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9 Spinal Cord Injury Sci [2]


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9 Spinal Cord Injury Sci [2]

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