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HEAD INJURIES
- MOST COMMON CAUSE OF DEATH FROM TRAUMA IN THE US
- INVOLVES SCALP, SKULL, OR BRAIN
- COMMONLY CAUSED BY MOTOR VEHICLE ACCIDENT, VIOLENCE, OR FALLS
- AT HIGHEST RISK ARE THOSE 15-24 YRS, AND MALES 3:1 OVER FEMALES

PREVENTION IS THE KEY (TO HEAD TRAUMA)

- WEAR HELMETS
- WEAR SEATBELTS
- OBEY TRAFFIC LAWS
- ELDERLY FALL PRECAUTIONS
- CAR SEATS IN THE BACKSEAT
- VIOLENCE AND SUICIDE PREVENTION
- WATER SAFETY - DEPTH’S WHEN DIVING
- KEEP FIREARMS LOCKED UP
- FALL PREVENTION

PATHO
- INJURY RESULTS FROM PENETRATION (BULLET) OR IMPACT (HEAD HITTING A WINDSHIELD)
- PRIMARY – INITIAL INJURY (CONTUSSION, HEMATOMA, ETC….). THIS IS GOING TO RESULT IN POTENTIAL
SECONDARY INJURY.
- SECONDARY – PROBLEMS CAUSED BY INITIAL INJURY (INCREASED ICP, INFECTION, HEMORRHAGE, ISCHEMIA,
AND HERNIATION)
- BRAIN INJURY IS WORST DUE TO NO ROOM FOR ANY EXPANSION OF CONTENTS. INJURIES IN OTHER AREAS OF
THE BODY (EXTREMITIES) HAVE ROOM FOR SWELLING, WHEREAS THE BRAIN IS ENCASED IN A HARD BOX WITH
LIMITED ROOM. THIS PLUS ALL OF THE VITAL CENTERS ARE CONTAINED WITHIN THE CRANIAL VAULT. ALL THE
THINGS THAT CONTROL OR PULSE, BLOOD PRESSURE, RESPIRATIONS AND SUCH. OUR ABILITY TO LIVE IS
CONTAINED IN THE CRANIAL VAULT. THE SKULL IS VERY RIGID WITH NO ROOM FOR EXPANSION, SO THERE IS AN
IMMEDIATE RISK FOR ICP WITH ANY SIGNIFICANT HEAD TRAUMA.

SCALP INJURY
USUALLY MINOR
MAJOR COMPLICATION: BLEEDING
CAN HAVE AN ABRASION OR A LACERATION TO THE SCALP
CAN DEVELOP A HEMATOMA UNDER THE LAYER OF THE SCALP IF YOU HAVE A SCALP INJURY.
THERE IS A RISK FOR INFECTION BECAUSE THERE IS TISSUE THAT HAS BEEN DISRUPTED.
THE ONLY TRUE EMERGENCY HERE IS IF THERE IS AN AVULSION TO THE SCALP OR A LOT OF BLOOD VESSELS HAVE BEEN
TORN AND THEN YOU ARE AT RISK FOR HEMORRHAGE.
NURSING CARE:
CLEAN AND DRESS WOUND
ASSIST WITH SUTURING

SKULL FRACTURES
CAN OCCUR WITH OR WITHOUT DAMAGE TO BRAIN
TYPES:
LINEAR – (70% OF SKULL FRACTURES ARE LINEAR) – USUALLY BENIGN, IT IS LIKE A CRACK IN THE SKULL. OFTEN
TIMES THEY DO NOT DO ANYTHING WITH LINEAR SKULL FRACTURES. ONCE THEY CONFIRM IT WITH X-RAY, THEY
MONITOR IT. THERE ARE USUALLY NO INTEVENTIONS NECESSARY.
COMMINUTED – THE BONE IS IN SEVERAL PIECES

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DEPRESSED – THERE IS INWARD DEPRESSION OF THE BONE FRAGMENTS – THIS IS GETTING A BIT MORE
DANGEROUS.
SIMPLE - THE DURA AND YOUR SCALP REMAINS INTACT. FOR INSTANCE IS YOU HAVE A BLUNT
TRAUMA AND HAVE A DEPRESSED SKULL FRACTURE BUT THE ACTUAL SCALP WAS NOT BROKEN
AND THE DURA (THICK COVERING THAT PROTECTS THE BRAIN) UP UNDER THE SKULL IS NOT
BROKEN
COMPOUND – THERE WILL BE SCALP LACERATIONS.
WE NOW ARE AT RISK FOR INFECTION. THE
DURA MAY OR MAY NOT BE TORN.
IF YOU HAVE A SCALP LACERTATION AND A TORN DURA WITH A
DEPRESSED FRACTURE, THERE ARE POTENTIAL COMPLICATIONS.
BASILAR – MORE SERIOUS AND COMPLEX – CAN BE LINEAR, COMMINUTED OR DEPRESSED

CLASSIFICATION 0F SKULL FRACTURES

OPEN – INDICATES THAT THERE IS A SCALP LACERATION OR A TEAR IN THE DURA – THE MAJOR COMPLICATION HERE
IS INFECTION
CLOSED – THE DURA AND THE SCALP ARE INTACT
CLINICAL MANIFESTATIONS OF A SKULL FRACTURE
LOCALIZED PAIN IN THE AREA OF THE FRACTURE
OTHER SYMPTOMS DEPEND ON LOCATION AND EXTENT OF INJURY
BASILAR SKULL FRACTURES (THESE ARE OFTEN NOT SEEN ON X-RAYS) – THESE ARE FRACTURES AT THE BASE OF
THE SKULL. SINCE THEY ARE OFTEN NOT SEEN ON X-RAYS, WE HAVE TO LOOK FOR OTHER SIGNS OF BASILAR
SKULL FRACTURE:
HEMORRHAGE FROM NOSE, PHARYNX (BACK OF THE THROAT) OR EARS
BATTLE’S SIGN – BRUISING OVER THE MASTOID BONE (LOOK BEHIND THE EAR AND YOU CAN SEE BRUISING BACK
THERE OVER THAT MASTOID BONE)
CSF OTORRHEA (DRAINAGE FROM THE EAR), RHINORRHEA (DRAINAGE FROM THE NOSE) – CLEAR DRAINAGE – IF
THE DRAINAGE IS CLEAR, YOU CAN PRETTY MUCH SUSPECT THAT IT IS CSF. HOW DO WE DETERMINE IF IT IS
JUST NASAL DRAINAGE OR CSF? WE ARE GOING TO USE A GLUCOSE STRIP. CSF WILL TEST POSITIVE FOR
GLUCOSE. WE CANNOT USE A GLUCOSE STRIP TO DETERMINE CSF ON BLOODY DRAINAGE BECAUSE BLOOD
ALSO CONTAINS GLUCOSE.
HALO SIGN – THERE IS A BLOODY SPOT IN THE MIDDLE OF THE BANDAGE WITH A CLEAR YELLOWISH HALO AROUND
THE BLOODY MIDDLE. THE CSF SEPARATES ITSELF FROM THE BLOOD.
MAJOR COMPLICATION OF A BASILAR SKULL FRACTURE IS: INFECTION
ASSESSMENT AND DIAGNOSTIC FINDINGS
NEUROLOGICAL EXAMINATION – SEE WHAT HAS BEEN AFFECTED
X-RAY
CT SCAN
MRI
MEDICAL MANAGEMENT
OBSERVATION – UNLESS THERE ARE BONEY FRAGMENTS
SURGERY- IF THE DURA IS TORN, THEY ARE PROBABLY GOING TO HAVE TO GO TO SURGERY AND GET THE DURA
REPAIRED AND REMOVE SOME OF THOSE BONEY FRAGMENTS. IT IS NOT ALWAYS REQUIRED; IT IS GOING TO
DEPEND ON HOW SEVERE THE SKULL FRACTURE IS.
RISK FOR INFECTION IF OPEN

- NURSING INTERVENTION
O OBSERVE FOR INFECTION
O OBSERVE FOR INCREASED ICP
O NO RESPIRATORY DEPRESSANTS (NARCOTICS) – THIS CAN DEPRESS THE RESPIRATORY EFFORT,
2
WHICH CAN DECREASE THEIR O LEVELS. WE DO NOT WANT ANYONE THAT IS AT RISK FOR INCREASED
ICP TO HAVE HYPOXIA AT ALL. ALSO, WE WANT TO BE ABLE TO ASSESS THIS CLIENT. IF WE GIVE
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THEM A BIG DOSE OF A RESPIRATORY DEPRESSANT (MORPHINE), NOT ONLY WILL THEY POSSIBLY NOT
HAVE ADEQUATE OXYENATION, BUT WE ARE NOT GOING TO BE ABLE TO ASSESS THEM AS WELL.
O CLOSE OBSERVATION FOR 24 HOURS – WE MAY SEND THEM HOME WITH FAMILY AND INSTRUCTIONS ON
WHAT TO LOOK OUT FOR AND WHEN TO NOTIFY THE PHYSICIAN OR COME BACK TO THE ER.
O START IV, LIMIT FLUIDS TO 1500-2000 CC/DAY (RISK FOR INCREASED ICP)
O ACCURATE I&O – WATCH FOR ADH DEFICIENCY OR ABUNDANCE (DIABETES INSIPIDUS)
O FREQUENT NEURO CHECKS AND VS – AT LEAST EVERY 2 HOURS - (LOOKING FOR INCREASED ICP,
AND LOC)
• WHAT MIGHT THE VITAL SIGNS BE ON A CLIENT WITH A DEPRESSED SKULL FRACTURE; THAT IS
SHOWING SIGNS OF INCREASED ICP? THE SYSTOLIC BLOOD PRESSURE WILL INCREASE,
WHILE THE DIASTOLIC WILL REMAIN THE SAME, THEIR PULSE WILL DECREASE
• WITH THEIR NEURO CHECKS, WHAT WILL BE ONE OF THE FIRST SIGNS THAT WE WILL SEE THAT
INDICATES A PROBLEM? A CHANGE IN THEIR LEVEL OF CONSCIOUSNESS
O CLEANSE AND ASSIST WITH SUTURING SCALP LACERATIONS IF PRESENT

BRAIN INJURY
THE MOST SERIOUS HEAD INJURY
CLASSIFICATION:
CLOSED HEAD INJURY (BLUNDT) – THE DURA REMAINS INTACT. THIS CAN RESULT FROM THE HEAD BEING STRUCK
BY A BLUNT OBJECT OR THE HEAD STRIKING A HARD SURFACE (SUCH AS FROM A FALL)
COUP/CONTRE-COUP – THIS IS TWO INJURIES THAT OCCUR WITH THE SAME ACCIDENT
 LET’S SAY WE HAVE SOMEONE THAT FALLS DOWN A FLIGHT OF STAIRS AND HITS THE
RIGHT TEMPLE AREA OF THEIR HEAD AND HAS A BRAIN INJURY ON THE RIGHT SIDE. THIS
WILL BE OUR COUP INJURY. THE EXACT PLACE OF IMPACT. AS A RESULT OF THIS, IF
THEY HIT HARD ENOUGH, THEIR BRAIN IS GOING TO GO TO THE OTHER SIDE AND IT IS
GOING TO BE SHIFTED TO THE OTHER SIDE OF THE HEAD AND THE LEFT SIDE OF THEIR
BRAIN CAN BE INJURED DUE TO HITTING THE SKULL. THEN YOU HAVE A CONTRE-COUP
INJURY. SO YOU HAVE THE COUP INJURY WHICH IS THE DIRECT POINT OF IMPACT AND
YOU HAVE THE CONTRE-COUP DIRECTLY OPPOSITE FROM WHEREVER THAT IS. SO IF YOU
HAVE A COUP INJURY TO YOUR FRONTAL AREA OF THE BRAIN. THE CONTRE-COUP
WOULD BE IN THE BACK OF THE BRAIN.
 IF THE COUP INJURY OCCURRED ON THE RIGHT TEMPLE AREA – OUR MOTOR
DEFICIT WILL BE ON THE LEFT SIDE.IF WE HAVE A CONTRE-COUP INJURY ON THE LEFT
SIDE– OUR MOTOR DEFICIT WILL BE ON THE RIGHT SIDE.
 SO IF YOU HAVE A COUP AND A CONTRE-COUP INJURY – YOU WOULD EXPECT
WEAKNESS ON BOTH SIDES
ACCELERATION/DECELERATION – BRAIN IS HURRIED FORWARD AND JARRED QUICKLY – YOU DON’T NECESSARILY HAVE
TO HAVE AN IMPACT WITH THIS TYPE OF INJURY. FOR INSTANCE, YOU ARE DRIVING DOWN THE ROAD AND
YOUR ARE IN A CAR WRECK AND YOUR VEHICLE SUDDENLY STOPS. YOU DO NOT NECESSARILY HAVE TO HIT
THE STEERING WHEEL, BUT YOUR HEAD IS SLUNG FORWARD AND THEN SUDDENLY BACKWARD. YOUR WHOLE
BODY IS MOVING AT 70 MILES PER HOUR AND THEN SUDDENLY IT STOPS, WELL THE BRAIN CAN KIND OF
BOUNCE AROUND IN THERE AND CAUSE ACCELERATION/DECELERATION INJURY. THERE WILL BE INJURY ON
TWO SIDES OF THE BRAIN.
OPEN HEAD INJURY – DURA IS TORN (VERY SERIOUS) – YOU HAVE A COMMUNICATION BETWEEN THE BRAIN AND
THE ENVIRONMENT. THERE IS AN INCREASED RISK FOR INFECTION. INFECTION LEADS TO SWELLING AND
IRRITATION AND EVENTUALLY INCREASED ICP.
TYPES:
CONCUSSION
CONTUSION
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DIFFUSE AXONAL INJURY

INTRACRANIAL HEMORRHAGE
CONCUSSION
LEAST SERIOUS BRAIN INJURY
TRANSITORY IMPAIRMENT OF NEUROLOGIC FUNCTION
CHARACTERIZED BY:
BRIEF LOSS OF CONSCIOUSNESS
PERIOD OF CONFUSION OR MEMORY LOSS SURROUNDING THE EVENT WHEN THEY COME TO.
SPONTANEOUS RECOVERY
OBSERVE FOR COMPLICATIONS - SIGNS OF INCREASED ICP, SWELLING, CONCUSSION MAY BE MORE SEVERE THAN
THOUGHT, MAY BE SOME UNDERLYING DAMAGE
A LOT OF TIMES THESE CLIENTS ARE GOING TO COME INTO THE ER AND THEY ARE GOING TO HAVE A SCAN, IT IS GOING
TO BE DETERMINED THAT IT WAS A CONCUSSION AND THEY WILL SEND THESE PEOPLE HOME. VERY DETAILED
DISCHARGE INSTRUCTIONS WILL BE GIVEN TO WHOEVER IT IS THAT WILL BE TAKING CARE OF THIS CLIENT.
IF DISCHARGED, INSTRUCT FAMILY ON
OBSERVATION OF CLIENT
RETURN TO ER IF CERTAIN SIGNS AND SYMPTOMS DEVELOP (SEE PAGE 1913 OF BRUNNER)
• DIFFICULTY AWAKENING THEM

• DIFFICULTY SPEAKING

• CONFUSION

• SEVERE HEADACHE THAT WORSENS – CAN INDICATE HEMORRHAGE OR INCREASING ICP

• VOMITING (A SIGN OF INCREASED ICP, OFTEN WITHOUT NAUSEA)

• WEAKNESS ON ONE SIDE OF THE BODY – MAY INDICATE BRAIN SWELLING

• BE SURE IF YOU DO DISCHARGE THIS CLIENT FROM THE ER AND YOU GIVE THE CLIENT’S
FAMILY INSTRUCTIONS, YOU NEED TO DOCUMENT EXACTLY WHAT INSTRUCTIONS WERE GIVEN TO
THEM; KEEP A COPY OF THEM; DOCUMENT THAT THEY VOICED AN UNDERSTANDING OF THE
INSTRUCTIONS
• THE BIGGEST THING THAT THEY NEED TO LOOK FOR AT HOME IS THAT CHANGE IN THE LEVEL OF
CONSCIOUSNESS
CONTUSION AND LACERATION
THIS IS A LITTLE MORE SERIOUS THAN A CONCUSSION
CONTUSION- BRUISING OF BRAIN WITH POSSIBLE SURFACE HEMORRHAGE
LACERATION- TEARING OF THE BRAIN TISSUES DUE TO SHARP FRAGMENTS, OBJECTS, OR SHEARING FORCES;
HEMORRHAGE A SERIOUS COMPLICATION WITH A BRAIN LACERATION.
CHARACTERIZED BY:
LOSS OF CONSCIOUSNESS FOR EXTENDED PERIOD (HOURS, DAYS) – USUALLY THE LONGER THEY ARE
UNCONSCIOUS, THE POORER THE PROGNOSIS IS.
MEMORY LOSS BEFORE AND AFTER EVENT
DAMAGE DEPENDS ON SEVERITY OF INJURY – THE TYPE OF DEFICIT THAT THEY ARE GOING TO HAVE WILL DEPEND
ON THE AREA OF THE BRAIN AFFECTED.
MAY BE AROUSED WITH DIFFICULTY, MAY BE VERY STUPOROUS OR LETHARGIC
MAY HAVE SEIZURES (WE HAVE HEMORRHAGING AND SWELLING. WE HAVE HEMORRHAGING FROM LACERATIONS
AND BLOOD IS VERY IRRITATING TO THIS TISSUE AND IT MAY DISRUPT THE ELECTRICAL ACTIVITY AND THEY CAN
HAVE SEIZURES).
DIFFUSE AXONAL INJURY
INVOLVES WIDESPREAD DAMAGE TO AXONS IN THE CEREBRAL HEMISPHERES, CORPUS CALLOSUM, AND BRAINSTEM
THE AXON CARRIES THE NERVE IMPULSE AWAY FROM THE NERVE CELL.
RESULTS FROM MILD, MODERATE OR SEVERE HEAD TRAUMA

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RESULTS IN AXONAL SWELLING AND DISCONNECTION

WHEN YOU HAVE THE AXON DISCONNECT AND THEY ARE NOT ABLE TO CARRY THAT NERVE IMPULSE, YOU ARE GOING TO
HAVE SOME SEVERE DAMAGE. IF YOU HAVE LOTS OF AXONS THAT HAVE BEEN DAMAGED, YOU ARE GOING TO SEE
GLOBAL CEREBRAL EDEMA (SWELLING ALL OVER THE CEREBRAL TISSUES).
EXAMPLE: SHAKEN BABY SYNDROME
NO LUCID INTERVALS
COMA, POSTURING, GLOBAL CEREBRAL EDEMA AND ALL OF THE OTHER SIGNS OF COMA AND SEVERE HEAD TRAUMA
RECOVERY DEPENDS ON SEVERITY OF THE AXONAL INJURY; IN OTHER WORDS HOW MANY AXONS WERE INVOLVED, BUT
GENERALLY THIS IS A VERY POOR PROGNOSIS.

INTRACRANIAL HEMORRHAGE
EPIDURAL HEMATOMA
SUBDURAL HEMATOMA
ACUTE AND SUBACUTE
CHRONIC
INTRACEREBRAL HEMORRHAGE AND HEMATOMA
HEMATOMAS IN THE CRANIAL VAULT CAN BE SOME OF THE MOST SERIOUS BRAIN INJURIES

EPIDURAL HEMATOMA
HEMORRHAGE THAT OCCURS BETWEEN SKULL AND DURA, USUALLY DUE TO A TEAR IN THE MIDDLE MENINGEAL ARTERY
(AROUND THE TEMPORAL AREA) – USUALLY ARTERIAL IN NATURE
MOST LIFE-THREATENING HEMORRHAGE DUE TO RAPID RATE OF PRESSURE ON THE BRAIN (50% MORTALITY) – WHEN
THERE IS AN ARTERIAL RUPTURE, IT HAPPENS VERY QUICKLY AND OUR BODY CANNOT COMPENSATE FOR THE RAPID
CHANGE IN ICP VERY WELL. THEY HAVE A 50% MORTALITY RATE WITH EPIDURAL HEMATOMA.
SKULL FRACTURE USUALLY PRESENT ALONG WITH THIS – THEY HAVE A SKULL FRACTURE THAT HAS TORN THAT MIDDLE
MENNINGAL ARTERY RESULTING IN AN EPIDURAL HEMATOMA.
CLINICAL MANIFESTATIONS:
LOSS OF CONSCIOUSNESS, FOLLOWED BY A PERIOD OF LUCIDITY (DUE TO COMPENSATION), THEN VERY RAPIDLY
THEIR LOC DETERIORATES AGAIN AND THEY GO INTO A COMA (HALLMARK SIGN). THE REASON WHY THERE IS A
PERIOD OF LUCIDITY IS A RAPID REABSORPTION OF CSF. THIS IS THE BODY’S LAST ATTEMPT TO TRY AND
SALVAGE BRAIN TISSUE AND PREVENT INCREASING ICP. SO YOU HAVE THIS EPIDURAL BLEED, IT CAUSES THE
CLIENT TO BECOME UNCONSCIOUS, THEN THE BODY RAPIDLY REABSORBS CSF AND DISPLACES IT EVERYWHERE
THAT IT CAN SO THEY MIGHT WAKE UP AND BE LUCID FOR A FEW MINUTES, BUT THEN THE BODY CANNOT
COMPENSATE LIKE THIS FOR VERY LONG AND THEY WILL PROGRESS INTO COMA.
HEMIPLEGIA ON THE OPPOSITE SIDE FROM THE HEMATOMA, DUE TO PRESSURE FROM THE BLEED
PUPILLARY CHANGES – DUE TO INCREASED ICP
RAPID NEUROLOGIC DETERIORIATION
MEDICAL MANAGEMENT:
EMERGENCY SURGERY NEEDED (BURR HOLES OR CRANIOTOMY FOR EVACUATION OF CLOT, CONTROL OF
HEMORRHAGE), THEY WANT TO GET DOWN TO THE VESSEL THAT IS ACTUALLY CAUSING THE BLEED AND CONTROL
THE HEMORRHAGE. A DRAIN MIGHT BE LEFT IN PLACE TO TRY AND DRAIN ANY EXCESS FLUID OR BLEEDING. THIS
DRAIN MAY BE LEFT IN PLACE FOR A FEW DAYS

SUBDURAL HEMATOMA
COLLECTION OF BLOOD BETWEEN DURA AND THE BRAIN
TRAUMA MOST COMMON CAUSE
USUALLY VENOUS IN ORIGIN, THEREFORE THE BLEEDING IS GOING TO BE SLOWER (THAN EPIDURAL HEMATOMA)
ACUTE
ASSOCIATED WITH MAJOR HEAD INJURY

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SYMPTOMS DEVELOP WITHIN 24-48 HOURS

MORE ACUTE BLEEDING, MAYBE MORE OR A LARGER VESSEL INVOLVED
SUBACUTE
RESULT OF LESS SEVERE HEAD TRAUMA
SYMPTOMS OCCUR BETWEEN 48 HOURS AND 2 WEEKS
CHRONIC
MORE COMMON IN ELDERLY
DEVELOP FROM SEEMINGLY MINOR HEAD INJURIES
ACTUAL INJURY MAY BE FORGOTTEN DUE TO DELAYED SYMPTOMS
SYMPTOMS MAY BE MISTAKEN FOR AN ISCHEMIC STROKE, OR MENTAL DETERIORATION BECAUSE THEY ARE HAVING
NEUROLOGICAL CHANGES
IT TAKES SO LONG FOR THSES SYMPTOMS TO MANIFEST BECAUSE WITH THE ELDERLY THERE IS ATROPHY OF THE
BRAIN TISSUE, THEY HAVE MORE ROOM IN THE CRANIAL VAULT AND THEY HAVE A VENOUS BLEED (WHICH IS A
SLOW BLEED) AND IF IT IS A MINOR TRAUMA IT MAY BE A SMALL VESSEL. IT WILL BE A VERY SLOW BLEED AND
THERE WILL BE SLOW CHANGES IN INTRACRANIAL PRESSURE WHICH OUR BODY ACCOMODATES FOR A LOT BETTER.
SO THIS IS WHY WE WILL SEE, EVEN WITH AN ACUTE, YOU MAY NOT SEE SYMPTOMS FOR A DAY OR TWO.
TREATMENT
SURGERY TO EVACUATE BLEED (ALTHOUGH NOT ALWAYS) – THEY MAY JUST COME IN AND MONITOR THE SUBDURAL
MONITORING AND TREATING INCREASED ICP AS IT OCCURS
THEY MAY DO REPEATED CT SCANS TO MAKE SURE THAT THE HEMATOMA IS RESOLVING AND THAT THERE IS NOT
ACTIVE BLEEDING THERE.
SIGNS AND SYMPTOMS OF SUBDURAL HEMATOMA
O HEMIPLEGIA ON OPPOSITE SIDE FROM HEMATOMA
O HEADACHE
O ALTERED LOC
O IRRITABILITY, MENTAL CONFUSION
O UNEQUAL PUPILS
O CONVULSIONS
O POSITIVE BABINSKI RESPONSE

INTRACEREBRAL HEMORRHAGE AND HEMATOMA

BLEEDING INTO THE BRAIN SUBSTANCE
OFTEN SEEN WHEN FORCE IS EXERTED OVER A SMALL AREA (BULLET, STAB WOUND)
OFTEN TIMES THIS IS INOPERABLE
CLINICAL MANIFESTATIONS:
o NEURO DEFICITS (DEPENDING UPON DIZZINESS
AREA OF THE BRAIN INVOLVED)
DROWSINESS
VOMITING HEADACHE
OTHER S/S OF INCREASED ICP
-
MANAGEMENT:
CONTROL INCREASED ICP,
CONTROL HYPERTENSION TO PREVENT FURTHER BLEEDING
SURGERY IF AREA IS ACCESSIBLE

ONE OF THE BIGGEST CAUSES OF HEMORRHAGIC STROKE IS UNCONTROLLED HYPERTENSION.

OUR CARE FOR THIS IS GOINGTO BE VERY SIMILAR TO CARE FOR HEMORRHAGIC STROKE, ANEURYSM RUPTURE, BRAIN
HEMORRHAGE, SUBARCHNOID HEMORRHAGE AND INTRACEREBRAL HEMORRHAGE. A LOT OF THE TREATMENT IS THE

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SAME. OF COURSE, THEY WILL NOT BE ON ANTICOAGULANTS. WE WILL PUT THEM ON BEDREST AND DECREASE
STIMULI. WE ARE WORRIED ABOUT INCREASING ICP WITH THESE CLIENTS BECAUSE THEY HAVE BLEEDING INTO THE
BRAIN AND THE CRANIAL VAULT. IF THEY CAN DO SURGERY THEY MIGHT, BUT OFTEN TIMES THEY CANNOT GET TO THE
AREA.

CLINICAL MANIFESTATIONS: BRAIN INJURY

VARIES WIDELY DEPENDING ON LOCATION OF THE INJURY AND THE RATE THAT INJURY DEVELOPED
ALTERED LOC
- CONFUSION VITAL SIGN CHANGES
PUPILLARY CHANGES (WE WORRY MOST ABOUT VISION AND HEARING IMPAIRMENT
THE FIXED DILATED PUPIL BECAUSE IT SENSORY DYSFUNCTION
INDICATES THAT WE MIGHT HAVE BRAIN STEM SPASTICITY
HERNIATION) HEADACHE
ALTERED/ABSENT GAG REFLEX MOVEMENT DISORDERS (ABNORMAL POSTURING
ABSENT CORNEAL REFLEX MOVEMENTS IN RESPONSE TO STIMULI)
SUDDEN ONSET OF NEURO. DEFICITS SEIZURES

BRAIN INJURY IS AN UPPER MOTOR NEURON INJURY. THE UPPER MOTOR NEURON LESIONS AFFECTS THE CENTRAL
NERVOUS SYSTEM. IF YOU HAVE A BRAIN INJURY, A LOT OF YOUR REFLEX ARCS MAY STILL BE INTACT, THEREFORE WE
WILL SEE SPASTICITY OF THE MUSCLES.

MEDICAL MANAGEMENT: BRIAN INJURY

DIAGNOSIS
NEUROLOGICAL ASSESSMENT
• ANY ALTERED LOC
• GLASCOW COMA SCALE
CT, MRI, PET, EEG, ARTERIOGRAPHY, LUMBAR PUNCTURE – TO DETERMINE THE TYPE AND EXTENT OF THE
INJURY. A LUMBAR PUNCTURE IS CONTAINDICATED IF THERE IS ANY TYPE OF INCREASED ICP.
MANAGEMENT
EVALUATION OF CERVICAL SPINE – VERY IMPORTANT – A CLIENT THAT COMES IN WITH A HEAD INJURY IS SUSPECTED
TO ALSO HAVE A CERVICAL SPINE INJURY UNTIL PROVEN OTHERWISE. THIS IS WHY WHEN SOMEONE COMES IN
WITH A SEVERE HEAD TRAUMA AND IMMEDIATELY START DOING “DOLL’S EYES” REFLEX. YOU WANT TO BE SURE
THAT THEIR CERVICAL SPINE IS NOT INJURED BEFORE THEY START DOING THOSE TYPES OF TESTS.
SURGICAL EVACUATION OF HEMORRHAGE – IF THIS IS POSSIBLE, THIS IS WHAT IS GOING TO BE DESIRED BECAUSE IT
IS GOING TO DECREASE THE AMOUNT OF INTRACRANIAL PRESSURE, BY GETTING SOME OF THE FLUID OUT.
PREVENTION OF SECONDARY INJURY
MONITORING AND MANAGEMENT OF CARDIOVASCULAR AND RESPIRATORY STATUS – WE WANT TO MAKE SURE THAT THEY
ARE ADEQUATELY OXYGENATED TO PREVENT THOSE INCREASES IN ICP FROM HYPOXIA. WE WANT TO MAKE
SURE THAT THEIR CARDIAC OUTPUT IS ADEQUATE TO GET ENOUGH PERFUSION TO THE BRAIN.
FREQUENT NEUROLOGIC ASSESSMENT – YOU WANT A GOOD BASELINE AND THEN YOU WANT FREQUENT REASSESSMENTS
TO DETECT EARLY CHANGES IN LOC.
TREATMENT OF INCREASED ICP (MEDICATIONS AND OTHER TREATMENTS THAT WE HAVE TALKED ABOUT)
SUPPORTIVE MEASURES (BASED ON THE TYPE OF DEFICITS THAT THE CLIENT HAS)
• MAY NEED ARTIFICIAL AIRWAY
• SUPPLEMENTAL TUBE FEEDING OR TPN
BRAIN DEATH – THE ETHICAL DILEMMA THAT ARISE AND THE HARD DECISIONS THAT A FAMILY HAS TO MAKE, SUCH
AS ORGAN DONATION OR CONTINUED LIFE SUPPORT. BRAIN DEATH IS DETERMINED BY A PHYSICIAN. THEY DO A
SERIES OF EEG’S TO SEE IF THERE IS ANY BRAIN ACTIVITY. ONCE THEY DETERMINE BRAIN DEATH, THIS MEANS
THE CLIENT ABSOLUTELY CAN NOT SUSTAIN LIFE OFF OF THE MACHINES.

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NURSING DIAGNOSES: BRAIN INJURY

- INEFFECTIVE AIRWAY CLEARANCE
INEFFECTIVE CEREBRAL TISSUE PERFUSION
DEFICIENT FLUID VOLUME
IMBALANCED NUTRITION
RISK FOR INJURY
RISK FOR INCREASED BODY TEMPERATURE
POTENTIAL FOR IMPAIRED SKIN INTEGRITY
DISTURBED THOUGHT PROCESSES
POTENTIAL FOR DISTURBED SLEEP PATTERN
POTENTIAL FOR COMPROMISED FAMILY COPING
DEFICIENT KNOWLEDGE
CP FOR ALTERED LOC AND INCREASED ICP

COLLABORATIVE PROBLEMS: BRAIN INJURY

DECREASED CEREBRAL PERFUSION – DUE TO SWELLING OR DUE TO ACTUAL TRAUMA TO THE BLOOD VESSELS
CEREBRAL EDEMA AND HERNIATION
IMPAIRED OXYGENATION AND VENTILATION
IMPAIRED FLUID, ELECTROLYTE, AND NUTRITIONAL BALANCE
RISK OF POST-TRAUMATIC SEIZURES

NURSING INTERVENTIONS: BRAIN INJURY

GO BACK TO CARE PLAN FOR ALTERED LOC & INCREASED ICP BECAUSE THESE ARE THE THINGS THAT WE ARE
TREATING.
MONITORING FOR DECLINING NEUROLOGIC FUNCTION
THOROUGH BASELINE ASSESSMENT (HISTORY, PHYSICAL ASSESSMENT)
LOC (GLASCOW COMA SCALE)
VITAL SIGNS
MOTOR FUNCTION
MAINTAINING THE AIRWAY
MIGHT NEED INTUBATION
ADEQUATELY OXYGENATE
MANAGE THEIR SECRETIONS
KEEP HOB ELEVATED (30°) NOT ONLY TO PREVENT INCREASED ICP AND PROMOTE VENOUS DRAINAGE BUT ALSO
FOR THE DRAINAGE OF RESPIRATORY SECRETIONS
MONITORING FLUID AND ELECTROLYTE BALANCE
BRAIN INJURY CAN CAUSE METABOLIC DYSFUNCTION WITHIN THE BODY
ADH – DIABETES INSIPIDUS
SIADH
WATCH THEIR I&O’S
WATCH THEIR ELECTROLYTE VALUES
CAN CAUSE NA IMBALANCE – A LOT OF TIMES THEY WILL DEVELOP LETHARGY OR CONFUSION
PROMOTING ADEQUATE NUTRITION – MAY NEED TPN OR ENTERAL FEEDINGS, THERE WILL BE INCREASED PROTEIN
DEMANDS
PREVENTING INJURY
MAY BE VERY AGITATED AND RESTLESS WHEN THEY COME OUT OF THE COMA
IF THEY ARE NOT COMPLETELY UNCONSCIOUS, THEY MAY HAVE BEHAVIORAL CHANGES AND THIS CAN BE A REAL SAFETY
ISSSUE AS FAR AS PULLING LINES AND TUBES.
CONFUSED, TRYING TO GET OUT OF THE BED, COMBATIVE
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WITH RESTRAINTS – USE THE LEAST RETRICTIVE THING POSSIBLE BECAUSE RESTRAINING CAUSES INCREASED ANXIETY
AND MORE RESTLESSNESS WHICH CAN LEAD TO AN INCREASE IN ICP.
PREVENTING ASPIRATION – SUCTION, O2 SAT, ABG’S, MAY NEED INTUBATION, HOB ↑
MAINTAINING BODY TEMPERATURE – BRAIN IRRITATION CAN RAISE TEMPERATURE OR COULD BE INFECTION
ANTIPYRETICS, COOLING BLANKETS
NEED TO CONTROL FEVER AND FIND OUT WHAT THE CAUSE IS
MAINTAINING SKIN INTEGRITY
FREQUENT TURNING
INSPECTION OF SKIN
LIMITING TIME ON THE WEAK OR PARALYZED SIDE
IMPROVING COGNITIVE FUNCTIONING
OFTEN TIMES YOU CAN HAVE SEVERE COGNITIVE DEFICITS THAT LAST A LONG TIME AFTER BRAIN INJURY, EVEN IF THEY
COME OUT OF THE COMA. THEY HAVE A LONG REHABILITATION PERIOD AHEAD MUCH OF THE TIME. SUPPORT THE
FAMILY, REORIENT THE CLIENT, DO THE THINGS THAT WE CAN TO IMPROVE THEIR COGNITIVE FUNCTION.
PREVENTING SLEEP PATTERN DISTURBANCE
UNLESS THEY HAVE SEVERE INCREASED ICP AND WE HAVE COMPLETELY BACKED OFF STIMULI, IF THEY HAVE STABLIZED
AND THEY ARE COMATOSE, THEN WE ARE GOING TO TRY TO MAINTAIN THE NORMAL DAY AND NIGHT PATTERNS. IT IS
VERY DIFFICULT TO GET REST, ESPECIALLY IN AN ICU SETTING.
SUPPORTING FAMILY COPING
IF THERE IS BRAIN TRAUMA, NO ONE EXPECTS THAT. THESE PEOPLE HAVE BEEN LIVING THEIR NORMAL DAILY LIVES AND
THEN SUDDENLY THEY HAVE TO DEAL WITH THIS DEVASTATING INJURY TO THEIR FAMILY MEMBER. IF THE ISSUE OF
BRAIN DEATH COMES UP, WE REALLY NEED TO PLAY THE SUPPORTIVE ROLE. IN GIVING FAMILY TRUE AND ACCURATE
INFORMATION, WE WANT TO BE AS OPTIMISTIC AS WE CAN WITHOUT GIVING THEM FALSE HOPE. IF ORGAN DONATION
BECOMES A SUBJECT THAT NEEDS TO BE TALKED ABOUT, WE NEED TO CALL THE ORGAN RECOVERY AGENCY. THE
TRAINED PROFESSIONALS DO A LOT BETTER JOB IN HAVING PEOPLE DECIDE TO DONATE ORGANS.
MONITORING AND MANAGING POTENTIAL COMPLICATIONS:
WITH HEAD TRAUMA, CEREBRAL EDEMA PEAKS AT ABOUT 48 -72 HOURS IF THERE ARE BRAIN INJURIES. WHAT
MEDICATIONS DO WE GIVE FOR CEREBRAL EDEMA? OSMOTIC DIURETICS (MANNITOL), CORTICOSTEROIDS
(DECADRON).
DECREASED CEREBRAL PERFUSION
KEEPING THIS PATIENT NORMOTENSIVE,
BY KEEPING THEM ADEQUATELY OXYGENATED,
PREVENT VASODILATION THAT INCREASES ICP AND STARTS THAT DECOMPENSATION CYCLE.
CEREBRAL EDEMA AND HERNIATION
IMPAIRED OXYGENATION AND VENTILATION
IMPAIRED FLUID, ELECTROLYTE, AND NUTRITIONAL BALANCE
POST-TRAUMATIC SEIZURES
MOST LIKELY WITH A BRAIN INJURY THEY WILL BE ON PROPHYLACTIC ANTICONVULSANT MEDICATIONS
TO PREVENT SEIZURES
PROMOTING HOME AND COMMUNITY-BASED CARE
TEACHING SELF-CARE
WANT TO INCLUDE THE CLIENT AS MUCH AS POSSIBLE IN MAKING DECISIONS ABOUT THEIR
TREATMENT PLAN
TEACH THE CLIENT AND THE FAMILY THE SIGNS AND SYMPTOMS THAT THEY NEED TO LOOK OUT FOR
AND REPORT TO THE DOCTOR (SIGNS OF INCREASING ICP, SIGNS OF INFECTION)
CONTINUING CARE
REQUIRES LONG TERM REAHABILITATION – THIS IS A LONG PROCESS AND SOME FUNCTION MAY
NEVER RETURN, BUT WITH THERAPY THEY CAN REGAIN A LOT OF THEIR PREVIOUS FUNCTIONING.
NEED TO BE REALISTIC WITH THE CLIENT AND THEIR FAMILY ABOUT THIS.

9
 TCA 4

SPINAL CORD INJURY

000 PEOPLE IN THE U.S. DISABLED FROM SCI
00 NEW INJURIES ANNUALLY
S 4:1
T COMMON CAUSES:
VA
OLENCE
ALLS
SPORTS-RELATED INJURIES
Y MAY BE PRIMARY OR SECONDARY
WHAT THIS IS TALKING ABOUT IS THAT YOU MIGHT HAVE A VERTEBRAL FRACTURE THAT LEADS TO A SPINAL
CORD INJURY.
VENTION IS THE KEY!

REVIEW OF NEURO. A&P

VERTEBRAL COLUMN:
7 CERVICAL VERTEBRAE (STARTING AT THE BASE OF THE SKULL AND GOING DOWN)
12 THORACIC
5 LUMBAR
5 SACRAL (FUSED)
4-5 COCCYGEAL (FUSED)
SPINAL CORD:
EXTENDS FROM C-1 TO L-2
PROTECTED BY VERTEBRAL COLUMN, MENINGES AND CSF
2-WAY CONDUCTION PATH BETWEENTHE BRAIN AND THE PERIPHERAL NERVOUS SYSTEM (MOTOR AND SENSORY)
IT ALSO CONTAINS THE REFLEX CENTERS FOR THOSE ACTIVITIES WHICH DO NOT REQUIRE CONTROL BY THE BRAIN
(EX: KNEE-JERK, BOWEL/BLADDER EMPTYING – THERE IS A REFLEX INVOLVED)
WITHIN THE CORD:
GRAY MATTER – AT THE CENTER OF THE CORD – HAS SENSORY AND MOTOR
WHITE MATTER – OUTER – MYELYNATED NERVE FIBERS THAT HELP INSULATE AND DIRECT THE NERVE IMPULSE TO
THE RIGHT PLACE.
SPINAL NERVES
31 PAIR; EACH HAS ANTERIOR (MOTOR) AND POSTERIOR (SENSORY) ROOT
LUMBAR AND SACRAL NERVES HAVE LONG FIBERS THAT EXIT AT THE LOWER VERTEBRAE (CAUDA EQUINA)

SPINAL TRAUMA
- MAY INVOLVE:
VERTEBRAL COLUMN ONLY
SURROUNDING LIGAMENTS THAT CONNECT THE VERTEBRAE TOGETHER AND MAINTAIN THE STABILITY OF THE
VERTEBRAL COLUMN.
SPINAL CORD
- MAY RESULT FROM THESE TYPES OF INJURIES:
HYPERFLEXION
HYPEREXTENSION
VERTICAL COMPRESSION – SUCH AS A DIVING ACCIDENT
ROTATIONAL FORCES – FOR INSTANCE THE SPINE OR THE NECK WAS TWISTED TOO FAR AND CAUSED AN INJURY
THAT WAY

VERTEBRAL INJURIES
- PREVENTING CORD DAMAGE IS MAIN CONCERN
10
 TCA 4

- DEFINITION
O INVOLVE THE VERTEBRAE AND/OR LIGAMENTS OF THE SPINAL COLUMN
- WITH VERTEBRAL INJURIES, YOU CAN HAVE EITHER FRACTURE OR DISLOCATION OF THE VERTEBRAE. THIS
INVOLVES THE VERTEBRAE AND/OR THE LIGAMENTS OF THE SPINAL COLUMN. THIS MAY OR MAY NOT RESULT IN
THE A SPINAL CORD INJURY. ONE OF THE PURPOSES OF THE VERTEBRAL COLUMN IS TO PROTECT THE CORD,
SO SOMETIMES YOU CAN INJURE THE VERTEBRAL COLUMN AND THE CORD WILL REMAIN INTACT AND UNINJURED.
- FRACTURES
O SIMPLE – USUALLY DON’T HAVE NERVE COMPRESSION WITH A SIMPLE VERTEBRAL FRACTURE
O COMPRESSED – THE VERTEBRAL BODY IS COMPRESSED, YOU MAY OR MAY NOT HAVE NERVE
COMPRESSION, IT WILL DEPEND UPON WHERE THE COMPRESSION FRACTURE IS
O COMMINUTED – SHATTERING OF THE VERTEBRAL BODY  SEVERE DAMAGE MAY OCCUR – BONEY
FRAGMENTS CAN BE DRIVEN INTO THE SPINAL CORD AND CAUSE DAMAGE TO THE SPINAL CORD.
O DISLOCATION – THIS IS INJURY TO THE LIGAMENTS AROUND THE VERTEBRAE. THE ALIGNMENT CAN BE
DISRUPTED; IT DEPENDS ON HOW SEVERE IT IS. YOU CAN SEE HOW 2 VERTEBRAE STACK ON TOP OF
EACH OTHER. IF YOU HAVE SEVERE DISLOCATION OF ONE OF THE VERTEBRAE, HOW THE CORD COULD
BE DAMAGED.

YOU CAN HAVE A VERTEBRAL INJURY WITHOUT A CORD INJURY, BUT SOMETIMES IN PARTICULARLY WITH THESE
COMMINUTED FRACTURES, WE HAVE SEVERAL PIECES OF BONE GOING EVERYWHERE THEN YOU ARE AT RISK FOR CORD
INJURY AS WELL.

SPINAL CORD INJURY

- DEFINITION
O REFERS TO INJURY OF SPINAL CORD ITSELF
O USUALLY ASSOCIATED WITH VERTEBRAL INJURY
O HOWEVER, CAN RESULT FROM AN INTERRUPTION OF THE CORD’S BLOOD SUPPLY

- SPINAL CORD INJURY MAY RESULT IN:

O CONCUSSION – THIS IS TRANSIENT DISRUPTION OF CORD FUNCTION, USUALLY DUE TO MILDER TRAUMA,
MIGHT HAVE A LITTLE BRUISING, BUT NO PERMANENT DAMAGE
O CONTUSION – BRUISING OF SPINAL CORD AND THAT MICROSCOPIC HEMORRHAGE  SWELLING
⇒ WILL HAVE A TEMPORARY LOSS OF FUNCTION THAT CAN BECOME PERMANENT DUE TO
THAT SECONDARY INJURY PHENOMENOM.
O COMPRESSION
⇒ IF YOU HAVE COMPRESSION OF THE CORD, FOR INSTANCE DUE TO ONE OF THOSE
DISLOCATION INJURIES OF THE VERTEBRAE OR A COMPRESSED FRACTURE OF THE VERTEBRAE THAT
IS ACTUALLY COMPRESSING THE NERVE TISSUE OR COMPRESSING THE CORD. THIS LEADS TO
ISCHEMIA OF THE CORD AND EDEMA. YOU MUST HAVE THE PRESSURE RELIEVED TO PREVENT
PERMANENT DAMAGE.
⇒ AN EXAMPLE MIGHT BE A RUPTURED DISK IN THE BACK, AND THERE ARE SOME
SYMPTOMS FROM A SPINAL NERVE OR PART OF THEIR CORD BEING COMPRESSED. THEY MIGHT BE
HAVING RIGHT LEG PAIN, NUMBNESS AND TINGLING. THIS CAN BECOME IRREVERSIBLE IF IT IS NOT
DECOMPRESSED. IT CAN ACTUALLY LEAD TO SEVERE ENOUGH ISCHEMIA AND EDEMA THAT YOU
HAVE NERVE CELL DEATH IN THAT AREA.
⇒ BOTH CONTUSION AND COMPRESSION DO RESOLVE RATHER SLOWLY AND CAN RESULT
IN PERMANENT DAMAGE IF SOMETHING IS NOT DONE TO PREVENT THAT SECONDARY INJURY.
O TRANSECTION – REFERS TO SEVERING OF THE SPINAL CORD. THIS CAUSES COMPLETE AND
PERMANENT DAMAGE WHEREVER THE TRANSECTION IS.

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 TCA 4

1. COMPLETE TRANSECTION – LOSS OF ALL SENSATION AND VOLUNTARY MOVEMENT IN

THE PARTS OF THE BODY BELOW THE LESION. YOU ALSO HAVE LOSS OF REFLEX FUNCTION AT
AND BELOW THAT LEVEL.
2. INCOMPLETE TRANSECTION – VARYING DEGREES OF LOSS; ASSESS WEAKNESS, PART
OF THE CORD IS SEVERED.
O LACERATION – CUTTING CORD; ISCHEMIA WITH CORD TISSUE DEATH (MAY NOT BE PERMANENT)
⇒ THIS CAN BE REVERSIBLE IF THE LACERATION IS VERY SLIGHT AND YOU HAVE NOT HAD
SPINAL TRACTS AND NERVES THAT HAVE BEEN SEVERED WITHIN THE CORD.
⇒ YOU WILL HAVE PERMANENT DAMAGE IF YOU DO HAVE SPINAL TRACTS AND NERVES
WITHIN THE CORD THAT HAVE BEEN SEVERED. NERVE TISSUE DOES NOT REGENERATE.
O HEMORRHAGE – DUE TO TRUAMA WITH ISCHEMIA OF TISSUE
⇒ HEMORRHAGE OR OBSTRUCTION OF THE BLOOD SUPPLY TO THE CORD CAN LEAD TO
ISCHEMIA AND PERMANENT DAMAGE AS WELL. JUST LIKE EVERYTHING ELSE IN THE BODY, THE
SPINAL CORD HAS TO HAVE BLOOD SUPPLY. SO IF THE BLOOD SUPPLY IS INTERRUPTED, THEN
YOU CAN HAVE PERMANENT DAMAGE
O SECONDARY INJURY –
⇒ ALL SPINAL CORD TRAUMA IS GOING TO LEAD TO SWELLING. THE SWELLING CAN
OCCUR BOTH ABOVE AND BELOW THE LEVEL OF THE INJURY. SO YOU NOT ONLY WORRY ABOUT IF
THEY HAVE A C5 CORD TRANSECTION, BUT YOUR WORRY ABOUT THOSE LEVELS ABOVE AND
BELOW THE INJURY BECAUSE OF THE EDEMA THAT CAN OCCUR. THE EDEMA IS GOING TO CAUSE
AN INHIBITION IN CORD FUNCTION WHILE IT IS PRESENT. IT IS ALSO GOING TO CAUSE FUNCTIONAL
LOSS
• IF YOU HAVE TOTAL TRANSECTION, THERE IS GOING TO BE PERMANENT LOSS IN THE AREA
THAT WAS INJURED, BUT YOU MIGHT HAVE SOME TEMPORARYADDITIONAL LOSS ABOVE THE
AREA OF THAT INJURY DUE TO EDEMA THAT WILL GET BETTER AS THE EDEMA SUBSIDES.
⇒ YOU ALSO CAN HAVE ISCHEMIA OR HEMORRHAGE THAT CAN DESTROY NERVE TISSUE
AND THE QUICKER THAT WE CAN GET THESE CLIENTS IN AND INITIATE TREATMENT, THE BETTER
THEIR OUTCOME IS GOING TO BE BECAUSE THE QUCKER THAT WE CAN CONTROL THE EDEMA AND
IDENTIFY AND CONTROL HEMORRHAGE AND PREVENT SECONDARY INJURY, THEY ARE GOING TO
HAVE A BETTER OUTCOME.
⇒ MOST OF THE EDEMA IS GOING TO OCCUR AT THE SITE OF THE INJURY AND 2
SEGMENTS ABOVE AND BELOW THAT LEVEL OF INJURY. YOUR SPINAL CORD EDEMA FROM TRAUMA
PEAKS AT ABOUT 72 HOURS.
CLINICAL MAINFESTATIONS:
- PAIN
- PARAPLEGIA (LOSS OF FUNCTION OF THE LOWER EXTREMITIES)
- QUADRIPLEGIA (LOSS OF FUNCTION FROM THE NECK DOWN)
- RESPIRATORY DYSFUNCTION
- “NEUROLOGIC LEVEL” (ASIA) – LOWEST LEVEL WHERE SENSORY AND MOTOR FUNCTION IS NORMAL.
O BELOW THAT NEUROLOGIC LEVEL, IN OTHER WORDS AT THE LEVEL OF INJURY AND BELOW. THIS IS
WHAT YOU WILL SEE BELOW. NO MATTER WHERE THE INJURY IS, IF YOU HAVE TOTAL TRANSECTION OF
THE CORD, THIS IS WHAT YOU ARE GOING TO SEE AT AND BELOW THE LEVEL OF INJURY: (INITIALLY-
SPINAL SHOCK PHASE)
⇒ SENSORY AND MOTOR PARALYSIS
⇒ LOSS OF BOWEL AND BLADDER CONTROL
⇒ LOSS OF SWEATING AND VASOMOTOR TONE
⇒ DECREASED BLOOD PRESSURE

SIGNS AND SYMPTOMS – DEPEND ON LEVEL, EXTENT AND MECHANISM OF INJURY

12
 TCA 4

- LEVEL OF INJURY
O CERVICAL
- MOST COMMON TYPE; C2 – C3 INJURY IS RAPIDLY FATAL (RESPIRATORY CENTER FAILURE).
- AT C2 & C3 YOU HAVE YOUR PHRENIC NERVE WHICH INVERVATES THE DIAPHRAGM, YOU
HAVE IMMEDIATE PARALYSIS OF THE DIAPHRAGM AND IT CAN LEAD TO RAPID RESPIRATORY
FAILURE AND DEATH
- WITH YOUR CERVICAL SPINAL CORD INJURY YOU HAVE DEVASTATING FUNCTIONAL INJURY.
THERE ARE QUADRIPEGICS THAT DO HAVE A LITTLE BIT OF FUNCTION IN THEIR ARMS. THEY
MAY BE ABLE TO MANIPULATE AN ELECTRIC WHEELCHAIR WITH THEIR FINGERS AND THEIR
ELBOWS. YOU CAN HAVE THIS IN YOUR LOWER CERVICAL AREA (C5 & C6) AND YOU GET A
LITTLE BIT OF THAT PARTIAL CONTROL, BUT THEY ARE STILL CONSIDERED QUADRIPLEGIC
- COMPLETE TRANSECTION  QUADRIPLEGIA @ C4 AND ABOVE
- C4 AND ABOVE CAUSES COMPLETE QUADRIPLEGIA, SOME OF YOUR C5 & C6 CAN HAVE A
LITTLE BIT OF ELBOW AND PARTIAL WRIST CONTROL AND POSSIBLY EVEN A LITTLE SHOULDER
MOVEMENT.
- SWELLING MAY HAPPEN TO SEGMENTS 2 ABOVE OR BELOW THE INJURY
O THORACIC
- LESS FREQUENT; REQUIRES VIOLENT INJURY TRANSECTION (GUNSHOT WOUND, HARD HIT TO
THE BACK)– RIBS PROTECT THIS SECTION
- @ T12 – L1 TRANSECTION  PARAPLEGIA
- WHAT YOU WORRY ABOUT IN THE THORACIC AREA – T1 TO T11 CONTROL THE INTERCOSTAL
MUSCLES WHICH HELPS WITH BREATHING. IF YOU HAVE A THORACIC TRANSECTION, YOU CAN
HAVE INEFFECTIVE BREATHING OR INADEQUATE OXYGENATION BECAUSE THEY ARE UNABLE TO
MOVE THE INTERCOSTAL MUSCLES.
O LUMBAR
- L4 - L5 MOST COMMON – HIT OR BENDING OVER
- USUALLY RESULTS FROM VERTEBRAL COMPRESION OR VERTEBRAL FRACTURE
O SACRAL AND COCCYGEAL
- USUALLY RESULT FROM FALLS OR DIRECT TRUAMA; NERVES SOMEWHAT PROTECTED
- SYMPTOMS OF LUMBAR/SACRAL INJURY (TOTAL TRANSECTION)
O THIS WOULD BE CONSIDERED LOWER MOTOR NEURON (BELOW T12)
• FLACCID PARALYSIS OF LOWER EXTREMITIES (REFLEX ARCS ARE LOST)
• LOSS OF DEEP TENDON REFLEXES
• URINARY RETENTION
• FECAL INCONTINENCE
• LOSS OF SENSATION
• SEVERE LOWER BACK PAIN (INITIALLY, AT THE TIME OF THE INJURY)

- MECHANISM OF INJURY
O HYPERFLEXION – NECK DOWN
O HYPEREXTENSION – NECK UP
O COMPRESSION – FALL FLAT ON FEET/HEAD
O ROTATIONAL FORCES – TWISTING NECK

EMERGENCY MANAGEMENT
- GOALS TO PRESERVE LIFE AND PREVENT FURTHER DAMAGE
O AT ACCIDENT SITE
- IMMEDIATELY IMMOBILIZE TO TRY TO PREVENT SECONDARY INJURY

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 TCA 4

- ABC’S (IF THEY HAVE SUSTAINED A CERVICAL INJURY, WE ARE WORRIED ABOUT THEIR AIRWAY
AND BREATHING)
- KEEP THEIR HEAD AND NECK IN A NEUTRAL POSITION
- GET THEM ON A SPINAL OR BACKBOARD ASAP
- AVOID TWISTING THEM (TO AVOID SECONDARY ROTATIONAL FORCE PROBLEMS)
- STABILIZE THEM AND TRANFER THEM ASAP
O IN ER
- ASSESS, EVALUATE, OBTAIN HISTORY OF INJURY, PROVIDE NECESSAR SUPPORT
- STABILIZE AND TRANSFER TO TRAUMA CENTER

ASSESSMENT AND DIAGNOSIS OF SCI

- FIRST OF ALL, ABC’S AND RESPIRATORY STATUS ARE GOING TO BE PRIORITY (PARTICULARLY WITH CERVICAL
INJURIES)
- A THOROUGH NEUROLOGIC EXAM – TO LOOK AT THE DEFICITS, THE FUNCTIONAL DISABILITIES, THIS WILL GIVE US
SOME INFORMATION ABOUT LEVEL OF INJURIES
- RADIOGRAPHIC STUDIES – X-RAY, CT, MRI – TO TRY TO LOCATE AND DETERMINE THE EXTENT OF THE
INJURY
- ASSESSING FOR OTHER INJURIES – FOR INSTANCE ALSO WANT TO ASSESS FOR HEAD INJURIES BECAUSE THEY
OFTEN OCCUR TOGETHER (PARTICULARLY IF THEY HAVE CERVICAL SPINE INJURY)
- CARDIAC MONITORING – BRADYCARIA AND ASSYSTOLE CAN OCCUR IN THE SPINAL SHOCK PHASE (ACUTE PHASE
AFTER SPINAL CORD INJURY)
- RESPIRATORY STATUS IS IMPORTANT IN THE CERVICAL AREA, BECAUSE THE PHRENIC NERVE BEING SEVERED
THAT CONTROLS THE DIAPHRAGM AND ALSO IN THE THORACIC AREA BECAUSE OF THE INTERCOSTAL MUSCLES.
YOU WANT TO MONITOR THE RESPIRATORY STATUS – EVEN IF THEY ARE BREATHING ON THEIR OWN, WE NEED
TO BE SURE THAT THEY ARE BREATHING EFFECTIVELY AND THAT THEIR OXYGENATION IS ADEQUATE.

NONSURGICAL MEDICAL MANAGEMENT

- CONTROLLING CORD EDEMA – RAPID ADMINISTRATION OF HIGH DOSE CORITCOSTEROIDS WITHIN 8 HOURS OF
INJURY IS A PRIORITY. THIS WILL DECREASE CORD EDEMA AND IT IS GOING TO PREVENT OR MINIMIZE THE
SECONDARY INJURY (ISHCEMIA, DAMAGE TO SEGMENTS OF THE CORD ABOVE AND BELOW THE ACTUAL LEVEL OF
INJURY) THAT CAN OCCUR. (SOLU-MEDROL, DECADRON)
- RESPIRATORY THERAPY
O O2 TO PREVENT HYPOXIA
O CAREFUL MANAGEMENT OF ET TUBE – PARTICULARLY WITH CERVICAL INJURY. IF A CLIENT COMES IN
WITH CERVICAL INJURIES, PARTICULARLY HIGH CERVICAL INJURY, THEY ARE GOING TO NEED TO BE
INTUBATED TO MAINTAIN RESPIRATORY FUNCTION.
O MONITOR RESPIRATORY STATUS
- IMMOBILIZATION OF FRACTURE PRESENT IN ADDITION TO CORD DAMAGE – GOAL IS TO STABILIZE THE VERTEBRAE
AND RESTORE A NORMAL POSITON OF THE VERTEBRAL COLUMN
O CERVICAL
- TONGS WITH TRACTION
- HALO DEVICE
• SCREWED INTO THE BONES OF THE SKULLS
• MAINTAINS STABILIZATION, IMMOBILITY AND PROPER ALIGNMENT OF THE SPINE
• EARLY MOBILIZATION
• SPECIALTY BEDS – IN THE ACUTE PHASES AFTER SPINAL CORD INJURY, IT IS VITAL THAT
THESE CLIENT’S VERTEBRAL AND SPINAL COLUMN IS IMMOBILIZED. THERE ARE BEDS THAT
WILL TURN THESE PATIENTS. THE BED WILL TURN THEM AS ONE UNIT. THEY EVEN HAVE
BEDS THAT CAN GET THESE CLIENTS INTO STANDING POSITION

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 TCA 4

O THORACIC OR LUMBAR
- BODY CASTS, HALO (ATTACHED TO FEMUR), OR BRACE
- POSITIONING
O SACRAL OR COCCYGEAL
- BED REST
- GIRDLES

SURGICAL MANAGEMENT – INDICATED FOR DECOMPRESSION, REDUCTION OF FRACTURE, EXPLORATION

- SPINAL CORD COOLING – NOT DONE MUCH DUE TO STEROID USE AND ↑ RISK FOR INFECTION – THIS GIVES A
COLD SALINE IRRIGATION FOR A MATTER OF HOURS TO THE CORD TO REDUCE CORD EDEMA.
- LAMINECTOMY – PROVIDES STABILITY
- SPINAL FUSION – STABILIZES SPINE
- HARRINGTON RODS - ↓ R/F COMPLICATIONS

COMPLICATIONS OF SCI
- SPINAL SHOCK – PHASE THAT OCCURS RIGHT AFTER SPINAL CORD INJURIES
• OCCURS IMMEDIATELY AFTER SPINAL CORD TRAUMA – LASTS FROM FEW DAYS TO MONTHS- USUALLY
LASTS BETWEEN 1 & 6 WEEKS.
• CAN OCCUR AFTER CONTUSION, CONCUSSION, COMPRESSION
• RESULTS FROM SUDDEN DEPRESSION OF REFLEX ACTIVITY BELOW THE LEVEL OF INJURY
• CESSATION OF ALL MOTOR, SENSORY, REFLEX, AND AUTONOMIC FUNCTIONS BELOW THE LEVEL OF THE
INJURY
• EVERYTHING SHUTS DOWN
• OBSERVE PATIENT CLOSELY FOR HYPOTENSION, BRADYCARDIA, HYPERTHERMIA, ATONIC BOWEL AND
BLADDER, AND FLACCID PARALYSIS DURING THE SPINAL SHOCK STAGE. BELOW THE LEVEL OF
TRANSECTION, THEY LOSE PERIPHERAL VASCULAR TONE SO YOU MAY SEE HYOPTENSION AND
BRADYCARDIA. WITH HYPERTHERMIA THEY MAY HAVE AN ABRUPT ONSET OF FEVER; THEY ARE UNABLE
TO SWEAT ON THE PARALYZED EXTREMITY.
O THE ATONIC BOWEL/BLADDER IS DUE TO THE LOSS OF REFLEX ACTIVITY. THEY CAN DEVELOP A
DISTENDED BLADDER. IT BECOMES ATONIC. THEY CAN HAVE OVERFLOW INCONTINENCE. WE
HAVE TO MONITOR FOR THAT AND MANAGE THEIR BLADDER FUNCTION DURING THIS PERIOD
(USUALLY THROUGH A CATHETER).
O PARALYTIC ILLEUS CAN RESULT, DUE TO THIS LOSS OF REFLEX ACTIVITY. THEY MAY NEED AN
NG TUBE TO DECOMPRESS THE ABDOMEN.
• RECOVERY OCCURS WITH RETURN OF SOME REFLEX ACTIVITY
O THE PARALYSIS IS GOING TO BECOME SPASTIC PARALYSIS IF YOU HAVE AN UPPER MOTOR
NEURON LESION (ABOVE T12). ABOVE T12, AS SPINAL SHOCK RESOLVES YOU BEGIN TO SEE
THOSE CHARACTERISTICS OF UPPER MOTOR NEURON LESIONS. THE RETURN OF THE REFLEXES
THAT REMAIN INTACT WHEN YOU HAVE AN UPPER MOTOR NEURON LESION.
O IF IT IS A LOWER MOTOR NEURON LESION (BELOW T12), THEIR BOWEL AND BLADDER IS GOING
TO REMAIN FLACCID, THEY ARE GOING TO KEEP THAT FLACCID PARALYSIS.
O YOUR AUTONOMIC FUNCTIONS BECOME RESTORED AFTER RECOVERY OF THIS SPINAL SHOCK
PHASE. SO YOU START TO DEVELOP ALL OF THAT PERIPHERAL VASOMOTOR TONE AGAIN.
O WITH THE UPPER MOTOR LESION, THE BOWEL AND BLADDER ARE GOING TO BEGIN
CONTRACTING REFLEXIVELY AGAIN - ANAL WINK: SHOCK IS RESOLVING
- DVT – DUE TO IMMOBILITY
• ABOUT 17% OF CIENTS WITH A SPINAL CORD INJURY WILL DEVELOP DVT’S
• THEY ARE AT RISK FOR PULMONARY EMBOLI
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 TCA 4

O ASSESS FOR:
⇒ PLEURITIC CHEST PAIN
⇒ ANXIETY
⇒ SHORTNESS OF BREATH
⇒ ABNORMAL ABG’S
• TO PREVENT DVT AND RESULTING PULMONARY EMBOLUS – THEY MAY GET LOW MOLECULAR WEIGHT
OR LOW DOSE HEPARIN THERAPY (HEPARIN OR LOVENOX), UNLESS CONTRAINDICATED. ANTIEMBOLISM
STOCKINGS, DOING THIGH AND CALF MEASUREMENT.
• IF THEY DO LOCATE A DVT, THEY MIGHT PLACE A VENA CAVA FILTER IN THE CLIENT TO PREVENT THE
PULMONARY EMBOLUS.
- RESPIRATORY COMPLICATIONS
• PNEUMONIA FROM IMMOBILITY OR FROM BEING VENTILATOR DEPENDENT OR FROM INADEQUATE
RESPIRATONS
• RESPIRATORY FAILURE – IF THEY HAVE PARALYSIS OR WEAKNESS OF THE RESPIRATORY MUSCLES
• INFECTION
- AUTONOMIC DYSREFLEXIA
• OCCURS ONLY AFTER SPINAL SHOCK HAS RESOLVED.
• THE FIRST EPISODE CAN BE AS LONG AS 6 YEARS AFTER THE INITIAL SPINAL CORD INJURY.
• THIS IS CAUSED BY AN EXAGERATED AUTONOMIC RESPONSE TO HARMLESS STIMULI. IT IS AN UNIHIBITED
SYMPATHIC RESPONSE.
• THIS RESULTS IN TOTAL BODY VASOCONSTRICTON
• CAUSES
O DISTENDED BLADDER (MOST COMMON CAUSE)
O DISTENDED BOWEL
O DECUBITIS ULCER
O COLD DRAFT IN THE ROOM

• MAY OCCUR IN CLIENTS WITH INJURY ABOVE THE T6. NOT EVERYONE WITH INJURY ABOVE T6 WILL
DEVELOP AUTONOMIC DYREFLEXIA, THEY ARE JUST THE ONLY ONES THAT ARE AT RISK FOR IT.
• SIGNS AND SYMPTOMS OF AUTONOMIC DYSREFLEXIA
O SEVERE POUNDING HEADACHE
O EXTREME HYPERTENSION – THEIR SYSTOLIC PRESSURE MIGHT BE 240 OR UP DUE TO TOTAL
BODY VASOCONSTRICTION
O BRADYCARDIA
O FLUSHING ABOVE THE INJURY AND PALLOR BELOW THE LEVEL OF INJURY.
O SWEATING ABOVE THE INJURY, PARTICULARLY ON THE FORHEAD

• WHAT WE WANT TO DO AS NURSES IS PREVENT THIS FROM OCCURING.

O KEEP THE BLADDER DRAINED
O KEEP THEM ON BOWEL PROGRAM
O KEEP FROM BECOMING CONSTIPATED
O MAINTAIN SKIN INTEGRITY
• THIS IS A LIFE THREATENING EMERGENCY WHEN IT DOES OCCUR.
• A TREATMENT OF AUTONOMIC DYSREFLEXIA IS TO REMOVE THE CAUSE:
1. THE FIRST THING THAT WE ARE GOING TO DO IS ELEVATE THE HOB TO HIGH FOWLERS. THIS IS
GOING TO DECREASE THE VENOUS RETURN TO THE HEART AND HELP WITH THE SEVERE
HYPERTENSION

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 TCA 4

2. LOOK FOR THE CAUSE – CHECK THE CATHETER FOR KINKS – IF THEY DO NOT HAVE A CATHETER,
WE ARE GOING TO PALPATE FOR BLADDER DISTENTION. WE PROBABLY WIL LJUST GO ON AND
CATHETERIZE THEM BECAUSE MOST OF THE TIME IT IS A DISTENDED BLADDER THAT CAUSES THIS
CONDITION
3. CHECK FOR AN IMPACTION IF IT IS NOT THEIR BLADDER. WE WANT TO USE A LOCAL ANESTHETIC
FIRST BECAUSE WE ARE GOING TO FURTHER STIMULATE SOME MORE SYPATHETIC ACTIVITY IF YOU
DON’T.
4. CHECK FOR PRESSURE AREAS
5. CHECK FOR DRAFTS IN THE ROOM OR WHATEVER STIMULUS YOU CAN THINK OF AT THIS POINT
THAT MIGHT BE CAUSING THIS RESPONSE.
• IF YOU REMOVE THE CAUSE, THE AUTONOMIC DYSREFLEXIA SHOULD SUBSIDE. IF THE SYMPTOMS DO
NOT SUBSIDE QUICKLY, YOU NEED TO NOTIFY THE PHYSICIAN AND THEY MAY ORDER APRESOLINE.
WHAT THIS IS GOING TO DO IS VASODILATE.
• ONCE THIS HAS OCCURRED IN YOUR SCI CLIENT, THEY ARE AT RISK TO DEVELOP IT AGAIN. THEIR
MEDICAL RECORD NEEDS TO BE LABELED. THE CLIENT NEEDS TO WEAR A MEDICAL ALERT BRACELET.
THEY CAN NOW HAVE THIS THROUGHOUT THEIR LIFE.
• TEACH YOUR CLIENT HOW TO PREVENT THIS.
• IF THIS AUTONOMIC DYSREFLEXIA IS LEFT UNTREATED, THE SEVERE HYPERTENSION CAN LEAD TO
CEREBRAL HEMORRHAGE. THIS WILL LEAD TO INCREASED ICP WHICH CAN LEAD TO STATUS
EPILEPTICUS. THIS IS A LIFE THREATENING EMERGENCY THAT NEEDS VERY RAPID TREATMENT.
- INFECTION
• NOT JUST PULMONARY INFECTION,

• BUT ALSO INFECTION OF THE URINARY TRACT. WITH EITHER TYPE OF BLADDER PROBLEMS, IF THEY ARE
BEING CATHETERIZED FREQUENTLY OR HAVING SOME TYPE OF INTERVENTION FOR THEIR BLADDER
EMPTYING, THEY ARE GOING TO BE AT INCREASED RISK FOR INFECTION
• CAN GET INFECTION OF LOCAL SKIN SITES – IF CERVICAL TRACTION OR HALO DEVICE
• IF THEY HAVE TO HAVE SURGERY - THEY WILL BE AT RISK FOR INFECTION
- HAZARDS OF IMMOBILITY – PRESSURE SORES

NURSING DIAGNOSIS:
- ACUTE INJURY
- INEFFECTIVE BREATHING PATTERNS
- IMPAIRED SKIN INTEGRITY
- ALTERED SENSORY PERCEPTION
- URINARY RETENTION
- CONSTIPATION
- ACUTE PAIN

NURSING DIAGNOSIS (LONG TERM)

- R/F DISUSE SYNDROME
- SEXUAL DYSFUNCTION
- INEFFECTIVE COPING
- KNOWLEDGE DEFICIT

NURSING MANAGEMENT
- GOALS
O PREVENT FURTHER INJURY

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O MAINTAIN INTACT FUNCTION

O PREVENT COMPLICATIONS
O REHABILITATION (STARTS THE MINUTE THE PATIENT COMES IN)
- IMMOBILIZATION (PRIORITY)
O IN THE ACUTE PHASE, YOU WANT TO KEEP THE VERTEBRAL COLUMN IN PROPER ALIGNMENT AND
IMMOBILIZED TO PREVENT FURTHER INJURY.
O CERVICAL

• IF THEY HAVE CERVICAL TONGS OR A HALO, INSPECT AND CLEAN TONG SITES, MONITOR THEM FOR
INFECTION.
• IF THEY HAVE THE CERVICAL TONGS AND TRACTION, WE WANT MONITOR THE WEIGHTS, MAKE SURE
ROPES ARE NOT FRAYED, THE WEIGHTS ARE HANGING FREELY, ETC.
• HALO – MONITOR THE TIGHTNESS OF THE JACKET – ONE THING THAT YOU WORRY ABOUT WITH
THE HALO DEVICES IS IMPAIRED SKIN INTEGRITY AROUND WHERE THE DEVICE SITS ON THE
SHOULDERS, YOU WANT TO MAKE SURE THAT IT IS FITTING SNUGGLY ENOUGH TO ACHIEVE THE
PURPOSE OF MAINTAINING STABILITY BUT YOU ALSO WANT TO HAVE IT PADDED ADEQUATELY.
• AVOID STRIKING METALS ONTO THE HALO OR THE TRACTION DEVICES – BONE IS A CONDUCTOR OF
VIBRATIONS, SO IF YOU WERE TO STRIKE THE METAL HALO ON THE FRAME OF THE BED, THIS WILL
BE VERY UNCOMFORTABLE FOR THE CLIENT.
• NEED TO HAVE A TORK(?) SCREWDRIVER AVAILABLE FOR EMERGENCIES, IF THE HALO DID HAVE
TO BE REMOVED.
• WITH THIS TYPE OF CERVICAL INJURY, IF WE ARE ALLOWED TO TURN THEM, WE WANT TO TRIPLE
LOG ROLL THEM. IT IS GOING TO TAKE THREE PEOPLE. YOU WANT ONE PERSON AT THE
SHOULDERS, ONE AT THE HIPS AND ONE AT THE LEGS BECAUSE IT IS ABSOLUTELY VITAL THAT WE
MOVE THIS CLIENT AS ONE UNIT AND NOT DO ANY OF THE ROTATIONAL THINGS THAT CAN CAUSE
FURTHER INJURY.
O THORACIC/LUMBAR
• THEY MIGHT BE IN A BODY CAST, IF THEY ARE WE WILL DO LOGROLLING AND CAST CARE.
• IF THEY HAVE A HALO (PINS IN THE FEMUR), INSPECT AND KEEP PINSITES CLEAN AND FREE OF
INFECTION
• IF THEY HAVE A BRACE, NEED TO BE SURE THAT IT IS FITTING PROPERLY AND THAT THEY ARE
WEARING IT AS THEY WERE INSTRUCTED. INSPECT FOR PRESSURE AREAS AND PLACES WHERE
THE BRACE MAY BE RUBBING THE SKIN
O SACRAL/COCCYGEAL
• USUALLY THESE CLIENTS ARE JUST ON BEDREST. ASSESS THEIR BOWEL AND BLADDER FUNCTION
FREQUENTLY BECAUSE IT IS MORE COMMON IN THIS SACRAL & COCCYGEAL AREA BECAUSE THE
INJURY IS IN THE EXACT AREA WHERE BOWEL AND BLADDER IS CONTROLLED.
• AVOID SITTING ON HARD SURFACES. THEY WILL NOT WANT TO BE SITTING UPRIGHT BECAUSE OF
THE PAIN THAT IT CAUSES TO THE AFFECTED AREA.
- DISUSE SYNDROME

- RESPIRATORY
O ↑ R/F PNEUMONIA AND RESPIRATORY FAILURE
O INJURY ABOVE C4
O RESPIRATORY STATUS MONITORED Q2
O CAREFULLY SUCTION THEM, PARTICULARLY WITH CERVICAL INJURY

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O TURN, COUGH AND DEEP BREATH. WE DISCOURAGE COUGHING IF THEY HAVE INCREASED ICP, BUT WITH
SPINAL CORD INJURY IN THE ABSENCE OF A HEAD INJURY, WE DO WANT THEM TO COUGH AND TURN AND
DEEP BREATH.
O RESPIRATORY THERAPY MAY BE USED
- CARDIOVASCULAR
O ↑ R/F THROMBUS, ORTHOSTATIC HYPOTENSION
O NO DANGLE B/C ↑ R/F STROKE; LAY DOWN
O PAIN, SWELLING REDNESS (SIGNS OF DVT)
O TED, LOVENOX
O FREQUENT VITAL SIGNS (ESPECIALLY IN THE SPINAL SHOCK STAGE – WHERE THEY ARE AT RISK FOR
HYPOTENSION AND BRADYCARDIA)
O MONITOR FOR SPINAL SHOCK SYNDROME
O MONITOR FOR ORTHOSTATIC HYPOTENSION (ESPECIALLY IN THE SPINAL SHOCK PHASE BECAUSE THEY HAVE
LOST THAT VASOMOTOR TONE SO THEY ARE GOING TO BE VERY SENSITIVE TO POSITIONAL CHANGES)
O PASSIVE ROM (TO PROMOTE CIRCULATION AND PREVENT JOINT DEFORMITIES)
O A TILT TABLE IS ONE WAY TO CHANGE THEIR POSITION SLOWLY
O VASOPRESSORS MAY NEED TO BE USED IF THEY ARE SEVERELY HYPOTENSIVE. THIS CAN HELP TO
INCREASE VASCULAR TONE.
- INTEGUMENTARY
O ↑ R/F PRESSURE ULCERS, BREAKDOWN, AND DECREASED SENSATION
O PARTICULARLY IMPORTANT WITH YOUR CLIENT THAT HAS A SCI AND PARALYSIS IS METICULOUS SKIN
CARE. THIS IS LONG TERM AND HAS TO BE DONE EVERY DAY, YOU CANNOT SLACK OFF ON THESE
THINGS.
O KEEP VERY CLEAN LINENS
O TURNING
- MUSCULOSKELETAL
O PREVENT CONTRACTURES
- PASSIVE ROM, VALIUM
- SPASTICITY MAJOR PROBLEMS WITH QUADS (MORE COMMON WITH UPPER MOTOR NEURON
INJURY)
- LOSE CALCIUM BECAUSE INCREASED STRESS BONES MUSCLE ATROPHY
O MAINTAIN BODY ALIGNMENT
O BONE DEMINERALIZATION IS A RISK FROM IMMOBILITY BECAUSE THEY ARE NOT WEIGHT BEARING. THIS
IS ONE REASON THAT THEY WOULD WANT THIS CLIENT TO GET INTO AN UPRIGHT POSITION SO THAT THEY
CAN HAVE A LITTLE BIT OF WEIGHT BEARING TIME ON THEIR BONES (TO DRIVE CALCIUM INTO THE BONE)
O MUSCLE ATROPHY (MORE COMMON IN LOWER NEURON LESIONS – BELOW T12) BECAUSE THE REFLEX
ARC IS LOST.
- NUTRITION
O FLUID VOLUME OVERLOAD
O DEHYDRATION, NG TUBE, KEOFEED
- IV FLUIDS
- BOWEL SOUNDS
- GAG/SWALLOW REFLEX
- SELF CARE FEEDING DEVICES
O ADVANCE THEIR DIET VERY SLOWLY AFTER THE SPINAL SHOCK PHASE IS OVER AND THEY DO HAVE
SOME GASTRIC MOTILITY TO SEE WHAT THEY CAN HANDLE.
O ASSIST WITH FEEDING
O MAY NEED DIETARY SUPPLEMENTS (SUCH AS ENSURE)
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O THEY ARE AT RISK FOR DISTRESS ULCERS, DUE TO THE DECREASED BLOOD FLOW TO THE STOMACH
- GENITOURINARY TRACT
O NEUROGENIC BLADDER
O DURING SPINAL SHOCK THE BLADDER IS ATONIC – THIS CLIENT MUST HAVE A CATH. THEY HAVE NO
BLADDER TONE; IT IS NOT GOING TO BE ABLE TO EMPTY. WE WANT TO ASSESS THEM FOR DISTENSION,
TRY TO PREVENT UTI’S AND KIDNEY STONE FORMATION. WE WANT TO KEEP THEM WELL HYDRATED,
GIVE GOOD CATHETER CARE.
O AS SPINAL SHOCK SUBSIDES YOU WILL SEE ONE OF TWO THINGS WITH TOTAL CORD TRANSECTION
(DEPENDING UPON THE LEVEL OF THE INJURY):
- UPPER MOTOR NEURON BLADDER – OCCURS ABOVE T12; BLADDER BECOMES HYPERTONIC
AND SPASTIC
• BLADDER EMPTIES AS REFLEX
• BLADDER RETRAINING IS MORE EFFECTIVE BECAUSE THEY HAVE REFLEX.
• WE CAN STIMULATE THE REFLEXIVE EMPTYING BY:
 STROKING THE THIGH
 PULLING A PUBIC HAIR
 POSSIBLE REFLEXIVELY REACT TO A COOL DRAFT OR BEING EXPOSED TO THE AIR.
• WE CAN ALSO DO THE BLADDER RETRAINING WITH THESE CLIENT BY INCREASING
FLUIDS RIGHT BEFORE THEY PLAN TO VOID. WE CAN SIT THEM UPRIGHT AND TRY THE
CREDE MANEUVER, TRY STROKING THE THIGH OR SOMETHING TO STIMULATE BLADDER
EMPTYING.
• EXTERNAL CATHETERS MAY BE USED IF THEY HAVE THE REFLEXIVE EMPTYING,
PROTECTS FROM THE DRAINAGE AND PREVENTS SKIN BREAKDOWN.
• URINARY DIVERSION PROCEDURES MIGHT BE DONE IN ORDER TO MAINTAIN SKIN
INTEGRITY AND PREVENT BREAKDOWN (UROSTOMY, SUPRAPUBIC CATHETER)
- LOWER MOTOR NEURON BLADDER – AT OR BELOW T12 BLADDER BECOMES ATONIC WITH
INCREASED BLADDER CAPACITY. THEY LOSE THE MOTOR AND THE SENSORY RESPONSE. THE
BLADDER IS ATONIC, IT BECOMES OVERDISTENDED AND YOU HAVE URINARY RETENTION IF YOU DO
NOT INTERVENE. MIGHT HAVE OVERFLOW INCONTINENCE
• LARGE AMOUNT OF URINE – LEAKING URINE – THESE CLIENTS WILL NEED
CATHETERIZATION.
• BLADDER – FLACCID
 WITH A FLACCID BLADDER GOING TO HAVE TO HAVE CATHETERIZATION, MAY USE
CREDE MANEUVER TO HELP TOTALLY EMPTY THE BLADDER
• T12 INJURYS ARE USUALLY PARAPLEGICS – SO YOU CAN TEACH THIS CLIENT
INTERMITTENT CATHETERIZATION. WE TEACH THEM CLEAN TECHNIQUE FOR HOME.
• WE USUALLY USE INTERMITTENT CATHETERIZATION BECAUSE WITH THE INTERMITTENT
CATH, THERE IS LESS RISK FOR INFECTION. INDWELLING CAHTETERS ARE A MEDIUM FOR
BACTERIA. THE INDWELLING CATHETER IS USED IN THE ACUTE STAGES OF SPINAL CORD
INJURY, BUT LONG TERM WE ARE GOING TO USE INTERMITTENT CATHETERIZATION.
• WE WANT TO TEACH THESE CLIENTS THE SIGNS AND SYMPTOMS OF UTI.
• URINARY DIVERSION PROCEDURES MIGHT BE DONE IN ORDER TO MAINTAIN SKIN
INTEGRITY AND PREVENT BREAKDOWN (UROSTOMY, SUPRAPUBIC CATHETER)
- BOWEL
O UPPER MOTOR NEURON
- BOWEL EMPTIES REFLEXIVELY – BOWEL RETRAINING WILL BE MORE EFFECTIVE IN THIS CLIENT
BECAUSE THEY HAVE THE ANAL SPHINCTER REFLEX INTACT. THIS WILLHELP TO HOLD THE
FECAL CONTENTS IN UNTIL READY TO EVACUATE THE BOWEL.

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O LOWER MOTOR NEURON  LOSS OF SPHINCTER CONTROL

- LOSS OF REFLEX ACTION WITH EXTERNAL SPHINCTER RELAXATION – YOU WILL SEE THIS
CONSTANT DISCHARGE OF WATERY STOOL – WE THEN HAVE TO WORRY ABOUT SKIN
BREAKDOWN (MIGHT HAVE TO HAVE A COLOSTOMY TO CATCH THE FECAL CONTENTS)
- BOWEL INCONTINENCE; BOWEL RETRAINING (ENEMA, STIMULATION)
O WITH BOTH UPN & LMN:
- WELL BALANCED DIET
- STOOL SOFTENERS
- VERY INDIVIDUALIZED
- STIMULATING THE REFLEX (UPPER MOTOR NEURON LESION)
- INCREASING INTRABDOMINAL PRESSURE
- PREVENT CONSTIPATION (ESPECIALLY IN YOUR UPPER MOTOR NEURON AND ABOVE THE T6 WE
WANT TO PREVENT THAT AUTONOMIC DYSREFLEXIA – WHICH CAN OCCUR IF THERE IS BOWEL
DISTENSION)
- NERVOUS SYSTEM
O AUTONOMIC HYPERREFLEXIA OR DYSREFLEXIA
- SIT UP IMMEDIATELY - ↓ ICP AND ↓ B/P
• OCCURS UP TO 6 YEARS POST INJURY
• FLAG CHART
• VASODILATOR VECASUE B/P WIL BOTTOM OUT
- OCCURS AFTER SPINAL SHOCK PHASE IN PATIENTS WITH INJURY AT OR ABOVE T6
- VERY SERIOUS EMERGENCY
- SIGNS/ SYMPTOMS
• SEVERE HEADACHE
• HTN (SYSTOLIC OVER 200) (GIVE APRESOLINE)
• BRADYCARDIA
• FLUSHING ABOVE THE INJURY LEVEL, PALLOR BELOW
• PROFUSE SWEATING ABOVE INJURY LEVEL ESPECIALLY THE FOREHEAD
- RESULTS FROM DISTENDED BLADDER, DISTENDED BOWEL, SKIN (PRESSURE, HEAT AND COLD)
• UNINHIBITED RESPONSE
• POSSIBLE UTI’S
- MANAGEMENT
• KEY IS PREVENTION
• TREATMENT CONSIST OF ELEVATING THE HOB AND REMOVING THE CAUSE – SPEED IS
ESSENTIAL
O CHECK FOR
 KINKS IN CATHETER
 IMPACTION
 PRESSURE AREA
 DISTENDED BLADDER
• IF HAVE NOT IDENTIFIED CUASE WITHIN 2-5 MINUTES CALL DR. IMMEDIATELY
- SAFETY
O BED LOW
O CALL BELL WITHIN REACH
O SIDE RAILS UP
O INSENSITIVE TO HOT/COLD/PRESSURE/PAIN BELOW THE LEVEL OF INJURY – SO WE HAVE TO BE
WATCHING OUT FOR THEM
O RESTRAIN THEM IN A WHEELCHAIR IF THEY ARE SITTING UP
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- PAIN
O COMFORT AND REST – VERY DEPENDENT UPON OTHERS FOR COMFORT MEASURES
O PAIN AT POINT OF INJURY
O WE DO WANT TO GIVE THEM NARCOTICS IN THE INITIAL RECOVERY PERIOD. WE ARE NOT GOING TO
GIVE THEM RESPIRATORY DEPRESSENTS IF THEIR RESPIRATORY STATUS IS AT ALL COMPROMISED. WE
WANT TO GET THEM TO SOMETHING NON-NARCOTIC BECAUSE THIS IS A LONG TERM PROBLEM. IF THEY
HAVE THE CERVICAL PAIN – NO NARCOTICS.
O ADDICTION PROBLEM WITH MANAGEMENT
O SURGERY CUT NERVE: ↓ FUNCTION, ↓ PAIN
- SEXUALITY
O SEXUAL FUNCTION IS GOING TO DEPEND UPON THE LEVEL OF INJURY AND THE NUMBER OF FIBERS
SEVERED.
O MALES – COMPLETE TRANSECTIONS – PRIMARY AREA OF CONCERN
- AN ERECTION IS MORE LIKELY WITH HIGHER INJURY BECAUSE THE REFLEX IS INTACT.
- UMN – C1 – T12; LARGE PERCENTAGE EXPERIENCE REFLEXOGENIC ERECTIONS DUE TO
INTACT REFLEX ARC. THEY DO NOT HAVE THE CEREBRAL CONTROL, IT IS JUST THE REFLEXIVE
RESPONSE WITH STIMULATION. MOST CANNOT EJACULATE. SO IF THEY WERE WANTING TO
HAVE CHILDREN – NEED TO CONSIDER ARTIFICIAL MEANS.
• VIAGRA CAN HELP BECAUSE IT IS A VASCULAR DRUG, NOT A NEUROLOGIC ISSUE.
• MAY CHOOSE TO HAVE PENILE IMPLANTS, BUT SENSATION IS GOING TO BE AN ISSUE,
THEY MAY DO THIS LARGELY FOR INTIMACY REASONS (FOR THEIR PARTNER)
- LMN – T12 – S4; NO REFLEXIVE RESPONSE; SMALL PERCENTAGE ABLE TO EXPERIENCE
PSYCHOGENIC ERECTIONS (THEY CAN HAVE THE CONSCIOUS CEREBRAL CONTROL OF THE
ERECTION)
• STIMULATES HIGHER THAN BRAIN LEVELS
• VIAGRA CAN HELP BECAUSE IT IS A VASCULAR DRUG, NOT A NEUROLOGIC ISSUE.
• MAY CHOOSE TO HAVE PENILE IMPLANTS, BUT SENSATION IS GOING TO BE AN ISSUE,
THEY MAY DO THIS LARGELY FOR INTIMACY REASONS (FOR THEIR PARTNER)
O FEMALES
- WITH UPPER MOTOR NEURON LESION – WHERE THERE IS STILL REFLEX – YOU CAN STILL SEE
LUBRICATION IN RESPONSE TO A STIMULUS
- WITH THE LOWER MOTOR NEURON LESION – POSSIBLY NO LUBRICATION BECAUSE THE REFLEX
IS DESTROYED.
- CAN GET PREGNANT NOTHING WRONG WITH REPRODUCTIVE SYSTEM
- LACK SENSATION
- VAGINAL DELIVERIES ARE POSSIBLE. IF IT IS BELOW THE T6 THERE WILL BE NO LABOR PAINS.
- IF YOU HAVE SOMEBODY ABOVE THE T6 THAT IS AT RISK FOR AUTONOMIC DYSREFLEXIA,
UTERINE CONTRACTIONS (STIMULUS) CAN TRIGGER THIS. CHILDBIRTH IS NOT THE TIME TO
HAVE AN EPISODE OF AUTONOMIC DYSREFLEXIA. SO THEY WILL PROBABLY HAVE PLANNED C-
SECTIONS
- PROBLEMS WITH LUBRICATION – KY JELLY
O WITH THESE CLIENTS AND SEXUALITY, KEEP AN OPEN MIND ABOUT THIS. THESE CLIENTS WILL HAVE
REAL CONCERNS ABOUT THEIR SEXUAL FUNCTIONING. HAVING KNOWLEDGE WILLHELP YOU GIVE THEM
REALISTIC EXPECTATIONS. REALIZE THAT THEY STILL NEED MEANINGFUL AND LOVING RELATIONSHIPS.
THESE CLIENTS MAY BE MARRIED AND WERE PLANNING TO HAVE CHILDREN AND THEY ARE GOING TO
HAVE QUESTIONS. IF YOU DON’T KNOW WHAT THE ANSWERS ARE, BE SURE TO REFER THEM TO
APPROPRIATE RESOURCES. DON’T JUST DISMISS QUESTIONS THAT THEY MIGHT HAVE. MAINTAIN
CONFIDENTIALITY.

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REHAB BEGINS ON ADMISSION TO HOSPITAL

PSYCHOSOCIAL CONSIDERATIONS – MAJOR LIFE CHANGE; MAY BE ANGRY OR BITTER, DEAL WITH THEM AND THEIR
FAMILIES, BE SUPPORTIVE AND NON-JUDGEMENTAL.

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