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