Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Timby/Smith: Introductory Medical-Surgical Nursing, 11/e Chapter 39: Caring for Clients With Head and Spinal Cord Trauma

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Concussion Pathophysiology and Etiology –Blow to the head that jars the brain –Temporary neurologic impairment Assessment Findings –Brief lapse of consciousness; disorientation –Headache; blurred or double vision –Emotional irritability; dizziness Diagnostic Findings: skull radiography, CT scan, MRI

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Concussion—(cont.) Medical Management –Temporary inactivity –Mild analgesia –Observation for neurologic complications Nursing Management –Neurologic assessment –Close observation: signs of increased ICP –Client instruction: contact physician, return to ED if symptoms of increased ICP occur

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusion Pathophysiology and Etiology –Coup and contrecoup injury –Cerebral edema Assessment Findings –Hypotension; rapid, weak pulse; shallow respirations; pale, clammy skin –Temporary amnesia –Effects of permanent brain damage Diagnostic Findings: skull radiography, CT scan, MRI

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Contusion assessment findings include hypertension; rapid, weak pulse; shallow respirations; and pale, clammy skin.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: Contusion includes hypotension; rapid, weak pulse; shallow respirations; and pale, clammy skin.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Contusion—(cont.) Medical Management –Drug therapy; mechanical ventilation Nursing Management –Periodically monitor LOC, neurologic changes, respiratory distress, Signs of increased ICP, vital signs –Head injury prevention Seatbelts, infant car seats, protective headgear, neck restraints, no alcohol or drugs while driving

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? Concussion is a blow to the head that jars the brain.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer True Rationale: Concussion is a blow to the head that jars the brain and is a temporary neurologic impairment.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chronic Traumatic Encephalopathy Repetitive concussions Sports related Long-term effects: dementia, depression, Parkinson’s disease, and early onset Alzheimer’s

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cerebral Hematomas Pathophysiology and Etiology –Head trauma –Cerebral vascular disorders –Types: epidural, subdural, intracerebral Assessment Findings –Location dependent, bleeding rate, hematoma size, autoregulation Diagnostic Findings: MRI, CT scan, ICP monitoring

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cerebral Hematomas ㄧ (cont.) Medical Management –Indications of surgical emergency: rapid change in LOC; signs of uncontrolled increased ICP Surgical Management –Burr holes –Intracranial surgery: craniotomy, craniectomy, and cranioplasty –Surgical Approaches Supratentorial Infratentorial

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cerebral Hematomas—(cont.) Nursing Management –All head injuries are emergencies. –Nurse’s role History, neurologic examination, vital signs, LOC Limb movement; pupil reactions –Trauma Head examination; respiratory status Neurologic changes

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Cerebral Hematomas—(cont.) Nursing Management—(cont.) –Preoperative Nursing Care Hair removal, vital signs, neurologic assessment; antiembolism stockings Restrict fluids –Postoperative Nursing Care Supine or side-lying position Regular monitoring; observe for increased ICP Control thrombus or embolus; cerebral edema

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Skull Fractures Pathophysiology and Etiology –Head injuries: open, closed –Skull fractures: simple, depressed, comminuted Assessment Findings: signs and symptoms Localized headache; bump, bruise, or laceration; hemiparesis; shock Rhinorrhea, otorrhea Periorbital ecchymosis, Battle’s sign Conjunctival hemorrhages, seizures

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Skull Fractures—(cont.) Diagnostic Findings: skull radiographs, CT scan, MRI Medical and Surgical Management –Simple fracture: bed rest; observation for increased ICP –Lacerated scalp: clean, débride, and suture –Depressed skull fracture Craniotomy, antibiotics Osmotic diuretics, anticonvulsants

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Skull Fractures—(cont.) Nursing Management –Signs of head trauma –Drainage from the nose or ear –Halo sign –Neurologic assessments Hourly: LOC; pupil, motor, and sensory status Every 15 to 30 minutes: vital signs Prepare for the possibility of seizures.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Cord Injuries Pathophysiology and Etiology –Accidents (vehicular), violence –Spinal shock (areflexia): poikilothermia –Autonomic dysreflexia (hyperreflexia) Assessment Findings –Pain, difficulty breathing, numbness, paralysis –Neurologic examination Diagnostic Findings –Radiography, myelography, MRI, CT scan

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Cord Injuries—(cont.) Medical Management –Cervical collar, cast or brace, traction, turning frame –IV, vital sign stabilization, corticosteroids –Surgical intervention Surgical Management –Bone fragment removal –Dislocated vertebrae repair –Spine stabilization

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process Assessment –Injury; treatment at scene –Neurologic assessment: document findings –Vital signs; respiratory status –Movement, sensation below injury level –Signs Worsening neurologic damage Respiratory distress Spinal shock

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Nursing Process—(cont.) Diagnosis, Planning, and Interventions –Ineffective Breathing Pattern; Ineffective Airway Clearance –Neuropathic pain –Impaired physical mobility –Anxiety –Risks: Impaired Gas Exchange; Disuse Syndrome; Ineffective Coping Evaluation of expected outcomes

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Nerve Root Compression Pathophysiology and Etiology –Trauma –Herniated intervertebral disks –Tumors of the spinal cord Assessment Findings: weakness, paralysis, pain, paresthesia Diagnostic Findings: spinal radiography, CT, MRI, myelography, electromyography

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Nerve Root Compression—(cont.) Medical Management –Cervical collar or brace; bed rest; skin traction; hot, moist packs –Skeletal muscle relaxants, drug therapy, corticosteroids, analgesics Surgical Management –Diskectomy –Laminectomy –Spinal fusion –Chemonucleolysis

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Nerve Root Compression—(cont.) Nursing Management –Neurologic examination –Conservative therapy Spinal support and alignment; bed rest in semi-Fowler’s position; tractions Proper body mechanics Muscle relaxants and analgesics; moist heat application Evaluation of client response to therapy

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Spinal Nerve Root Compression—(cont.) Postsurgical Nursing Management –Monitor vital signs –Hourly deep breathing exercises –Examine the dressing for CSF leakage or bleeding –Assess neurovascular status –Voiding status –Fracture bed pan

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Postoperatively, how often should deep-breathing exercises be done for a patient who had surgery for a spinal cord injury? A) Hourly B) Every 2 hours C) Every 3 hours D) Every 4 hours

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer A) Hourly Rationale: Postoperatively, deep-breathing exercises be done hourly for a patient who had surgery for a spinal cord injury.