Nur258 Complex - SCI Chap 68
Battle's Sign
(an area of ecchymosis may be seen over the mastoid).
While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak?
18 to 36 hours Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours.
ICP should be at
50-70.
The nurse is caring for a patient with a spinal cord lesion above T6. Which of the following stimuli is known to trigger an episode of autonomic dysreflexia?
A number of stimuli may trigger this reflex: distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, and pressure ulcer). The trigger is removed, and the patient is placed in a sitting position immediately to lower blood pressure.
Which type of brain injury has occurred if the patient may be aroused with effort, but soon slips back into unconsciousness?
A patient with a contusion may be aroused with effort but soon slips back into unconsciousness. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brain stem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.
When the hypothalamus is involved in a brain injury
A record of intake and output is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. Excessive output will alert the nurse to possible fluid imbalance early in the process.
Glascow Coma Scale
A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient
Autonomic dysreflexia
Above T6 a life-threatening emergency in spinal cord injury patients that causes a hypertensive emergency;
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Absence of reflexes along with flaccid extremities
Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order:
Adverse effects of methylprednisolone sodium succinate and other steroids include GI bleeding and wound infection. To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine (Pepcid).
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?
An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (BURR HOLESs; see Fig. 66-8 in Chapter 66) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.
A patient arrives at the ED via ambulance following a motor cycle accident. The paramedics state the patient was found unconscious at the scene of the accident, but briefly regained consciousness during transport to the hospital. Upon initial assessment, the patient's GCS score is 7. The nurse anticipates which of the following?
Immediate Craniotomy The patient is experiencing an epidural hematoma. An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease ICP emergently, remove the clot, and control the bleeding. A craniotomy may be required to remove the clot and control the bleeding. Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. During this lucid interval, compensation for the expanding hematoma takes place by rapid absorption of CSF and decreased intravascular volume, both of which help to maintain the ICP within normal limits.
Halo Device with SCI
It allows for stabilization of the cervical spine along with early ambulation
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures.
A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?
Monitoring is needed as rapid neurologic deterioration may occur.
ICP is maintained by
P. Other measures include elevating the head of the bed as prescribed, maintaining the patient's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.
The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?
Pulse and blood pressure
Which of the following is an acute complication of spinal cord injury?
Spinal and neurogenic shock and DVTs. The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury.
Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?
Subdural Hematoma, venous bleed
A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?
Suction Airway
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
T6
The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
The client has cerebral spinal fluid (CSF) leaking from the ear.
The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?
The nurse recognizes that autonomic dysreflexia is an exaggerated sympathetic nervous system response. Symptoms include severe hypertension, slow heart rate, pounding headache, etc. and can lead to seizures, stroke, and death.
When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred?
The nurse should anticipate that the injury has occurred at level C5. Injuries above C3 result in the loss of spontaneous respiratory function. Clients with injuries at T6 and L1 retain some degree of upper limb use and sensation
While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have
There are three grades of concussion or mild traumatic brain injury defined by the American Academy of Neurology when the injury is sports related (Ruff, Iverson, Barth, et al., 2009). A grade 1 concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. A grade 2 concussion also has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes. In a grade 3 concussion, there is any loss of consciousness lasting from seconds to minutes
The nurse is admitting a client from the Emergency Department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae.
Transcranial Doppler
Transcranial Doppler flow studies are used to study a tumor's blood flow within intracranial blood vessels.
A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patien
Vomiting is a sign of increasing intracranial pressure and should be reported immediately
Depressed Fracture
When bone fragments are embedded into the brain tissue,
Decerebrate posturing
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?
Fever in the patient with a TBI can be the result of
amage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the patient's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia
Nuchal rigidity and Kernig's sign
are associated with meningitis
Contusions
are bruising, and sometimes, hemorrhage of superficial cerebral tissue.
Posttraumatic seizures
are classified as immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury)
Monro-Kellie hypothesis
because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others.
Epidural Hematoma
bleeding between the inner skull and the dura, compressing the brain underneath. By arteries
Intrecerebral Hemorrhage
bleeding in the brain or the cerebral tissue with displacement of surrounding structures
Intracerebral hemorrhage (hematoma
bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries).
Simple Linear Fracture
break in continuity of the bone.
The three cardinal signs of brain death on clinical examination`
coma, absence of brain stem reflexes, and apnea
A basilar skull fracture
commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function.
To assist in controlling ICP in clients with severe brain injury, the following are recommended:
elevate the head of the bed as prescribed (gravity helps drain fluid), maintain head/neck in neutral alignment (no twisting or flexing), give sedation as ordered to prevent agitation, and avoid noxious stimuli (scatter procedures so that client does not become overtired).
Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2), because
hypoxemia can create or worsen a neurologic deficit of the spinal cord.
Posttraumatic seizures are classified as
immediate (within 24 hours after injury), early (within 1 to 7 days after injury), or late (more than 7 days after injury). Seizure prophylaxis is the practice of administering antiseizure medications to patients with head injury to prevent seizures. It is important to prevent posttraumatic seizures, especially in the immediate and early phases of recovery, because seizures may increase intracranial pressure and decrease oxygenation
The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?
immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration.
The first sign of possible subdural hematoma
is a change in LOC. Speech may be affected later as the client experiences continued reduction in oxygenation. Bradycardia and a decreased heart rate occur later if the condition isn't treated
Cerebral angiography
may be used to study a tumor's blood supply or obtain information about vascular lesions
Pupillary changes are common in skull fractures with associated
meningeal artery bleeding and uncal herniation from an epidural hematoma, This causes rapid pressure on the brain from bleeding into the thin portion of the temporal bone
Characteristics of a central cord injury include
motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities)
Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate?
n the early stages of cerebral ischemia, the vasomotor centers are stimulated and the systemic pressure rises to maintain cerebral blood flow. This is typically accompanied by a slow, bounding pulse and respiratory irregularities. These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP. • Respiratory irregularities • Slow bounding pulse • Widened pulse pressure
Flaccid Posturing
no motor function, is limp, and lacks motor tone
Which of the following terms refers to muscular hypertonicity with increased resistance to stretch?
pasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes.
Decorticate Posturng
patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.
Persistent Vegetative state
phrase used to describe a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function. (
Cushing's response
phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure.
Akinetic mutism
phrase used to refer to unresponsiveness to the environment.
Akathisia
refers to a restless, an urgent need to move around, and agitation
Comminuted Skill Fracture
refers to a splintered fracture line
Ataxia
refers to impaired ability to coordinate movemen
Myoclonus
refers to spasm of a single muscle or group of muscles
Cushing's triad
three classic signs—bradycardia, hypertension, and bradypnea—seen with pressure on the medulla as a result of brain stem herniation
A turning frame
used to change the client's position without altering the alignment of the spine
A cast and a cervical collar
used to immobilize the injured portion of the spine
Risk Factors for SCI
• Young age • Alcohol use • Drug abuse