Nervous System Alterations

Part 2
Powerpoint Created by Esther Dorsey, RN, MSN, CCRN
Presented by Debra Mulkey Mott, RN, BSN, CCRN
UTMB Graduate Student

Copyright 2013, 2009, 2005, 2001, 1997,

1993 by Saunders, an imprint of Elsevier Inc

Neurological Case Study

Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Case Study
The nurse admits Mrs.
S to the ED. She was
found down in the
bathroom by a relative.
Initial vital signs
include BP 110/60 mm
Hg, HR 56 beats/min,
RR 10 breaths/min,
SpO2 93%;
temperature 98.9 F.
The patient is
obtunded but moving
all extremities to pain.
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Case Study
Mrs. S is transferred to the ICU. Upon
admission, the nurse completes a
baseline neurological assessment.
Vital signs include BP 100/50 mm Hg, HR
90 beats/min, RR 6-8 breaths/min and
shallow, SpO2 91% on 100% nonrebreather mask.
The patient is unresponsive to voice and
localizes to painful stimuli.
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

COne
asehour
Study
later, the nurse assesses Mrs.

Stanley to be unresponsive to voice and

notes flexion posturing of the extremities.
The nurse also notes the patient to be
having 10 second periods of apnea.
The physician arrives 30 minutes later
and places a right ventriculostomy.

Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Quick Quiz!
Following insertion of the ventriculostomy
(ICP), additional vital signs assessed by the
nurse include MAP 80 mm Hg and ICP 18 mm
Hg. What is the patients cerebral perfusion
pressure (CPP)?
A. 30 mm Hg
B. 40 mm Hg
C. 62 mm Hg
D. 98 mm Hg
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Case Study
Mrs. S is stabilized 24 hours after
admission after insertion of a
ventriculostomy drain (ICP).
Diagnostic CT scan and angiography
indicate a ruptured anterior
communicating artery aneurysm. The
patient undergoes surgical clipping of the
aneurysm.
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Anatomy & Physiology: Spine

Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Spine
Spinal nerves and

plexi as they relate

to vertebral level.
The names of the
vertebrae are listed
on the left, and the
corresponding
spinal nerves and
plexi are listed on
the right.
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Spine
33 vertebrae
7 cervical (C1 -C7
nerve exits over
vertebrae)
12 thoracic (T1
and below the
nerve exits below
the vertebrae)
5 lumbar
5 sacral (fused)
4 coccygeal
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Spine
Ligaments
Anterior &

Posterior support
complex
Can cause
instability of the
spinal column

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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Spine Dermatones

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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

13

Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Spinal Cord Injury (SCI)

Motor vehicle

crashes (MVCs)
Falls
Gunshot wounds
Sports injuries
Diving accidents

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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

SCI- MOI

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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

SCI Lesions
Complete
Incomplete
Anterior cord

syndrome
Central cord
syndrome
Brown-Squard
syndrome

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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Spinal Cord Injury (SCI)- Shock

Spinal Shock

Neurogenic Shock

Complete loss below

Disruption of

level of injury

autonomic pathways

Motor

Temporary disruption of

Sensory
Reflex activity

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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

autonomic pathways
below level of injury

Spinal Cord Injury

Assessment
Airway and ventilation
Paralysis of diaphragm

and intercostal muscles

will result in ineffective
breathing patterns
C1 to C3: ventilator

dependent
C4 to C5: may or may
not need ventilator
Below C5: have intact
diaphragmatic breathing
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Spinal Cord Injury

Assessment (continued)
Neurological
Hemodynamic
Gastrointestinal tract
Autonomic dysfunction
Bowel or bladder dysfunction
Skin
Psychological

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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Spinal Cord Injury Nursing

Management
Airway management
Assessment of

respiratory function
Optimize pulmonary
function
Positioning
Cardiovascular stability
Maintain spinal cord

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perfusion
MAP 85-90 mm Hg
DVT prophylaxis
Gastric decompression
Skin care
Elimination
Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Spinal Cord Injury

Medical Management
Spinal cord

stabilization
Halo vest
Surgical intervention

(plates, rods, bone

grafts)
Medication
Glucocorticoids high

dose
Vasopressors/fluids
Proton pump inhibitors
IV fluids
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Autonomic Dysreflexia
Occurs T6 or above after

resolution of spinal shock

Intense sympathetic

response to stimuli
Kinked urinary catheter
Fecal impaction

Severe hypertension,

headache, and
bradycardia
Assess and remove the

cause
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Traumatic Brain Injury:

Skull Fractures
Skull fractures:
A- Linear; open,

depressed;
basilar; and
comminuted
fractures.
B-View of base of
skull with
fractures.
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

24

Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Quick Quiz!
The nurse admits a patient who hit his head on
the concrete following a fall from a ladder. The
nurse assesses bruising behind the left ear,
bilateral periorbital bruising, and clear nasal
drainage. What do these findings indicate?
A.Subdural

hematoma
B.Basilar skull fracture
C.Linear skull fracture
D.Depressed skull fracture
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Traumatic Brain Injury:

Classifications
Primary
Direct injury to brain
from impact
Coup injury
Contrecoup injury

Types

Concussion
Contusion
Penetrating injuries
Diffuse axonal injuries
Hematomas

Complications
Intracranial bleeding

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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Traumatic Brain Injury:

Classifications
Secondary
Consequence of
initial trauma
Inflammatory response
Release of cytokines
Vasogenic edema

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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Quick Quiz!
Paramedics arrive on the scene of a high school
baseball game. The pitcher, after being struck in
the left temple with a line drive, was knocked
unconscious. Now the paramedics note the
player to be sitting up on the mound and talking.
What is the best interpretation of these
assessment findings?
A.Subdural hematoma
B.Epidural hematoma
C.Concussion
D.Coup/Contrecoup injury
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

Traumatic Brain Injury

Management
Nursing
Medical/Surgical
Neurological assessment
Same as increased
Glasgow Coma Scale

Airway assessment
ICP monitoring
Hemodynamic

monitoring
Interventions to control
elevated ICP
Evaluation of diagnostic
tests
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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc

intracranial pressure
Several surgical
procedures
Craniotomy
Bone fragments
Evacuation hematoma
Foreign body removal

Questions???

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Copyright 2013, 2009, 2005, 2001, 1997, 1993 by Saunders, an imprint of Elsevier Inc