2 Concept Map: Selected Topics in Neurological Nursing PATHOPHYSIOLOGYTraumatic Brain InjurySpinal Cord InjurySpecific Disease Entities:Amyotropic Lateral SclerosisMultiple SclerosisHuntington’s DiseaseAlzheimer’s DiseaseMyasthenia GravisGuillian-Barre’ SyndromeMeningitisParkinson’s DiseaseASSESSMENTPhysical AssessmentInspectionPalpationPercussionAuscultationICP Monitoring“Neuro Checks”Lab MonitoringPHARMACOLOGY--Decrease ICP--Disease Specific MedsCare PlanningPlan for client adl’s,Monitoring, med admin.,Patient education, more…basedOn Nursing Process:A_D_P_I_ENursing Interventions & EvaluationExecute the care plan, evaluate forEfficacy, revise as necessary
3 Objectives Recall anatomy and physiology of the brain & cranial nerves Explain pathophysiology of various brain (head) injuriesDetail signs, symptoms and prevention of Increased Intracranial Pressure (ICP)Demonstrate effective use of Glasgow Coma ScaleDiscuss medical & nursing management of brain injuries
4 Sometimes:The Lights are on….But nobody’s home….
11 Risk Factors Highest in young people and the elderly *Age 65 – 75 has highest incidence of HI of ALL age groups*Occurs twice as often among males compared with femalesMotor vehicle crashes account for the major proportion of head and brain injuries….and involve a disproportionately large number of young personsAlcohol intoxication is a compounding factor in at least 30% to 50% of head injuries and is a contributing factor in almost ½ of all fatal motor vehicle crashes in the United States
12 Laws that require helmet use have been shown to Did you Know ?Laws that require helmet use have been shown toreduce deathsin motorcyclistsby about 30%
13 “The second collision” Boxing:Coup-Contre CoupInjury :“The second collision”
33 History of Injury Loss of Consciousness? Other victims seriously hurt? Mechanism of injury?Driver / passenger / seatbelt ?Fall height / what caused fall?Hit where and with what?Gunshot / impaled object ?
35 DiagnosticsDamaged areas of the brain have a reduced or no blood flow or glucose metabolism. This can be seen in the images below where there has been a blow to the head by a rock
36 Skull FracturesPresent on CT scans in about two thirds of patients after head injurySkull fractures can be linear, depressed, or diastatic and may involve the cranial vault or skull base
37 Depressed Skull Fractures A portion of the skull is extending into the intracranial spaceOften results in pressure on the brain or direct injury to the brainIn addition, the bone fragment may cause a laceration of the dura mater resulting in a cerebrospinal fluid leakOutcome is based upon the underlying brain injury. If no brain injury is present the surgery represents a cosmetic procedure and the outcome is generally quite good
38 Frontal Lobe- associated with reasoning, planning, parts of speech, movement, emotions, and problem solvingParietal Lobe- associated with movement, orientation, recognition, perception of stimuliOccipital Lobe- associated with visual processingTemporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech
39 Basal Skull Fractures Clinical Clues may include: CSF leakage through the ear or nose (otorrhea or rhinorrhea)Hemotympanum (blood behind the eardrum)Bruising behind the ears (postauricular ecchymoses)“Battle Sign”Bruising around the eyes (periorbital ecchymoses)“Raccoon Eyes” “Panda Eyes”Injury to cranial nerves:VII Facial nerve - weakness of the faceVIII Acoustic nerve - loss of hearingI Olfactory nerve - loss of smellII Optic nerve - vision lossVI Abducens nerve - double vision
41 Basal Skull FracturesInvolve the floor of the skull and include fractures of the cribriform plate, frontal bones, sphenoid bones, temporal bone and occipital bones1 frontal 2 ethmoid 3 sphenoid 4 temporal 5 parietal 6 occipital
42 1. Frontal sinus 2. Crista galli 3. Cribriform plate 4 1. Frontal sinus 2. Crista galli 3. Cribriform plate 4. Lesser wing of sphenoid 5. Superior orbital fissure 6. Superior border of petrous part of temporal bone 7. Dense shadow of petrous part of temporal bone 8. Perpendicular plate of the ethmoid 9. Vomer 10. Maxillary sinus 11. Inferior concha 12. Ramus of mandible 13. Body of mandible
43 CSF LeakageRhinorrhea and otorrhea are clinical signs of cerebrospinal fluid (CSF) leakage in patients with skull fracturePresence of glucose (CSF) in otorrhea and rhinorrhea detected by Beta-2 transferrin. Nasal/ear discharge (glucostix) was traditionally used to diagnose CSF leak at the bedside, but has fallen into disuse as it has poor positive predictive valueCSF leakage opens the brain & spinal canal to infectionCSF is needed to cushion the brain, maintain pressure within the eye and cleanse the CNS (like the lymphatic system serves the same function in the rest of the body)
45 Prevent Infection !Cover any suspected source of CSF leakage with a Sterile Dressing STAT !
46 CSF InfectionNuchal RigidityCSF has WBCsIncreased Temperature
47 Basal Skull FracturesMost basal skull fractures do not require treatment and heal themselvesPersistent CSF leakage may warrant operative repair of the leakage, particularly CSF leaks related to frontal bone and cribiform plate fractures
48 Associated with Brain Injury Blood in the anterior chamber of the eye (hyphaema) as a complication of blunt trauma. Eyes with hyphaema may show other signs of damageBlood on Ocular Surface
49 Another Clue….Avulsed eye and lacerations to the forehead