3. Emergency Assessment
and
Nursing Care of Patients
with
Traumatic Brain Injury
and
Spinal Cord Injury
By:
Mr.Chandan Pradhan
Asso. Prof.
KALINGA INSTITUTE OF NURSING SCIENCES
KIIT DEEMED TO BE UNIVERSITY
4. Learning objectives of this session
• To learn about the emergency assessment of clients with traumatic
brain injury.
• To recognize the theoretical application of nursing care of clients with
traumatic brain injury.
• To know about the emergency assessment of clients with spinal cord
injury.
• To understand the art and science of nursing care of clients with
spinal cord injury.
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5. Traumatic Brain Injury
• Definition: A traumatic brain injury (TBI) can be caused by a forceful
bump, blow, or jolt to the head or body, or from an object that
pierces the skull and enters the brain.
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TBI is extremely heterogeneous, with short and long-term outcomes
affected by the specific intracranial injury, concomitant extracranial
injury, age, and pre-existing comorbidities.
6. MONROE KELLIE doctrine
It Dictates that “the
total volume of the
intracranial contents
must be remained
constant”
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10. Emergency Assessment of Traumatic Brain Injury
Assessment of individuals with TBI
requires collaboration with
the individual and their family members,
medical professionals, rehabilitation specialists,
and other professionals.
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11. Emergency Assessment of Traumatic Brain Injury
• Neurological assessment will judge motor and sensory skills and test
hearing and speech, coordination and balance, mental status, and
changes in mood or behavior.
• The Glasgow Coma Scale is the most widely used tool for assessing
the level of consciousness after TBI. GCS is directly proportional to
prognosis of TBI.
• ICP monitoring:Tissue swelling from a traumatic brain injury can
increase pressure inside the skull and cause additional damage to the
brain. Probe will be inserted through the skull to monitor this
pressure.
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13. Severity Scale
Classification of categories Glasgow Coma Scale and clinical characteristics
Mild GCS 13–15
Category 0 GCS 15, No LOC
Category 1 GCS = 15, LOC < 30 min, PTA < 1 h
Category 2 GCS = 15 and risk factors present
Category 3 GCS = 13–14, LOC < 30 min, PTA < 1 h, with or without risk factors
Moderate GCS = 9–12
Severe GCS ≤ 8
Critical GCS 3–4, unreactive pupils and absent/decorticate motor reactions
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14. Contd.
• Screening/diagnostic tools will help in medical evaluation for an
accurate medical diagnosis.
• CT creates a two-dimensional image of organs, bones, and tissues and
can show a skull fracture or any brain bruising, bleeding, or swelling.
Thus it’s the most common imaging technique used.
• MRI produces detailed images of brain tissue.
• Neuropsychological tests to assess brain functioning are often used
along with imaging techniques.
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15. Answers to the following questions will be
beneficial in judging the severity of injury:
• How did the injury occur?
• Did the person lose consciousness? (If Yes- How long?)
• Did you observe any other changes in alertness, speaking,
coordination or other signs of injury?
• Where was the head or other parts of the body struck?
• Can you provide any information about the force of the injury?
• Was the person's body whipped around or severely jarred?
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19. Nursing Management
• Prevention of secondary brain injury by optimizing cerebral
perfusion, early recognition of complications, and management of
multisystem problems.
• As a member of collaborative interdisciplinary approach a nurse has
both independent and interdependent roles.
• Evidence-based nursing practice, or best practice, should be
provided.
• Nursing measures to treat and prevent ICP elevation include proper
positioning, elevation of the head of bed at 30 degrees, and
prevention of jugular venous obstruction by keeping the head in a
midline position.
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20. Contd.
• The nurse must monitor the amount of CSF drainage closely.
• Hemodynamic stability of the client is an important role of nurse.
• Monitoring technology such as the cardiac monitor and the
maintenance of the pulmonary catheter in critically ill patients.
• Knowledge about critical parameters is important to recognize any
abnormalities.
• Maintaining a patent airway is also top priority in TBI management.
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21. Contd.
• Suction is needed to prevent an increase in carbon dioxide and
subsequent hypercapnia, which contributes to cerebral
vasodilatation, cerebral edema, and increased ICP.
• To assess the lungs for atelectasis, the nurse auscultates the chest for
breath sounds, making sure to listen to the entire chest, especially the
bases of the lungs.
• Nursing management should also be directed toward immediately
addressing nutritional needs and beginning feeding expeditiously.
• Bowel movement should be monitored and abnormalities such as
diarrhea and constipation
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22. Contd.
• Another important nursing intervention is early initiation of
rehabilitation therapies through referral to physical therapy,
occupational therapy, and speech language pathology, as indicated.
• Patient positioning, range of motion exercises, and coma stimulation
at the bedside may also be provided by the nurses.
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23. Spinal Cord Injury
• Definition: The term ‘spinal cord injury’ refers to damage to the spinal
cord resulting from trauma (e.g. a car crash) or from disease or
degeneration (e.g. cancer).
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24. Emergency Assessment of Spinal Cord Injury
Assessment of individuals with SCI
requires collaboration with
the individual and their family members,
medical professionals, rehabilitation specialists,
and other professionals.
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30. Assess the person for spinal injury, initially
taking into account the factors listed below:
• has any significant distracting injuries
• is under the influence of drugs or alcohol
• is confused or uncooperative
• has a reduced level of consciousness
• has any spinal pain
• has any hand or foot weakness (motor assessment)
• has altered or absent sensation in the hands or feet (sensory assessment)
• has any unconsciousness
• has a history of past spinal problems, including previous spinal surgery or
conditions that predispose to instability of the spine.
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31. Nursing Care of Clients with SCI
• Signs and Symptoms of Acute Spinal Cord Trauma: The higher the
level of injury, the greater will be the loss of motor, sensory, and
reflex function.
• Respiratory Insufficiency: Carefully assess the respiratory rate, chest
wall expansion, abdominal wall movement, cough, and chest wall for
respiratory compromise.
• Arterial blood gases and pulse oximetry are useful at the bedside to
monitor for hypoxia.
• Aggressive pulmonary care is essential
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33. Contd.
• Hemodynamic Instability:All SCI patients should be monitored with
telemetry for bradyarrhythmia’s.
• Orthostatic Hypotension: Orthostatic hypotension is defined as a
rapid drop in blood pressure when the vertical position is assumed.
• Regular BP checks is a must
• Use of a belly binder to help prevent abdominal pooling of blood; TED
hose, sequential compressive devices, and adequate hydration.
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34. Contd.
• Autonomic Dysfunction:A patient with a complete spinal cord injury
essentially takes on the temperature of their environment. Nursing
assessment takes this into account before concern for fever.
• Ascending Spinal Cord edema: With spinal cord trauma, edema
develops soon after injury as a physiologic response. Monitor the
highest sensory and motor level frequently in the first 72 hours and
document. Ascending edema can develop rapidly and result in
respiratory difficulty in patients with cervical SCIs.
• Pressure Ulcers: Mobilization, 2 hrly position changing, passive range
of motions, skin massage by nurses will help client
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35. Contd.
• Venous Thromboembolism Prophylaxis: To prevent DVT should be
prescribed.
• Pain:Pain after acute SCI is common and multifactorial. Medication to
treat neuropathic pain & diversional therapies are to be applied.
• Paralytic Ileus: Paralytic ileus is not only a sign of spinal shock
syndrome, but also can indicate intra-abdominal injury. Therefore diet
management is very important.
• Atonic Bladder: CIC has to be taught using health education for long
term management.
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36. Nursing Interventions
• Address respiratory status
• Oxygen administration
• Ventilator support to those in distress
• Continuous monitoring of cardiovascular status
• Monitor fluid status and prevent bladder over distention; 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)
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37. Contd.
• 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 is important
• Secure head and maintain client in supine position
• Care with all transfers not to complicate original injury
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39. References
• The Clinical Practice of Neurological & Neurosurgical Nursing by
Joanne.V.Hickey
• Linda S. Willams, Paula D.Hopper, Understanding Medical Surgical
Nursing,7th Edition,2020, F.A. Davis Company, Page No. 179-195.
• https://www.ninds.nih.gov/health-information/disorders/traumatic-
brain-injury-tbi#toc-what-is-a-traumatic-brain-injury-tbi-
• https://bestpractice.bmj.com/topics/en-gb/515
• https://www.sciencedirect.com/science/article/pii/S00070912173478
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