Nursing Care of the Patient

with Neurologic
Dysfunction
Infectious Disease of the Nervous
system, Degenerative Diseases, Cranial
Nerve disease, Spinal Cord Injuries,
Spinal Cord Tumour, CVA
September 11, 2017
OBJECTIVE

At the end of the session the students should

be able to:
describe the mechanism of injury, clinical

signs and symptoms, diagnostic testing and the

treatment options for patients with traumatic
brain and spinal cord injuries.

formulate and use the nursing process to care

for the patient with traumatic brain injury
OBJECTIVE
 differentiate among the infectious disorders of
the Nervous System according to causes,
manifestations, medical care and nursing
management

 develop a plan of care for the patient with

cranial nerve disorders
OBJECTIVE

 describe brain and spinal cord tumours, their

classifications, clinical manifestation,
diagnoses, medical and nursing management

 review the pathophysiological processes

responsible for various degenerative
disorders
OBJECTIVE

 describe the incidence and social impact of

Cerebrovascular disorders

 compare the various types of CVA disorders,

aetiology, clinical manifestation and medical
management
INFECTIOUS NEUROLOGIC
DISORDERS

MENINGITIS
Meningitis
Definition: inflammation of the meninges.

The severity of the disease is dependent upon:

 The specific micro-organism involved

 The presence of other neurological disorders

 The general health of the patient

 The speed of diagnosis, and

 The initiation of treatment

 Causes of Meningitis
Infectious microorganisms travel to the meninges via
the bloodstream or through direct extension from an
infected area (such as the middle ear or paranasal
sinuses).
Common microorganisms include:
 Meningococcus
 Streptococcus
 Staphylococcus
 Pneumococcus
Contaminated head injury
Infected shunt
Contaminated lumbar puncture.
Pathophysiology
 Entry is either bloodstream as a result of
infection or invasive procedure

 Enters the blood- brain barrier and multiply in

CSF

 Due to small space in brain edema may cause

ICP
Describe the Signs and Symptoms
Signs and Symptoms of Meningitis
 Elevated temperature
 Chills
 Headache (often severe)
 Nausea, vomiting
 Nuchal rigidity (stiffness of the neck)
 Photophobia.
 Opisthotonos (extreme hyperextension of the head
and arching of the back due to irritation of the
meninges).
 Altered level of consciousness.
 Multiple petechiae on the body.
Diagnostic Evaluation Procedures
 Blood cultures (key)
 Physical examination
 Lumbar puncture to identify the causative
organism in the cerebrospinal fluid
 Computed Tomography (CT)
 Magnetic Resonance imagining (MRI)
Medical Management
Early detection and administration of :
Antibiotics e.g. Vancomycin hydrochloride

combined with cephalosporins eg. ceftriaxone

sodium
Dexamethasone

Fluid volume expanders (shock, dehydration)

Phenytoin (seizures)
Nursing Management
 Administer intravenous fluids and medications.

 Antibiotics should be started immediately

 Corticosteroids may be used for the critically ill

patient

 Drug therapy may be continued after the acute

phase of the illness is over to prevent recurrence.
Nursing Management
 Record intake and output carefully, observe patient
closely for signs of dehydration due to insensible
fluid loss
 Monitor vital signs and neurological status and
record. (pulse oximetry, arterial blood gases)
 Level of consciousness. Utilize GCS for accuracy
and consistency
 Monitor rectal temperature at least every 4 hours
and, if elevated, provide cooling measures and
administration of ordered antipyretics .
Nursing Management

 During isolation measures, inform family

members

 Ensure staff compliance of isolation procedures

in accordance with OSHA standard operating
procedures (SOP).

 Provide basic patient care needs.

 Nursing Management
 Maintain dim lighting in the patient's room to
reduce photophobic discomfort

 Provide discharge planning information to the

patient and family

 Follow up appointments with the physician

 Discharge medication instruction

 Possible follow-up with the community health
nurse
BRAIN ABSCESS

 Occurs as a result of an underlying disorder and

in persons who are immunosuppressed

 Common in males

 Frequent within the first two decades

Pathophysiology
 Infectious substance collected within the brain
 Bacteria is the most frequent organism
 Can result from intracranial surgery,
penetrating head injury or tongue piercing

 The abscess develops when organism access

the brain through hematologic spread from
lungs, gums, tongue, heart and intra
abdominal wounds.
Clinical Manifestations
 Headaches

 Fever

 Vomiting

 Focal neurologic deficit e.g. weakness,

decrease vision
 Increase ICP
Diagnostic Findings

 MRI

 CT (ring around a hypodense area)

 Aspiration

 Chest X-ray
Medical Mgtment

 Intravenous antimicrobial therapy

 Corticosteroids

 Anti-seizure medication
Nursing Mgtment
 Ongoing neurologic status

 Administer medication

 Blood test especially blood glucose and

serum potassium

 Patient safety
ENCEPHALITIS
Herpes Simplex virus

 An acute inflammatory process of the brain

tissue

 HSV-1 (children and adults)

 HSV-2 (neonates)
Pathophysiology

 This constitutes local necrotized bleeding that

Is eventually generalized

 Break down of nerve cell bodies occurs.

Clinical Manifestations
 Fever
 Headache
 Confusion
 Behavioural changes
 Seizures
 dysphasia
Diagnostic Findings

 EEG
 CSF examination
 MRI
 Polymerase chain reaction
Medical management

 Antiviral e.g. Acyclovir

 Continue treatment up to three weeks

Nursing management

 Continue Neurological assessment

 Comfort measures (headaches, noise)

 Administer analgesics

 Monitor blood chemistry

Arthropod-Borne Virus

 Caused by vectors

 Primary vectors- mosquito (North America)

birds (West Nile virus)

 Secondary vector- humans

Pathophysiology
 Viral replication
 Host immune system attempts control
 Inadequate response viremia ensues
 Virus migrates to Central Nervous System
via cerebral capillaries
 Spreads from neuron to neuron cortical grey
matter, brain stem, thalamus
 Meningeal exudates ensues- irritate meninges
 Increasing ICP
Clinical manifestation and diagnostic
findings
 Early flulike symptoms
 Rash on neck, trunk, arms (West nile)
 Parkinsonian like movements (both)
 Seizures (both)

 Neuroimagining
 Immunoglobulin M antibodies (serum,CSF)
Medical Management

 No Specific Medication
 Control seizures
 Manage increase ICP
Nursing Mgt

 Assess neurological status

 Note improvement or deterioration
 Prevent injury
 Family support
 Education (prevent mosquito bites,ticks)
FUNGAL

 Occurs rarely
 Geographic area
 Compromised immune system-medication
 Organism – Cryptococcus neoformans
 Exposure to bird droppings, handlers
Pathophysiology

 Spores enters via inhalation

 Infect lungs
 Fungemia
 Overwhelms immune system-spreads to CNS
Clinical Manifestation and
Diagnostic findings
 Fever
 Malaise
 Headache
 Change in LOC, cranial nerve
 Increase ICP related to hydrocephalus

 CSF –elevated WBC, protein levels (C.

neoformans
 Blood cultures-
Medical Mgtment

 Causative agent identified

 Medication to control seizures
 Lumber puncture
 Antifungal agents given- amphotericin B- IV
 Maintenance dose
Nursing Mgtment

 Early recognition of IICP –control and

management
 Non-opioid analgesic
 Diphenhydramine (Benadryl) prevent flulike
symptoms
DEGENERATIVE DISORDERS

PARKINSONS
What is Parkinson’s Disease?
 https://www.youtube.com/watch?
v=wM2SP_V-hfE
Parkinson’s Disease
Definition
Parkinson's disease is a progressive neurological
disorder affecting the brain centers that are
responsible for control of movement.
Primary degenerative changes of the basal ganglia
and their connections prevent motor transmission of
automatic movements (blinking, facial expressions,
muscle tone).

The exact cause of Parkinson's is unknown.

Suspected causes include genetic factors, viruses,
chemical toxicity, encephalitis, and cerebrovascular
disease.
Pathophysiology

 Linked to decreased levels of dopamine

 Neurotransmitter controls complex body
movements
 Acetylcholine- excitory
 Dopamine- inhibitory
 Creates imbalance that affects voluntary
action
Parkinson’s signs and symptoms
 Bradykinesia, which usually becomes the most
disabling symptom

 Tremor which tends to decrease or disappear on

purposeful movements

 Rigidity, particularly of large joints

Signs and Symptoms (Cont’d)
 Classic shuffling gait

 Muscle weakness which affects eating, chewing,

swallowing, speaking, writing

 Mask-like facial expression with unblinking eyes

 Depression

 Dementia
Nursing Management
 Eat a well-balanced diet. Nutritional problems
develop from difficulty chewing and swallowing
and dry mouth from medications

 Encourage patient to be an active participant in

his/her therapy and in social and recreational
events, as Parkinsonism tends to lead to
withdrawal and depression

 Support groups in some countries. Jamaica none

as yet.
Alzheimer’s Disease
http://www.webmd.com/alzheimers/ss/slideshow-alzheimers-overview
 “Alzheimer’s causes nerve cell death and
tissue loss throughout the brain. As the
disease gets worse, brain tissue shrinks and
areas that contain cerebrospinal fluid become
larger. The damage harms memory, speech,
and comprehension.”

http://www.webmd.com/alzheimers/ss/slideshow-alzheimers-overview
 Client with Alzheimer’s Disease
 Form of dementia characterized by progressive,
irreversible deterioration of general intellectual
functioning

 Begins with memory loss (initially subtle)

 Progresses: deteriorating cognition and judgment

 Eventually physical decline and total inability to

perform ADL.
Risk factors
 Older age

 female

 family history

 Exact cause is unknown; theories include loss of

transmitter stimulation, genetic defects, viral and
autoimmune cases.
Warning signs include:
 Memory loss affecting ability to function in job

 Difficulty with familiar tasks

 Problems with language, abstract thinking

 Disorientation, changes in mood and

personality.
Manifestations : Stage I
 Appears healthy and alert

 Cognitive deficits are undetected

 Subtle memory lapses, personality changes

 Seems restless, forgetful, uncoordinated.

Stage II
 Memory deficits more apparent

 Less able to behave spontaneously

 Wandering behavior, deterioration in orientation to

time and place

 Changes in sleeping patterns, agitation, stress

Stage II
 Trouble with simple decisions

 Sundowning: increased agitation, wandering,

disorientation in afternoon and evening hours

 Echolalia, scanning speech, total aphasia at

times, apraxia, astereognosis, inability to write

 Becomes frustrated and depressed

 Stage III
 Increasing dependence with inability to
communicate, loss of continence

 Progressive loss of cognitive abilities, falls,

delusion, paranoid reactions

 Average life expectancy is 7 years from

diagnosis to death, often from pneumonia,
secondary to aspiration
Collaborative Care

 No cure
 Supportive care for client and family
 Diagnostic Tests
 Diagnosis by ruling out other conditions including
depression, hypothyroidism, infection, stroke

 EEG shows slow pattern in later stages of

disease

 MRI and CT scan: shrinkage of hippocanthus

(section of brain that facilitates memory)
Diagnostic Tests (Cont’d)

 Positron emission tomography (PET):visualizes

brain activity and interactions

 Folstein Mini-Mental Status: instrument reflecting

loss of memory and cognitive skills.
 Medications
 Cholinesterase inhibitors used to treat mild to
moderate dementia

 Tacrine hydrochloride (Cognex)

 Donepezil hydrochloride (Aricept)

 Rivastigmine (Exelon)

 Medications to treat depressions

 Medications
 Tranquilizers for severe agitation

 Thioridazine (Mellaril)

 Haloperidol (Haldol)

 Antioxidants: vitamin E, anti-inflammatory

agents, estrogen replacement therapy in
women
Complementary Therapy

 Massage, herbs, ginko biloba, Coenzyme

Q10

 Art therapy, music, dance

 Nursing Care
 Monitor vital signs and LOC

 Keep requests simple and avoid confrontations

 Maintain a consistent environment and frequently

reorient the patient

 Maintain functional abilities

 Maintain safety of client and caregiver

 Nursing Diagnoses
 Impaired Memory
Include written or verbal reminders
Use cues to deal with memory loss

 Chronic Confusion
 Anxiety
 Hopelessness
 Caregiver Role Strain
 Home Care
 Education regarding disease, anticipation of
needs, use of memory cues, support groups and
peer counseling

 Advise family that, as AD progresses, so does the

need for supervision of ADLs such as cooking and
bathing

 Advise family to lock windows and doors to

prevent wandering.
Home Care (Cont’d)

 Explain that patient should wear a ID bracelet, in

case he/she gets lost

 Refer to home health agencies, family support,

group support.
SPINAL CORD TUMOURS (SCT)
Classification of SCT

 Intramedullary lesion (within the spinal cord

 Extramedullary-intradural lesion (within or

under the spinal dura)
Spinal Cord Tumours

Signs and Symptoms

Localized or shooting pain

Weakness

Loss of reflexes above tumor

Loss of motor function

Paralysis

Sensory deficit below level of tumor

Assessment and Diagnostic Findings
 Neurological examination includes
assessment of pain, loss of reflexes, loss of
sensation or motor function, presence of
weakness, paralysis.
 Pain duration- longer than a month
 Elevated erythrocyte sedimentation rate
 X-rays
 Radionuclide bone scan
 CT and MRI
Medical Mgtment

 Primary treatment –Surgery

Not always possible

 Successful treatment depends on degree of

impairment, the speed at which symptoms
occur, origin of tumour.
Nursing Management
Assist with ADL
Bowel and bladder, weakness, sensory and

motor deficits, spasticity, muscle wasting

After surgery- monitor for deterioration in

neurologic status- sign of vertebral collapse

Check for movement, strength, sensation

Pinching of skin, arms, vital signs

Pain control
CRANIAL NERVE DISORDER
Trigeminal Neuralgia
 Definition: Trigeminal Neuralgia, also
known as Tic Douloureux, is a disorder of
the 5th cranial nerve/trigeminal nerve;
(responsible for facial sensation, corneal reflex and mastication).

 Characterized by sudden paroxysms of

burning pain along one or more of the
branches of the trigeminal nerve.

 Pain alternates with periods of complete

comfort.
 Signs and Symptoms
 Sudden, severe pain appearing without warning-
along one or more branches of trigeminal nerve

 Numerous individual flashes of pain, ending

abruptly and usually on one side of the face only

 Attacks provoked by pressure on a "trigger point"

(the terminals of the affected branches of the
trigeminal nerve).
Signs and Symptoms
Such triggers include:
 Shaving

 Talking

 Yawning

 Chewing gum

 Cold wind
 Nursing Care Considerations
Instruct patient to avoid exposing affected cheek
to sudden cold if this is known to trigger the nerve.

Triggers to avoid:
Iced drinks
Cold wind
Swimming in cold water
Administer drug therapy, as ordered

Tegretol or Dilantin--relieves and prevents pain in some

patients.
 Nursing Care Considerations
Serum blood levels of drug are monitored in long term
use

Surgical procedures to sever the affected nerve

provide optimum pain relief with minimum
impairment

Instruct patient in methods to prevent environmental

stimulation of pain
Nursing Care Considerations

Eat foods that are easily chewed and are served

at room temperature

Avoids drafts and breezes.

CEREBROVASCULAR
ACCIDENT(STROKE, BRAIN
ATTACK)
CVA
Cerebral vascular accident (CVA) (stroke)
CNS dysfunction
The disruption of the blood supply to the brain,
resulting in neurological dysfunction
 CVA
Causes
Thrombosis-blood clot within a vessel in the brain
or neck

Cerebral embolism

Stenosis of an artery supplying the brain

Cerebral hemorrhage-rupture of a cerebral blood

vessel with bleeding/pressure into brain tissue.
Risk Factors
Risk Factors
 Hypertension

 Previous transient ischemic attacks (TIA)

 Cardiac disease (atherosclerosis,

arrhythmias, valvular heart disease)

 Advanced age

 Diabetes
Differentiate the 2 Types of stroke
Pathophysiology
Ischemic Hemorrhagic
85% of all strokes
 15% of CVA
Blood vessels obstructed due
 Bleeding into the brain
to disruption in blood flow.
tissue, ventricles.
CBF to less than 25 mL/100g
 Metabolism interrupted by
of bld/min.
brain being exposed to
 Mitochondria switch to
blood.
anaerobic respiration- lactic
acid.
Neurons unable to produce

adenosine triphosphate (ATP)


 Signs and Symptoms

 Highly dependent upon size and site of lesion

 Motor loss--hemiplegia (paralysis on one side of the

body) or hemiparesis (motor weakness on one side
of the body)

 Communication impairment

 Receptive aphasia (inability to understand the

spoken word).
 Penumbra Region (area of low blood flow):
around the area of infarction. If treatment is
delayed death of neurons result

 Rate of destruction: 1.9 mil. Neurons each

minute without treatment

 Ischaemic brain ages 3.6 years/hour.

What are the Signs and Symptoms
of CVA?
S&S
 Expressive aphasia (inability to speak)

 Vision loss

 Sensory loss

 Bladder impairment

 Impairment of mental activity

 Signs and Symptoms

Onset of symptoms is sudden

 Level of consciousness varies from

lethargy, to mental confusion, to deep coma

 Blood pressure may be severely elevated

due to increased intracranial pressure

 Patient may experience sudden, severe,

headache with nausea and vomiting
S&S
 May remain comatose for hours, days, or even
weeks and then recover

 Longer the coma, the poorer the prognosis

 ICP is a frequent complication resulting

from hemorrhage or ischemia and subsequent
cerebral edema.
What is the objective of Medical and
Nursing Management?
Medical and Nursing Management
during the Acute Phase
Objectives of care during the acute phase:

 Keep the patient alive

 Minimize cerebral damage by providing

adequate oxygenated blood to the brain

 Support airway, breathing, and circulation.

Medical and Nursing Management
during the Acute Phase
Maintain neurological flow sheet with frequent
observations of the following:
 Level of consciousness

 Pupil size and reaction to light

 Patient's response to commands.

Nursing Management
 Movement and strength

 Patient's vital signs--BP, pulse, respirations, and

temperature

 Be aware of changes in any of the above

 Deterioration could indicate progression of the

CVA.
Medical and Nursing Management
during the Acute Phase
 Reorient patient to person, place, and time (day,
month) even in a coma

 Confusion results when regaining

consciousness, or due to a neurological deficit

 Maintain proper positioning/body alignment

 Prevent complications of bed rest.

 Medical and Nursing Management during
the Acute Phase

 Apply foot board, sand bags, trochanter rolls,

and splints as necessary

 Keep head of bed elevated 30º, or as ordered,

to reduce increased intracranial pressure

 Place air mattress or alternating pressure

mattress on bed and turn patient every two
hours to maintain skin integrity.
Medical and Nursing Management during
the Acute Phase
 Ensure adequate fluid and electrolyte balance

 Fluids may be restricted in an attempt to reduce

intracranial pressure (ICP)

 Intravenous fluids are maintained until patient's

condition stabilizes, then nasogastric tube feedings
or oral feedings are begun depending upon
patient's abilities

 Administer medications, as ordered.

Medical and Nursing Management
during the Acute Phase
 Anti-hypertensive drug

 Antibiotics, if necessary

 Seizure control medications

 Anticoagulants
Medical and Nursing Management
during the Acute Phase
 Sedatives and tranquilizers are not given
because they depress the respiratory center and
obscure neurological observations

 Maintain adequate elimination.

Medical and Nursing Management
during the Acute Phase

 A Foley catheter is usually inserted during the

acute phase; bladder retraining is begun during
rehabilitation

 Provide stool softeners to prevent constipation.

Straining at stool will increase intracranial
pressure.
 Medical and Nursing Management
during the Acute Phase

 Include patient's family and significant others in

plan of care

 Allow them to assist with care

 Keep them informed and help them to

understand the patient's condition.
Rehabilitation of the Patient with CVA

 Include patient when setting goals for

rehabilitation

 Teach patient to use strength and abilities that

are intact to compensate for impaired functions

 Learning to become independent in activities of

daily living (bathing, dressing, eating).
Rehabilitation of the Patient with CVA

 Developing behavior patterns that are likely to

prevent the recurrence of symptoms

 Taking prescribed medications

 Stop smoking

 Reducing day-to-day stress

 Modifying diet.
 Rehabilitation CVA
 Specific teaching, encouragement, and support
are needed

 Individualized exercise program involving both

affected and unaffected extremities is required

 Speech therapy, as indicated by patient's

condition, may be necessary

 Continuous revaluation of goals and patient's

ability to meet the goals is required to maintain a
realistic plan of care.
Rehabilitation CVA
 Counseling and support to family is an
integral part of the rehabilitation process

 Both family and patient need direction and

support in coping with intellectual and
personality impairment

 Instruct family to expect some emotional

lability such as inappropriate crying,
laughing, or outbursts of temper.
Brain Tumour
Brain Tumor

 Definition: A brain tumor is a localized

intracranial lesion which occupies space
within the skull and tends to cause a rise in
intracranial pressure.
Signs and Symptoms

 A brain tumor is usually characterized by a

progressive course of symptoms over a period of
time

 Symptoms depend primarily on the location of

the mass
Signs and Symptoms (Cont’d)

 Symptoms related to increased intracranial

pressure will occur
 Decrease in level of consciousness -confusion.

 Headache, Lethargy, Vomiting,

 Papilloedema--edema of optic nerve

 Alterations in mentation. Aphasia

 Hemiparesis

 Visual field defects

 Sensory defects (smell, hearing)

 Seizures.
 Nursing Management
Preoperative Medical and Nursing Management.
Instruct patient and family about the necessity and
importance of diagnostic tests to determine the exact
location of the tumor

Monitor and record vital signs and neuro status

accurately q2-4h, or as ordered. Report changes to
charge nurse immediately

Institute measures to prevent inadvertent increases

in ICP
- Elevate head of bed 30º.
- Stool softeners to prevent straining at stool.
Nursing Management

Preoperative Medical and Nursing

Management.
Institute seizure precautions at patient's
bedside

Supportive nursing care is given depending

upon the patient's symptoms and ability to
perform activities of daily living
 Nursing Management

 Administer all doses of steroids and antiepileptic

agents on time
- Withholding steroids can result in adrenal
crisis)
- Withholding of antiepileptic agents frequently
precipitates seizure

 Surgery (craniotomy) is performed to remove

neoplasm and alleviate symptoms.
Post Operative Nursing Care
Considerations
 Meticulous nursing management and care aimed at
prevention of post-op. complications –critical for
patient's survival

 Accurately monitor and record all vital signs and

neurological signs.
- Postoperative cerebral edema peaks between
48 and 60 hours following surgery.

- Patient may be lucid during first 24 hours, then

experience a in level of consciousness during
this time.
Post Operative Nursing Care
Considerations
 Administer artificial tears (eye drops) as ordered,
to prevent corneal ulceration in the comatose
patient

 Maintain skin integrity

 Bone flap may not have been replaced over

surgical site; turning patient to the affected side,
if the flap has been removed, can cause
irreversible damage in the first 72 hours

 Maintain head of bed at 30ºelevation.

Post Operative Nursing Care
Considerations
 Perform passive range of motion exercises to all
extremities every 2-4 hours

 Maintain body temperature

 of body temperature in the neurosurgical patient

may be due to cerebral edema around the
hypothalamus

 Monitor rectal temperature frequently

 Place patient on hypothermia blanket, as ordered.

Post Operative Nursing Care
Considerations
 Institute seizure precautions at patient's bedside
(airway)

 Maintain accurate record of intake and output

 Prevent pulmonary complications associated with

bedrest.
Post Operative Nursing Care
Considerations
 Cough and deep breathing every 2 hours

 Perform gentle chest percussion, with the patient in

the lateral position, if allowed / tolerated

 Continuously talk to the patient while providing care,

reorienting him to person, place, and time.
Head Injury
TERMINOLOGIES

 Concussion – a temporary loss of neurological

function with no apparent structural damage to
the brain

 Contusion – bruising of brain surface

 Primary injury – initial damage to the brain that

results from the traumatic event.
TERMINOLOGIES

 Secondary injury – an insult to the brain

subsequent to the original traumatic event

 Monro-Kellie doctrine – the cranial vault is a

closed system, if one of the three components
increases in volume, at least one of the other
two must decrease in volume, or the pressure
increases.
Head Injury
 A broad classification including injury to the:
 Scalp

 Skull

 Brain

 A head injury may lead to mild concussion to coma

and death

 The most serious form of head injury is called TBI

– traumatic brain injury.
Skull / Brain Injuries
Skull Fractures
A skull fracture is a break in the continuity of the
skull bones or a separation of the sutures

 Basilar skull fractures are potentially serious

injuries due to the proximity of the brain stem

 Depressed skull fractures may be open or

closed. In either case, the underlying brain
tissue may be damaged

 Linear skull fractures are "cracks." They may be

dangerous if they overlie vascular structures.
Brain Injury

 Contusion

 Concussion

 Haematomas – epidural, subdural,

subarachnoid.
 Concussion: Concussion results from violent
jarring of the brain against the interior of the
skull. The patient experiences a brief loss of
consciousness followed by confusion, headache,
and irritability. Complete recovery is usual.

 Contusion: This injury is more serious than a

concussion. The severe jarring of the brain
causes bruising of the brain. (This bruising is the
result of blood vessel rupture.) Permanent
damage may result.
Hematomas are a result of bleeding within the
closed compartment of the skull. They may cause
compression of brain tissue.

 Epidural hematoma is caused by bleeding

between the skull and the dura

 Subdural hematoma is caused by bleeding

between the dura and the arachnoid membrane.

 Subarachnoid hemorrhage/hematoma is caused

by bleeding into the subarachnoid space.
 Nursing Interventions
 Monitor neurological functions

 Maintain airway

 Fluid and electrolyte balance

 Adequate nutrition

 Prevent injury

 Maintain body temperature

Nursing Interventions

 Maintain skin integrity

 Improve cognitive functioning

 Prevent sleep pattern disturbance

 Supporting family coping

 Monitor and managing potential complications

Spinal Cord Injuries
https://www.google.com.jm/search?
q=image+of+spinal+cord&dcr=0&tbm=isch&imgil=6-eGIU8JumiZpM%253A
Spinal Cord Injuries
Common causes of spinal cord injuries include:
 Automobile accidents

 Athletic injuries (diving, hard-contact sports)

 Falls

 Gunshot wounds, stab wounds.

 Industrial accidents
 Visit website:
http://www.spinalinjury101.org/details/levels
-of-injury
“Some clients have been paralyzed from :
inflammation of the spinal cord (transverse
myelitis)- viral diseases (Lyme disease, West Nile
virus, influenza, etc).

The level of injury ranges from C2 to L2 with

diagnoses of complete or incomplete. Much like a
fingerprint, no two injuries or clients are alike.”
http://www.projectwalk.com/Disabilities/Spinal-Cord-
Injury.asp
Spinal Cord Injuries

Common locations of spinal cord injuries

 Flexion-extension injuries are commonly located

at C4 - C7 ("whiplash")

 T11, T12, and L1 are frequent sites of spinal

cord injury resulting from falls.
Spinal Cord Injuries

Mechanisms of spinal cord injury

 Flexion-extension: whiplash, seen with rapid

deceleration injuries.

 Subluxation: incomplete or partial dislocation.

 Torsion: twisting of the spinal cord.

 Compression.
Pathophysiological Changes
 Damage to the cord may be:
- a concussion
- contusion
- laceration
- compression or,
- complete transection (severing) of
the cord)
 Cord's response to injury includes
hemorrhage, ischemia, and edema
Spinal Cord Injuries Signs and
Symptoms
 Patient's symptoms will mirror the level of the
cord injury

 There will be total sensory loss and motor

paralysis below level of the injury

 Cervical spinal cord injuries will produce

quadriplegia/tetraplegia--loss of function of all
four extremities

 Injuries to the thoracic spinal cord below the

level of T1 will produce paraplegia--paralysis of
the lower extremities.
 Spinal Cord Injuries Signs and
Symptoms
Loss of bowel and bladder control; usually urinary
retention and bladder distention

 Loss of sweating and vasomotor tone below the

level of the cord injury

 Marked reduction of blood pressure due to loss of

peripheral vascular resistance

 Neck/back pain

 Priapism--persistent, painful erection of the penis.

Diagnostic Findings

 Detailed Neurological Findings

 X- Ray
 CT
 MRI
 Myelogram
Medical Mgtment
 Corticosteroids IV -high dose

 Oxygen administration

 Endotracheal intubation

 Fracture reduction (cervical)

 Surgery
Nursing Management

Objectives of care:
Reduce the fracture/dislocation and obtain
immobilization of the spine as soon as possible to
prevent further cord damage

Observe for symptoms of progressive

neurological damage

Maintain patient on a turning frame or Circo-

lectric bed to maintain spinal alignment
 Nursing Management

 Patient with cervical spine injury will have some

form of skeletal traction. Maintain traction and
provide nursing care in accordance with local
policy.

 Continuously observe patient's breathing pattern.

- Patients with injuries at high levels are at
risk for respiratory failure

- Observe strength of cough effort.

Nursing management
Continuously observe patient for motor and
sensory changes due to cord edema or
hemorrhage, which may further compromise cord
function

Testpatient's motor ability by asking him/her to

spread fingers, grip your hands, shrug shoulders,
etc.

 Test sensory level by gently pinching the skin at

shoulders and progressing down sides; ascertain
level at which patient can no longer feel pinch.
Nursing management

 Note presence/absence of sweating.

 Carefully record findings in patient's clinical

record; report changes in patient's
motor/sensory level immediately to professional
nurse.

 Be alert for signs of spinal shock and report

immediately
Nursing management
 Spinal shock represents a sudden loss of
continuity between the spinal cord and higher
nerve centers

 It is characterized by a complete loss of motor,

sensory, reflex, and autonomic activity below the
level of the injury

 Though temporary, spinal shock may last for

several weeks.
 Nursing Management

 If turning is allowed and patient is not on a turning

frame or turning bed, the patient must be carefully
log-rolled with the spine maintained in alignment.

 Surgery, depending upon the injury and

pathological findings, may have to be performed to
stabilize the spine before rehabilitation can begin

 Patient will require passive range of motion

exercises.
 Assist with active rehabilitation procedures when
patient is stable.

- Program is designed according to

neurological deficit

- Usually involves 6 weeks of gradual

mobilization with brace or cast, depending
upon level of injury

 Provide constant encouragement and psychological

support to the patient with a spinal cord injury.
Complications

 Spinal and Neurologic shock

 Deep Vein Thrombosis

 Pulmonary Embolism
NEUROLOGICAL SURGERY
Approaches depends on the type of tumour,
location and its accessibility
 Craniotomy

 Burrholes

Nonsurgical
 Stereotactic procedures – use of a three

dimentional frame that allows very precise

localisation of the tumor.
Craniotomy
The scalp is shaved, to gain access to the area for
surgery

Incision is made through the skin, a high speed drill

and special saw are used to remove a small piece of
bone above the tumour

The tumour- located and removed

Usually the bone is then replaced and incision
stitched closed.
Craniotomy

A scalpel, laser, ultra sound devise maybe used to

get rid of the tumour

Sometimes the flap is not replaced until a while

after e.g. in raised intracranial pressure
Craniotomy

INDICATIONS
 Removal of tumour

 Relief of elevated ICP

 Evacuation of blood clots

 Control of haemorrhage
BURR HOLES

What are Burr Holes?

BURR HOLES

Instead of performing a craniotomy,

intracranial structures could be approached
through burrholes, which are circular
openings made in the skull by either a small
drill or an automatic craniotome (has a self
controlled system to stop the drill when the
bone is penetrated)
https://www.google.com.jm/search?
q=picture+of+burr+holes+surgery&dcr=0&tbm=isch&imgil=g3S4pOpN6cY5W
M%253A%25
http://www.pediatricneurosciences.com/article.asp?issn=1817-
1745;year=2010;volume=5;issue=2;spage=115;epage=120;aulast=Kapu
Uses of Burr Holes
Determine presence of cerebral swelling and injury

Size and position of ventricles

Evacuation of intracranial hematoma or abscess

To make a boneflap in the skull to allow access to

the ventricles for decompression, ventriculography
or shunting procedures.
NURSING MANAGEMENT
 Airway maintenance is critical, as pt is at risk for
aspiration due to cranial nerve dysfunction

 Assist clients to guide food and fluid carefully to

prevent choking and aspiration

 Have pt sit upright when drinking or eating

 Offer semi solid, soft foods

 Have suction close by in case of emergency

Nursing Management (Cont’d)
 Neurological assessment, chart, report changes

 Reorient pt as the need arises

 Supervise and assist pt with self care

 Monitor closely to prevent injuries esp. Pts with

seizure disorders
 Read text for details of patient undergoing
intracranial surgery
REFERENCES
 Black, J.M., Hokanson Hawke, J., & Keene,
A. (2009). Medical-surgical nursing:
Clinical management for positive
outcome. St Louis: W.B Saunders
Company.

 Hinkle, J. L., & Cheever, K. (2014). Brunner &

Suddarth’s Textbook of medical surgical
nursing (13th ed.). China: Lippincott, Williams
and Wilkins.
 REFERENCES
 Sezer,N., Akkuş,S., Gülçin Uğurlu, F.
(2015). Chronic complications of spinal
cord injury. World Journal of Orthopedics,
6(1):23-33. doi: 10.5312/wjo.v6.i1.24

 Smeltzer, S. C., Bare, B. G., & Hinkle, J. H.

(2013 ). Textbook of medical surgical
nursing. Philadelphia, PA: Lippincott,
Williams and Wilkins.