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Concept Map: Selected Topics in Neurological Nursing

ASSESSMENT PATHOPHYSIOLOGY PHARMACOLOGY

Physical Assessment Traumatic Brain Injury
Inspection Spinal Cord Injury --Decrease ICP
Palpation
Percussion --Disease /
Auscultation Specific Disease Entities:
Amyotropic Lateral Sclerosis Condition
ICP Monitoring
“Neuro Checks”
Multiple Sclerosis Specific Meds
Huntington’s Disease
Lab Monitoring Alzheimer’s Disease
Huntington’s Disease
Myasthenia Gravis
Guillian-Barre’ Syndrome
Meningitis
Parkinson’s Disease

Care Planning Nursing Interventions & Evaluation

Plan for client adl’s, Execute the care plan, evaluate for
Monitoring, med admin., Efficacy, revise as necessary
Patient education, Discharge
Planning, more…based
On Nursing Process: A_D_P_I_E
Objectives
Explain pathophysiology of various SCIs and related
conditions

Detail signs & symptoms and functionality of

different level SCIs

Differentiate between Neurogenic Shock and Spinal

Shock

Explain Autonomic Dysreflexia / Hyperreflexia and

list appropriate nursing interventions

Discuss overall medical & nursing management of

SCIs
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SCI Involves loss of:

Motor function
Sensory function
Reflexes
Control of elimination

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Common Causes SCI

Motor vehicle accidents (MVA)

MVA - Auto and motorcycle
accidents the leading cause of spinal cord injuries

Acts of Violence – mostly gunshot wounds

Falls – SPI after age 65 is often caused by a fall

Sports and recreation injuries - Impact sports and diving in

shallow water * ATV *

Diseases - Cancer, infections, arthritis and inflammation

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 Breakdown of Road
Traffic Accident
Statistics

Breakdown
of Sports
Statistics

Breakdown of Fall
Statistics

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SCI Type
Incomplete / Partial spinal cord injury
- Spinal cord is able to convey some messages to or
from the brain. Therefore, retain some sensation and
possibly some motor function below the affected area

Complete injury
- Complete loss of motor function and sensation below
the area of injury

**** Even in a complete injury, the spinal cord is almost never completely cut in half.
Doctors use the term "complete" to describe a large amount of damage to the spinal
cord.

It's a key distinction because many people with partial spinal cord injuries are able to
experience significant recovery, while those with complete injuries are not

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Complete or Partial ?

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Compressison / Wedge Fracture
 As the forces push forwards
and backwards, pressure is
applied to the front and/or
back of the spinal bones
causing damage in these
areas as indicated by the
arrow
 In these injuries, direct
compression forces
downwards literally squash
the bones, resulting in a loss
of height seen on x-ray. This
x-ray also shows a chip
fracture at the front of the
lumbar vertebrae (green
arrow)
arrow (See how much
bigger and stronger this bone
is compared to the cervical
bone in the picture on the
left)

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Spinal Cord Injury
Most trauma to the spinal cord causes permanent
disability or loss of movement (paralysis) and
sensation below the site of the injury

Paralysis can involve all four extremities, a condition

called quadriplegia or tetraplegia, or only the lower
body, a condition called paraplegia

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 C4
C6

T6

L1

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SCI Causal Categories

 Traumatic spinal cord injury may stem from:

- Sudden, traumatic blow that fractures, dislocates,
crushes or compresses one or more of vertebrae
- Gunshot or knife wound that penetrates and cuts your
spinal cord
- Additional (secondary) damage usually occurs over days
or weeks because of bleeding, swelling, inflammation and
fluid accumulation in and around spinal cord

 Non-traumatic spinal cord injury may be caused by

arthritis, cancer, blood vessel problems or bleeding,
inflammation or infections, or disk degeneration of the
spine
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Risk factors
Gender - Spinal cord injury affects a disproportionate amount of
men

Age – (Young adults and seniors)

- Between ages 16 and 35 / MVA leading cause
- Another peak in people older than 60 / falls leading cause

People active in sports – High risk athletic activities include

football, rugby, wrestling, gymnastics, diving, surfing, ice hockey
and downhill skiing

Predisposing conditions - A relatively minor injury can cause

spinal cord injury in people with conditions that affect their
bones or joints, such as arthritis or osteoporosis
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 At
the
Scene

Priorities
1. Maintaining ability to breathe
2. Preventing shock
3. Immobilization to prevent
further spinal cord damage
(Backboard & C-Collar)
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Vertebrae Commonly Involved

C5

T12

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Baseline Assessment At Scene &
Upon Arrival to ER

ABCs / ATLS assessment includes

Vital Signs & Glasgow Coma Score

Neck / Spine stabilization

Maintaining BP

Multisystem support

May be sedated

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Diagnosis
X-Ray

C-Spine

FIRST !!

Swimmer’s
View

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 Be Vigilant !
Spinal cord injury isn't always obvious

Numbness or paralysis may result immediately after a spinal

cord injury or gradually as bleeding or swelling occurs in or
around the spinal cord

In either case, time between injury and treatment is a critical

factor that can determine the extent of complications and the
level of recovery

It's safest to assume that trauma victims have a spinal cord

injury until proved otherwise

If you suspect that someone has a back or neck injury

Spinal Immobilization STAT !
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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 ?

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Mechanism of Injury

Different
mechanism
of injury

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CT Scan

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MRI

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Continued…
MRI – For identifying herniated disks, blood clots or other
masses that may be compressing the spinal cord. But…
MRI can't be used on people with pacemakers or on trauma
victims who need certain life-support machines or cervical
traction devices

Myelography - Dye injected into spinal canal then X-rays

or CT scan can suggest a herniated disk or other lesions.
Used when MRI isn't possible

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Primary Spinal Injury

Result of initial
trauma

Injury usually
permanent

©2000 Brian Smith

Greg Louganis's Diving Accident, 1988 Sports Illustrated
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Secondary Spinal Injury
Occurs after Spinal cord trauma
Damage at cellular level
Necrosis (Cells swell, burst and leak toxic substances to other
cells)

 Apoptosis (Programmed cell death / cell suicide to prevent

bursting)

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Secondary SCI

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Secondary SCI

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SCI Disability

1. Depends on Location

Injuries (lesion) higher in the spinal cord produce more paralysis

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SCI Disability
2. Depends on type of injury

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Spinal Cord - Horizontal View

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American Spinal Injury Association (ASIA) Classification

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Incomplete / Partial SCI
Central

Lateral / Brown-Sequard Syndrome

Anterior

Posterior

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Anterior Cord Syndrome
Damage o front 2/3 of spinal cord, loss of pain and temperature
sensation, and motor function below level of injury

Light touch (pressure) and position and vibration sensation preserved

Possible for some people with this injury to later recover some
movement

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Central Cord Syndrome
Usually with unbelted MVA and falls of elderly

Typically results greater weakness in arms vs lower extremities

Sensory loss varies but more severe in upper extremities

Control over the bowel and bladder varies and may be preserved

Possible for some recovery from this type of injury, usually starting in
the legs, gradually progressing upwards

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Brown-Sequard Syndrome
Usually stab or GSW

Damage is towards one side of the spinal cord

Ipsilateral (same side as the cord injury) Impaired or loss of

movement, touch, pressure and vibration
** (Hemiparaplegia)

Contralateral (opposite side of cord injury) loss of pain and

temperature sensation ** (Hemianesthesia)

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Posterior Cord Syndrome
Damage is towards the back of the spinal cord

May leave the person with good muscle power, pain

and temperature sensation

However they may experience difficulty coordinating

movement of their limbs

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Motor (blue) and
Sensory (red) axons
in the spinal cord
and peripheral
nerves.

Sensory neurons
reside in the dorsal
root ganglia (DRG)
while Motoneurons
reside in the spinal
cord and innervate
muscle (yellow).

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SCI Goals of Care
There's no way to reverse damage

Treatment focuses on:

1. Preventing further injury

2. Enabling people to return to an active and

productive life within the limits of their disability

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