NEURO - Unit 2. The Patient with Neurological Trauma

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1 NEURO - Unit 2 The Patient with Neurological Trauma

2 Student Learning Goals Differentiate among common head traumas and explain: concussion, contusion, epidural hematoma, subdural hematoma, intracerebral hemorrhage and penetrating injuries. Describe nursing care for the patient with a head injury. Discuss brain tumors, symptoms and treatment. Explain the physical effects of spinal cord injuries. Identify one result of injury to each division of the spine. Describe the medical and surgical treatment during the acute phase of spinal cord injury. List the data to be included in the nursing assessment of the patient with a spinal cord injury. Describe spinal shock. Discuss the symptoms, cause and nursing care for the patient experiencing autonomic dysreflexia. Describe nursing care for the patient with spinal cord injury.

3 Head Injury: Types Scalp injuries Concussion Contusion Hematoma Intracerebral hemorrhage Penetrating injuries

4 May see: Lacerations of scalp Contusions of scalp Abrasions of scalp Hematomas of scalp May bleed profusely Scalp Injuries May or may not be associated with skull or brain injuries

5 CONCUSSION Trauma with no visible injury to the skull or brain Brief loss of consciousness (< 5 min.) May have Headache Amnesia about event N & V No permanent damage Recurrent injury can be a problem

6 CONTUSION Bruising and bleeding in the brain tissue More serious than concussion Risk with contusion is Edema & increased bleeding Why is this a problem?

7 A collection of blood 2 classifications: Subdural HEMATOMA Usually venous bleeding and slow forming Blood collects below the dura Epidural Usually arterial bleeding and rapid forming Blood collects above the dura

9 Subdural Hematoma 3 types Acute Within 24 hours Subacute More than 24 hours, less than one week Chronic Weeks to months

10 Epidural Hematoma Generally bleeding due to tear in middle meningeal artery Initially unconscious, then lucid briefly, then unconscious as pressure increases May see rapid increase in ICP Why?

11 Intracerebral Hemorrhage From lesions within the tissue of the brain itself What else do we call this? Can result from head trauma as well Penetrating Injuries Sharp objects penetrate the skull and brain tissue See: Brain Injury Wound contamination

12 Head Injury Surgical treatment Directed at evacuating hematomas and débriding damaged tissue

13 Head Injury: Nursing Care Nursing Diagnosis & Interventions Ineffective Tissue Perfusion - Cerebral Ineffective Breathing Pattern Risk for Injury Risk for Infection Impaired Physical Mobility Disturbed Body Image and Ineffective Role Performance

14 NURSING CARE Neuro checks Note sx. of ICP Fluid management Bedrest Quiet environment HOB Low - mid fowlers Nursing care that decreases ICP Avoid neck/hip flexion Limit suctioning Spacing of nursing care

15 ?Critical Thinking Questions? How does increased ICP affect respirations? Why would the patient lose consciousness when the ICP goes up?

16 Critical Thinking Question An 18-year-old man was admitted to the emergency department as a result of a motor vehicle accident. He appeared alert and was talking clearly to his parents in between x-ray examinations and laboratory tests. He had a moderate laceration on his forehead, which was sutured. As the nurse was applying a dressing, she noticed that his pupils were unequal. What should the nurse do next? What diagnosis may be likely?

17 General info Brain Tumors Some are primary tumors Some are metastatic Not all malignant Benign tumors can be a problem Why? Cause and risk factors Causes generally unknown Some congenital; others may be related to heredity Drug/environmental factors may play a role in development

18 Brain Tumors Signs and symptoms Directly related to area of brain invaded by the tumor Visual disturbances and headache New-onset seizure activity Difficulties with balance and coordination Medical treatment Surgery often followed by radiation with or without chemotherapy

19 Brain Tumors: Nursing Care Nursing Diagnosis/Nursing Interventions Acute Pain Disturbed Thought Processes Disturbed Sensory Perception Impaired Physical Mobility and Self-Care Deficit Ineffective Coping

20 Chapter 29 Spinal Cord Injury

22 BACKGROUND ASSESSMENT How is a diagnosis of incomplete spinal cord injury determined? What are possible psychosocial effects of a complete spinal cord injury?

23 Diagnostic Tests and Procedures Neurologic examination Initial evaluation provides the nurse with a baseline assessment of function and problems Ongoing assessment: To monitor the effects of neurologic injury To detect related complications To determine patient s need for assistance in activities of daily living Focuses on the motor and sensory systems Movement, muscle strength, reflex activiry

24 Diagnostic Tests and Procedures Imaging studies Radiography Detects vertebral compression, fractures, or problems with alignment Computed tomography (CT) Noninvasive examination of the specific levels of the spinal cord to be visualized, bony vertebrae, and the spinal nerves Magnetic resonance imaging (MRI) Produces precise, clear images of internal structures Myelogram Visualizes the spinal cord and vertebrae

25 Spinal Cord Injury (SCI) Head and neck permit movement in various directions Because the thoracic vertebrae is not flexible, the neck and cervical spine are vulnerable to injury

26 Spinal Cord Injuries may be classified: By Location/Level of Cord affected Cervical Thoracic Lumbar As Open or Closed By extent of damage to the cord Complete transection Incomplete transection

27 Effects of Spinal Cord Injury (SCI) Factors include extent of cut and level of injury Sometimes cannot be fully determined initially symptoms of spinal cord edema may mimic partial or complete transection With incomplete spinal cord injuries some function remains below the level of the injury Specific tracts may be involved, causing particular patterns of neurologic dysfunction

28 Patterns of Injury and Neurological Dysfunction

29 Effects of Spinal Cord Injury The higher the level of injury, the more encompassing the neurologic dysfunction Quadriplegia High cervical spine injuries; loss of motor and sensory function in all four extremities Paraplegia Injuries at or below T2 may cause paralysis of the lower part of the body

30 Respiratory Impairment Injuries at or above the level of C5 Called High Cervical May result in instant death Often die before reach hospital Ventilator dependent Cervical injuries below the level of C4 spare the diaphragm can involve impairment of intercostal and abdominal muscles

31 Degree of Functional Loss with Level of SCI See Table 29-3 Key is Respiratory Muscles involvement? Diaphragm vs. intercostals affected Where does full use of arms begin? What about lower extremities?

36 Spinal Shock An immediate, transient response to injury May appear as early as minutes May persist days, weeks, months Reflex activity below the level of the injury temporarily ceases

37 Symptoms Spinal Shock Below level of injury Immediate flaccid paralysis Loss of all sensation Loss of reflex activity Loss of autonomic function As it resolves see spastic involuntary movements Tx: General support of body systems

38 Autonomic Dysreflexia One of most serious and potentially dangerous complications of SCI Exaggerated response of autonomic nervous system to noxious (painful) stimuli Occurs with injury at or above the level of T6 As Spinal Shock resolves Risk for Autonomic Dysreflexia increases

39 Autonomic Dysreflexia What happens? Excessive stimulation of sensory receptors below the level of the injury precipitates autonomic dysreflexia. The sympathetic nervous system is stimulated, but an appropriate parasympathetic modulation response cannot be elicited because of the spinal cord injury that separates the two divisions of the autonomic nervous system

40 Autonomic Dysreflexia Sympathetic stim > Arterioles constrict: Leads to severe hypertension Can lead to seizure or stroke Regulatory vasodilation Only takes place above level of injury Sweating, flushing, nasal congestion, pounding headache Hypertension > vagal stim Bradycardia Vagal stim would dilate but cannot below level of SCI

41 Autonomic Dysreflexia Triggers Triggered by various stimuli distended bladder Constipation/fecal impaction renal calculi ejaculation uterine contractions may be caused by pressure sores, skin rash, enemas, or even sudden position changes

42 Autonomic Dysreflexia Nursing Care: Prevention: Avoid bladder distention How? Avoid bowel distention How? Topical Anesthetic agents for pressure sores Emergent Situation Raise HOB; sit patient up > lowers BP Relief of cause

43 Spasticity Most SCI pts. experience this Muscle spasms may be incapacitating can hamper efforts at rehabilitation Hyperactive reflexes accompany Generally see gradual reduction in 1 2 years Meds can help what type?

44 Impaired Sensory and Motor Function Impaired motor function can affect: mobility self-care And increases risk for complications r/t immobility Loss of sensation puts patient at risk for skin breakdown other injuries because pressure and pain are not perceived

45 Impaired Bladder Function During spinal shock all bladder and bowel function ceases Indwelling cath > intermittent cath Once spinal shock resolves, reflex activity returns May see spastic bladder Bladder retraining individualized

46 Impaired Bowel Function Initially may need gastric decompression Usually peristalsis returns w/i 3 days Most SCI pts can maintain bowel function the large bowel musculature has its own neural center that responds to distention by the fecal mass Bowel retraining programs For regular evacuation

47 Impaired Temperature Regulations May lose these regulatory mechanisms What regulatory mechanisms? May be unable to adapt to temperature extremes Especially tetraplegics Why?

48 Impaired Sexual Function Spinal levels S2, S3, and S4 control sexual function Injury at or above these levels results in sexual dysfunction Ability to achieve erection and ejaculation is variable Women resumes normal menses

49 Impaired Skin Integrity Pressure ulcers common r/t Immobility Loss of Sensation Locations most vulnerable??? Portals for infection Interrupt rehab efforts and wheelchair training Complete SCI interrupts vasomotor tone of the vascular system results in vasodilation and pooling of blood in the periphery; impedes perfusion of the skin; and encourages the development of pressure sores

50 Altered Self-Concept and Body Image SCI has tremendous impact Every aspect of life can be affected Timing of information impt. Prevent from overwhelming Often met with shock, disbelief and denial Take suicidal threats seriously Facilitate independence and control

51 OH NO!! Mr Studinski, 20 YO, was canoeing with several friends when they Came across a rope swing along the river. Mr Studinski failed To check the depth of the water before swinging himself high Over the river bed and diving into the water. The water level was 6. The pt comes to us with a c6 spinal cord injury and an epidural Hematoma. He is unconscious at this time. Dr. Spinalson is the md. Vitals: 142/75, 98, 98.5, 20. No home meds. Lab work: HGB 12.4, BUN 16, HCT 1.0, PT 12.4, NA 128, K 3.8. Currently in room With distraught family. MD waiting on CT results and will devise Course of treatment. NS running at 50ml/hr. No other meds ordered At this time. Diet NPO. Activity Bedrest. NKA.

52 Medical Treatment in the Acute Phase

53 Goals in Acute Phase Save patient s life Prevent further injury Preserve function

54 Saving the Patient s Life Establish Airway Use Jaw-thrust method of opening the airway Conventional head-tilt chin-lift: inappropriate with spinal injury; increases risk of cord damage Neck flexion avoided even that caused by a pillow or other support, must be avoided

55 Saving the Patient s Life Once airway is open administer 100% oxygen by mask and manual resuscitator Placement of endotracheal or tracheostomy tube allows direct access to the airway and facilitates optimal oxygenation Any injury that compromises ventilation must be treated immediately

56 Preventing Further Cord Injury Traction Immobilization with skeletal traction Gardner-Wells tongs Secured just above the ears; doesn t actually penetrate skull Crutchfield tongs Halo vest Applied directly to the skull just behind the hairline immobilizes and aligns cervical vertebrae usually placed during surgery that is done to internally stabilize fractures and relieve the compression of nerve roots Allows mobility OOB or Ambulatory

59 Preventing Further Cord Injury Special beds and cushions Kinetic bed, such as the Roto Rest bed, continually rotates the patient from side to side Overlay air mattresses: flotation devices placed on standard hospital beds Air-fluidized and flotation beds may be used after the spine has been stabilized Stryker wedge frame: canvas and metal frame bed that may be used to help turn the patient Types of cushions include those inflated with air, flotation devices, and gel pads

61 Preventing Further Cord Injury Drug therapy Methylprednisolone Reduces the damage to the cellular membrane Administered within the first 8 hours of injury Completely paralyzed patients often regain about 20% of function Partially paralyzed have regained up to 75% of function

62 Preserving Cord Function Early surgical intervention to repair cord damage Cord compression by bony fragments, compound vertebral fractures, and gunshot and stab wounds Surgery within the first 24 hours is most desirable Laminectomy Involves removing all or part of the posterior arch of the vertebra Alleviates cord compression/nerve root compression Spinal fusion If multiple vertebrae are involved Placing a piece of donor bone into area between the involved vertebrae

63 Nursing Care in Acute Phase Monitor respiratory status level of consciousness pupils motor and sensory function vital signs intake and output

64 Nursing Care in Acute Phase Obtain Health History Present Illness Past Medical Hx. Review of Systems S&S related to neuro dysfunction Functional Assessment Physical Exam

65 Functional Assessment Patient s self-care abilities Patient s roles and responsibilities as a family member Occupation, hobbies, usual activity pattern, habits, and diet Emotional response to the spinal injury Usual coping strategies Spiritual beliefs; other sources of support

66 Physical Examination Record the patient s reported height and weight Take vital signs Be alert for Spinal Shock Level of responsiveness, posture, and spontaneous movements Examine pupils for size, equality, reaction to light Respiratory effort and breath sounds

67 Physical Examination Inspect the skin for lacerations, bruises, pressure ulcers Inspect abdomen; auscultate for bowel sounds Inspect extremities for open fractures or abnormal positions Range of motion Ability to perceive sharp and dull sensation use a dermatome chart

69 Nursing Diagnosis/Interventions Ineffective Breathing Pattern Risk for Injury and Disturbed Sensory Perception Risk for Autonomic Dysreflexia Risk for Disuse Syndrome Bowel Incontinence Impaired Urinary Elimination

70 Nursing Diagnosis/Interventions Risk for Infection Ineffective Thermoregulation Feeding/Dressing/Grooming Self-Care Deficit Sexual Dysfunction Ineffective Coping Ineffective Therapeutic Regimen Management

71 Rehabilitation Activities that assist individual to achieve highest possible level of self-care and independence Begins on admission During Acute Phase Focus on preventing further disability and avoiding complications The interdisciplinary team addresses all aspects of function Physician, nurse, physical therapist, occupational therapist, speech therapist, dietitian, social worker, psychologist, and counselor Patient and family must be emotionally and physically prepared to make adjustments

72 CRITICAL THINKING QUESTION A nurse working the night shift on a medical-surgical unit looks up from the nurses station to see a patient walking toward the elevator. Evidently, the patient removed the traction device being used to treat his high cervical (C2, C3) fractures sustained in a fall off a porch. The Gardner-Wells tongs are still attached to his skull. He insists he is leaving to go get a drink. What should the nurse do?

Spinal Cord Injury Transection Injury, Spinal Shock, and Hermiated Disc. Copyright 2014, 2011, 2006 by Saunders, an imprint of Elsevier, Inc.

Spinal Cord Injury Transection Injury, Spinal Shock, and Hermiated Disc 1 Spinal Cord Injury Results from fracture and/or dislocation of vertebrae // Compresses, stretches, or tears spinal cord Cervical