation, venous pooling, and decreased cardiac output. Manifestations include significant hypotension (< 90 mmHg), bradycardia, and temperature dysregulation. Neurogenic shock can continue for 1 to 3 weeks.5 Hypotension can result in poor perfusion and oxygenation to the spinal cord and worsen spinal cord ischemia.6

jugular venous bulb catheter

Placed in internal jugular vein The measurements of the jugular oxygen saturation normal range is 55%-75% less than this (50%) demonstrate impaired cerebral oxygenation •Measures jugular venous oxygen saturation (SjvO2)

coup and counter coup

Primary impact affects the posterior part of the brain when it comes in contact with the skull Secondary: counter coup; When the head is hit and the brain rocks back and fourth it is called coup counter-coup

Alpha Adrenergic Blockers

Relax certain muslces and help small blood vessels remain open. They work by keeping the hormone norepinephrine from tightening the muscles in the walls of smaller arteries and veins. Blocking that effect causes the vessels to remain open and relaxed. This imporves blood flow and lowers BP. used to relax the urethral sphincter doxazosin terazosin

spinal cord injury ppt

Spinal cord carries signals from brain to body, an SCI disrupts this Primary injury occurs first due to actual damage (trauma) p 1404 Further damage occurs over time (Secondary damage) fig 60.1 Ongoing Cellular damage, Hemorrhage leads to infarction, vasospasms, edema

spinal shock

Spinal shock- 30 minutes after injury for up to 6 weeks (temporary) Flaccid paralysis and loss of reflexes below level of injury Spinal shock may occur shortly after acute SCI. It is characterized by loss of deep tendon and sphincter reflexes, loss of sensation, and flaccid paralysis below the level of injury. This syndrome lasts days to weeks. It often masks postinjury neurologic function.

Cranium anatomy

The cranium is a rigid bony structure that contains 3 main components: brain tissue, cerebrospinal fluid (CSF), and blood. The pressure in the cranium is normally less than 20 mm Hg. Increased intracranial pressure (ICP) occurs when there is an increase in the volume of one or more components which cannot be offset by a volume reduction or displacement in some other component

Mx of ICP

The prompt recognition and management of patients with increased ICP requires knowledge of at-risk patient populations and the signs and symptoms of elevated ICP. Acute intracranial hypertension resulting from rapid elevation of intracranial pressure is a medical emergency requiring immediate stabilization of airway, breathing and circulation followed by immediate brain imaging for confirmation and diagnosis of the underlying etiology. ICP monitoring, and in certain cases CSF drainage, is a cornerstone of management. The neuroscience ICU nurse provides a calm, quiet environment, vigilant monitoring, and interventions to optimize cerebral blood flow and prevent complications.

autonomic hyperreflexia ppt pt 2

The return of reflexes after the resolution of spinal shock means patients with injury at T6 or higher may develop autonomic dysreflexia. Autonomic dysreflexia (AD) is a massive, uncompensated cardiovascular reaction mediated by the SNS. It involves stimulation of sensory receptors below the level of the SCI. The intact SNS below the level of injury responds to the stimulation with a reflex arteriolar vasoconstriction that increases BP. The parasympathetic nervous system is unable to directly counteract these responses via the injured spinal cord. Baroreceptors in the carotid sinus and aorta sense the hypertension and stimulate the parasympathetic system. This causes a decrease in heart rate. Visceral and peripheral vessels do not dilate because efferent impulses cannot pass through the injured spinal cord. It most often presents in the chronic phase after SCI.20 The most common precipitating cause of AD is a distended bladder or rectum. However, any sensory stimulation, including contraction of the bladder or rectum, stimulation of the skin, or stimulation of pain receptors can cause AD. AD is a life-threatening condition that requires immediate resolution. Proper identification and elimination of the inciting stimulus for AD can resolve the event. If uncorrected, it can lead to status epilepticus, stroke, myocardial infarction, and even death. Manifestations include hypertension, throbbing headache, marked diaphoresis above the level of injury, bradycardia (30 to 40 beats/min), piloerection from pilomotor spasm, flushing of the skin above the level of injury, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. Measure BP when a patient with SCI reports a headache. Suspect AD in adults with SBP elevation of 20 to 40 mm Hg above baseline.20 Immediate nursing interventions include elevating the head of the bed 45 degrees or sitting the patient upright (to lower the BP) and determining the cause (bowel impaction, urinary retention, UTI, PI, tight clothing). Notify the HCP. The most common cause is bladder irritation. Immediate catheterization to relieve bladder distention may be needed. Instill lidocaine jelly in the urethra before catheterization. If a catheter is already in place, check it for kinks or folds. If it is plugged, perform small-volume irrigation slowly and gently to open the catheter or insert a new catheter. Stool impaction can cause AD. Apply an anesthetic ointment to avoid increasing symptoms, then perform a digital rectal examination (if trained). Remove all skin stimuli, such as constrictive clothing and tight shoes. Monitor BP often during the episode. If symptoms persist after the source has been relieved, give a rapid-onset and short-duration agent, such as nitroglycerin, nitroprusside, or hydralazine. Continue careful monitoring until vital signs stabilize. Teach the patient and caregiver to recognize causes and symptoms of AD (Table 60.7). They must understand the life-threatening nature of AD, know how to relieve the cause, and activate the ERS, if needed.

transection of the cord

Transection of the cord § 1. Complete transection of the cord: The spinal cord is severed completely, with total loss of sensation, movement, and reflex activity below the level of injury. Partial transection of the cord § a. The spinal cord is damaged or severed partially. b. The symptoms depend on the extent and location of the damage.c. If the cord has not suffered irreparable damage, early treatment is needed to prevent partial damage from developing into total and permanent damage.

basilar skull fracture

Usually occurs following diffuse impact to the head (such as in falls, motor vehicle crashes); generally results from extension of a linear fracture to the base of the skull and can be difficult to diagnose with a radiograph (x-ray).

anatomy of spine

Vertebrae Cervical (7) Thoracic (12) Lumbar (5) Sacral (5) Coccyx (4) (fused) above T6 is risk for neurogenic shock

ventriculostomy

a catheter placed in one of the lateral ventricles of the brain to measure intracranial pressure and allow for drainage of fluid •Ventriculostomy •Catheter inserted into lateral ventricle •Used w/external transducer

ventriculoperitoneal shunt

a tube used to drain fluid from brain ventricles into the abdominal cavity o A ventriculoperitoneal shunt diverts cerebrospinal fluid from the ventricles into the peritoneum. post op interventions o Position the client supine and turn from the back to the nonoperative side. o Monitor for signs of increasing intracranial pressure resulting from shunt failure. o Monitor for signs of infection.

Mr. M continues to be incontinent. You plan to establish a bladder retraining program for him. Which are important points for the program? 1. Remove the indwelling foley 2. Use intermittent catheterization q 4 3. Gradually increase intervals between catheterizations 4. Teach the patient to initiate voiding by tapping on his bladder q 4 5. Teach the patient how to perform self catheterization 6. Administer urecholine 20mg orally twice a day 7. Encourage the client to limit fluid intake to 1000 mL

all but 7

Air pouch/pneumatic technology

another system for monitoring ICP, has an air filled pouch at the tip of the catheter that maintains a constant volume; the pressure changes within the cranium are transmitted through the changes exerted on this pouch to monitor •Air-filled pouch at catheter tip •Senses pressure changes within cranium •https://www.spiegelberg.de/en/products/icp-probes/ https://www.spiegelberg.de/en/products/icp-monitors/

anticholingeric

atropine used to increase heart rate in symptomatic bradycardia

stool softeners

bisacodyl and docusate sodium used to regulate stool consistency and promote bowel movements

crede method

done by gently pressing down on the bladder to try to trigger urination

vasopressors

dopamine and phenylephrine and norepi used in the acute phase to maintain the mean arterial pressure at a level greater than 90 mm Hg so that perfusion to the spinal cord is improved.

antispasmodic drugs

drugs that inhibit hydrochloric acid secretion, smooth muscle contraction, and peristalsis in the gastrointestinal tract to limit muscle spasms baclofen dantrolene tizanidine Used to control spasms associated with SCI (both skeletal and pelvic floor muscles). Botulism toxin injections may also be given to treat severe spasticity.

blood thinners

enoxaparin heparin fondaparinux dalteparin used for DVT prophylaxis watch for bleeding and thrombocytopenia

brain pushes on Pituitary

leads to changes in ADH DI and SIADH then may need to go on vasopressin med (if DI)

cerebral aneurysm

o A. Description § 1. Dilation of the walls of a weakened cerebral artery § 2. Aneurysm can lead to rupture. o B. Assessment § 1. Headache and pain § 2. Irritability § 3. Diplopia § 4. Blurred vision § 5. Tinnitus § 6. Hemiparesis § 7. Nuchal rigidity § 8. Seizures o C. Interventions § 1. Maintain a patent airway (suction only with an HCP's prescription). § 2. Administer oxygen as prescribed. § 3. Monitor vital signs and for hypertension or dysrhythmias. § 4. Avoid taking temperatures via the rectum. § 5. Initiate aneurysm precautions (Box 66-15)

more anticholinergics

oxybutynin tolterodine may be used to suppress bladder contraction

spinal shock

physiologic response that occurs between 30 and 60 minutes after trauma to the spinal cord and can last up to several weeks. spinal shock presents with total flaccid paralysis and loss of all reflexes below the level of injury. § A complete but temporary loss of motor, sensory, reflex, and autonomic function that occurs immediately after injury as the cord's response to the injury. It usually lasts less than 48 hours but can continue for several weeks § ■ Flaccid paralysis § ■ Loss of reflex activity below the level of the injury § ■ Bradycardia § ■ Hypotension § ■ Paralytic ileus

Cushing's triad

r/t ICP wide pulse pressure bradycardia bradypnea

PPIs and H2 antagonists

ranitidine famotidine pantoprazole omeprazole Used to reduce acid production, treat GERD, prevent Curling's (stress) ulcer

Bell's Palsy

temporary paralysis of the seventh cranial nerve that causes paralysis only on the affected side of the face

Fiberoptic catheter

uses sensor transducer located within catheter tip to provided direct measurement of brain pressure •Sensor transducer found within catheter tip •Catheter tip placed within the ventricle •https://neuro.natus.com/products-services/intracranial-pressure-monitoring-systems-catheters

To prep for test

watch vid take chapter questions cardiac quizlet?? pics on phone of so many things

o O. Surgical interventions for thoracic, lumbar, and sacral injuries

§ 1. Decompressive laminectomy § a. Removal of one or more laminae § b. Allows for cord expansion from edema; performed if conventional methods fail to prevent neurological deterioration § 2. Spinal fusion § a. Spinal fusion is used for thoracic spinal injuries. § b. Bone is grafted between the vertebrae for support and to strengthen the back. § 3. Postoperative interventions § a. Monitor for respiratory impairment. § b. Monitor vital signs, motor function, sensation, and circulatory status in the lower extremities. § c. Encourage breathing exercises. § d. Assess for signs of fluid and electrolyte imbalances. § e. Observe for complications of immobility. § f. Keep the client in a flat position as prescribed. § g. Provide cast care if the client is in a full body cast. § h. Turn and reposition frequently by logrolling side to back to side, using turning sheets and pillows between the legs to maintain alignment. § i. Administer pain medication as prescribed. § j. Maintain on NPO status until the client is passing flatus. § k. Monitor bowel sounds. § l. Provide the use of a fracture bedpan. § m. Monitor intake and output. § n. Maintain nutritional status.

assessment of spinal cord injuries

§ 1. Dependent on the level of the cord injury § 2. Level of spinal cord injury: Lowest spinal cord segment with intact motor and sensory function § 3. Respiratory status changes § 4. Motor and sensory changes below the level of injury § 5. Total sensory loss and motor paralysis below the level of injury § 6. Loss of reflexes below the level of injury § 7. Loss of bladder and bowel control § 8. Urinary retention and bladder distention § 9. Presence of sweat, which does not occur on paralyzed areas

craniotomy

§ 1. Description § a. Surgical procedure that involves an incision through the cranium to remove accumulated blood or a tumor § b. Complications of the procedure include increased ICP from cerebral edema, hemorrhage, or obstruction of the normal flow of CSF. § c. Additional complications include hematomas, hypovolemic shock, hydrocephalus, respiratory and neurogenic complications, pulmonary edema, and wound infections. § d. Complications related to fluid and electrolyte imbalances include diabetes insipidus and inappropriate secretion of antidiuretic hormone. § e. Stereotactic radiosurgery (SRS) may be an alternative to traditional surgery and is usually used to treat tumors and arteriovenous malformations. Preoperative interventions § a. Explain the procedure to the client and family. § b. Ensure that informed consent has been obtained. § c. Prepare to shave the client's head as prescribed (usually done in the operating room) and cover the head with an appropriate covering. § d. Stabilize the client before surgery.

hematoma

§ 1. Description: Hematoma is a collection of blood in the tissues and can occur as a result of a subarachnoid hemorrhage or an intracerebral hemorrhage. Assessment § a. Assessment findings depend on the injury. § b. Clinical manifestations usually result from increased ICP. § c. Changing neurological signs in the client § d. Changes in level of consciousness § e. Airway and breathing pattern changes § f. Vital signs change, reflecting increased ICP. § g. Headache, nausea, and vomiting § h. Visual disturbances, pupillary changes, and papilledema § i. Nuchal rigidity (not tested until spinal cord injury is ruled out) § j. CSF drainage from the ears or nose § k. Weakness and paralysis § l. Posturing § m. Decreased sensation or absence of feeling § n. Reflex activity changes § o. Seizure activity § CSF can be distinguished from other fluids by the presence of concentric rings (bloody fluid surrounded by yellowish stain, Halo sign) when the fluid is placed on a white sterile background, such as a gauze pad. CSF also tests positive for glucose when tested using a strip test.

spinal medication

§ 1. Dexamethasone (Decadron) § a. Used for its antiinflammatory and edema-reducing effects § b. May interfere with healing § 2. Dextran: Plasma expander used to increase capillary blood flow within the spinal cord and to prevent or treat hypotension § 3. Dantrolene (Dantrium), baclofen (Lioresal): These medications are used for clients with upper motor neuron injuries to control muscle spasticity.

cervical injuries

§ 1. Injury at C2 to C3 is usually fatal. § 2. C4 is the major innervation to the diaphragm by the phrenic nerve. § 3. Involvement above C4 causes respiratory difficulty and paralysis of all four extremities. § 4. Client may have movement in the shoulder if the injury is at C5 through C8, and may also have decreased respiratory reserve.

lumbar and sacral level injuries

§ 1. Loss of movement and sensation of the lower extremities may occur. § 2. S2 and S3 center on micturition; therefore, below this level, the bladder will contract but not empty (neurogenic bladder). § 3. Injury above S2 in males allows them to have an erection, but they are unable to ejaculate because of sympathetic nerve damage. § 4. Injury between S2 and S4 damages the sympathetic and parasympathetic response, preventing erection or ejaculation.

thoracic level injuries

§ 1. Loss of movement of the chest, trunk, bowel, bladder, and legs may occur, depending on the level of injury. § 2. Leg paralysis (paraplegia) may occur. § 3. Autonomic dysreflexia with lesions or injuries above T6 and in cervical lesions may occur. § 4. Visceral distention from a noxious stimuli such as a distended bladder or impacted rectum may cause reactions such as sweating, bradycardia, hypertension, nasal stuffiness, and goose flesh.

nursing care for autonomic hyperreflexia

§ 1. Raise the head of the bed. § 2. Loosen tight clothing on the client. § 3. Check for bladder distention or other noxious stimulus. § 4. Administer an antihypertensive medication. § 5. Document the occurrence, treatment, and response. Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to contact a health care provider (HCP) and sit the client up in bed in a high Fowler's position and remove the noxious stimulus. The nurse would loosen any tight clothing and then check for bladder distention. If the client has a Foley catheter, the nurse would check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact the client, if necessary. The nurse assesses the environment to ensure that it is not too cool or too drafty and also monitors vital signs, particularly the blood pressure, every 15 minutes. Antihypertensive medication may be prescribed by the HCP to minimize cerebral hypertension. Finally, the nurse documents the occurrence, treatment, and client response.

interventions during hospitalization

§ 1. Respiratory system § a. Assess respiratory status because paralysis of the intercostal and abdominal muscles occurs with C4 injuries. § b. Monitor arterial blood gas levels and maintain mechanical ventilation if prescribed to prevent respiratory arrest, especially with cervical injuries. § c. Encourage deep breathing and the use of an incentive spirometer. § d. Monitor for signs of infection, particularly pneumonia. § 2. Cardiovascular system § a. Monitor for cardiac dysrhythmias. § b. Assess for signs of hemorrhage or bleeding around the fracture site. § c. Assess for signs of shock, such as hypotension, tachycardia, and a weak and thready pulse. § d. Assess the lower extremities for deep vein thrombosis. § e. Measure circumferences of the calf and thigh to identify increases in size. § f. Apply thigh-high antiembolism stockings as prescribed. § g. Remove antiembolism stockings daily to assess the skin. § h. Monitor for orthostatic hypotension when repositioning the client. § 3. Neuromuscular system § a. Assess neurological status. § b. Assess motor and sensory status to determine the level of injury. § c. Assess motor ability by testing the client's ability to squeeze hands, spread the fingers, move the toes, and turn the feet. § d. Assess absence of sensation, hyposensation, or hypersensation by pinching the skin or pricking it with a pin, starting at the shoulders and working down the extremities. § e. Monitor for signs of autonomic dysreflexia and spinal shock. § f. Immobilize the client to promote healing and prevent further injury. § g. Assess pain. § h. Initiate measures to reduce pain. § i. Administer analgesics as prescribed. § j. Monitor for complications of immobility. § k. Prepare the client for decompression laminectomy, spinal fusion, or insertion of instrumentation or rods if prescribed. § l. Collaborate with the physical therapist and occupational therapist to determine appropriate exercise techniques, assess the need for hand and wrist splints, and develop an appropriate plan to prevent footdrop. § 4. Gastrointestinal system § a. Assess abdomen for distention and hemorrhage. § b. Monitor bowel sounds and assess for paralytic ileus. § c. Prevent bowel retention. § d. Initiate a bowel control program as appropriate. § e. Maintain adequate nutrition and a high-fiber diet. § 5. Renal system § a. Prevent urinary retention. § b. Initiate a bladder control program as appropriate. § c. Maintain fluid and electrolyte balance. § d. Maintain adequate fluid intake of 2000 mL/day. § e. Monitor for urinary tract infection and calculi. § 6. Integumentary system § a. Assess skin integrity. § b. Turn the client every 2 hours. § 7. Psychosocial integrity § a. Assess psychosocial status. § b. Encourage the client to express feelings of anger and depression. § c. Discuss the sexual concerns of the client. § d. Promote rehabilitation with self-care measures, setting realistic goals based on the client's potential functional level. § e. Encourage contact with appropriate community resources.

hyperthermia

§ 1. Temperature higher than 105° F, which increases the cerebral metabolism and increases the risk of hypoxia § 2. Causes include infection, heat stroke, exposure to high environmental temperatures, and dysfunction of the thermoregulatory center Assessment § 1. Temperature higher than 105° F § 2. Shivering § 3. Nausea and vomiting Interventions § 1. Maintain a patent airway. § 2. Initiate seizure precautions. § 3. Monitor intake and output and assess the skin and mucous membranes for signs of dehydration. § 4. Monitor lung sounds. § 5. Monitor for dysrhythmias. § 6. Assess peripheral pulses for systemic blood flow. § 7. Induce normothermia with fluids, cool baths, fans, or a hypothermia blanket. Inducement of normothermia § 1. Prevent shivering, which will increase intracranial pressure and oxygen consumption. § 2. Administer medications as prescribed to prevent shivering and to lower body temperature. § 3. Monitor neurological status. § 4. Monitor for infection and respiratory complications because hyperthermia may mask the signs of infection. § 5. Monitor for cardiac dysrhythmias. § 6. Monitor intake and output and fluid balance. § 7. Prevent trauma to the skin and tissues. § 8. Apply lotion to the skin frequently. § 9. Inspect for frostbite if a hypothermia blanket is used.

spinal cord injury

§ 1. Trauma to the spinal cord causes partial or complete disruption of the nerve tracts and neurons. § 2. The injury can involve contusion, laceration, or compression of the cord. § 3. Spinal cord edema develops; necrosis of the spinal cord can develop as a result of compromised capillary circulation and venous return. § 4. Loss of motor function, sensation, reflex activity, and bowel and bladder control may result. § 5. The most common causes include motor vehicle accidents, falls, sporting and industrial accidents, and gunshot or stab wounds. § 6. Complications related to the injury include respiratory failure, autonomic dysreflexia spinal shock, further cord damage, and death. o B. Most frequently involved vertebrae § 1. Cervical—C5, C6, and C7 § 2. Thoracic—T12 § 3. Lumbar—L1

nursing care for ICP

§ 4. Maintain body temperature. § 5. Prevent shivering, which can increase ICP. § 6. Decrease environmental stimuli. § 7. Monitor electrolyte levels and acid-base balance. § 8. Monitor intake and output. § 9. Limit fluid intake to 1200 mL/day. § 10. Instruct the client to avoid straining activities, such as coughing and sneezing. § 11. Instruct the client to avoid Valsalva's maneuver.

hyperosmotic agent

§ A hyperosmotic agent increases intravascular pressure by drawing fluid from the interstitial spaces and from the brain cells. § Monitor renal function. § Diuresis is expected.

emergency interventions

§ Always suspect spinal cord injury when trauma occurs until this injury is ruled out. Immobilize the client on a spinal backboard with the head in a neutral position to prevent an incomplete injury from becoming complete. § 1. Emergency management is critical because improper movement can cause further damage and loss of neurological function. § 2. Assess the respiratory pattern and maintain a patent airway. § 3. Prevent head flexion, rotation, or extension. § 4. During immobilization, maintain traction and alignment on the head by placing hands on both sides of the head by the ears. § 5. Maintain an extended position. § 6. Logroll the client. § 7. No part of the body should be twisted or turned, and the client is not allowed to assume a sitting position. § 8. In the emergency department, a client who has sustained a cervical fracture should be placed immediately in skeletal traction via skull tongs or halo traction to immobilize the cervical spine and reduce the fracture and dislocation (Fig. 66-3).

BP meds

§ Blood pressure medication may be required to maintain cerebral perfusion at a normal level. Notify the HCP if the blood pressure range is lower than 100 or higher than 150 mm Hg systolic

concussion

§ Concussion is a jarring of the brain within the skull, with no loss of consciousness.

contusion

§ Contusion is a bruising type of injury to the brain tissue. § ■ Contusion may occur along with other neurological injuries, such as with subdural or extradural collections of blood.

corticosteriods

§ Corticosteroids stabilize the cell membrane and reduce leakiness of the blood-brain barrier. § Corticosteroids decrease cerebral edema. § A histamine blocker may be administered to counteract the excess gastric secretion that occurs with the corticosteroid. § Clients must be withdrawn slowly from corticosteroid therapy to reduce the risk of adrenal crisis.

IV fluids with head/spine injury

§ Fluids are administered intravenously via an infusion pump to control the amount administered. § Hypertonic intravenous solutions are avoided because of the risk of promoting additional cerebral edema.

infratentorial surgery

§ Infratentorial surgery involves surgery below the tentorium of the brain. § The HCP may prescribe a flat position without head elevation or may prescribe that the head of the bed be elevated at 30 to 45 degrees. § Do not elevate the head of the bed in the acute phase of care following surgery without a HCP's prescription.

skull fractures

§ Linear § Depressed § Compound § Comminuted

nursing care post craniotomy

§ Monitor vital signs and neurological status every 30 to 60 minutes. § Monitor for increased intracranial pressure. § Monitor for decreased level of consciousness, motor weakness or paralysis, aphasia, visual changes, and personality changes. § Maintain mechanical ventilation and slight hyperventilation for the first 24 to 48 hours as prescribed to prevent increased intracranial pressure. § Assess a health care provider's (HCP's) prescription regarding client positioning. § Avoid extreme hip or neck flexion, and maintain the head in a midline neutral position. § Provide a quiet environment. § Monitor the head dressing frequently for signs of drainage. § Mark any area of drainage at least once each nursing shift for baseline comparison. § Monitor the Hemovac or Jackson-Pratt drain, which may be in place for 24 hours. § Maintain suction on the Hemovac or Jackson-Pratt drain. § Measure drainage from the Hemovac or Jackson-Pratt drain every 8 hours, and record the amount and color. § Notify the HCP if drainage is more than the normal amount of 30 to 50 mL per shift. § Notify the HCP immediately of excessive amounts of drainage or a saturated head dressing. § Record strict measurement of hourly intake and output. § Maintain fluid restriction at 1500 mL/day as prescribed. § Monitor electrolyte levels. § Monitor for dysrhythmias, which may occur as a result of fluid or electrolyte imbalance. § Apply ice packs or cool compresses as prescribed; expect periorbital edema and ecchymosis of one or both eyes, which is not an unusual occurrence. § Provide range-of-motion exercises every 8 hours. § Place antiembolism stockings on the client as prescribed. § Administer anticonvulsants, antacids, corticosteroids, and antibiotics as prescribed. § Administer analgesics such as codeine sulfate or acetaminophen (Tylenol) as prescribed for pain.

patient education for halo device

§ Notify a health care provider (HCP) if the halo vest (jacket) or ring bolts loosen. § Use fleece or foam inserts to relieve pressure points. § Keep the vest lining dry. § Clean the pin site daily. § Notify the HCP if redness, swelling, drainage, open areas, pain, tenderness, or a clicking sound occurs from the pin site. § A sponge bath or tub bath is allowed; showers are prohibited. § Assess the skin under the vest daily for breakdown, using a flashlight. § Do not use any products other than shampoo on the hair. § When shampooing the hair, cover the vest with plastic. § When getting out of bed, roll onto the side and push on the mattress with the arms. § Never use the metal frame for turning or lifting. § Use a rolled towel or pillowcase between the back of the neck and bed or next to the cheek when lying on the side, and raise the head of the bed to increase sleep comfort. § Adapt clothing to fit over the halo device. § Eat foods high in protein and calcium to promote bone healing. § Have the correct-sized wrench available at all times for an emergency (tape the wrench to the vest). § If cardiopulmonary resuscitation is required, the anterior portion of the vest will be loosened and the posterior portion will remain in place to provide stability.

client position post craniotomy

§ Positions prescribed following a craniotomy vary with the type of surgery and the specific postoperative health care provider's (HCP's) prescription. § Always check the HCP's prescription regarding client positioning. § Incorrect positioning may cause serious and possibly fatal complications.

anticonvulsants

§ Seizures increase metabolic requirements and cerebral blood flow and volume, thus increasing intracranial pressure. § Anticonvulsants may be given prophylactically to prevent seizures.

supratentorial surgery

§ Supratentorial surgery involves surgery above the tentorium of the brain. § The HCP may prescribe that the head of the bed be elevated at 30 degrees to promote venous outflow through the jugular veins. § Do not lower the head of the bed in the acute phase of care following surgery without a HCP's prescription.

antipyretics and muscle relaxants

§ Temperature reduction decreases metabolism, cerebral blood flow, and thus intracranial pressure. § Antipyretics prevent temperature elevations. § Muscle relaxants prevent shivering.

anterior cord syndrome

§ a. Anterior cord syndrome is caused by damage to the anterior portion of the gray and white matter of the spinal cord. § b. Motor function, pain, and temperature sensation are lost below the level of injury; however, the sensations of position, vibration, and touch remain intact.

Autonomic Dysreflexia

§ a. Autonomic dysreflexia is also known as autonomic hyperreflexia. § b. Autonomic dysreflexia generally occurs after the period of spinal shock is resolved and occurs with lesions or injuries above T6 and in cervical lesions. § c. It is commonly caused by visceral distention from a distended bladder or impacted rectum. § d. It is a neurological emergency and must be treated immediately to prevent a hypertensive stroke. BBB (bladder bowel and breakdown of skin) § ■ Sudden onset, severe throbbing headache § ■ Severe hypertension and bradycardia § ■ Flushing above the level of the injury § ■ Pale extremities below the level of the injury § ■ Nasal stuffiness § ■ Nausea § ■ Dilated pupils or blurred vision § ■ Sweating § ■ Piloerection (goose bumps) § ■ Restlessness and a feeling of apprehension

Brown-Séquard syndrome

§ a. Brown-Séquard syndrome results from penetrating injuries that cause hemisection of the spinal cord or injuries that affect half the cord. § b. Motor function, vibration, proprioception, and deep touch sensations are lost on the same side of the body (ipsilateral) as the lesion or cord damage. § c. On the opposite side of the body (contralateral) from the lesion or cord damage, the sensations of pain, temperature, and light touch are affected.

Cauda equina syndrome

§ a. Cauda equina syndrome occurs from injury to the lumbosacral nerve roots below the conus medullaris. § b. The client experiences areflexia of the bowel, bladder, and lower reflexes. Conus Medullaris/Cauda Equina: •Result from damage to conus (lowest portion of the spinal cord) and cauda equina (lumbar and sacral nerve roots). •Flaccid paralysis of the lower limbs and areflexic (flaccid) bladder and bowel. •If patients with cauda equina syndrome do not seek immediate treatment to relieve the pressure, it can result in permanent paralysis, impaired bladder and/or bowel control, loss of sexual sensation, and other problems. Even with immediate treatment, some patient may not recover complete function.

Central Cord Syndrome

§ a. Central cord syndrome occurs from a lesion in the central portion of the spinal cord. § b. Loss of motor function is more pronounced in the upper extremities, and varying degrees and patterns of sensation remain intact.

Conus medullaris syndrome

§ a. Conus medullaris syndrome follows damage to the lumbar nerve roots and conus medullaris in the spinal cord. § b. Client experiences bowel and bladder areflexia and flaccid lower extremities. § c. If damage is limited to the upper sacral segments of the spinal cord, bulbospongiosus penile (erection) and micturition reflexes will remain.

halo device

§ a. Halo traction is a static traction device that consists of a headpiece with four pins, two anterior and two posterior, inserted into the client's skull. § b. The metal halo ring may be attached to a vest (jacket) or cast when the spine is stable, allowing increased client mobility. § c. Monitor the client's neurological status for changes in movement or decreased strength. § d. Never move or turn the client by holding or pulling on the halo traction device. § e. Assess for tightness of the jacket by ensuring that one finger can be placed under the jacket. § f. Assess skin integrity to ensure that the jacket or cast is not causing pressure. § g. Provide sterile pin site care as prescribed. Client education for halo traction device (Box 66-14) § 5. Initiate interventions in support of the client's self image. § 6. Teach the client and family pin care, care of the vest, and signs and symptoms of infection to report to his or her health care provider.

shock interventions

§ a. Monitor for signs of spinal shock following a spinal cord injury. § b. Monitor for hypotension and bradycardia. § c. Monitor for reflex activity. § d. Assess bowel sounds. § e. Monitor for bowel and urinary retention. § f. Provide supportive measures as prescribed, based on the presence of symptoms. § g. Monitor for the return of reflexes.

hematoma interventions

§ a. Monitor respiratory status and maintain a patent airway because increased CO2 levels increase cerebral edema. § b. Monitor neurological status and vital signs, including temperature. § c. Monitor for increased ICP. § d. Maintain head elevation to reduce venous pressure. § e. Prevent neck flexion. § f. Initiate normothermia measures for increased temperature. § g. Assess cranial nerve function, reflexes, and motor and sensory function. § h. Initiate seizure precautions. § i. Monitor for pain and restlessness. § j. Morphine sulfate may be prescribed to decrease agitation and control restlessness caused by pain for the head-injured client on a ventilator; administer with caution because it is a respiratory depressant and may increase ICP. § k. Monitor for drainage from the nose or ears because this fluid may be CSF. § l. Do not attempt to clean the nose, suction, or allow the client to blow his or her nose if drainage occurs. § m. Do not clean the ear if drainage is noted, but apply a loose, dry sterile dressing. § n. Check drainage for the presence of CSF. § o. Notify the HCP if drainage from the ears or nose is noted and if the drainage tests positive for CSF. § p. Instruct the client to avoid coughing because this increases ICP. § q. Monitor for signs of infection. § r. Prevent complications of immobility. § s. Inform the client and family about the possible behavior changes that may occur, including those that are expected and those that need to be reported.

posterior cord syndrome

§ a. Posterior cord syndrome is caused by damage to the posterior portion of the gray and white matter of the spinal cord. § b. Motor function remains intact, but the client experiences a loss of vibratory sense, crude touch, and position sensation.

c-spine

§ a. Skeletal traction is used to stabilize fractures or dislocations of the cervical or upper thoracic spine. § b. Two types of equipment used for cervical traction are skull (cervical) tongs and halo traction (halo fixation device). § 2. Skull tongs § a. Skull tongs are inserted into the outer aspect of the client's skull, and traction is applied. § b. Weights are attached to the tongs, and the client is used as countertraction. The nurse should not add or remove weights. § c. Monitor the neurological status of the client. § d. Determine the amount of weight prescribed to be added to the traction. § e. Ensure that weights hang securely and freely at all times. § f. Ensure that the ropes for the traction remain within the pulley. § g. Maintain body alignment and maintain care of the client on a special bed (such as a RotoRest bed or Stryker or Foster frame) as prescribed. § h. Turn the client every 2 hours. § i. Assess insertion site of the tongs for infection. § j. Provide sterile pin site care as prescribed.

subarachnoid hemorrhage

§ ■ A subarachnoid hemorrhage is bleeding into the subarachnoid space. It may occur as a result of head trauma or spontaneously, such as from a ruptured cerebral aneurysm.

tetraplegia

§ ■ Injury occurring between C1 and C8 § ■ Paralysis involving all four extremities

paraplegia

§ ■ Injury occurring between T1 and L4 § ■ Paralysis involving only the lower extremities

intracerebral hemorrhage

§ ■ Intracerebral hemorrhage occurs when a blood vessel within the brain ruptures allowing blood to leak inside the brain.

subdural hematoma

§ ■ Subdural hematoma forms slowly and results from a venous bleed. § ■ Subdural hematoma occurs under the dura as a result of tears in the veins crossing the subdural space.

epidural hematoma

§ ■ The most serious type of hematoma, epidural hematoma forms rapidly and results from arterial bleeding. § ■ Epidural hematoma forms between the dura and skull from a tear in the meningeal artery. § ■ It is often associated with temporary loss of consciousness, followed by a lucid period, that rapidly progresses to coma. § ■ Epidural hematoma is a surgical emergency.

The development of increased ICP may be acute or chronic. It is a common clinical problem in neurology or neurosurgical units. Many diseases or insults can result in increased ICP:

• Increase in brain volume o Cerebral edema (trauma, ischemia, hyperammonemia, encephalitis, high altitude) o Hematoma o Tumor o Abscess o Blood clots • CSF Dysregulation o Increase in cerebrospinal fluid (infection, choroid plexus tumor) o Decreased re-absorption of CSF (obstructive hydrocephalus, meningitis) • Increase in blood volume o Increased cerebral blood flow (hypercarbia, aneurysms) o Venous stasis from venous sinus thromboses o Elevated central venous pressures (severe heart failure) • Other causes o Idiopathic intracranial hypertension o Skull deformities such as craniosynostosis o Vitamin A intoxication o Tetracycline use

ambulation care: head injury

•Ambulatory care •Acute rehabilitation •Seizure disorders •Motor, sensory & communication abilities •Cognitive, memory & intellectual fxn •Nutrition •Bowel & bladder management •Family participation & education

head injury causes

•Any trauma to •Scalp •Skull •Brain •Traumatic brain injury (TBI) •Most common causes •Falls •Motor vehicle accidents •Other causes •Firearms & Assaults •Sports-related trauma •Recreational injuries •War-related injuries •TBI - 2x as common in males > females •High potential for poor outcome •Deaths occur at three points after injury

complete spinal cord injury

•Cervical (respiratory support): C1-C3 often fatal, C4: tetraplegia (Quad), C5-7 may regain some hand movement -C 4 or C5 most common level of injury •Thoracic: paraplegia •Lumbar: may regain ambulation

cerebral edema: clinical manifestations

•Change in LOC •Flattening of affect •Decreased responsiveness (coma) •VS changes •Cushing's triad •Change in body temperature •Headache •Often continuous •Worse in the morning •Vomiting •Unexpected •Projectile

complications and Dx: cerebral edema

•Complications •Inadequate cerebral perfusion •Cerebral herniation •Tentorial herniation •Uncial herniation •Cingulate herniation •Diagnostic Studies •CT/MRI/PET •EEG •Cerebral angiography •ICP •Brain tissue oxygenation measurement (LICOX catheter) •Doppler & evoked potential studies •NO lumbar puncture

compression of cranial nerve 3

•Compression of cranial nerve (CN) III - oculomotor nerve •Ipsilateral dilated pupil •Response to light - sluggish or none •Inability to move eye upward, adduct •Ptosis of the eyelid •Fixed, unilateral, dilated pupil is considered a neurologic emergency

CSF leak considerations

•Considerations for CSF leak •HOB up •Loose collection pad under nose/over ear •No sneezing or blowing nose •No NG tube •No NT suctioning

contusion ppt

•Contusion •Brain tissue bruise •Closed head injury •May have areas of hemorrhage, infarction, necrosis, edema •May bleed or rebleed •Focal & generalized manifestations •Monitor for seizures •Extra concern w/anticoagulants

cerebral blood flow

•Definition •Amount of blood (mL) passing through 100 g of brain tissue in 1 minute •~ 50 mL/min per 100 g of brain tissue Autoregulation •Automatic adjustment in diameter of cerebral blood vessels •Ensures consistent CBF •Only effective if mean arterial pressure (MAP) 70 to 150 mm Hg

head injury Dx

•Diagnostics (Dx) •CT scan •Best diagnostic test to evaluate for head trauma •MRI, PET, evoked potential studies •Transcranial doppler studies •Cervical spine x-ray

more types of head injry

•Diffuse (generalized) • Concussion •Sudden transient mechanical injury •Brief disruption in LOC •Retrograde amnesia •Headache (HA) •May result in postconcussion syndrome Postconcussion Syndrome •Persistent HA •Lethargy •Change in personality & behavior •Attention span & decreased short-term memory decrease •Intellectual ability change

head injury emergent Tx

•Emergency Tx •CAB •Stabilize C-spine •O2, IV access •Intubate w/GCS < 8 •Control external bleeding •Maintain normothermia •Give fluids cautiously •Frequent VS & neuro assessment •Tx principles •Prevent secondary injury •Timely diagnosis •Surgery if needed •Concussion & contusion •Frequent assessment & management of ICP •Skull fractures •Conservative tx •Surgery if depressed fx •Subdural epidural hematomas •Surgical evacuation •Craniotomy, burr-holes •Craniectomy if extreme swelling anticpated

emergent care: SCI

•Emergency care (table 60-3 pg 1408) * Patent Airway, give O2 * Stabilize * Vital Signs, Neuro assessment * Assess for other injuries, use of ETOH/drugs * Keep warm * IV- isotonic fluids, may need to administer atropine or dopamine (keep systolic >90), EKG * CT scan (diagnose level of injury) * Foley (30 mL/hr) * NG placement Current evidence for the use of methylprednisolone is mixed. Guidelines for managing spinal cord injuries issued by both the American Association of Neurological Surgeons and Congress of Neurological Surgeons do not recommend its use for treating acute SCI.14 The FDS no longer approves its use either. However, recommendations in the AOSPine 2017 Guidelines suggest a 24-hour infusion of high-dose methylprednisolone within 8 hours of acute SCI.2 So, some HCPs may consider this option. VTE prophylaxis with low-molecular-weight heparin (LMWH) (e.g., enoxaparin [Lovenox]) or fixed, low-dose heparin should start within 72 hours after injury, unless contraindicated. Contraindications include internal or external bleeding and recent surgery. For those with abnormal kidney function, heparin is best as LMWH is mainly excreted via the kidneys. Vasopressor agents (e.g., phenylephrine, norepinephrine) are used in the acute phase of injury as adjuvants to treatment. They maintain the MAP to improve perfusion to the spinal cord. Use of vasopressors has significant risk for complications. These include ventricular tachycardia, troponin elevation, metabolic acidosis, and atrial fibrillation. Dopamine has more complications than phenylephrine in SCI. Considerations for vasopressor selection include level of injury, patient age, and comorbidities (e.g., heart problems).

epidural hematoma ppt

•Epidural hematoma •Bleeding between the dura and inner surface of the skull •Neurologic emergency •Slow if venous origin •Rapid if arterial origin •Initial period of unconsciousness •Brief lucid interval followed by decrease in LOC •HA, nausea, vomiting •Focal findings •Requires rapid evacuation

factors that influence ICP

•Factors that influence ICP •Arterial pressure •Venous pressure •Intraabdominal and intrathoracic pressure •Posture •Temperature •Blood gases (CO2 levels)

elevated ICP goals

•Goals are to •Treat underlying cause of increased ICP •Support brain function •Adequate oxygenation •PaO2 greater than or equal to 100 mm Hg •PaCO2 of 35 to 45 mm Hg •Mechanical ventilation •Surgery to remove mass or lesion Drug therapy •Mannitol (Osmitrol) •Plasma expansion •Osmotic effect •Monitor F&E •Hypertonic saline •Moves water from cells into blood •Monitor BP & Na+ •What else should be assessed frequently? •Corticosteroids •Vasogenic edema •Improve neurogenic function •Monitor fluid intake, Na+ & glucose •Antacids, H2 receptor blockers, proton pump inhibitors (PPIs) •Antiseizure medications •Antipyretics •Sedatives •Barbiturates •IV 0.9% NaCl preferred over D5W or 0.45% NaCl

Monroe-Kellie

•If one component increases, another must decrease to maintain ICP •Normal ICP 5-15 mmHg •Elevated ICP - sustained >20 mmHg

cerebral edema

•Increased extravascular fluid in brain •Variety of causes •Three types: 1.Vasogenic 2.Cytotoxic 3.Interstitial •1. Vasogenic cerebral edema •Most common •Occurs mainly in white matter •Fluid leaks from intravascular to extravascular space •Variety of causes •Continuum of symptoms → coma •2. Cytotoxic cerebral edema •Disruption of cell membrane integrity •Causes: destructive lesions or trauma •Fluid & protein shifts from extracellular to intracellular spaces •3. Interstitial cerebral edema •Usually result of hydrocephalus •Excess CSF production, obstruction of flow, or inability to reabsorb •Tx: ventriculostomy or shunt

intracerebral hematoma

•Intracerebral Hematoma •Bleeding in the brain tissue •Common in frontal & temporal lobes •Size & location of hematoma are key in determining patient outcome

lacerations

•Laceration •Brain tissue tear •Depressed & open fx & penetrating injuries •Intracerebral hemorrhage •Subarachnoid hemorrhage •Intraventricular hemorrhage

measuring ICP: nursing

•Measure as mean pressure •Waveform should be recorded •Normal, elevated & plateau waves (slide 19) •Immediately report sustained ICP elevation •Prevent & assess for infection •Compare ICP changes & patient assessment •Inaccurate ICP readings may be caused by •CSF leaks •Obstruction in catheter/kinks in tubing •Difference in height of catheter & transducer •Incorrect height of drainage system •Bubbles/air in tubing •Can control ICP by removing CSF (w/ventric) •Intermittent or continuous drainage •Careful monitoring of volume of CSF drained is essential

Nursing Mx: SCI pt 3

•Neurogenic skin -Reposition every 2 hours, if in w/c shift every 15 min. cushions, monitor pre-albumin •Sexuality: p 1417 -95% of males can produce sperm for fertility -Does not affect ability to become pregnant or delivery •Grief and depression 60-12 pg 1419 Various drugs can be used to treat patients with a neurogenic bladder. Anticholinergic drugs (e.g., oxybutynin, tolterodine [Detrol]) may be used to suppress bladder contraction. α-Adrenergic blockers (e.g., terazosin, doxazosin [Cardura]) can relax the urethral sphincter. Antispasmodic drugs (e.g., baclofen) may decrease spasticity of pelvic floor muscles. Botulinum toxin is an effective alternative in patients with neurogenic detrusor overactivity who cannot tolerate or had an inadequate response to anticholinergic drugs.22

ICP regulation

•Normal compensatory adaptations •Changes in CSF volume •Changes in intracranial blood volume •Changes in tissue brain volume •Compensation is limited •If volume continues to increase, ICP rises à decompensation à compression à finally ischemia

head injury Nursing Dx and Mx

•Nursing Diagnoses •Decreased intracranial adaptive capacity •Ineffective tissue perfusion •Hyperthermia •Risk for injury •Anxiety •Planning •Goals: Patient will •Maintain adequate cerebral oxygenation & perfusion •Remain normothermic •Be pain free •Be infection free •Have adequate nutrition •Attain maximal cognitive, motor, & sensory fxn •Implementation •Health promotion •Prevent MVAs •Promote driver safety •Home safety to prevent falls •Acute care •Maintain CPP •Prevent secondary cerebral ischemia •Neuro assessment •Patient & family teaching •Acute care cont'd •Care for increased ICP •Eyes - Eye drops, compresses, patch •Maintain normothermia •Acute Care cont'd •DVT & Ulcer prophylaxis •Antiemetics •Analgesics •Preop preparation, if needed

ICP: nursing diagnoses

•Nursing Diagnoses •Decreased intracranial adaptive capacity •Ineffective tissue perfusion •Risk for injury •Goals •Patent airway •ICP WNL •Normal fluid, electrolyte & nutritional balance •Prevent complications from immobility & decreased LOC

nurtrition

•Nutritional therapy •Hypermetabolic & hypercatabolic state •Enteral or parenteral nutrition •Early feeding (within 3 days of injury) •Keep patient euvolemic

cranial nerves affected by edema

•Other cranial nerves •Optic (CN II) •Trochlear (CN IV) •Abducens (CN VI) •S/S: Diploplia, blurred vision, EOM changes

elevated ICP: acute care

•Respiratory function •Maintain patent airway & ventilation •HOB 30o •Monitor ABGs •Suction PRN •Prevent abdominal distention •Positioning •Avoid neck & hip flexion •Turn slowly •Manage Pain & Anxiety •Opioids •Propofol (Diprivan) •Dexmedetomidine (Precedex) •Neuromuscular blockade •Benzodiazepines •F&E •Monitor IV fluids •Daily weights •Serum electrolytes •Anticipate DI or SIADH •Minimize complications of immobility •Protection from self-injury •Judicious use of restraints; sedatives •Seizure precautions •Quiet, nonstimulating environment •Psychologic considerations •Evaluation •Expected outcomes •Maintain ICP & CPP WNL •No serious increases in ICP during or after care activities •No complications of immobility

types of head injuries

•Scalp lacerations •External head trauma •Scalp is highly vascular •Potential for significant blood loss, infection •Skull fractures •Linear or depressed •Simple, comminuted, or compound •Closed or open •Location determines manifestations •Complications •Infection •Hematoma •Tissue damage

stages of increased ICP

•Stages of increased ICP •Stage 1: Total compensation •Stage 2: ↓ Compensation; risk for ↑ICP •Stage 3: Failing compensation; clinical manifestations of increased ICP (Cushing's triad) •Stage 4: Herniation imminent leading to death •Factors affecting cerebral blood vessel tone •CO2 •O2 •Hydrogen ion concentration

subdural hematoma ppt

•Subdural hematoma •Bleeding between dura mater & arachnoid •Most commonly from •Veins that drain brain surface into sagittal sinus •May also be arterial—develops more rapidly •Acute subdural hematoma •Within 24 to 48 hours of injury •Symptoms of elevated ICP •Decreased LOC, headache •Ipsilateral pupil dilated (fixed if severe) •Subacute subdural hematoma •Within 2 to 14 days of the injury •May appear to enlarge over time •Chronic subdural hematoma •Weeks or months after seemingly minor head injury •More common in older adults •Focal symptoms •Increased risk for misdiagnosis

assessment: ICP

•Subjective data •Level of consciousness (LOC) •Glasgow Coma Scale •Cranial nerves •Eye movements •Corneal reflex •Oculocephalic reflex (doll's eye reflex) •Oculovestibular (cold caloric reflex) •Motor strength •Squeeze hands •Pronator drift test •Raise foot off bed or bend knees •Motor response •Spontaneous or to pain •Vital signs

nursing Mx head injury

•Subjective data •PMH/Mechanism of injury •Meds - Anticoagulants? •ETOH/drug use •HA, mood or behavioral changes •LOC changes •Impaired judgment/risky behaviors •Aphasia, dysphasia •Fear, denial, anger, aggression, depression •Objective data •Altered mental status/Seizures •Respiratory status •Cough & gag reflex •Cushing's triad •Vomiting •Bowel & bladder control •Lacerations, contusions, abrasions •Hematoma •Battle's sign, Raccoon eyes; Rhinorrhea, otorrhea •Objective data cont'd •Exposed brain •Increased ICP •Increased or decreased blood glucose level •Abnormal CT or MRI •Abnormal EEG •Pupil dysfunction •Cranial nerve deficit(s) •Motor deficit •Palmar drift •Paralysis •Spasticity, Flaccidity •Posturing •Positive toxicology screen or alcohol level •Uninhibited sexual expression

motor function

•↓ In motor function •Contralateral hemiparesis/hemiplegia •Decerebrate posturing (extensor) •Indicates more serious damage •Decorticate posturing (flexor) •https://www.youtube.com/watch?v=yZUE2Dvf1Q4