Neuro: Management of Patients with Neurologic Dysfunction

• Blood: Supplies the brain with oxygen and nutrients (glucose) and removes waste.

• CSF (cerebrospinal fluid): Cushions and protects the brain and spinal cord and maintains a stable environment.

• Blood-brain barrier (BBB): Controls which substances pass from the blood into brain tissue, helping protect the brain from harmful substances.

Clinical Assessment - LOC

• Arouse to wakefulness

  • Call name

  • Touch

  • Shake firmly

• Assess orientation

  • Person, place, time, situation

  • Behavior changes: restless, irritable, combative

Clinical Assessment - Noxious Stimuli

• Nail bed pressure: Apply pressure to the nail bed to assess the response to pain.

• Supraorbital pressure: Apply pressure above the eye at the supraorbital notch; avoid if facial injury is suspected.

• Trapezius squeeze: Squeeze the trapezius muscle to assess the response to pain.

• Sternal rub: Rub the sternum to assess the response; may cause bruising or skin injury.

Assess the response:

• Purposeful movement (localizes pain)

• Withdrawal from pain

• Abnormal flexion or extension (posturing)

• No response

Normal Pupils

Pupillary Changes

• Pupillary size:

  • Blown pupil: Fully dilated.

  • Pinpoint pupil: Very small, constricted.

• Pupillary reaction:

  • Sluggish: Reacts slowly to light.

  • Non-reactive: Does not respond to light.

• Unequal pupils: Pupils are different sizes.

• Irregular shape: Pupils are not round; may occur after cataract or other eye surgery.

• Medications:

  • Opioids → constrict pupils.

  • Anticholinergics → dilate pupils.

Pupillary Assessment

• Observe both pupils together and compare their size and reaction to light.

• Measure and document pupil size in millimeters (mm).

• The optic nerve is located at the back of each eye and carries visual information to the brain.

• When assessing eye opening in an unresponsive patient, use appropriate technique, such as pressure on the supraorbital ridge when indicated.

Disconjugate gaze:

Eyes point in different directions instead of moving together.

Oculocephalic reflex (Doll’s eyes):

• Rapidly turn the patient’s head side to side only if cervical spine injury has been ruled out.

• Normal: Eyes move opposite the direction of the head movement.

• Abnormal: Eyes move with the head or do not move as expected.

Oculovestibular reflex (cold caloric test):

• Instill cold water (e.g., 20 mL ice water, per protocol) into the ear to assess eye movements in an unresponsive patient.

• Normal: Eyes move toward the ear receiving cold water.

• Abnormal: No eye movement response.

Clinical Assessment - Motor

• Strength of muscles groups

• Bilateral hand grips, then release

• Strength/Movement of extremities

  • 5 – full strength, no deficit or weakness

  • 4 - holds up without wavering

  • 3 – holds up with wavering

  • 2 – slides along surface

  • 1 – flicker or trace of movement

  • 0 – no movement

Reflexes

• Primitive reflexes: Present at birth; may reappear with brain dysfunction. They are among the last reflexes to disappear with normal aging or neurological decline.

  • Examples: sucking, startle, and grasp reflexes.

• Corneal reflex (blink): Touch the cornea with a sterile swab or wisp of cotton; normal response is blinking.

• Gag reflex: Stimulation of the back of the throat causes gagging.

• Babinski reflex:

  • Normal adult: Toes curl downward.

  • Abnormal adult: Big toe moves upward and other toes fan out.

  • Infants: Upward big toe and fanning are normal.

• Deep tendon reflexes (DTRs): Assess reflex responses to tendon tapping, such as the knee-jerk reflex.

Decorticate Posturing

less severe

Decerebrate Posturing

Glasgow Coma Scale

• ≥13 mild injury

• 9-12 moderate

• ≤8 severe impairment

Eye Opening (E)	Verbal Response (V)	Motor Response (M)
4=Spontaneous 3=To voice 2=To pain 1=None	5=Normal conversation 4=Disoriented conversation 3=Words, but not coherent 2=No words......only sounds 1=None	6=Normal 5=Localizes to pain 4=Withdraws to pain 3=Decorticate posture 2=Decerebrate 1=None
		Total = E+V+M

Intracranial Pressure (ICP)

• Pressure inside the skull created by three components:

  • Brain tissue

  • Blood volume

  • Cerebrospinal fluid (CSF)

• Compensation (Monro-Kellie doctrine): If one component increases, the body compensates by reducing the volume of the others to maintain pressure.

  • Shifting CSF out of the skull.

  • Increasing CSF absorption.

  • Decreasing cerebral blood volume.

Intracranial Pressure (ICP) - Normal Range

10-20 mmHg

Cerebral Perfusion Pressure (CPP)

• Pressure that drives blood flow to the brain.

• CPP = MAP − ICP

Cerebral Perfusion Pressure (CPP) - Normal

70–100 mmHg

MAP (Mean Arterial Pressure):

• Average pressure in the arteries during one cardiac cycle.

• MAP = (SBP + 2 × DBP) ÷ 3

• SBP = systolic blood pressure; DBP = diastolic blood pressure.

CPP < 50 mmHg

• can cause inadequate brain perfusion and potentially irreversible neurological damage.

CPP > 100 mm Hg

• permanent ischemic injury

Example: Calculating MAP and CPP

Given:

• SBP = 120 mmHg

• DBP = 80 mmHg

• ICP = 15 mmHg

MAP = 93.3 mmHg; CPP = 78.3 mmHg.

Increased ICP: Signs & Symptoms Early

• Altered LOC

• Headache

• Restlessness/confusion

• Drowsiness

• Pupil changes

• Vomiting/projectile/possibly without nausea

  • Vomiting = ICP is going up

• Visual disturbances

• Increased respiratory effort

Increased ICP: Signs & Symptoms Late

• Stuporous/Unarousable

• Loss of reflexes

• Projectile vomiting

• Comatose

• Abnormal motor responses

  • Decorticate

  • Decerebrate

Increased ICP: Cushing’s Response

• The body's attempt to maintain cerebral perfusion when ICP rises.

  • Compensation: The body increases BP to try to maintain blood flow to the brain.

Increased ICP: Cushing’s Triad (Late Sign)

• Increased systolic BP with widened pulse pressure.

• Bradycardia: Decreased heart rate.

• Abnormal respirations: Slow, irregular breathing; may include Cheyne–Stokes respirations.

Increased ICP: Complications & Monitoring

• Widened pulse pressure: Increased difference between systolic and diastolic BP.

  • Example: 180/60 = 120 mmHg pulse pressure.

• Severe increased ICP: Can compress brain tissue, cause brain herniation, and lead to irreversible damage.

• Monitoring: Watch for changes in BP, heart rate, respirations, LOC, and pupils.

ICP Monitoring - Purpose:

• Identify increased ICP early.

• Directly measure pressure inside the skull.

• Drain and collect CSF for testing when appropriate.

ICP Monitoring - Types of ICP monitors:

• Ventriculostomy – lateral ventricle

• Subarachnoid bolt – subarachnoid space

• Epidural or subdural catheter

• Fiberoptic monitor – either

ICP Monitoring: ICP Waveforms

• A waves: Sustained pressure elevations; may indicate severely reduced intracranial compliance and impaired cerebral perfusion.

• B waves: Rhythmic ICP fluctuations that may be associated with increased ICP.

• C waves: Small, rapid ICP fluctuations related to changes in blood pressure and respirations.

Nursing Management of Increased ICP - Goals

• Decrease cerebral edema (brain swelling).

• Maintain cerebral perfusion pressure (CPP).

• Reduce CSF and intracranial blood volume.

• Early treatment improves outcomes.

Nursing Management of Increased ICP - Decrease cerebral edema:

• Mannitol (osmotic diuretic): Pulls fluid out of brain tissue to reduce swelling.

• Corticosteroids (dexamethasone): Reduce vasogenic edema, especially with brain tumors.

• Fluid restriction: Only as prescribed; avoid dehydration.

• Lower body temperature: Treat fever to reduce cerebral metabolic demand.

Nursing Management of Increased ICP - Maintain CPP:

Dobutamine: Increases cardiac contractility and cardiac output when indicated.

Nursing Management of Increased ICP - Mannitol — Nursing considerations:

• Administer IV as prescribed.

• Monitor BP, vital signs, fluid balance, electrolytes, kidney function, and urine output.

• Check for crystals; follow product instructions for warming and filtration before administration.

• Excreted by the kidneys.

Nursing Management of Increased ICP - Corticosteroids — Nursing considerations:

• Monitor blood glucose, weight, and fluid retention.

• Monitor temperature and signs of infection; steroids may mask infection.

• Monitor liver and kidney function as indicated

• Ex: methyprednisone, hydrocortisone, cortisone, hydrocortisone

Nursing Management of Increased ICP - Dobutamine — Nursing considerations:

• Monitor ECG, BP, heart rate, respiratory rate, and fluid balance.

• Avoid extravasation because it can cause tissue ischemia.

Nursing Management of Increased ICP - Control fever:

• Administer antipyretics (e.g., Tylenol/acetaminophen).

  • May be administered through an enteral feeding tube if prescribed and appropriate for the formulation.

  • Rectal suppositories may be used when appropriate.

  • Never give oral medication to an unconscious patient because of aspiration risk.

• Use a cooling blanket as prescribed.

• Prevent shivering because it increases metabolic demand and oxygen consumption.

Nursing Management of Increased ICP - Maintain oxygenation:

• Monitor ABGs, oxygen saturation, and hemoglobin.

• Monitor ventilator settings and respiratory status.

• Assess for bleeding at arterial blood gas (ABG) puncture sites.

Nursing Management of Increased ICP - Reduce metabolic demands:

• Barbiturates: Pentobarbital (Nembutal) may reduce cerebral metabolic activity in selected patients.

• Paralyzing agents: Vecuronium and pancuronium reduce muscle movement.

• Important:

  • paralyzing agent: can’t move/see, but don’t affect consciousness, pain perception, or hearing

  • Sedating agent: affect consciousness, pain perception, or hearing

  • Have to use both

Nursing Management of Increased ICP - Maintain head and neck alignment:

• Keep the head in a neutral position.

• Avoid neck flexion or rotation to promote venous drainage.

• When moving patients, use a cervical collar if indicated and log-roll while maintaining spinal alignment.

Nursing Management of Increased ICP - Monitor:

• BP, ECG, and vital signs.

• Intake and output (I/O).

• Blood glucose.

• IV site and intracranial catheter/bolt insertion site.

• Glasgow Coma Scale (GCS), pupils, and neurological status.

• ABGs and ventilator function.

Complications of Increased ICP

• Herniation

  • Brain tissue shifts due to increased pressure; can compress the brainstem and become life-threatening.

• Seizures

• Respiratory failure (respiratory drive/failure to maintain airway)

  • Damage to brain centers controlling breathing or inability to maintain the airway.

• Diabetes insipidus

  • lack of ADH

  • Polyuria

  • Polydipsia – craving for water, ice chips

  • dehydration

  • replace volume – IV fluids

  • replace hormone - Vasopressin

• SIADH syndrome of inappropriate antidiuretic hormone

  • too much ADH

  • oliguria

  • water intoxication 

  • cerebral edema

  • fluid restriction

• Fever

  • Increases metabolic demand and oxygen consumption.

ICP - Seizure Precautions: Nursing Implications

• Prepare the environment:

  • Keep the bed in a low position.

  • Pad side rails according to facility policy.

  • Remove sharp or hazardous objects.

  • Keep suction and oxygen equipment available.

• Identify triggers: Ask about flashing lights, stress, sleep deprivation, and seizure history.

• Monitor medications: Check therapeutic drug levels when indicated.

• Observe for auras: Recognize warning signs before a seizure when present.

During a Seizure

• Stay with the patient.

• Protect the head with a soft object.

• Loosen tight clothing around the neck.

• Turn the patient onto their side when possible to help maintain the airway.

• Time the seizure from beginning to end.

• Observe and document movements, responsiveness, and breathing.

• Do not restrain the patient.

• Do not put anything in the patient's mouth.

• Do not force the patient into a position during active convulsions.

After a Seizure (Postictal Care)

• Assess airway, breathing, and circulation (ABCs).

• Provide oxygen as needed and per protocol.

• Reorient the patient; confusion and sleepiness may occur.

• Allow the patient to rest and recover.

• Check neurological status and vital signs.

• Notify the healthcare provider according to the patient's condition and facility protocol.

• Document the seizure's duration, movements, responsiveness, interventions, and recovery.

• Monitor ABGs if clinically indicated.

Increase ICP: Related Nursing Diagnoses….

• Ineffective tissue perfusion

• Ineffective breathing pattern

• Ineffective airway clearance

• Risk for injury r/t LOC

• Ineffective thermoregulation

• Impaired elimination: bowel/urinary

• Interrupted family processes

• Risk for impaired tissue integrity

• Sensory deprivation/stimulation

Craniotomy

• Opening the skull to gain access to intracranial structures

• Purposes:

  • Remove a brain tumor.

  • Relieve elevated ICP.

  • Evacuate a blood clot (hematoma).

  • Control intracranial hemorrhage.

• Bone flap storage: If the brain is swollen, store the skull bone in the abdomen until it can be replaced.

Preoperative Management of Craniotomy

- Diagnostic tests

• CT: Detects fractures, bleeding, and blood clots.

• MRI: Provides detailed images of soft tissues; identifies brain tumors and other abnormalities.

• Endocrine studies: Assess pituitary gland function.

• PET scan: Shows metabolic activity when indicated.

- Prophylaxis

• Anticonvulsants: Prevent seizures when indicated.

• Corticosteroids: Reduce cerebral edema, especially tumor-related swelling.

• Antibiotics: Prevent infection when indicated, especially with contamination risk.

- Medications

• Anxiolytics (e.g., Valium): Reduce anxiety.

• Diuretics (e.g., IV mannitol, furosemide/Lasix): Reduce cerebral edema or ICP when prescribed.

- Imaging safety

• CT: Usually takes about 5–15 minutes.

• MRI: Often takes 30–60 minutes or longer.

• PET: Often takes 60–90 minutes.

• MRI: Screen for metal implants or foreign bodies and inform the MRI technologist.

Craniotomy: Family Education

• Pre-Op teaching

  • Deficits post-op

  • What will they see post-op?

    • Shaved head

    • Large head dressing

    • Facial swelling

    • Swollen eyes

  • Equipment

    • Ventilator/A-line

    • Urinary catheter

    • Ventriculostomy/burr holes

  • Communication

Craniotomy: Pre-Op Assessment

• Baseline Neuro Assessment

  • LOC

  • Responsiveness to stimuli

  • Paralysis

  • Vision

  • Speech

  • Bladder/Bowel Function

  • Motor Strength

  • Position is important – lay on non operative side and monitor operative site

Intracranial Surgery:

• Craniotomy – surgical opening in head

• Transphenoidal – through the nose

• Supratentorial – side of head

• Infratentorial – nape of skull

• Craniectomy – excision of portion of skull

• Cranioplasty – repair with plastic or metal

• Burr holes – holes made for exploration

Craniotomy: Postoperative Management

• Reduce cerebral edema: Administer prescribed medications and monitor neurological status.

• Monitor ICP: Use a ventricular catheter connected to a drainage system, if present.

• Observe for CSF leakage: Clear CSF drainage may form a halo sign on the pillow; report suspected leakage.

• Prevent seizures:

  • Administer anticonvulsants on time to maintain therapeutic levels.

  • Phenytoin (Dilantin): Therapeutic blood level is typically 10–20 mcg/mL.

  • Diazepam (Valium): Used for acute seizure control when indicated.

• Relieve pain and discomfort:

  • For transsphenoidal surgery, nasal packing may cause mouth breathing.

  • Provide frequent oral care to prevent dry mouth.

• Provide emotional support:

  • Support the patient and family.

  • Encourage coping and promote a positive self-image.

Craniotomy: Nursing Care and Monitoring

Respiratory, Neurological Status, and Vital Signs

• Monitor respiratory status and signs of respiratory infection to prevent cerebral ischemia.

• Assess level of consciousness, responsiveness, and Glasgow Coma Scale (GCS).

• Compare neurological status with preoperative baseline.

• Monitor vital signs and prevent fever using prescribed medications, ice packs, or hypothermia blanket.

• Perform frequent assessments.

• Shivering increases metabolic rate and oxygen consumption.

Positioning

• Turn every 2 hours using a draw sheet.

• Avoid extreme head rotation; maintain neutral neck alignment.

• Infratentorial: Side-lying, small firm pillow, log-roll, elevate head slowly as tolerated.

• Supratentorial: Back or non-operated side, one pillow, elevate HOB according to ICP and surgeon's preference.

Increased ICP and Other Complications

• Increased ICP signs: ↑ BP, ↓ pulse, respiratory failure.

• Bleeding under bone flap is life-threatening; watch for failure to awaken and new neurological deficits.

• Monitor fluids and electrolytes, especially with pituitary involvement.

• Watch for SIADH and DI.

• Corticosteroids and H2 blockers may be prescribed.

Infection, Seizures, and Edema

• Monitor temperature and signs of infection; administer prescribed antibiotics.

• Maintain seizure precautions and administer antiseizure medications as ordered.

• Periorbital edema: Apply cold compresses if permitted; report worsening swelling to the provider.

Later Complications

• DVT and pulmonary embolism (PE).

• Infection.

• Pressure ulcers.

Self-Care and Family Care

• Include family in care and allow expression of feelings and concerns.

• Identify strengths, weaknesses, and limitations.

• Use a protective helmet when indicated if part of the skull is absent.

• Provide PT, OT, and speech therapy as needed.

• Keep scalp dry until sutures are removed, following postoperative instructions.

• A hat, scarf, or wig may be used.

Head Injuries

Because the brain cannot store oxygen and glucose, even minor injuries to the brain can have grave consequences.

Closed head injury

• Brain injury without an open skull wound.

• Acceleration/deceleration: Brain moves rapidly inside the skull.

• Coup/contrecoup: Injury occurs at the impact site and/or on the opposite side of the brain.

• Rotational injury: Twisting movement of the brain.

• Whiplash: Rapid back-and-forth head movement can cause brain injury.

Open head injury

• Injury involves an opening in the skull or penetration.

• Simple/linear fracture: Straight break in the skull.

• Comminuted fracture: Skull breaks into multiple pieces.

• Depressed fracture: Broken bone pushed inward.

Concussion

• Temporary neurological dysfunction, sometimes with brief loss of consciousness.

• Symptoms: seeing stars or spots, confusion, and amnesia.

• Requires assessment and monitoring; observation depends on symptoms and provider instructions.

Contusion

• Bruising of brain tissue, often caused by a direct blow.

• May cause abnormal vital signs, abnormal eye movements, and changes in consciousness.

• Severe injury can progress to coma or death.

Closed Head Injury (CHI): Subdural Hematoma

• Bleeding between the dura mater and the brain, usually due to trauma; may also occur with coagulopathy (impaired blood clotting).

• Acute: Develops within 24–48 hours; often associated with major head injury, contusion, or laceration.

• Subacute: Develops within 48 hours to 2 weeks; associated with less severe head trauma.

• Chronic: Develops over 2–3 weeks or longer after a minor head injury.

Basal Skull Fracture - Linear fracture: Base of cranium

Linear fracture at the base of the skull; may be associated with a dural tear.

Basal Skull Fracture - Signs and symptoms:

• Battle’s sign: Bruising behind the ear over the mastoid.

• CSF otorrhea: Cerebrospinal fluid (CSF) leaking from the ear.

• CSF rhinorrhea: CSF leaking from the nose.

• Hemotympanum: Blood in the middle ear.

• Raccoon eyes: Bruising around the eyes (periorbital ecchymosis).

• Cranial nerve deficits: Loss of smell (anosmia), hearing loss, or double vision.

Basilar Skull Fracture: Nursing care:

• Assess the ear canal with an otoscope as appropriate.

• Clear drainage from the nose may be tested for glucose per protocol; beta-2 transferrin is more specific for identifying CSF.

• Monitor for CSF leakage and neurological changes.

• Avoid inserting anything into the nose or ear or packing a suspected CSF leak.

• Important: Basilar skull fractures can be serious because of possible CSF leakage, infection, and brain injury.

Brain Injury: Diagnostic Testing

• CT

  • Detects bleeding, skull fractures, and acute brain injuries.

  • Assess kidney function and contrast reactions if IV contrast is used.

  • Oral contrast may be needed for certain scans.

  • Time: 5–15 minutes.

• MRI

  • Provides detailed images of brain and soft tissues.

  • Remove all metal objects.

  • Screen for pacemakers, implants, and metal in the body.

  • Assess kidney function if contrast is used.

  • Time: 30 minutes–2 hours.

• PET

  • Detects metabolic activity in the brain.

  • NPO for 4–6 hours before exam, except water, as instructed.

  • Monitor blood glucose if indicated.

  • Encourage fluids afterward if permitted.

  • Time: 60–90 minutes.

• X-Ray

Brain Injury: Signs & Symptoms

• Seizures

• Paralysis

• Permanent brain dysfunction

• Persistent vegetative state

  • Coma>1 month

  • Survive d/t nursing care

• Brain death

• Support paralyzed limbs-with orthotics, braces, etc

Assessment of Brain Injuries

- Initial assessment

• Assess ABC (airway, breathing, circulation).

• Assess level of consciousness (LOC): anxiety, irritability, dizziness, confusion, lethargy, obtundation, stupor, or coma.

• Watch for difficulty awakening or speaking, severe headache, vomiting, one-sided weakness, visual disturbances, and CSF leakage from the ears or nose.

- Older adults

• TBI symptoms may be mistaken for normal aging.

• Even ground-level falls can cause serious or fatal injuries.

• Older adults may fall without reporting it.

- Neurological checks every 1–4 hours or as ordered

• LOC: Alertness, attention, orientation, behavior, and ability to follow commands.

• Face and tongue: Check symmetry.

• Strength: Compare bilateral hand grips and foot push/pull.

• Sensation: Have the patient identify which extremity is touched with eyes closed.

• Pupils: Assess size, equality, and reaction to light.

• Vital signs: Monitor for changes.

- Priority: Report any new or worsening neurological changes immediately and perform a more complete assessment as indicated.

Nursing Care in Traumatic Brain Injury (TBI)

- Monitor neurological changes

• Perform frequent neurochecks, including cranial nerve exams.

• Observe for seizures; administer anticonvulsants as ordered (phenytoin/Dilantin, sodium valproate).

- Maintain airway and breathing

• Watch for airway obstruction (snoring respirations) and low SpO₂.

• Monitor for neurogenic pulmonary edema.

- Cardiovascular support

• Monitor heart rate, dysrhythmias, and BP to maintain cerebral perfusion.

• Watch for Cushing’s triad: increased BP, decreased HR, and irregular respirations.

• Monitor electrolytes (Na⁺, K⁺, Mg²⁺), serum osmolality, and urine specific gravity for fluid imbalances.

- Prevent complications of immobility

• Elevate HOB as ordered.

• Perform passive range-of-motion (PROM) every 4 hours as ordered.

• Use multipodus boots to prevent foot drop, hand rolls, mitts if needed for safety, and positioning supports.

• Turn and maintain proper body alignment to prevent pressure injuries.

- Gastrointestinal support

• Provide adequate nutrition; use enteral feedings if needed.

• Use high-fiber, calorie-adequate feeding as appropriate.

• Keep HOB at 30° or higher during tube feedings; pause feedings when the head must be flat, according to protocol.

• Promote bowel function with prescribed stool softeners (e.g., docusate) and monitor constipation.

- Urinary support

• Monitor Foley catheter output for signs of SIADH or diabetes insipidus (DI).

• Secure and handle the catheter properly to reduce infection risk.

- Family support

• Explain the patient's condition and provide emotional support.

• Offer spiritual counseling and connect family with support systems.

- Long-term care and rehabilitation

• Provide PT, OT, and speech therapy as needed.

• Recovery may involve inpatient or outpatient rehabilitation, assisted living, independent living, or long-term care.

• Some patients recover fully; others may have permanent physical, cognitive, or personality changes.

Brain Death

• Irreversible loss of all brain function

• EEG and CBF studies

• Potential organ donation

  • Life Link of Georgia

  • It is possible to transplant 25 different organs and tissues, including corneas, heart, heart valves, liver, kidneys, bone and cartilage, bone marrow, skin, pancreas, lungs, intestine and more.

organ donation

Approximate preservation times for the following organs and tissues are:

• Kidney 48 to 72 hours

• Liver Up to 24 hours

• Heart 4 to 6 hours

• Heart/Lung 4 to 6 hours

• Pancreas 12 to 24 hours

• Lung 4 to 6 hours

• Corneas 7 to 10 days

• Bone Marrow Up to 3 years

• Skin 5years or more

• Bone 5 years or more

Spinal Cord Injuries

• Major Health Problem

• 200,000 people in US

• 11,000 new injuries yearly

• Males>Females

• 16-30 yrs

• African American > Caucasians

• Goal: Primary Prevention!

• ETOH/Drug Abuse

• MVA 35%

• Violence 30%

• Falls 19%

• Sports 8%

• 5th, 6th, & 7th Cervical

• 12th Thoracic

• 1st Lumbar

Spinal Cord Injury SCI

• Injury to spinal cord

  • Trauma, penetrating wound

  • Vertebral injuries

  • Spinal Cord infarction

• Primary injury

  • Occurs at time of event

  • Usually permanent

• Secondary

  • Follows primary

  • Etiology unknown

  • Spread of injury

  • Can be mitigated with treatment

Emergency Management SCI

• Speed and correct handling is paramount to preserving neurological function

• Anyone having MVA, diving injury, contact sports injury, fall or direct trauma to head and neck is assumed to have SCI until otherwise proven.

• Initial care includes

  • Extrication

  • Rapid assessment

  • Immobilization

  • Stabilization

  • Transportation to trauma center

Emergency Management SCI

• Immobilize

  • Backboard

  • Neck brace

  • Neutral position

• One person controls head

  • Four persons to move client to backboard

Emergency Management SCI

• Respiratory support

  • O2 to keep PO2 high

  • High cervical injuries interfere with innervation of diaphragm (T1-T11)

    • Apnea/hypoventilation

    • Intubation and ventilation

• Cardiovascular support

  • Maintain perfusion

• Pharmacology

  • High dose corticosteroids within 8 hrs of injury

  • Steroid early on – tend to do better 

• C3-C4 – everything below is paralyzed

  • higher chance to stop breathing

Management SCI

• Immobilization and reduction of fractures

  • Cervical fractures

    • Crutchfield Tongs – Burr holes

    • Gardner-Wells Tongs – noninvasive

    • Halo traction/Halo vest

• Surgical management

  • Cord compression

  • Unstable vertebrae

  • Cord penetration

  • Bony fragments in spinal canal

  • Deteriorating neurologic status

Spinal Cord Injury: Signs and symptoms

• Loss of sensation and/or motor ability below level of injury

• Paralysis

  • Paralysis (plegia): Complete loss of voluntary movement; sensation may or may not be lost.

  • Paresis: Partial weakness with some movement remaining; sensation may or may not be affected. Recovery determined by extent of secondary injury

• Function determined by location and whether complete or partial

• C1-C3 fx generally incompatible with life

Spinal Cord Injury SCI: Complete

• Usually acute

• Usually cervical

• Loss of motor, sensory, autonomic and reflexes below level of injury

Spinal Cord Injury SCI: Partial

• Some motor or sensory function remains below the level of injury.

• May be associated with lumbar injuries.

Paralysis - Flaccid paralysis

• No muscle tone (limp muscles).

• No voluntary movement.

• Absent reflexes.

• Urinary and bowel incontinence.

• Muscle wasting (atrophy).

• Example: Polio.

Paralysis - Spastic paralysis

• Increased muscle tone (stiff muscles).

• No voluntary movement.

• Urinary and bowel retention.

• Unregulated reflex activity (hyperreflexia).

• Upper extremities (UE): Flexion.

• Lower extremities (LE): Extension.

Paraplegia:

Paralysis of both lower extremities (legs).

Hemiplegia:

Paralysis of one side of the body (arm and leg).

Quadriplegia (Tetraplegia):

• Paralysis of all four extremities (both arms and legs), usually due to cervical spinal cord injury.

Nursing Care for SCI

• Adequate breathing & airway clearance

  • Ventilator management & oxygenation

• Improving mobility

• Adaptation to sensory & perceptual alterations

• Urinary elimination

• Bowel elimination

• Skin integrity

Spinal/Neurogenic Shock

Sudden loss of reflex activity below the level of spinal cord injury (SCI).

• Duration: Hours to weeks.

• Can occur with any type of SCI, even if spastic paralysis develops later.

• Loss of autonomic nervous system (ANS) function: Disrupts regulation of heart rate, blood pressure, breathing, digestion, and sweating.

• Sympathetic nervous system: Normally helps the body respond to stressful situations; disruption can cause vasodilation, hypotension, and bradycardia.

Spinal/Neurogenic Shock - Signs and symptoms:

• Absent reflexes.

• Flaccid paralysis.

• Loss of bowel and bladder control.

• Venous pooling in extremities.

• Peripheral vasodilation.

• ↓ BP → ↓ cardiac output.

• ↓ HR (bradycardia).

• No perspiration below the lesion.

Autonomic Dysreflexia

• Occurs after spinal/neurogenic shock resolves.

• Exaggerated sympathetic nervous system (SNS) response.

• Usually occurs with spinal cord injuries at T6 or above.

• Can cause stroke, seizures, or death if untreated.

• Why it happens

  • The SNS triggers the fight-or-flight response.

  • A stimulus below the injury causes an exaggerated sympathetic response, leading to vasoconstriction and a sudden increase in BP.

  • The brain attempts to lower BP, which can cause bradycardia, but signals cannot adequately control the response below the injury.

Autonomic Dysreflexia - Causes / Triggers

• Distended bladder (common trigger)

• Distended bowel or constipation

• Skin stimulation or irritation

• Other irritating stimuli below the level of injury

• In spinal cord injury patients, many different stimuli can trigger this response.

Autonomic Dysreflexia - Signs and Symptoms

• Severe hypertension (sudden increase in blood pressure)

• Severe headache

• Flushed face

• Sweating above the injury

• Cold, pale skin below the injury

• Goosebumps (piloerection) below the injury

• Bradycardia (slow heart rate)

• Nausea

• Nasal congestion

Nursing Care Autonomic Dysreflexia

• Rapid assessment: Check BP and assess for signs and symptoms.

• Remove the triggering stimulus.

  • Usually urinary or bowel related.

  • Check for a distended bladder or blocked catheter.

  • Empty the bladder or bowel as appropriate.

• Place the patient in a sitting position.

  • Promotes venous pooling in the lower extremities, helping decrease BP.

• Administer prescribed antihypertensive medication.

  • Hydralazine IV (Apresoline) 10–20 mg slowly, per order and facility protocol.

• Label MR

• Teach the family how to recognize, prevent, and respond to autonomic dysreflexia.

• Treat as an emergency.

Long Term Effects of SCI

• Loss of bladder and bowel function

• Possible ventilator dependency

• Respiratory complications

• Loss of sexual function

• Postural hypotension

• Deep vein thrombosis

• Sensory deprivation

• Peripheral edema

• Skin breakdown

• Contractures

• Rehabilitation

Long Term SCI Rehabilitation:

The Shepherd Center is a private, non-profit hospital in Atlanta, Georgia. Founded in 1975, the hospital focuses on rehabilitation for people with spinal cord injury and disease, acquired brain injury, multiple sclerosis, chronic pain and other neuromuscular problems.

Long Term Nursing Management SCI

• Increase mobility

  • Specialty beds and positioning devices

  • Encourage mobility and rehabilitation as appropriate

• Promote skin integrity

  • Use gel pads and pressure-relieving devices.

  • Reposition regularly and inspect skin for pressure injuries.

• Bladder and Bowel management

  • Self-catheterization

  • manual digital stimulation of anus

    • high fiber

    • hydration

    • exercise

• Coping

  • Depression

  • alterations in cognition

  • Anger

  • Suicidal

• Sexual function

  • penile implants

• Prevent Complications

  • Spasticity: Splints and other prescribed interventions.

  • Infection and sepsis: Monitor for pulmonary, skin, and urinary infections.

  • Pulmonary complications: Encourage coughing, deep breathing, and turning/repositioning.

  • Urinary complications: Maintain appropriate bladder-emptying routines.

  • Skin complications: Continue pressure relief and skin assessments.

• Home care

  • Home health nurse

  • specialty care givers

  • family

Management of Patients with Neuromuscular Disorders

• Multiple Sclerosis

• Parkinson’s Disease

• Myasthenia Gravis

• Guillain-Barre

Multiple Sclerosis MS

• Chronic demyelinating disease of the central nervous system (CNS).

  • The immune system damages myelin, disrupting or slowing nerve impulse conduction.

  • MRI may show lesions (white spots) in the CNS.

• Cause: Thought to be autoimmune.

• Common age: 20–40 years.

  • More common in women than men.

• Disease pattern: Exacerbations (flare-ups) and remissions (symptoms improve or decrease).

Multiple Sclerosis MS - Signs and Symptoms

• Fatigue: Pervasive/common symptom.

• Spasticity: Muscle stiffness and spasms.

• Ataxia: Poor coordination and balance.

• Paresthesias/pain: Tingling, numbness, or pain.

Multiple Sclerosis MS - Symptoms by CNS Area

Area affected	Possible symptoms
Optic nerve	Blurred vision, diplopia (double vision), and sometimes severe vision loss
Cerebrum	Emotional lability, euphoria, depression, and possible suicidal thoughts
Cerebellum	Ataxia, poor coordination, and tremors
Brainstem	Motor and sensory problems; swallowing or other functions may be affected
Spinal cord	Spasticity, weakness, and sensory changes

Multiple Sclerosis MS - Treatment

• Corticosteroids: Shorten the duration of acute exacerbations; they do not cure MS.

• Disease-modifying therapies (including certain immunosuppressive or immunomodulating medications): Reduce disease activity and may slow progression.

• Supportive care: Manage fatigue, spasticity, pain, mobility problems, and other symptoms.

Multiple Sclerosis MS - Prognosis

• MS varies greatly from person to person.

• Many people live for decades with MS and may die from unrelated causes.

• Severe disease can cause complications, including respiratory problems, though respiratory failure is not the usual outcome for most patients.

Multiple Sclerosis MS - Primary Symptoms

• Fatigue

• Depression

• Weakness

• Numbness

• Impaired coordination/loss of balance

• Pain

Multiple Sclerosis MS - Secondary Symptoms

• UTI

• Constipation

• Pressure ulcers

• Contractures

• Decreased bone mass

• Dependent pedal edema

• Pneumonia

• Reactive depression

Multiple Sclerosis - Diagnosis

• MRI – visualizes plaques

• CSF – fluid (presence of immune elements)

• Neuropsychological testing

  • in-depth assessment of skills and abilities linked to brain function.

• Urodynamic studies

  • bladder, sphincters, and urethra hold and release urine. These tests can show how well the bladder works and why there could be leaks or blockages.

• Sexual history

Management of Multiple Sclerosis (MS) -

• No cure

• Goals:

  • Delay disease progression.

  • Reduce the severity and duration of exacerbations.

  • Manage symptoms and prevent complications.