9 Spinal Cord Injury  Sci [2]
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9 Spinal Cord Injury  Sci [2] 9 Spinal Cord Injury Sci [2] Presentation Transcript

  • Spinal Cord Injury (SCI) and Intracranial Disorders
  • Background
    • 1. Usually due to trauma
    • 2. Most common in the 16 – 30 age group
  • Causes
    • 1. Motor vehicle accidents
    • 2. Falls, violence, sport injuries (diving)
  • Physical Description
    • Concussion, contusion, laceration, transection, hemorrhage, damage to blood vessels supplying spinal cord.
    • Fractured vertebrae damage cord
    • Injuries are identified by vertebral level
  • Risk Factors
    • 1. Age
    • a. Youth (take risks)
    • b. Older adults (age-related vertebral degeneration)
    • 2. Gender: males more than females
    • 3. Alcohol or drug use
  • Pathophysiology
    • Primary injury causes microscopic hemorrhages in gray matter of cord and edema of white matter of cord
    • Microcirculation of cord is impaired by edema and hemorrhage; further impaired by vasospasm
  • Pathophysiology
    • Necrosis of gray and white matter occurs and function of nerves through injured area is lost
    • Acceleration and deceleration as occurs in motor vehicle accidents and falls and is most common cause of abnormal spinal column movements
  • Pathophysiology
    • Other causes include penetration by bullets or foreign objects
  • Sites of Pathology: Most common areas of involvement
    • 1. Cervical (C1, C2, C4 - C6)
    • 2. T11 to L2
  • Classifications
    • Completeness
    • Complete SCI: motor and sensory neural pathways are completely transected resulting in total loss of motor and sensory function below level of injury
    • Incomplete SCI: motor and sensory neural pathways are only partially interrupted resulting with variable loss of function below level of injury function below level of injury
  • Classifications
    • Cause of injury: specific as to trauma
    • Level of injury: area of spinal cord affected
  • Manifestations
    • General
    • Depend upon degree and level spinal cord is injured
    • Affects every body system
  • Manifestations
    • Spinal Shock
    • Temporary loss of reflex function (areflexia) below level of injury beginning immediately after complete transection of spinal cord
  • Manifestations
    • 1. Bradycardia and hypotension
    • 2. Flaccid paralysis of skeletal muscles distal to injury
    • 3. Loss of all sensation of distal to injury
    • 4. Absence of visceral and somatic sensations
    • Bladder and bowel dysfunction
    • 6. Loss of ability to perspire
  • Manifestations
    • Spinal shock begins within hour of injury and lasts from few minutes up to several months; ends with return of reflex activity: hyperreflexia, muscle spasticity, reflex bladder emptying
  • Manifestations
    • Client with cervical cord injuries may have persistent cardiovascular changes after spinal shock resolves
    • Orthostatic hypotension, bradycardia
    • Decreased peripheral resistance and loss of muscle tone leading to sluggish circulation and decreased venous return
    • Client at risk for thrombophlebitis
  • Manifestations
    • Motor Neuron Involvement
    • Upper motor neuron involvement includes spastic paralysis, hyperreflexia, inability to carry out skilled movement
    • Lower motor neuron involvement: flaccid muscle and extensive muscle atrophy, loss of voluntary and involuntary movement
    • Partial motor neuron movement: partial paralysis
    • All motor neurons affected: complete paralysis
    • Client may be treated with antispasmodics such as baclofen (Lioresal) or diazepam (Valium)
  • Manifestations
    • Paraplegia
    • Paralysis of lower portion of body involving injury to thoracic, lumbar, or sacral portion of spinal cord
    • Impairment of sensory and/or motor function
  • Manifestations
    • Tetraplegia (formerly quadriplegia)
    • Injuries affecting the cervical segments of cord
    • Impairment of upper extremities as well
  • Manifestations
    • Autonomic Dysreflexia (autonomic hyperreflexia)
    • Exaggerated sympathetic response occurring in clients with cord injuries at T6 or higher and after resolution of spinal shock
    • Because of lack of control of autonomic nervous system by higher centers, a stimuli such as full bladder results in mass reflex stimulation of sympathetic nerves below level of injury
  • Manifestations
    • Client develops bradycardia and severe HPT, flushed, warm skin with profuse sweating above the lesion and dry skin below and anxiety; if sustained could result in stroke, myocardial infarction or seizures
    • Stimuli include
    • Abdominal discomfort: full bladder
    • Stimulation of pain receptors: pressure ulcers
    • Visceral contractions: fecal impaction
  • Collaborative Care
      • Prompt intervention is required
        • Elevate client’s head and remove any support hose: this will immediately decrease the blood pressure since client has orthostatic hypotension
        • Monitor blood pressure while assessing for causative factor: relief of full bladder, impacted stool, skin pressure
  • Collaborative Care
      • If there is a history of autonomic dysreflexia, client may be able to warn of occurrence
      • Notification of physician and administration of medication to lower blood pressure
  • Collaborative Care
    • Care must start at scene of injury to reduce injury, preserve function
    • Rapid assessment of ABC (airway, breathing, circulation)
    • Immobilize and stabilize head and neck
    • Use cervical collar before moving onto backboard
    • Secure head and maintain client in supine position
  • Collaborative Care
    • Care with all transfers not to complicate original injury
    • Fractures at C1 – C4 levels result in respiratory paralysis but advances in trauma care allow clients to survive (will require ventilator assistance)
    • Address other injuries that may necessitate immediate care
  • Collaborative Care
    • Care in emergency department.
    • Assessment of level of injury
    • Manifestations of injury at cervical level
    • Paralysis or weakness of all extremities
    • Respiratory distress
    • Pulse < 60; blood pressure < 80
    • Decreased peristalsis
  • Collaborative Care
    • Manifestations of injury at thoracic or lumbar level: Paralysis or weakness of lower extremities
  • Collaborative Care
    • Findings indicative of spinal shock
    • Loss of skin sensation
    • Areflexia, flaccid paralysis
    • Absent bowel sounds
    • Bladder distention
    • Decreasing blood pressure
    • Loss of cremasteric reflex in male
  • Collaborative Care
    • Interventions
    • Address respiratory status
    • Oxygen administration
    • Ventilator support to those in distress
    • Continuous monitoring of cardiovascular status
  • Collaborative Care
    • Monitor fluid status and prevent bladder overdistention; insert indwelling urinary catheter
    • Paralytic ileus: insertion of nasogastric tube and connect to suction
    • Administration of high-dose corticosteroid to prevent secondary cord damage from edema and ischemia (within 8 hours of injury and continued for 23 hours)
  • Diagnostic Tests
    • Xrays of cervical spine to establish level and extent of vertebral injury
    • T scan and MRI: changes in vertebrae, spinal cord, tissues around cord
    • Arterial blood gases to establish baseline
  • Medications
    • Corticosteroids
    • Vasopressors to treat bradycardia and hypotension
    • Histamine H2 antagonists to prevent stress ulcers
    • Anticoagulation if not contraindicated
  • Treatments
    • Surgery may be indicated early, if there is evidence of spinal cord compression by bone fragments or hematoma; surgeries include decompression laminectomy, spinal fusion, insertion of metal rods
  • Treatments
    • Stabilization and Immunization
    • Application of traction (Gardner-Wells tongs)
    • External fixation (halo external fixation device): allows for greater mobility, self care, participation in rehabilitation program
  • Health Promotion
    • Education regarding prevention of injuries including use of seat belts
  • Nursing Diagnoses
    • Impaired Physical Mobility
    • Intervention to maintain joint mobility, prevent contractures
    • Maintain skin integrity; use of special beds
    • Prevention of deep venous thrombosis
  • Nursing Diagnoses
    • Impaired Gas Exchange
    • Ventilator support often indicated in cervical injuries
    • T1- T7 injuries impair intercostal muscles
    • Assist client to cough by splinting lower chest region
  • Nursing Diagnoses
    • Ineffective Breathing Pattern
    • Dysreflexia
    • Altered Urinary Elimination and Constipation
    • Long-term client usually requires intermittent catheterization procedure
    • Use of stool softeners and bowel training program
  • Nursing Diagnoses
    • Sexual Dysfunction
    • Males have different abilities to have erections depending on injuries (reflexogenic or psychogenic)
    • Females usually do not have sensation but pregnancy is possible
    • Discuss client concern, referral for counseling
  • Nursing Diagnoses
    • Low Self-esteem
    • Client has sustained threat to body image, self-esteem, role performance
    • Promotion of self-care, independent decision making
  • Home Care
    • Client moves from intensive care, intermediate care to rehabilitation to home care
    • Client needs continued support home health agency, physical therapy, support groups for client and family
  • Client with Herniated Intervertebral Disk
  • Definition
    • Rupture of cartilage surrounding intevertebral disk with protrusion of nucleus pulposus
    • Occurs more often as persons enter middle age and affects males more than females
    • Site most commonly affected: L4, L5, S1; if herniated disk occurs in cervical region C6, C7are affected
  • Pathophysiology
    • Protrusion occurs spontaneously or as result of trauma; pressure on adjacent spinal nerves causes manifestations
    • Abrupt herniation causes intense pain and muscle spasms
    • Gradual herniation occurs with degenerative changes, osteoarthritis and develops as slow onset of pain and neurologic deficits
  • Manifestations
    • Herniated disk in lumbar disk
    • Recurrent episodes of pain in lower back with radiation across buttock
    • Sciatica: lumbar pain following sciatic nerve down posterior leg
    • Motor deficits: weakness, difficulties with sexual function and urinary elimination
    • Sensory deficits: paresthesia and numbness
  • Manifestations
    • Herniated disk in cervical area
    • Pain in shoulder, arm, neck
    • Paresthesias, muscle spasms
  • Diagnostic Tests
    • Xray: lumbosacral and cervical area to identify deformities and narrowing of disk spaces
    • CT scan and MRI
    • Myelography: used to rule out tumors
    • Electromyography (EMG): measures electrical activity of skeletal muscles at rest; identification of muscles affected by pressure of herniated disk
  • Medications
    • Management of pain with analgesics, NSAIDs
    • Management of muscle spasms with muscle relaxants
  • Treatment
    • Conservative treatment is utilized for 2 – 6 weeks
    • Decrease activity level
    • Avoid flexion of spine
    • Adequate support (corset, cervical collar)
    • Firm mattress
    • Prescribed exercise program
    • Take analgesics, NSAIDs, muscle relaxants
    • TENS units
  • Treatment
    • Surgery (may be combination of different procedures
    • Laminectomy: removal of part of vertebral lamina to relieve pressure on nerve
    • Diskectomy: removal of nucleus pulposus of intervertbral disk;
    • Microdiskectomy: use of microscopic procedure through very small incision
    • Spinal fusion: insertion of wedge-shaped piece of bone or bone chips between vertebrae to stabilize them; results in limited movement
  • Nursing Care
    • Emphasis on prevention: proper body mechanics, proper lifting techniques
  • Nursing Diagnoses
    • Acute Pain
    • Chronic Pain
    • Constipation
  • Home Care
    • Adequate pain control to enable client to be able to participate in ADL
    • Utilization of nonpharmacological methods
  • Client with spinal cord tumor
  • Definition
    • Tumors may be benign or malignant, primary or metastatic
    • Occur most often in thoracic area; also cervical and lumbarsacral areas
    • Affect clients in age group 20 – 60
  • Classifications
    • Intramedullary tumors arise from tissues of spinal cord
    • Extramedullary tumors develop from tissues outside spinal cord
  • Pathophysiology
    • As tumors grow neural deficits result from further compression, invasion, or ischemia, secondary to vascular obstruction
  • Manifestations
    • Depend on area of tumor and anatomic level of involvement
    • Pain
    • Locally at site of tumor
    • Radicular pain: involving nerve that is compressed
  • Manifestations
    • Motor deficits: paresis, paralysis, hyperactive reflexes
    • Sensory deficits
    • Changes in bowel and bladder elimination, sexual function
  • Diagnostic Tests
    • Flat plate xray of spine
    • CT scan, MRI :site of cord compression
    • Myelogram: clarify area of tumor involvement
    • Lumbar puncture: CSF when tumors are present is often xanthochromic (yellow in color)
  • Medications
    • Analgesics and NSAIDs to control pain
    • Steroids (dexamethasome (Decadron): to decrease tumor size and inflammation
  • Treatment
    • Surgery: procedures include microsurgery, laser surgery for excision; then laminectomy and fusion to stabilize spine
    • Radiation therapy: used to treat metastatic tumors reduce pain, stop progression of neurologic deficits
  • Nursing Care: similar in aspects to care of client with SCI
    • similar in aspects to care of client with SCI
  • Altered Cerebral Function occurs with illness and injury
  • Brain Function Deterioration
    • Follows a predictable rostral to caudal progression
    • Higher levels of function progress to more primitive function
  • Altered Level of Consciousness (LOC)
    • Consciousness
    • Condition in which person is aware of self and environment and able to respond to stimuli appropriately
    • Requires
    • -Arousal: alertness; dependent upon reticular activating system (RAS); system of neurons in thalamus and upper brain stem
  • Altered Level of Consciousness (LOC)
    • Cognition: complex process involving all mental activities; controlled by cerebral hemispheres
    • Components depend on normal physiologic function and connection between 2 systems
  • Altered Level of Consciousness (LOC)
    • Pathophysiology
    • Lesions or injuries affecting cerebral hemisphere directly or that compress or destroy neurons in RAS
    • Metabolic disorders
  • Altered Level of Consciousness (LOC)
    • Arousal affected by
    • Destruction of RAS: stroke, demyelinating diseases
    • Compression of brain stem producing edema and ischemia: tumors, increased intracranial pressure, hematomas or hemorrhage, aneurysm
    • Cerebral hemisphere function depends on continuous supply or oxygen and glucose
    • -Most common impairment caused by global ischemia, hypoglycemia
    • -Localized masses: hematoma, cerebral edema
  • Altered Level of Consciousness (LOC)
    • Processes within brain that destroy or compress structures affect LOC:
    • Increased intracranial pressure
    • Stroke, hematoma, intracranial hemorrhage
    • Tumors
    • Infections
    • Demyelinating disorders
  • Altered Level of Consciousness (LOC)
    • Systemic conditions affecting brain function
    • Hypoglycemia
    • Fluid and electrolyte imbalances
    • -Hyponatremia
    • -Hyperosmolality
    • -Acid-base alterations: hypercapnia
    • -Accumulated waste products from liver or renal failure
    • -Drugs affecting CNS: alcohol, analgesics, anesthetics
    • Seizure activity: exhausts energy metabolites
  • Altered Level of Consciousness (LOC)
    • Client assessment results with decreasing LOC
    • Increased stimulation required to elicit response from client
    • More difficult to rouse; client agitated and confused when awakened
    • Orientation changes: loses orientation to time first; then place; finally person
    • Continuous stimulation required to maintain wakefulness
    • Client has no response, even to painful stimuli
  • Patterns of breathing
    • As respiratory center are affected: predictable changes in breathing patterns
    • Types of respirations and brain involvement
    • Diencephalon: Cheyne-Stokes respirations (as with acidosis)
    • Midbrain: neurogenic hyperventilation; may exceed 40/minute; due to uninhibited stimulation of respiratory centers
    • Pons: apneustic respirations: sighing on mid inspiration or prolonged inhalation and exhalation; excessive stimulation of respiratory centers
    • Medulla:ataxic/apneic respirations (totally uncoordinated and irregular); loss of response to CO2
  • Pupillary and oculomotor responses: Predictable progression
    • Localized lesion effects ipsilateral pupil (same side as lesion)
    • Generalized or systemic processes pupils affected equally
    • Compression of cranial nerve III at midbrain, pupils become oval and eccentric (off center); progress to pupils become fixed (no response to light); progress to dilation
  • Pupillary and oculomotor responses: Predictable progression
    • With deteriorating LOC, spontaneous eye movement is lost and reflexive ocular movements are altered
    • Loss of simultaneous eye movement
  • Pupillary and oculomotor responses: Predictable progression
    • Loss of normal reflex functioning:
    • Doll’s eye movements: eye movement in opposite direction of head rotation (normal function of brain stem)
    • Oculocephalic reflex: eyes move upward with passive flexion of neck; downward with passive neck extension (normal function)
    • Oculovestibular response (cold caloric testing): instillation of cold water in ear canal cause nystagmus (lateral tonic deviation of eyes) toward stimulus (normal function)
  • Motor Function
    • Predictable progression
    • Assessment of level of brain dysfunction and side of brain affected
    • Client follows verbal commands
    • Pushes away purposely from noxious stimulus
    • Movements are more generalized and less purposeful (withdrawal, grimacing)
    • Reflexive motor responses:
    • -Decorticate movement: flexion of upper extremities accompanied by extension of lower extremities
    • -Decerebrate posturing: adduction and rigid extension of upper and lower extremities
    • Flaccid with little or no motor response
  • Coma States
    • Outcome of altered LOC
    • Comas range from full recovery, without any residual effects, to persistent vegetative state (cerebral death) or brain death
  • Coma States
    • Stages
    • Irreversible coma (vegetative state)
    • -Permanent condition of complete unawareness of self and environment; death of cerebral hemispheres with continued function of brain stem and cerebellum
    • -Client does not respond meaningfully to environment but has sleep-wake cycles and retains ability to chew, swallow, and cough
    • -Eyes may wander but cannot track object
    • -Minimally conscious state: client aware of environment, can follow simple commands, indicate yes/no responses; make meaningful movements (blink, smile)
    • -Often results from severe head injury or global anoxia
  • Coma States
    • Locked-in syndrome
    • Client is alert and fully aware of environment; intact cognitive abilities but unable to communicate through speech or movement because of blocked efferent pathways from brain
    • Motor paralysis but cranial nerves may be intact allowing client to communicate through eye movement and blinking
    • Occurs with hemorrhage or infarction of pons; disorders of lower motor neurons or muscles (polyneuritis, myasthenia gravis, amyotrophic lateral sclerosis (ALS)
  • Coma States
    • Brain death
    • Cessation and irreversibility of all brain functions
    • General criteria
    • -Absent motor and reflex movements
    • -Apnea
    • -Fixed and dilated pupils
    • -No ocular responses to head turning and caloric stimulation
    • -Flat EEG
  • Prognosis
    • Outcome varies according to underlying cause and pathologic process
    • Young adults can recover from deep coma
    • Recovery within 2 weeks associated with favorable outcome
  • Collaborative Care
    • Management includes identifying cause, preserve function and prevent deterioration
    • Involves total system maintenance in many cases
  • Diagnostic Tests
    • Blood glucose: cerebral function declines rapidly when < 40 – 50 mg/dL
    • Serum electrolytes: hyponatremia: coma and convulsions when Na < 115 mEq/L
    • ABG: hypoxemia frequent cause of altered LOC; increased levels CO 2 especially if acute
    • BUN and creatinine: renal function
    • Liver function tests: tests determine liver function; high ammonia levels interfere with cerebral metabolism
    • Toxicology screening of blood and urine (acute drug or alcohol)
  • Diagnostic Tests
    • CBC: anemia or infectious cause of coma
    • CT, MRI: identification of neurologic damage
    • EEG: evaluate electrical activity of brain, unrecognized seizure activity
    • Radioisotope brain scan: identify abnormal brain lesions
    • Cerebral angiography: visualization of cerebral vascular system including aneurysms, occluded vessels, tumors
    • Transcranial Doppler: assess cerebral blood flow
    • Lumbar puncture: CSF to assess infection, possible meningitis
  • Medications
    • IV fluids normal saline, lactated Ringer’s
    • Specific medications to address specific problems
    • 50% glucose: hypoglycemia
    • Naloxone for narcotic overdose
    • Thiamine:Wernicke’s encephalopathy
    • Regulation of osmolality with diuretics
    • Antibiotics: infections
  • Surgery
    • May be indicated if cause of coma is tumor, hemorrhage, hematoma
  • Other Measures (as indicated)
    • 1. Airway support and mechanical ventilation if indicated; controlled hyperventilation to promote vasoconstriction to reduce cerebral edema
    • 2. Maintenance of nutritional status with enteral feedings
  • Nursing Diagnoses
    • Ineffective Airway Clearance: limit suctioning to < 10 – 15 seconds; hyperoxygenate before
    • Risk for Aspiration
    • Risk for Impaired Skin Integrity: preventative measures, continual inspection
  • Nursing Diagnoses
    • Impaired Physical Mobility: maintain functionality of joints, physical therapy
    • Risk for Imbalanced Nutrition: Less than body requirements
    • Anxiety (of family)
    • -Extremely stressful time
    • -Reinforce information from physician
    • -Encourage to speak with client who is in coma
  • Increased Intracranial Pressure
  • Intracranial Pressure (ICP)
    • Pressure within cranial cavity measured within lateral ventricles
    • Transient increases occur with normal activities coughing, sneezing, straining, bending forward
  • Intracranial Pressure (ICP)
    • Sustained increases associated with
    • Cerebral edema
    • Head trauma
    • Tumors
    • Abscesses
    • Stroke
    • Inflammation
    • Hemorrhage
  • Monro-Lellie hypothesis
    • Within skull there are 3 components that maintain state of dynamic equilibrium
    • Brain (80%)
    • Cerebrospinal fluid (10%)
    • Blood (10%)
    • If volume of any one increases the volume of others must decrease to maintain normal pressure
  • Normal intracranial pressure
    • 5 – 15 mm Hg, with pressure transducer with head elevated 30 degrees
    • 60 – 180 cm water, water manometer with client lateral recumbent
  • Background regarding regulation of ICP
    • Cerebral blood flow and perfusion account for twice the amount of increase as CSF does
    • Cerebral blood vessels respond to changes in arterial oxygen and carbon dioxide
    • Cerebral perfusion pressure (CPP) is pressure needed to perfuse brain cells
    • -Difference between mean arterial pressure (MAP) and ICP
    • -Normal pressure is 80 – 100 Hg; to maintain blood flow CPP must be 50 mm Hg
  • Background regarding regulation of ICP
    • Autoregulation: compensatory mechanisms in which cerebral arterioles change diameter to maintain cerebral blood flow when ICP increases
    • Pressure autoregulation: receptors within small vessels respond to changes in arterial pressure
    • -Vasodilation: in response to elevated blood pressure
    • -Vasoconstriction: in response to low blood pressure
    • Chemical (metabolic) autoregulation
    • -Vasodilation: carbon dioxide, increased hydrogen ion concentration, low oxygen
    • -Vasoconstriction: fall in carbon dioxide
  • Background regarding regulation of ICP
    • There is limited ability of brain to respond to ICP; ability for autoregulation is severely limited
  • Increased ICP
    • Increased ICP must be recognized early when interventions can be instituted to stop its progress
    • Medical emergency requiring intensive nursing care
  • Increased ICP
    • Manifestations
    • Changes in LOC: initially behavior and personality changes and progresses in predictable pattern to coma and responsiveness
    • Pressure affects motor functioning: initially hemiparesis on contralateral side and if not effectively treated progresses to decorticate and decerebrate positioning
    • Altered vision (blurred vision, diplopia, decreased acuity) pupillary response (gradual dilation, sluggish response)
  • Increased ICP
    • Headache on rising; common with slowly developing increased ICP
    • Papilledema noted on fundoscopic exam
    • Projectile vomiting
    • CNS ischemic response: occurs late in course of increased ICP; Cushing‘s response (triad): increased MAP, increased pulse pressure, bradycardia
    • Changes in respiratory pattern and dramatic rise in temperature
  • Increased ICP
    • Causes
    • Space occupying lesions
    • Cerebral edema: increase in volume of brain tissue due to abnormal accumulation of fluid; local process or affecting entire brain
    • Hydrocephalus: increase in volume of CSF within ventricular system, which becomes dilated
    • -Noncommunicating: obstruction in CSF drainage from ventricular system
  • Increased ICP
    • -Communicating: CSF is not effectively reabsorbed through arachnoid villi
    • -Normal pressure hydrocephalus: occurs in persons > 60 in which ventricles enlarge causing cerebral tissue compression
    • -Manifestations depend on rate of onset: progressive cognitive dysfunction, gait disruptions, urinary incontinence
    • Intracranial hemorrhage
  • Brain herniation
    • Cerebral tissue can be displaced to more compliant area, if ICP is not treated
    • Displacement of brain tissue results in further increased ICP and brain damage including lethal brain damage
  • Brain herniation
    • Brain herniation syndromes are categorized according to location
    • Cingulate herniation
    • Central or transtentorial herniation
    • Uncal or latral transtentorial herniation
    • Infratentorial herniation
  • Collaborative Care
    • Identify and treat underlying condition
    • Control ICP to prevent herniation syndromes
  • Diagnostic Tests
    • Diagnosis is made on observation and neurological assessment
    • Measures to control pressure are instituted while identifying underlying cause
  • Diagnostic Tests
    • Tests for underlying cause
    • CT scan and MRI: identify possible cause and evaluate therapeutic options
    • Serum osmolality: used as indicator of hydration status; usually maintained slightly elevated to draw excess fluid into vascular system from brain tissue
    • Arterial blood gases: monitor pH, CO2, pO2 levels and effect on cerebral circulation; hydrogen ions and carbon dioxide are potent vasodilators; hypoxemia also causes vasodilation but to lesser degree
  • Medications
    • Diuretics
    • Osmotic diuretics increase osmolarity of blood and draw fluid from edematous brain tissue into vascular bed where it can be eliminated by kidneys
    • Mannitol is commonly used
    • Loop diuretics such as furosemide are used, in addition, to further promote diuresis
    • Serum electrolytes and osmolality are monitored
    • Urine specific gravity may also be monitored at intervals
  • Medications
    • Antipyretics or hypothermia blanket: used to control hyperthermia, which increases cerebral metabolic rate
    • Anticonvulsants to manage seizure activity
    • Histamine H2 receptors to decrease risk of stress ulcers
    • Barbiturates: may be given as continuous infusion to induce coma and decrease metabolic demands of injured brain; controversial
    • Vasoactive medications may be given to maintain blood pressure to support cerebral perfusion
  • Surgery
    • May be indicated to treat underlying cause of increased ICP
    • Include removal of brain tumors, burr holes, insertion of drainage catheter or shunt to drain excessive CSF
  • ICP Monitoring
    • Continuous intracranial pressure monitor is used for continual assessment of ICP and to monitor effects of medical therapy and nursing interventions
    • Allows for more precise manipulation of therapeutic measures to maintain adequate cerebral perfusion while controlling ICP
    • Systems include intraventricular catheter, subarachnoid bolt or screw and epidural catheters; can be used to drain CSF and measure ICP
    • Risk for infection exists with invasive procedure
  • Mechanical Ventilation:
    • Involves airway management and prevention of hypoxemia and hypercapnia , which both increase intracranial pressure
  • Nursing Care
    • Protect client from sudden increases in ICP and decrease in cerebral blood flow
    • Clients are often critically ill and are in special neurological intensive care unit for constant observation and continuous treatment
  • Nursing Diagnoses
    • Ineffective Tissue Perfusion: Cerebral
    • Frequent neurologic assessment based on client baseline and changing status
    • Early signs are LOC and breathing patterns
    • Measures in place to limit increases in intracranial pressure; limit stimulation
  • Nursing Diagnoses
    • Risk for Infection: open head wounds and intracranial monitoring device require meticulous aseptic technique
    • Anxiety (of family): need for teaching to maintain restful environment, emotional support
  • Client with a Headache
  • Pain within cranial vault and occuring commonly
    • May be due to benign or pathological condition
    • Majority are mild
  • Pathophysiology
    • Multiple pain-sensitive structures within cranial vault, face, and scalp
  • Types of Headaches
    • Tension
    • Most common
    • Characterized by sensation of tightness around head and may have specific localized painful areas
    • Caused by sustained contraction of muscles of head and neck
    • Precipitated by stress and anxiety
  • Types of Headaches
    • Migraine
    • Recurring vascular headache often initiated by triggering event and accompanied by neurologic dysfunction
    • More common in females between ages 25 -55
    • Cause not understood but related to abnormalities in cerebrovascular blood flow, reduction in brain activity, or increase release of sensory substances (e.g. serotonin)
  • Types of Headaches
    • Stages include
    • -Aura: visual disturbances; lasts 5 – 60 minutes
    • -Headache: throbbing pain often with nausea and vomiting; hypersensitive to light and sound; lasts hours to 1– 2 days
    • -Postheadache: area of headache is sensitive; client exhausted
    • Triggers include stress, fluctuating glucose levels, fatigue, hormones, bright lights
  • Types of Headaches
    • Cluster
    • Common with middle-aged men
    • Typically awakens client with unilateral pain around eye accompanied by rhinorrhea, lacrimation, flushing
    • Attacks occur in clusters of 1 – 8 days for weeks
  • Collaborative Care
    • identification of underlying cause and therapeutic management
  • Diagnostic Tests
    • may involve neurodiagnostic testing depending on client history and assessment
  • Medications: According to type of headache
    • Migraine headache may require prophylactic therapy including serotonin antagonist or beta blocker
    • Management of migraine may include
    • Ergotamine tartrate (Cafergot)
    • Sumatriptan (Imitrex)
    • Zolmitriptan (Zomig)
    • Narcotic analgesic and anti-emetics
  • Medications: According to type of headache
    • Cluster headaches are often treated with same medications as migraines
    • Tension headaches are treated with aspirin, acetaminophen
  • Complementary Therapies
    • Supplements
    • Relaxation techniques
    • Herbal therapy
    • Osteopathic manipulation
  • Nursing Care
    • Teach client to manage discomfort effectively, identify any triggers (headache diary), stress management
    • Use of medications, and effective use of heat and cold
  • Client with Seizure Disorder
  • Seizures:
    • paroxysmal motor, sensory, or cognitive manifestations of spontaneous abnormal discharges from neurons in cerebral cortex
    • May involve all or part of brain: consciousness, autonomic function, motor function, and sensation
    • Epilepsy: any disorder characterized by recurrent seizures
    • Affects 2.3 million Americans; increased incidence in children and elderly
  • Cause
    • may be idiopathic or associated with birth injuries, infection, vascular abnormalities, trauma, tumors
    • Theories propose causes related to altered permeability of ions, neuron excitability, imbalances of neurotransmitters
    • When seizure threshold exceeded, a seizure may result; neurons that initiate seizure activity are called epileptogenic focus
    • Unprovoked seizures have no known cause; provoked seizure are related to another condition such as fever, rapid withdrawal from alcohol, electrolyte imbalance, brain pathology
  • Affects of seizure on brain tissue
    • Increased metabolic demand: fourfold requirement of additional glucose and oxygen, resulting in increased cerebral blood flow
    • If unmet, cellular destruction can result
  • Categorization of seizures
    • Partial seizures: activation of part of one cerebral hemisphere
    • Simple partial seizure: no altered consciousness; recurrent muscle contraction; motor portion of cortex affected
    • Complex partial seizure: impaired consciousness; may engage in automatisms (repetitive nonpurposeful activity such as lip smacking); preceded by aura, originates in temporal lobe
  • Categorization of seizures
    • Generalized seizures: involves both brain hemispheres; consciousness always impaired
    • Absence seizures (petit mal): characterized by sudden brief cessation of all motor activity, blank stare and unresponsiveness often with eye fluttering
    • Tonic-clonic seizures
    • -Most common type in adults
    • -Preceded by aura, sudden loss of consciousness
    • -Tonic phase: rigid muscles, incontinence
    • -Clonic phase: altered contraction, relaxation; eyes roll back, froths at mouth
    • -Postictal phase: unconscious and unresponsive to stimuli
  • Status epilepticus
    • Continuous seizure activity, generally tonic-clonic type
    • Client at risk to develop hypoxia, acidosis, hypoglycemia, hyperthermia, exhaustion
  • Status epilepticus
    • Life threatening medical emergency requiring immediate treatment
    • Establish and maintain airway
    • Diazepam (Valium) and lorazepam (Ativan) intravenously at 10-minute intervals
    • 50% Dextose intravenously
    • Phenytoin (Dilantin) intravenously
    • Possibly Phenobarbital
  • Collaborative Care
    • Control seizure
    • Establish cause
    • Prevent further seizures
  • Diagnostic Tests
    • Neurologic exam
    • EEG to confirm diagnosis and locate lesion
    • Xray, MRI, CT scan identify any neurologic abnormalities
    • Lumbar puncture may be done if infection suspected
    • CBC, electrolytes, BUN, blood glucose
    • ECG to determine cardiac dysrhythmias
  • Medications
    • Anticonvulsants
    • Manage but do not cure seizure
    • Actions
    • -Raise seizure threshold
    • -Limit spread of abnormal activity within brain
    • Try to use lowest dose of single medication to control seizures if possible; may need to try different medications and use combinations
  • Medications
    • Medications
    • Carbamazepine (Tegretol)
    • Phenytoin (Dilantin)
    • Valproic acid (Depakote)
    • Tiagabine (Gabitril)
  • Surgery: if all attempts to control seizures are not successful
    • May attempt to excise tissue involved in seizure activity
    • EEG done during surgery to identify epileptogenic focus
  • Care of client during a seizure
    • Protect client from injury and maintain airway
    • Do not force anything into client’s mouth
    • Loosen clothing around neck
  • Health Promotion: Stress the following to clients
    • Importance of medical follow-up, taking prescribed medications
    • Driving privileges are prohibited in clients with seizure disorders; driver’s licenses are reinstated after seizure free period and statement from health care practitioner
    • Client needs proper identification
    • Family members need to be educated in preventing injury if seizure occurs
  • Nursing Diagnoses
    • Risk for Ineffective Airway Clearance
    • Anxiety
  • Home Care
    • Education of client and family regarding seizure disorder; safety measures, avoidance of alcohol and caffeine
    • Referral to support group, national organizations
  • Client with traumatic brain injury
  • Traumatic brain injury:
    • a leading cause of death and disability; any traumatic insult to brain causing physical, intellectual, emotional, social, or vocational changes
    • Includes penetrating head injury (open) and closed head injury
    • Estimates of 1 million persons are treated and released with head injuries yearly in USA
  • Traumatic brain injury:
    • Risk Factors
    • Motor vehicle accidents
    • Elevated blood alcohol levels
    • Greatest risk: males aged 15 – 30 and those over 75
  • Mechanisms of trauma
    • Acceleration injury: head struck by moving object
    • Deceleration injury: head hits stationary object
    • Acceleration-deceleration (coup-contrecoup phenomenon): head hits object and brain rebounds within skull
    • Deformation: force deforms and disrupts body integrity: skull fracture
  • Types of injuries
    • Skull fracture: break in continuity of skull usually resulting in brain trauma
    • Classifications
    • Linear: dura remains intact; subdural or epidural hematoma may occur underneath
    • Comminuted and depressed skull fractures: increase risk for direct injury to brain tissue from contusion (bruise) and bone fragments; risk for infection
  • Types of injuries
    • Basilar:
    • -Involves base of skull and usually involve extension of adjacent fractures
    • -If dura disrupted may have leakage of CSF occurring as
    • -Rhinorrhea: through nose
    • -Otorrhea: through ear
  • Types of injuries
    • May appear on xray; signs of basilar skull fracture
    • Hemotypanum: blood behind tympanic membrane
    • Battle’s sign: blood over mastoid process
    • “ Raccoon eyes”: bilateral periorbital ecchymosis
  • Types of injuries
    • Test clear fluid from ear or nose for glucose by using glucose reagent strip: if positive indicates CSF
    • CSF leakage: increased risk of infection
    • Keep nasopharnyx and external ear clean
    • No blowing nose, coughing or hard sneezing
    • Prophylactic antibiotic
  • Collaborative Care
    • All require minimal bed rest and observation of underlying injury
    • Depressed skull fractures require surgical intervention to debride wound and remove bone fragments embedded in brain tissue
    • Basilar fractures with CSF leakage may require surgery
  • Nursing Care/Home Care
    • Client must be monitored for signs of increased intracranial pressure
    • Observe in hospital
    • Educate family regarding changes in LOC: wake up every 2 hours during first 24 hours home
    • Follow–up care
  • Client with focal or diffuse brain injury
  • Primary and secondary mechanism occur with brain injury
    • Primary: impact of injury
    • Progression of initial injury affecting perfusion and oxygenation of brain cells: intracranial edema, hematoma, infection, hypoxia, ischemia
  • Focal brain injuries
    • Specific observable brain lesion confined to one area of brain; includes epidural hemorrhage, subdural and intracerebral hematoma
    • Depending on site and rate of bleeding, manifestations may occur within hours to weeks
    • Client may develop increased ICP with altered level of consciousness and potential for brain herniation
  • Specific types of brain injuries
    • Contusion: bruise of surface of brain; manifestations and degree of impairment depend on size and location of injury; slow recovery of consciousness
  • Specific types of brain injuries
    • Epidural hematoma (extradural hematoma): blood collects in potential space between dura and skull
    • Occurs more often in young to middle aged adults
    • Occurs with skull fracture from torn artery, tend to occur rapidly
    • May have brief lucid period after injury and then rapid decline from drowsiness to coma with neurological deficits
    • Require rapid treatment to prevent complications
  • Specific types of brain injuries
    • Subdural hematoma
    • Localized mass of blood collects between dura mater and arachnoid mater
    • More common than epidural hematoma
    • Types
    • -Acute subdural hematomas develop within 48 hours of injury
    • -Chronic subdural hematomas develop over weeks to months
    • Manifestations of neurologic deficits develop at the same rate of the hematomas
  • Specific types of brain injuries
    • Intracerebral hematomas: occur more often in older clients because cerebral blood vessels are more fragile and easily torn
    • Diffuse brain injury (DBI): affects entire brain and is caused by shaking motion with twisting movement
  • Specific types of brain injuries
    • Mild concussion
    • Momentary interruption of brain function with or without loss of consciousness
    • Manifestations:
    • Retrograde and antegrade amnesia
    • Headache
    • Drowsiness, confusion, dizziness
    • Visual disturbances
  • Specific types of brain injuries
    • Classic cerebral concussion
    • Diffuse cerebral disconnection from brain stem RAS
    • Has manifestations as with mild concussion but immediate period of loss of consciousness is less than 6 hours; client may have exhibited seizure and respiratory arrest with bradycardia and hypotension
    • May have postconcussion syndrome
    • Diffuse axonal injury: high speed acceleration-deceleration injury causing widespread disruption of axons in white matter; Poor prognosis: death or persistent vegetative state
  • Treatment
    • Concussion
    • Client should be observed for 1 – 2 hours in emergency department
    • Discharged home with instruction for observations, if loss of consciousness only a few minutes
    • Longer period of unconsciousness, admit to hospital for observation
  • Treatment
    • Acute TBI
    • Recognition and management begins at scene with transport to emergency department
    • Hospitalization with critical care and specific neurologic observation and interventions as indicated
  • Diagnostic Tests:
    • same tests as increased ICP
  • Treatments
    • Management of increased ICP
    • Surgery: epidural and subdural hematomas; surgical evacuation of clot through burr holes
  • Health Promotion:
    • Injury prevention: use of seat belts, bicycle and motorcycle helmets, gun safety
  • Client CNS infection
  • CNS infections
    • Most common is bacterial meningitis
    • Mortality rate 25% in adults
    • Meningococcal occurs in epidemics with people living in close contact
    • Pneumococcal effects very young and very old
  • Risk Factors
    • High risk for old and young
    • High risk for clients with debilitating diseases, or immunosuppressed
  • Pathophysiology
    • Pathogens enter CNS and meninges causing inflammatory process, which leads to inflammation and increased ICP
    • May result in brain damage and life-threatening complications
  • Meningitis
    • Inflammation of pia mater, arachnoid, and subarachnoid space
    • Spreads rapidly through CNS because of circulation of CSF around brain and spinal cord
    • May be bacterial, viral, fungal, parasitic in origin
    • Infection enters CNS though invasive procedure or through bloodstream, secondary to another infection in body
  • Bacterial meningitis
    • Causative organisms: Neisseria meningitis , meningoccus, Streptococcus pneumoniae , Haemophilus influenzae , E. Coli
    • Risk factors: head trauma with basilar skull fracture, otitis media, sinusitis, immunocompromised, neurosurgery, systemic sepsis
  • Bacterial meningitis
    • Manifestations
    • Fever chills
    • Headache, back and abdominal pain
    • Nausea and vomiting
    • Meningeal irritation: nuchal rigidity, positive Brudzinski’s sign, Kernig’s sign, photophobia
    • Meningococcal meningitis: rapidly spreading petechial rash of skin and mucous membranes
    • Increased ICP: decreased LOC, papilledema
  • Bacterial meningitis
    • Complications
    • Arthritis
    • Cranial nerve damage (deafness)
    • Hydrocephalus
  • Viral meningitis
    • Less severe, benign course with short duration
    • Intense headache with malaise, nausea, vomiting, lethargy
    • Signs of meningeal irritation
  • Encephalitis
    • Acute inflammation of parenchyma of brain or spinal cord
    • Usually caused by virus
    • Inflammation occurs with manifestations similar to meningitis
    • LOC deteriorates and client may become comatose
    • Arboviruses are agents including West Nile virus
  • Brain abscess
    • Infection with a collection of purulent material within brain tissue usually in cerebrum
    • Causes include open trauma and neurosurgery; infections of ear, sinuses
    • Common pathogens are streptococci, staphylococci, bacteroids
    • Becomes space-occupying lesion
    • At risk for infection and increased ICP
  • Brain abscess
    • Manifestations
    • General symptoms associated with acute infectious process
    • Client develops seizures, altered LOC, signs of increased ICP
    • Specific neurologic symptoms are related to location
    • May be drained surgically, if considered feasible
  • Collaborative Care
    • Bacterial meningitis: requires immediate treatment and isolation of client
    • Viral meningitis: supportive treatment and management of client symptoms
    • Brain abscess treatment focuses on antibiotic therapy
  • Diagnostic Tests
    • Lumbar puncture: definitive test for bacterial meningitis demonstrating infection: turbid cloudy appearance, increased WBC, gram stain, culture
    • CT scan, MRI
  • Medications
    • Meningitis: immediate treatment with effective antibiotics for 7 – 21 days; according to culture results; dexamethasone to suppress inflammation
    • Encepahlitis: viral treated with anti-viral medications
    • Brain abscess: antibiotic therapy, which may include intraventricular administration; anticonvulsant medications, antipyretics
  • Health Promotion
    • Vaccinations for meningococcal, pneumococcal, hemophilic meningitis
    • Prophytlactic rifampin for persons exposed to meningococcal meningitis
    • Mosquito control
    • Prompt diagnosis and treatment of clients with infections
    • Asepsis care for clients with open head injury or neurosurgery
  • Nursing Diagnoses
    • Ineffective Protection
    • Risk for Deficient Fluid Volume
  • Home Care
    • Client education for future prevention
    • Complete medications and treatment plan
  • Client with a brain tumor
  • Description
    • Growths within cranium including tumors of brain tissue, meninges, pituitary gland, blood vessels
    • May be benign or malignant, primary or metastatic
    • May be lethal, due to location (inaccessible to treatment) and capacity to impinge on CNS structures
    • In adults most common tumor is glioblastoma followed by meningioma and cytoma
    • Cause is unknown: factor associated include heredity, cranial irradiation, exposure to some chemicals
  • Description
    • Tumors within brain
    • Compress or destroy brain tissue
    • Cause edema in adjacent tissues
    • Cause hemorrhage
    • Obstruct circulation of CSF, causing hydrocephalus
    • Estimated 25% persons with cancer develop brain metastasis, often multiple sites throughout the brain
  • Manifestations: Multiple depending on location of lesion and rate of growth
    • Changes in cognition and LOC
    • Headache usually worse in morning
    • Seizures
    • Vomiting
    • Manifestations associated with cerebral edema, increased ICP, cerebral ischemia leading to brain herniation syndromes
  • Collaborative Care
    • Effective treatment includes chemotherapy, radiation therapy, and/or surgery
    • Treatment depends on size and location of tumor, type of tumor, neurologic deficits, and client’s over all condition
  • Diagnostic Tests
    • CT scan or MRI: determine tumor location and extent
    • Arteriography
    • EEG: information about cerebral function, seizure data
    • Endocrine studies if pituitary tumor suspected
  • Treatment
    • Medications: Chemotherapy, corticosteroids, anticonvulsants
    • Surgery
    • Purposes include tumor excision, reduction, or for symptom relief
    • Craniotomy: location according to approach to tumor
    • Radiation: Alone or as adjunctive therapy
    • Specialty procedures: Stereotaxic techniques and use of laser beam
  • Nursing Care
    • Support during diagnosis and management through selected treatment
    • Nursing care involves interventions to deal with altered LOC, increased ICP, and seizures
  • Nursing Diagnoses
    • Anxiety
    • Risk for Infection
    • Ineffective Protection
    • Acute Pain
    • Disturbed Self-esteem
  • Home Care
    • Education, support to client and family
    • Instructions for treatment plan and follow-up care
    • Referral to home care agencies
    • Referrals to therapies, community resources, support groups as appropriate