Seminar #11: Neuro Flashcards
1
Q
When would a nurse need to perform an advanced neurological assessment?
A
- showing signs of impaired cognition
- orientation has changed
- falls
- stroke
2
Q
What is the pupil assessment?
A
PERRLA
3
Q
PERRLA - what are the components?
A
P: Pupils
E: Equal?
- assess size prior to testing for reaction
- 20% of people naturally have asymmetrical pupils “physiological anisocoria,” other types of anisocoria = pathological or mechanical
**R: round? **
- irregular shaped pupil can be heriditary, trauma related, or from surgery
RL: reactive to light?
- assess each pupil for both direct + consensual reactoin
- reaction brisk or sluggish? non-reactive/fixed?
- shine light from side
A: accomodation?
- do pupils dilate when focusing on distant object?
- do they constrict/converge when focus shifts to an object close-up?
- yes = can accomodate; fixed pupil = concerning
4
Q
What are the pupil sizes?
average, dilated or constricted?
A
average pupil: 2-8mm; size varies, depending on light
dilated: >8mm
- aka “blown out”
- unilateral or bilateral
constricted: <2 mm
- aka pinpoint, small
- unilateral or bilateral
5
Q
Unilateral Dilation - what does this mean?
A
- brain hematoma
- brainstem herniation
- migraine
- compressed cranial nerve #3 – may have limited ocular movement, ptosis, diplopia
6
Q
Bilateral Dilation/Fixed Pupils - what does this mean?
A
- midbrain injury
- poor prognosis if >24h or GCS <3
7
Q
Bilateral Dilation/Sluggish Pupils - what does this mean?
A
- eye diseases
- illicit substances (amphetamines/cocaine/LSD/MDMA)
- post-seizure
8
Q
bilateral pupil constriction - what does this mean?
A
- brain trauma (pons cva)
- opioids/narcotics
- medications (clonidine, benzos, etc)
- enviro toxins
- eye trauma
- diseases (neuro-syphillis, diabetes, MS)
- heat stroke
9
Q
Unilateral pupil constriction - what does this mean?
A
- horner’s syndrome
- iris inflammation
- adhesions
- medication (pilocarpine)
10
Q
Cranial nerves - how many? what are their functions?
A
12 pairs of cranial nerves that send signals b/t brain, face, neck, and torso
- some sensory: taste, smell, hear, and feel
- some motor: make facial expressions, blink eyes, vocalize, swallow food
- some nerves have both sensory + motor functions
11
Q
Cranial nerve I
A
olfactory, sensory
12
Q
CN II
A
optic, sensory
13
Q
CN III
A
oculomotor, motor
14
Q
CN IV
A
trochlear, motor
- up and down movement of eye
15
Q
CN V
A
trigeminal - both sensory + motor
- mastication mov’t, sensation of face, scalp, cornea, and mucous membrane of mouth + nose
16
Q
CN VI
A
abducens, motor
- lateral movement of eyes
17
Q
CN VII
A
Facial, both sensory + motor
- movement of facial muscles, closes eyes, closes mouth, labial speech
- taste on anterior 2/3 tongue
18
Q
CN VIII
A
vestibulocochlear, sensory
- hearing and equilibrium
19
Q
CN IX
A
glossopharyngeal, sensory + motor function
- movement of pharynx (phonation + swallowing)
- taste on posterior 2/3 tongue, gag reflex, parotid gland stimulation, and carotid reflex
20
Q
CN X
A
vagus, sensory + motor nerve
- carotid reflex, general sensation from carotid body, carotid sinus, pharynx, viscera
- movement of pharynx + larynx
21
Q
CN XI
A
spinal accessory, motor
- movemet of trapezius + sternomastoid muscles
22
Q
CN XII
A
hypoglossal, motor
- movement of tongue
23
Q
what are the cranial nerve mnemonics?
A
OOOTTAFVGVAH - cranial nerves
SSMMBMBSBBMM - function
24
Q
What are dermatomes?
A
- area or zone of skin
- sensory function on body can be assessed by testing dermatomes
- each dermatome associated w/ single spinal nerve
- 31 pairs of spinal nerves, only 30 dermatomes
- c1 doesn’t correlate w/ dermatome
- test when there is an injury/tumour, epidural
25
how do you test dermatomes?
have pt close eyes
- pain sensation: gently touch skin w/ sharp object and ask pt to tell you when you feel the sensation + whether it feels sharp/soft
- light touch sensation: touch skin w/ soft object, ask pt to tell you when they feel sensation and if it feels soft/sharp
- test bilaterally
26
How do you test motor function?
- balance
- gait: smooth? coordinated arm movement? effortless?
- sensory ataxia: romberg test (stand eyes closed; negative = no swaying for 1min)
- coordination: finger-to-finger test, heel-to-shin test, rapid alternating movement
- muscles: strength + symmetry
27
what are reflexes?
- instantaneous + involuntary response to stimulus
- sensory info directly relayed to motor neurons in spine, before brain gets involvd
- normal reflex indicates functional pathway b/t: stimulus/sensory neuron/interneuron/motor neuron/muscle
- test deep tendon reflex (DTR) using percussion hammer
- compare one side of body to the other
28
what is the scoring for reflexes?
0 = absent
1+ = diminished
2+ = brisk: normal
3+ = very brisk
4+ = clonus, or repetitive contraction of muscle
- clonus = abnormal movements, e.g., touching end of foot, it will flex up and stay there
29
What is a stroke?
- when blood stops flowing to any part of brain, ischemia occurs, brain cells damaged
- often caused by: blockage (ischemic) or spontaneous bleeding (hemorrhagic)
- sometimes underlying conditions can cause stroke: tumor, infection, brain swelling, congenital abnormalities
30
S/S of Right-Sided Stroke/Right-Brain damage?
- paralyzed left side: hemiplegia
- left-sided neglect
- spatial-perceptual deficits
- tends to deny/minimize problems
- rapid performance, short attention span
- impulsive; safety problems
- impaired judgement
31
S/S Left-Sided Stroke/ left brain damage
- paralyzed right side: hemiplegia
- impaired speech-language (aphasias)
- impaired right-left discrimination
- slow performance, cautious
- aware of deficits: depression, anxiety
- impaired comprehension related to language, math
32
What nursing assessments are used for stroke in acute care?
- GCS
- national institute of health stroke scale (NIHSS)
- canadian neurological scale
- toronto bedside swallowing screen (TOR-BSST)
- IH adult swallowing screen (SST)
- IH stroke PPO
33
what is a seizure?
- sudden onset of uncontrolled activity in 1+ areas of brain
- may accompay other disorders or occur spontaneously without apparent cause
- s/s: LOC change, change in emotions, loss of muscle control, sensory changes, loss of bladder/bowel, respiratory changes, staring/rapid blinking
34
Seizure: extracranial causes?
excess/deficit: glucose, lytes, triglycerides, etc.,
toxins:
- internal: e.g., kidney, liver, metabolic disease
- external: poisons
35
Seizures: intracranial causes?
secondary epilepsy:
- progressive brain disease (e.g., tumour)
- static brain disease (e.g., scar after trauma)
primary epilepsy: idiopathic
36
What is seizure classification based on?
3 key features
1. where seizures begin in brain
2. level of awareness during seizure
3. describing other featuers of seizure (movements/automatisms)
37
Where do seizures begin in the brain?
**focal seizure**: onset in one area on one side of brain
**generalized**: involves both sides of brain @ onset
**unknown onset**: onset not known, may be determined later
**focal to bilateral seizures**: starts in one side/part of brain, spreads to both sides
38
What are the level of awarenesses during a seizure?
**focal aware:** awareness intact, even if person unable to talk or respond during seizure
**focal impaired awareness:** awareness impaired/affected @ any time during seizure
**awareness unknown**: not always possible to know if person is aware or not
**generalized seizures**: presumed to affect person's awareness or consciousness
39
What are some features of a seizure?
**focal motor seizure**: body movement occurs (twitching, jerking, stiffening), or automatisms (lip licking, chewing, rubbing hands, walking/running, laughing/crying)
**focal non-motor seizures**: changes in sensation, emotions, thinking, or experiences
**generalized motor seizure:** "generalized tonic clonic" = seizures w/ stiffening (tonic) and jerking (clonic); previously grand mal
**generalized non-motor seizure**: primarily absence seizures (petit mal) w/ brief changes in awareness, starting, and may present w/ automatisms
40
What is a focal seizure?
simple focal onset = don't lose consciousness
focal seizure:
- might be quick pause, can be hard to diagnose b/c pt doesn't remember
- gapping out for few seconds
- usually don't lose consciousness
41
what is a mid-clonic seizure?
more of a repetitive movement with one limb / on one side
42
what is a complex seizure?
causes altered cognitive state
43
what are the seizure phases?
prodromal, early ictal/aural phase, ictal phase, postictal phase
44
seizure phases: Prodromal
- precedes seizure with signs (headache, confusion, mood/behaviour changes)
- can occur over several days or minutes prior to seizure
45
seizure phases: Early Ictal/Aural phase
- sensory warnings (vision changes, smells, auditory, sensations, fear, panic, nausea, deja vu) prior to seizure
- an aura = focal seizure
46
seizure phases: Ictal Phase
- seizure activity, loss of awareness, repeated movements, convulsions, tachycardia, trouble breathing
- seizure actually starting
47
Seizure phases: Postictal phase
- rest + recovery
- nausea, muscle weakness, exhaustion, fear, fatigue, decr LOC
- generally still confused, can last up to 30 mins
48
Status epilepticus
| complications of seizures
= state of constant seizure or when seizures recur in rapid succession without return to consciousness b/t seizures
- back to back seizures, brain not recovering
- neurological emergency
- can invovle any type of seizure
- brain uses more energy than is supplied
- neurons become exhausted and cease to function
- permanent brain damage can result
49
tonic-clonic status epilepticus
| complications of seizures
= most dangerous, can cause ventilatory insufficiency, hypoxemia, cardiac arrhythmias, hyperthermia, systemic acidosis
50
What are some complications of seizures?
- trauma - can lead to severe injury or death
- social stigma: interferes w/ values of self-control, conformity, and independence; may experience depression, anxiety, anger, problems w/ relationships
- discrimination in employment + education
- driving sanctions
- depression common, can lead to impaired daily function, sleep deprivation, incr seizure activity
51
what are some seizure precautions?
- padding lining bed rails
- mitigate triggers if possible (bright lights, loud noises, smells, startles)
- ensure bedside safety check has been completed
- suctioning, o2
52
What are some diagnostics + treatments for seizures?
- pt hx + physical examination
- seizure hx
- EEG, bld work, CT, MRI, lumbar puncture
- medications
- vagal nerve stimulation (thought to interrupt synchronization of epileptic brain wave activity)
- surgery
- counselling
- special diet - e.g., ketogenic (high fat, low carb): ketones produced and passed into brain, replace glucose as E source
53
What are some triggers for seizures?
- stress
- excessive excitement/stimulation
- excessive fluid intake
- extremely low BS in DM
- flickering lights
- sunlight, heat, humidity
- skipping meals, poor nutrition
- illness, fever, allergies
- lack of sleep
- withdrawal from meds, illegal drugs, alc
- missed meds
54
What are some seizure precations for Ictal Phase?
**- DON'T insert anything into mouth**
**- DON'T restrain person**
**- call code blue if status warranted**
- ensure safety + patent airway
- place pt in lateral position if possible
- observe + time seizure activity
- apply o2 + suction as needed; assist w/ ventilation if needed after seizure
- establish IV + give meds as ordered
55
Nursing assessment for Ictal phase
- abnormal respiratory rate, rhythm, sounds, apnea
- airway occlusion
- HTN, tachycardia, bradycardia
- excessive salivation
- length of ictal phase
56
Nursing assessment - post-ictal phase
- any precipitating factors (abnormal CT, MRI, EEG, bld work, lytes, toxicology screen, hx)
- bitten tongue, soft tissue damage
- cyanosis
- bowel/urinary incontinence
- diaphoresis
- weakness, paralysis, ataxia
- neuro-vitals
57
Seizure Precautions, Post-Ictal Phase
monitor: VS, LOC, GCS
assess, reassure, orient pt
- may be aggressive + guarded after seizure
- use calm, quiet voice
- keep lights low + minimize staff
- monitor for hypoglycemia
document
58
# why + what supplies are needed?
Seizures - Oral Suctioning
suction to:
- remove secretions that obstruct airway
- facilitate ventilation
- obtain secretions for diagnostic purposes
- prevent infection that may result from accumulated secretions
supplies:
- hand hygiene
- gloves
- yankauer suction catheter
- suction tubing + suction canister
59
What rate should suctioning be set at for adults? How long and what intervals?
- suction should be set at 100-150 mm Hg
- 10-15 seconds max, 30s-1min intervals
60
LT effects of alcohol on CNS
- wernick'e encephalopathy (ataxia, confusion)
- korsakoff's syndrome (irreversible)
- impaired cognition
- decr pyschomotor skills
- impaired abstract thinking + memory
- sleep disturbances
- depression/labile mood
- attention deficit
- seizures
61
What is alcohol use disorder?
= impaired ability to stop / control alcohol use despite adverse social, occupational, or health consequences
- alc = primary drug leading to health-related problems
- AUD = chronic + fatal condition if not treated; abrupt withdrawal can have life-threatening effects d/t neurochemical changes
62
how can alcohol use re-wire the brain?
- nts in CNS heavily suppressed by alcohol consumption --> alc inhibits excitatory receptors (glutamate) of CNS + enhances inhibitory receptors (GABA) of CNS
- when someone stops using alc, nts must readjust to regain sensitivity needed to correctly function
- brain has excitatory overload, which results in symptoms of withdrawal
- every time CNS gets depressed, it gets more excitable the next time they drink alcohol
63
What are some ST effects of alcohol on CNS?
- initial relaxation
- decr inhibition
- lack of coordination
- impaired judgement
- slurred speech
- anxiety/agitation
- hypotension
- bradycardia
- bradypnea
64
what is Wernicke's encephalopathy?
- caused by thiamine deficiency
- still reversible in acute state, if caught early
- moves into Korsakoff's syndrome if not caught early
65
Mild to moderate s/s of AWS?
- tremors
- anxiety
- n/v
- headache
- tachycardia
- diaphoresis
- irritability
- confusion
- insomnia
- nightmares
- HTN
66
what is CIWA?
clinical institute withdrawal assessment for alcohol scale
- standardized assessment tool used to assess + monitor s/s caused by alc withdrawal
- assesses 10 most common s/s of AWS
- used to direct treatment by scoring symptoms
67
severe s/s AWS?
- profound confusion
- agitation
- aggression
- fever
- seizures
- tactile disturbances
- auditory and/or visual disturbances
- excessive diaphoresis
- tachycardia, tachypnea
- tremors
- HTN
68
which population is CIWA not appropriate for?
- language barrier
- cognitive impairment
- decr LOC
- delirium
69
what are the 10 most common symptoms of AWS?
1. n/v
2. tremor
3. tactile disturbances
4. auditory disturbances
5. paroxysmal sweats
6. visual disturbances
7. anxiety
8. headache
9. agitation
10. orientation/clouding of sensorim
70
CIWA score 0-9
not intervening with medication, reassess q4h
71
CIWA score 10-19
medical intervention, reassess q1h
diazepam: 10 mg PO/IV q1h (max 120mg/24h)
or
lorazepam (if respiratory distress / >70 y/o: 1mg SL/ IM/ IV q1h (max 12mg/24h)
or
lorazepam (underlying liver disease or unable to take PO/IV meds): 2 mg SL / IM / IV q1h (max 12 mg/24h)
72
CIWA score: 20+
diazepam: 20 mg PO/IV q1h
lorazepam (age/resp distress): 2 mg SL/IM/IV q1h
lorazepam (liver disease/unable to take IV/PO): 4 mg SL/IM/IV q1h
- reassess q1h until score less than 10
73
what are some additional PRN meds to help with AUD withdrawal symptoms?
- gabapentin for anxiety, agitation, insomnia
- ondansetron: n/v
- acetaminophen: pain/fever
- loxapine: hallucinations - only use if benzos alone not effective
74
Nursing considerations for CIWA medication
- if resp rate < 8/min, hold med + notify prescribers
- notify prescriber if pt receives max dose 120mg diazepam/ 12mg lorazepam per 24h period
- treatment goal = mild sedation (rouses easily), CIWA-Ar score <10
- if GCS <8, notify prescriber
- if pt maxed out on diazepam, still have 17, call MRP
75
Stages of alcohol withdrawal: 6-12h after cessation
minor withdrawal symptoms:
- insomnia, tremors, anxiety
- GI upset, anorexia, nausea
- headache, diaphoresis
- palpitations, tachycardia, HTN
76
Stages of alcohol withdrawal: 12-24h after alc cessation
alcoholic hallucinations: visual, auditory, or tactile hallucinations
77
stages of alcohol withdrawal: 24-48h after alc cessation
withdrawal seizures: generally tonic-clonic seizures
78
stages of alcohol withdrawal: 48-72h after alc cessation
alcohol withdrawal delirum (delirum tremens):
- hallucinations (predominantly visual)
- disorientation
- agitation
- diaphoresis
79
# incr risks? how soon after last drink?
Alcohol withdrawal - withdrawal seizures
incr risk:
- long hx of alcohol use
- aged ≥ 40
- seizures usually occur ~24h after last drink
- can occur as soon as 2h after last drink, may occur up to 48h later
- usually occur in cluster of 1-3 seizures
- generalized tonic-clonic
- 30-50% experiencing seizures will progress to DTs
80
What are the increased risks for Delirium Tremens (DT's) & when does it occur?
incr risk:
- heavy, prolonged alc use
- hx previous DT/ withdrawal seizure
- age > 30
- concurrent illness + comorbidities
- more severe withdrawal symptoms @ presentation
- presence of alc withdrawal symptoms while blood alc level is still elevated
- prior detoxification
occurs 48-72h after last drink
- hallucinations, agitation, disorientation, profuse sweating
81
what is the kindling phenomenon?
with each episode of alcohol use + alcohol withdrawal (even mild), brain becomes more:
- excitable
- sensitive to effects of alcohol withdrawal
with each episode of alcohol withdrawal
- clinical manifestations become more severe
- people beocme increasingly likely to experience seizures + DT
82
Alcohol withdrawal challenges: Hypovolemia/dehydration
- alc = diuretic
- n/v
- poor appetite d/t gastritis
- not drinking adequate h2o
- diaphoresis
83
Alcohol withdrawal challenges: Malnutrition/electrolyte imbalances
- gastritis = malabsorption of vitamins (thiamine) + nutrients
- alc can cause pancreatitis
- people may not eat nutritious diet when using alc
- people who are severely malnourished often have low leevls of many electrolytes, e.g., potassium, calcium, magnesium, phosphorus (lyte imbalnce, dt n/v)
- malnourished pts at risk for "refeeding syndrome"
84
What is thiamine (vit b1) deficiency? and what can it cause?
- thiamine deficiency = common in people who drink excessive amounts of alcohol
- thiamine essential for E metabolism -- converts carbs into glucose
- can cause beri beri
85
dry beriberi vs wet beriberi?
dry: affects CNS + PNS
wet: affects heart + circulatory system
86
what can dry beriberi lead to?
wernicke's encephalopathy
- acute / sudden syndrome requiring urgent treatment
- swelling causes damage to nerves + bld vessels in brain
- ataxia, confusion, nystagmus
- if untreated, can lead to korsakoff's syndrome
87
what is korsakoff's syndrome?
- irreversible, significant short-term memory impairment
- inability to learn new things or retain new information
- some loss of LT memory
- aphasia
- lack of insight
- confabulation
88
Nursing role in managing alcohol withdrawal?
1. early + accurate assessment
- hx of substance use on admission, CAGE questions
2. recognition + management of s/s
- neuro assessment; CIWA; manage nause/GI s/s
3. supportive nursing care
- env't, approach, if diaphoretic change bedding, encourage fluids/nutrition
89
What are the leading causes of spinal cord injuries (SCI)?
- motor vehicle accidents (35%)
- falls (17%)
90
How do you classify SCI?
1. mechanism of injury
2. level of injury
3. degree of injury (partial = SC didn't completely severe; complete = SC severed)
91
SCI: Mechanism of Injury
1. traumatic: mva, fall, sporting activity, violent incident
2. non-traumatic: tumour, inflammation, infection, birth defect
3. flexion: forward dislocation, ruptured posterior ligaments
4. hyperextension: ruptured anterior ligament, compressed ligaments
5. compression fracture: compression of SC, fractured vertebrae
6. flexion-rotation injury: displacement of vertebrae
92
SCI: level of injury, skeletal
- vertebrae + ligaments damaged
- higher the injury, the more body parts affected
- cervical: tetraplegia, all 4 limbs/trunk
- thoracic + lumbar: paraplegia, lower limbs/trunks affected
93
SCI: Level of Injury - Neurological level
lowest segment of normal motor + sensory function (bilateral)
94
SCI: Level of Injury, vertebrae
| which vertebral injury causes tetraplegia, paraplegia, etc
C4 = neck, tetraplegia
C6 = armpit, tetraplegia
T6 = below boob, paraplegia
L1 = groin, paraplegia
95
SCI: Degree of Injury - Complete vs Incomplete
complete:
- SC completely severed
- complete loss of mobility and sensation below injury
- paraplegia/ tetraplegia/quadriplegia --> straight across
incomplete:
- incomplete/partial severance
- some movement and/or sensory below level of injury
- paraplegia, tetraplegia/quadriplegia -- can be skewed, e.g., one side more affected than the other
96
Primary vs Secondary SCI
neurological damage results from both primary + secondary injruty
inflammatory process (during secondary injury) is important to:
- eliminating invading pathogens
- remove debris
- promote wound healing
BUT - substances produced during inflammatory response accumulate and become toxic --> damage to otherwise intact SC tissue
- extent of injury not immediately clear
97
Acute Phase - Primary Injury
- hemorrhage
- death
98
Acute phase - Secondary Injuries
- decr [ATP]
- vascular disruption
- edema
- necrosis + apoptosis
- ionic imbalance
- glutamate excitotoxicity
- inflammation
- macrophage infiltration
99
SCI - Chronic Phase is from what?
- white matter disruption
- grey matter demyelination
- connective tissue deposition
- glial scar/cyst formation
- axonal sprouting
100
SCI: Diagnostic studies
- CT scan to assess stability of injury, location, degree of vertebrae injury
- MRI = 'gold standard' for imaging neurological tissues, including SC (soft tissue)
- comprehensive neurological exam
101
SCI - Clinical Manifestations of Respiratory System, Above C4
- total loss of respiratory muscle function
- mechanical ventilation requried to keep pt alive
- artificial airway - direct access for pathogens
- paralysis of abdominal + intercostal muscles - ineffective cough
- pulmonary edema - neurogenic, fluid overload
102
SCI: Clinical Manifestations of Respiratory System, Below C4
- diaphragmatic breathing if phrenic nerve functional
- hypoventilation common w/ diaphragmatic breathing
- paralysis of abdominal + intercostal muscles --> depending on level + degree of injury; ineffective cough
103
# what happens?
SCI Clinical Manifestations: CVS system, Injury T6 or higher
neurogenic shock
- bradycardia (HR <40) - drugs (atropine) may be necessary to incr HR
- peripheral vasodilation
hypovolemia d/t incr venous capacitance
decr venous return to heart = decr cardiac ouput = hypotension
IV fluids or vasopressor drugs may be req to support BP
- cardiac monitoring necessary
104
# What happens?
SCI Clinical Manifestations: Urinary System - Neurogenic Bladder
1. acute SCI + spinal shock:
- urinary retention common
- bladder atonic + overdistended
- in-dwelling catheter inserted -- incr risk of infection, should start intermittent catheterization asap
2. Post- SCI: 80% ppl require bladder management
- depending on level/degree of injury bladder can be: spastic (above t12) or flaccid (below t12)
- recommend fluid intake 1800-2000 mL/day
- bladder vol shouldn't exceed 500 mL
- empty bladder regularly
105
# what happens?
GI system - Neurogenic bowel, T5 or above
| SCI Clinical Manifestations
injury T5 or above - problems mostly associated w/ hypomotility
- constipation
- paralytic ileus
- gastric distension --> nasogastric tube may relieve gastric distension
- medications e.g., metoclopramide may help w/ motility
- stress ulcers common (H2-receptor blockers + PPIs)
106
# what happens?
GI System - Neurogenic Bowel, Injury T12 or above
| SCI Clinical Manifestations
reflex (spastic) bowel
- cannot voluntarily relax anal sphincter
- may have constipation
- signals b/t colon & brain disrupted
- reflex that triggers BM still works, but may not be felt --> bowel incontinence when rectum full
107
# What happens?
GI - Neurogenic bowel, Injury T12 or below
| SCI Clinical Manifestations
Areflexic (flaccid) bowel
- decr peristalsis
- loose sphincter
- risk for constipation w/ bowel incontinence
108
SCI Clinical manifestations: integumentary system
- lack of mobility + sensation causes breakdown
- pressure ulcers can occur quickly
- can lead to infection/sepsis
109
SCI clinical manifestations: thermoregulation
Poikilothermia
- inability to maintain core temperature
- SNS interruption prevents peripheral temp sensatons from reaching hypothalamus
- sweating + shivering doesn't occur below level of injury
- can lead to hypo/hyperthermia
110
SCI clinical manifestations: metabolic needs
- loss of body weight common post injury
- nutritional needs much greater than expected for immobilized person
- positive nitrogen balance + high-protein diet
--> prevents skin breakdown + infection
--> decr rate of muscle atrophy
if pt reqs NG suction?
- can lead to metabolic acidosis
- monitor lytes until suctioning is discontinued + normal diet resumed
111
SCI clinical manifestations: Peripheral Vascular Problems
- DVT common problem during first 3 months
--> can be asymptomatic
--> DVT assessments: doppler exam, measurement of legs + thigh girth
- pulmonary embolism = leading cause of death in SCI
112
SCI clinical manifestations: Musculoskeletal (Mechanical) Pain
- injury/damage to bones, muscles, tendons, joints, and ligaments
- pain signal d/t injury may illicit incr spasticity instead of pain sensation
113
SCI clinical manifestations: Visceral pain
- produced by signals from internal organs (stomach, bowel, or bladder)
- constipation or full bladder may send signal
114
SCI clinical manifestations: Neuropathic pain
- injured nerves try to reconnect - can become over excitable - sending inaccurate/distorted messages to brain
- N/T, throbbing, burning, stabbing, cold sensations, or tightness
- non-painful sensations can feel painful even if theyre's no injury (e.g., clothing, cold, vibrations)
- felt as spontaneous bursts of pain, but no tissue is actually being damaged/injured
115
SCI Surgical Therapy - Early Surgery Criteria?
- cord decompression may result in decr secondary injury
- evidence of cord compressoin
- progressive neurological deficit
- compound fracture
- bony fragments
- penetraing wounds of spinal cord or surrounding structures
116
SCI: Common surgical procedures?
- decompression
- realignment
- anterior and/or posterior stabilization w/ instrumentation
117
# what medications are used? any under research?
SCI Drug Therapy?
medications
- steroids, vasopressors agents
under research
- neuroprotective drugs, antibodies, stem cells
118
SCI - Nonoperative stabilization, what is it?
- focused on stabilization of injured spinal segment + decompression
- through traction or realignment
- eliminates damaging motion @ injury site
- intended to prevent secondary damage
119
# what is the purpose + what is used?
SCI - Immobilization of Cervical Spine
- stabilization + decompression
- intended to prevent/limit secondary damage
- maintain neutral/aligned position
--> traction (AxO pts only)
--> halo vest
--> SOMI brace (sternal-occipital mandibular-immobilizer)
120
# purpose + what is used?
SCI - Thoracic/Lumbar Spine Immobilization
- prevent/limit secondary injury
- maintain neutral/aligned position
--> thoraco-lumbar-sacral orthosis (TSLO brace): controls spinal flexion/extension/rotation
--> jewett brace: limits forward flexion
121
SCI Rehab + Home Care Considerations?
- rehab complex, can take long time
- physiological + psychological
- intensive + specialized
- home modifications
- vehicle modifications
- accomodations in workplace
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SCI collaborative care: immediate goals
- patent airway
- adequate ventilation
- adequate circulating blood volume
- treat systemic + neurogenic shock to maintain BP
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SCI collaborative care: thoracic + lumbar injuries
- less intense than cervical injury
- respiratory compromise not as severe
- bradycardia ≠ problem
- specific problems treated symptomaticlally
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SCI collaborative care: assessment
- motor + sensory exam, note spontaneous movements
- brain injury may have occurred, assess for unconciousness, signs of concussion, incr intracranial pressure
- mskl injuries
- trauma to internal organs
after stabilization, hx obtained
- how injury occurred
- extent of injury as perceived by pt
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What is autonomic dysreflexia?
- injury leve @ T6 or higher may develop autonomic dysreflexia
- massive uncompensated cardiovascular reaction mediated by SNS
- occurs in response to sustained painful/uncomfortable stim below T6
- most common precipitating factor = distended bladder or rectum
- if resultion doesn't occur, condition can lead to status epilepticus, stroke, MI, or death
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What are the manifestations of autonomic dysreflexia?
- HTN (in tetraplegia, normal BP = 90-100 mm Hg)
- blurred vision
- dilated pupils
- throbbing headache
- diaphoresis above injury level
- bradycardia (30-40 bpm)
- piloerection (erection of body hair)
- flushing of skin above injury level
- spots in visual field
- nasal congestion
- anxiety
- nausea
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Autonomic Dysreflexia - Nursing Interventions
- elevate HOB 45 degrees or sit pt upright (30 degree)
- assess cause
- remove stimulus
- notify MRP if symptoms don't resolve
if bladder distension is cause:
- instill lidocaine jelly + immediate catheterize
- if catheter in place, check for kinks + blockage
if stool impaction is cause:
- digital rectal exam should be performed only after application of anesthetic ointment to decr rectal stimulation + prevent incr in s/s
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What is ICP? and what can it be caused by?
ICP can lead to brain ischemia + infarction
- life-threatening situation resulting from incr in brain tissue, blood, csf
**brain** component: cerebral neoplasm, abscess, cerebral edema
**blood **component: hematoma, hemorrhage, metabolic/physiological factors, vascular anomalies
**CSF**: csf secreting tumors or hydrocephalus
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What factors influence ICP?
changes in:
- BP
- cardiac function
- intra-abdominal + intra-thoracic pressure
- body positoin
- temp
- blood gases
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What are the clinical manifestations of ICP?
- changes in LOC (early sign)
- ocular signs
- headache
- vomiting
late signs:
- changes in VS (cushing's triad)
- decr in motor function (decorticate/decerebrate)
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What are the types of head injuries?
- scalp lacerations: most minor type, blood loss + infection
- skull fractures: open/closed
- battle sign, bilateral periorbital ecchymosis, CSF rhinorrhea or CSF otorrhea
- intracranial infections, hematoma
- head trauma: diffuse injury or focal injury
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Nursing Care for pt with ICP?
- monitor GCS
- monitor neurological function, including cranial nerves
- vital signs
- respiratory function
- protection from injury - can be confused, agitated, risk for seizures
- psychological consideration: family
monitor for
- abdominal distension
- pain + anxiety
- opioid + sedative medication use
- ABGs
- lyte + fluid balance
- ICP (normal = 5-15 mm Hg)
- body position: HOB 30 degrees, monitor for extreme neck flexion
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what is post-concussion syndrome?
- 2 weeks to > 2 months
- persistent headache
- lethargy
- personality and behavioural changes
- shortened attention span/decr ST memory
- changes to intellectual ability, can affect ability to perform ADLs
- may req CT scan + admission to hospital for observation
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What is diffuse axonal injury (DAI)?
| Head trauma
- takes 12-24h to develop
- decr LOC, incr ICP
- decerebrate or decorticate posturing
- global cerebral edema
- severe DAI remain in persistent vegetative state
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What is a concussion?
diffuse head trauma
- may / may not lose consciousness
- brief disruption of LOC
- amnesia of event
- headache
- manifestations of short duration
- clinet usually discharged home
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Brain injury classification
mild: GCS 13-15
moderate: GCS 9-12
- significant cognitive impairment following injury
- often req CT scan + admission to hospital for observation
severe: GCS 3-8
- contusions, intracerebral lacerations, intracranial hemorrhage
- CT scan of brain + admission to hospital
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What are focal brain injuries?
- **lacerations**: active tearing of brain tissue
- **cranial nerve injuries**
- **contusion:** freq occurs near site of skull fracture, bruising of brain tissue within focal area
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what is a coup-contrecoup injury?
1. primary impact = coup -- brain strikes skull on side of impact
2. secondary impact = countrecoup, impacts posterior area of skull (opposite of 1st side of impact)
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What are some head injury complications?
1. **epidural hematoma:** collection of blood b/t dura + inner surface of skull
2. **subdural hematoma**: collection of blood that results from bleeding b/t dura & arachnoid of meningeal brain covering
3. **intraparenchymal / intracerebral hematoma**: collection of bld w/in parenchyma that results from bleeding within brain tissue itself
4. **traumatic subarachnoid hemorrhage**
- result of traumatic force damaging superfical vascular structures that exist in subarachnoid space
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what are some nursing interventions for head injuries?
- ensure patent airway
- spinal stabilization if needed
- monitor VS
- monitor LOC, GCS, neurologic status, symptoms of ICP
- ensure IV access + monitor fluid intake
- assess CSF rhinorrhea or otorrhea
