jcmendiola_Achievers2013

Care of Clients with Problems In Inflammatory

& Immunologic Response, Perception & Coordination
(NCM104)
Patients With Neurologic Alterations III

Care of Clients with
Peripheral Nervous System
Disorders

Low Back Pain (LBP)
o Spinal cord cant be bent and
support weight of the body
o If spinal cord is OVERUSED it
can result to LBP

Etiology
Problems that lead to back pain
1. Biochemical Origin that include:
a. Compression of the disc
b. Herniation of the disc
***Impairment of the INTERVERTEBRAL DISC
2. Destructive Origin such as:
a. Infection of the spine
b. Tumor
c. Rheumatoid Arthritis associated with the ageing process
3. Degenerative Problems:
a. Osteoporosis
b. Spinal Stenosis

Cervical Disc Disorders (Different Conditions):
1. Back Strain
Due to poor posture (by sitting or standing)
Also due to poor body mechanics (Lifting heavy objects)
2. Disc Herniation
Intervertebral Disc
Acts as a CUSHION
If it traumatized, it well get misplaced and will exhibit symptoms
of low back pain (due to strenuous activities)
3. Lordosis Excessive BACKWARD CONCAVITY in the lumbar spine
The LUMBAR SPINE is affected
Exaggerated lumbar curve:
4. Spondylolisthesis FORWARD SLIPPING of a VERTEBRA
Impairment of the spinal cord wherein it has forward slipping of the
vertebra
5. Spondylolysis
It is a structural defect on the lamina / neural arch of the spine where the
vertebral arch slips forward
Difference with Spondylolisthesis is what specific part is affected

Topics Discussed Here Are:
1. Care of Clients with Peripheral Nervous System Disorders
a. Low Back Pain (LBP)
b. Cervical Disc Disorders
c. Disorders of the Cranial Nerves
i. Trigeminal Neuralgia
ii. Bell's Palsy
d. Disorders of the Peripheral Nerves
i. Carpal Tunnel Syndrome
2. Care of Clients with Degenerative Disorders
a. Alzheimer's Disease
b. Myasthenia Gravis
c. Multiple Sclerosis
d. Parkinson's Disease
e. Guillain-Barre Syndrome (GBS)
f. Amyotrophic Lateral Sclerosis (ALS)
3. Care of Clients with Neurological Trauma
a. Brain Injury
b. Spinal Cord Trauma
i. Spinal Shock
ii. Autonomic Dysreflexia
LOOKY
HERE

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6. Spinal Stenosis
Associated with the ageing
process
Narrowing down of the
spinal canal which will bring
about compression of the
spinal cord


Clinical Manifestations
E Pain LANDMARK MANIFESTATION
1. Lumbar Disc Pain Radiates into the POSTERIOR THIGH
2. Sciatic Pain Begins in the BUTTOCKS which radiates on the AFFECTED LOWER
EXTREMITY
3. Disc Herniation Pain
Associated with muscle spasm and hyperesthesia (numbness and tingling of the
affected side)
Exacerbated by straining (coughing, sneezing, defecation)
Straight-leg raising in the affected side is limited
***Complete EXTENSION of the LEG is not possible when the thigh is flexed on the
abdomen (Lasegues Sign)
4. Spinal Stenosis
Begins SLOWLY
Includes:
a) Aching pain with standing and walking
b) Paresthesia
c) Heaviness of the legs that progresses as client walks
***Similar with Intermittent Claudication

Management
Medical Management
1. Control Pain
a. Drugs:
NSAIDs/Analgesics = Most IMPORTANT
Muscle Relaxants
Narcotics For SEVERE PAIN
b. Ice for 1
st
48 HOURS, then HEAT THERAPY
If the client complains of pain for the 1
st
time, give ICE FIRST!
c. Position
Supine Position Lordosis, but put a small pillow at the lumbar area
Lateral Position Client will be placed on the UNAFFECTED side
2. Improve Mobility
a. Teach client to minimize stress on the back CORRECT BODY MECHANICS
b. Back Exercise
Surgical Procedure
1. Chemonucleolysis Injection of chymopapain in to the disc to digest the protein in the
disc and to SHRINK it! (Advantage: Less trauma)
2. Percutaneous Discectomy Excision of the CENTER of an herniated disc material with a
TROCAR (Less minor type of surgery)
3. Microdiscectomy Use of microsurgical instruments to remove the herniated fragment
4. Decompression Laminectomy Surgical removal of the posterior arc of the vertebra
5. Spinal Perfusion
a. Placement of bone grafts between the vertebra to immobilize the spine
b. A Harrington Rod will be placed to fuse the vertebra as one, but client can no
longer bend!

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Disorders of the Cranial Nerves
1. Trigeminal Neuralgia
+ Definition: Chronic irritation of the 5
th
CRANIAL NERVE
+ Incidence:
50 60 years old
60% on Women
More on the RIGHT Side
+ Causes:
Intrinsic Lesion (Neuralgia affecting the Trigeminal Nerve)
o Lesion within the nerve
Extrinsic Lesion (Cause is outside the Trigeminal Nerve)
o Compression by a tumor
o There is a mass / metastasis on the 5
th
Cranial Nerve

Clinical Manifestations
1. Pain
FIRST SIGN!!!
Abrupt on Onset
Pain is VERY VERY SEVERE
Relieved with use of ANALGESICS
Triggered by:
Rubbing of Face after washing
Talking, or chewing
Most prevalent area is the MANDIBULAR / MAXILLARY Area
Unilateral!!

Diagnostic Findings
- NONE (No specific diagnostic procedure, only through CLINICAL
MANIFESTATIONS)
- But can use MRI / CT Scan

Management
1. Anticonvulsant Drugs
Carbamazepine (Tegretol)
To reduce the activity of the 5
th
Cranial Nerve
If not relieved through the use of drugs use
SURGERY
2. Surgery Nerve blocks with alcohol and glycerol
Rhizotomy Resection / Cutting of the root of the nerve
KILL the root
Point of nerve to inject a substance
2. Bells Palsy
a. Definition: Affectation of the motor aspect of the facial nerve [CN VII]
(Does not include the SENSORY ASPECT!!!!)
b. Unilateral paralysis of the muscle
c. Incidence:
Affects both Male and Female
20 40 years old
d. Etiology: ??

Clinical Manifestations
1. Bells Phenomenon/Phenomena Upward movement of the eye balls on
closure
(Normal: If eyes are closed, no change in movement)

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2. Drooping of mouth
3. Flattening of the nasolabial folds (paralysis of the lower face)
4. Widening of the palpebral fissure
5. Slight lag in closing the eyes
6. Difficulty in eating Worst case scenario
***Asymmetry of the face is the most common

Management No known cure (Not specific)
1. Analgesics NSAIDS
2. Steroids
3. Physiotherapy as heat, gentle massage most acceptable management

Disorders of the Peripheral Nerves
1. Carpal Tunnel Syndrome
a. Definition: An entrapment neuropathy that occurs when the MEDIAN NERVE
is compressed as if passes through the wrist along the pathway to the hand
b. Etiology:
No known cause
Common cause is repetitive motion of the wrist
Improper use of the computer

Manifestations
1. Pain and Paresthesia
^ Pain at the distal finger
2. Motor loss

Diagnosis
1. Tinels Sign
Development of tingling
in the hands and fingers
when the wrist is tapped
2. Phalens Sign
Development of
numbness and tingling
after forceful flexion of
the wrist for 20 30
seconds
3. Wrist Compression
Manual compression of 30 seconds
If paresthesia develops after compression Result is (+)

Management
1. Rest the wrist Splint in neutral position
2. Vitamin B
6
Strengthens the nerves
3. Gentle squeezing the distal metacarpals Squeeze a jackstone ball
4. Surgery Carpal tunnel release


jcmendiola_Achievers2013
Care of Clients with Degenerative Disorders
A. Alzheimers Disease
Definition: Most common form of DEMENTIA
Etiology:
1) Age
2) Genetic Factors (Deficit in Chromosome 21)
3) Down Syndrome
4) Vascular Disease
5) Role of neurotransmitter as Somatostatin

Clinical Manifestations Impairment of DECISION MAKING
Stages:
1. Stage I = 1
st
1 3 Years (Not yet diagnosed )
a. Memory Disturbances 1
st
Feature
Example: Client forgets to turn off the faucet (Loss of memory
of RECENT EVENTS ONLY, has memory of REMOTE
EVENTS)
b. Poor Judgment and Problem Solving Skills
c. Do well in familiar surroundings
Able to follow routines in the house Familiar place
But if outside, client will forget
d. Irritable, suspicious and indifferent
e. Agitation, Apathy
***Common is FORGETFULNESS
2. Stage II = About 2 10 Years
a. Language Disturbance Characterized by:
Impaired word finding
Client wants to say something, but cant say it
Circumlocution
o Talking round a subject than about it directly
o Makes stories around the bush
Paraphasias Words used in a wrong context
Palilalia Repeats words and phrases just spoken by
THEMSELVES
Echolalia Repeats words and phrases spoken by OTHERS
b. Motor disturbance (Apraxia)
c. Hyperorality Desire to take everything into the mouth and chew/taste
d. Wandering at Night
COMMON and DANGEROUS!!
Somnambulism (Sleepwalking) is DIFFERENT
3. Stage III = Duration of 8 12 Years
^ All mental and speech ability are lost
^ Has LOST all ability for SELF-CARE
^ Client is MALNOURISHED and UNTIDY (Like GRASA )

Management
1. Drugs
O Acetylcholine and Anti-acetylcholinesterase
g MOA: To enhance memory and cognitive function
1. Tacrine (Cognex)
O Alpha-Tocopherol (Vitamin E)
g MOA: Delays development of the disease process
2. Nursing Care
O Improve Verbal Communication (For Stage II Clients)

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g Adapt to manner of communication, align with the level of client
g Speak slowly and firmly
g Voice must be calm and reassuring (MUST NOT BE Pitched)
g Use non-verbal communication
O Altered Thought Process (For Stage III Clients)
g Measures to enhance memory
1. Put pictures of family members in the room so they will be
oriented
2. Put clocks and calendars everywhere in the room
3. Allow the client to reminisce
4. REPETITION is useful
O Risk for Injury
g Eliminate Safety Hazards
1. Dont LET the client IRON the CLOTHES!
2. Dont leave them alone in the house!!
3. Dont let them leave the house alone!!
g Identification Card
g Cooking and Driving is ASSESSED! (Dont allow to drive!)
O Self-care Deficit (For Stage III Clients)
g Encourage client to do as much as possible
g Help client maintain her autonomy
Give instructions to the client during an activity
STEP-BY-STEP
O Urge Incontinence
g Anticipate elimination needs
g Establish a pattern of defecating and voiding (q3 hours)
***Because client cant keep track of their elimination

B. Myasthenia Gravis
Definition: Characterized by deficit of Acetylcholine (ACh) that presents as muscular
weakness and fatigue















Myoneural Junction
; This is the point at which the motor nerves meet the skeletal muscles
; Acetylcholine (Neurotransmitter) is found in the myoneural junction
; To transmit the impulses from motor nerves into the skeletal muscles
***REMEMBER: If the amount of ACh is , the transmission of messages will also have
muscular contractions in the form of muscle weakness
Incidence:
g 2 Peaks of Onset
1. Early Onset (20 30 years old; more on WOMEN)


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2. Late Onset (After 50 years)
Cause: - ?
g Thought to be brought about by an AUTOIMMUNE DISORDER

CLINICAL MANIFESTATIONS:
1. Weakness with sustained MUSCLE CONTRACTIONS
` Manifestations of weakness (Tired feet)
` Regains strength after a period of rest
` Weakness more at the end of the day
2. Ocular Manifestations
` PTOSIS and DIPLOPIA
` The EYE muscles are the 1
st
MUSCLES AFFECTED!!
3. Expressionless Face Mask Like Appearance
4. Dysphagia
` Difficulty of swallowing
` Aphagia Failure / absence of swallowing either solids / liquids
5. Respiratory Distress
` PREPARE AT THE BEDSIDE: (Client at risk for Cardio-Pulmonary
Arrest)
ET Tube
Tracheostomy Set
Electronic Cart

DIAGNOSTIC TESTS
1. EMG Confirms the diagnosis
2. Tensilon Test (Edrophonium)
Edrophonium A readily reversible acetylcholinesterase inhibitor
Short-acting Anticholinesterase
Give 10 mg IV and Observe for muscle weakness
Effects: Muscle weakness can either be /

MANAGEMENT
1. Use of Drugs
a. Anti-Cholinesterase Drugs as Masteron and Neostigmine
i. Desired Effect:
1. To PREVENT Breaking down of ACh
2. Client will have reduced muscle weakness
ii. Normally: Should be taken in the MORNING so client will be
able to do ADLs
iii. Effect:
1. OVERCOMPLIANT = Too much
2. NON-COMPLIANT
***Whether Compliant or Non-compliant, same effect:
SEVERE BODY WEAKNESS

COMPLICATIONS of MYASTHENIA GRAVIS
1. Myasthenia Crisis Under Medication
a. Sudden worsening
b. Sudden withdrawal of Anti-Cholinesterase
and Infection
2. Cholinergic Crisis Over Medication
a. Muscular weakness disappears before under
medication
***REMEMBER: Medications should be taken
REGULARLY
Antidote: Atropine Sulfate TANDAAN!!

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b. Steroids
2. Plasmapheresis
Plasma is separated from formed elements of blood
Removes Plasma Protein
Globulin and Albumin are the TWO PROTEINS Present
within BLOOD
Globulin ONLY is REMOVED
Function: For production of IMMUNOGLOBULINS
and ANTIBODIES
3. Thyroidectomy
4 Removal of the THYMUS GLAND
4 The Thymus Gland is no longer functional at our age, it is only active
during FETAL stage
4 Function of Thymus Gland: To produce antibodies
4 Rationale for Removing: To alter the immunologic control mechanism
4. Nursing Care
a. Deep Breathing Exercises At risk for Pneumonia
b. Rest

C. Multiple Sclerosis
Definition: A chronic degenerative disease that affects the myelin sheath of neurons
(There is presence of demyelination)
Incidence: Between 20 40 years old
Etiology: = ?
1) Autoimmune
2) Genetic Susceptibility Chromosome 6
3) Stress

What To Expect or Common Manifestations:
1. Affectation on vision Optic Neuritis
2. Throat
3. Musculo-skeletal Manifestations
4. Bones
5. Urinary tract/bowels Incontinence

DIAGNOSTIC TESTS
History and MRI

MANAGEMENT
1. Medical Use of Drugs! (3 S)
a. Symptomatic
b. Supportive
c. Steroids Due to inflammatory process
2. Steroids After IV/PO
3. Immunosuppressant Drugs as Cytoxan or Imuran
4. Interferon B-1b (Betaseron)
To reduce the number of exacerBations
5. Interferon B-1a (Avonex)
To reduce number of severity of relApses
6. Glatiramer Acetate (Copaxone)
Mimics Myelin Protein
To prevent further destruction

CLINICAL MANIFESTATIONS
1. Central
Fatigue
Cognitive Impairment
Depression
Unstable mood
Visual
Nystagmus
Optic Neuritis
Diplopia
Speech
Dysarthria
Throat
Dysphagia
Musculoskeletal
Weakness
Spasms
Ataxia
Sensation
Pain
Hypoesthesias
Paresthesias
Bowel
Incontinence
Diarrhea or Constipation
Urinary
Incontinence
Frequency or Retention
***As long as the body has nerves, it will be
affected!!

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2. Nursing Care
1. Altered Urinary Elimination
a. Maintain fluid at 2000 ml/day (Should not be BELOW, at risk for
stone formation)
b. Void q3 hrs
2. Constipation
a. Fiber
b. Fluid intake
c. Stool Softeners
d. Bowel Program Routine Defecation
***REMEMBER: Client can be given LAXATIVES but only ONCE (1
st
AND LAST)
[May have dependency]
3. Activity Intolerance
a. Plan activities at peak energy level In the morning
b. Plan periods of rest
4. Risk for Self-care Deficit
Use of mobility aids such as wheel chairs

D. Parkinsons Disease
E Definition: Chronic progressive disease that affects the BASAL GANGLIA resulting to
impairment of motor activity characterized by; motor activity, rigidity, and involuntary
movements due to DOPAMINE
E Enumeration: (MRI)
1) Motor Activity
2) Rigidity
3) Involuntary Movements

Forms and Causes
1. Post-Encephalitic
a. Associated with EPIDEMICS
b. Said to be due to VIRAL INFECTIONS
c. Ask the client if they have had any recent viral infections
2. Drug Induced Long term use of Phenothiazines
a. Reduces blood pressure by decreasing Dopamine ? Eh
b. 3 Neurotransmitters that BP (Epinephrine, Norepinephrine, and
Dopamine)
3. Toxin Induced Carbon Monoxide and Mercury
4. Exposures to agricultural herbicides (Fertilizers, pesticides)
5. Trauma

CLINICAL MANFESTATIONS
Facial Appearance
Flat affect / apathetic looking, lacks facial expression
Eyes:
Lacks blinking reflex
Eyes are wide open At risk for Keratitis (Inflammation of the Cornea)
Tremors
Seen at rest
Pill-rolling movement As if client is playing with a small object
Rigidity
Cogwheel Phenomena
Arm is flexed, then extended and has jerking movement (Hold on to the
clients arm)
Bradykinesia Dyskinesia Akinesia
Kinesia Movement

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If defined with Parkinsons Disease, it means walking
1) Bradykinesia
^ Slow in terms of walking / movement
^ Tremors are more prominent
^ There is a SHORT PAUSE and has stiffness
2) Dyskinesia
^ Difficulty of initiating to walk
^ There is a LONGER PAUSE and has stiffness
3) Akinesia
^ Failure to initiate walking
Loss of Balance and Control
Shuffling gait while walking
Posture:
^ Kyphotic
Elevated shoulder
Stooping forward (Forward tilt of trunk)
Reduced arm swinging
Voice Nasal ***SOMETHING***

MEDICAL MANAGEMENT (Medical Use of Drugs)
1. Levodopa (Carbidopa, Sinemet)
Synthetic precursor of Dopamine
Treats Bradykinesia and Rigidity
2. Anti-Cholinergic (Artane, Cogentin)
Rigidity and tremors
3. Catechol O-methylTransferase (COMT) Inhibitors
To make the remaining Dopamine to be ALWAYS in USE by the client

SURGERY
1. Thalamotomy
Destruction of the part of the Thalamus
Rationale: To block the spread of abnormal brain activity
2. Pallidotomy
Removal of a part of the Globus Pallidus
Function: Just like a break of a bicycle, used for slowing down
Rationale: Done to lessen the muscular activities ?? Hmm

NURSING CARE
1. Safety of client
2. Nutrition
a. Observe for tremors on hands
b. Feed the client!

E. Guillain-Barre Syndrome (GBS)
C An inflammatory disease of unknown origin that involves degeneration of the myelin
sheath of the peripheral nerves
C Etiology: - Microorganisms
1) Cytomegalovirus
2) Epstein-Barr Virus
3) Campylobacter jejuni
1. Most IMPORTANT CULPRIT!!
2. Found in poultry, pets, raw milk and contaminated water
3. People who kiss their pets may acquire this
4. Drinking raw milk ew
C Incidence:

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1) Usually affects men
2) 30 40 years old

CLINICAL MANIFESTATIONS
1. Initial Phase (Rapid 90% of the body are immediately affected)
a. Ascending Weakness (Characteristic feature!!)
Most important characteristic
Starts from the FOOT going UPWARD
Typical complaint in the morning is weak balance and falling
Poliomyelitis From top to bottom
***DANGER: If the muscles of respiration are affected
b. Loss of tendon reflexes
c. Paresthesia (Tingling sensation) Can appear before ascending paralysis
2. Plateau Phase
- NO PROGRESSION of PARALYSIS and NO RECOVERY of MOTOR
PART of the body
a. Deep-aching pain in shoulder girdle
b. Most damaging feature
Respiratory muscle weakness
Autonomic neuropathy involving sympathetic and
parasympathetic systems
***Orthostatic Hypotension / Hypertension
***Pupillary Changes
***Paralytic Ileus (Impairment of the GIT peristaltic movement)
***Urinary incontinence
3. Recovery Phase Improvement and Recovery occur with remyelination
N Remyelination occurs in a DESCENDING PATTERN
Improvement/Recovery will start on the respiratory muscles (ang
galing XD)
N 85% - 90% of clients recover completely

DIAGNOSTIC TESTS
History:
Has the client been exposed to an infection a month ago?
Has the client been outside of the country recently?
What is the clients source of water?
CSF - CHON and Few WBCs
WBC is not really significant
CHON is SIGNIFICANT
Nerve conduction velocity is slowed

MANAGEMENT
1. Medical
a. Plasma Exchange
Similar to Plasmapheresis (Difference is the machine used)
Also like a BLOOD TRANSFUSION
GLOBULIN is removed!
Removes old plasma, and replaces it with new plasma
Rationale: GBS can be an auto-immune disorder, this is done to
remove circulating antibodies
b. IV Immunoglobulin
Administration of immunoglobulins via IV
2. Nursing Care Affectation of muscles of respiration
a. Monitor Respiratory function Swallowing and Autonomic function (Vital
Signs)
b. Control of infection

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Isolation technique is a must
Meticulous handwashing technique
c. Prevention of complication associated with immobility
Bedsores, Contractures, Stone formation, Incontinence

F. Amyotrophic Lateral Sclerosis (ALS)
^ Not very common
^ Synonym: Charcots Disease, Lou Gehrig (Gebrig?) Disease
^ Definition:
Involves degeneration of both ANTERIOR HORN CELLS and the
CORTICOSPINAL TRACTS
A fatal paralytic disorder
1. Do not expect that the patient will die
2. Death is brought about by complication
3. Comes after 2 -5 years
^ Incidence
Onset Middle age
Common on Males

CLINICAL MANIFESTATIONS (Only the MOTOR ASPECT is INVOLVED, not the SENSORY)
1. Lower Motor Neurons
a. Weakness
b. Cramps Series of muscular contractions (Continuous) MORE SEVERE
c. Fasciculations Irregular TWITCHING of muscle fibers and bundles (Only a portion of
muscle fibers)
2. Upper Motor Neurons
a. Spasticity - Severe contractions which are HARD!
b. Hyperreflexia Too much irritation
3. Corticospinal Tract
a. Dysphagia
b. Dysarthria
***SENSORY SYSTEM and COGNITION are NOT AFFECTED

DIAGNOSTIC TESTS
1. Through the Clinical Manifestations
2. EMG Recording of the electrical activity of the muscles
***PROGNOSIS: Death may occur from Pneumonia (#1 cause of death for GBS)

MANAGEMENT
1. Drug
a. Riluzole (Rilutek)
Has neuroprotective effects
Protects the nerves
b. Minocycline
Antibiotic
Inhibits production of carpase (caspase) enzymes (Linked to motor nerve cell
death)
2. Supportive Nursing Care
a. On-going Assessment
Nurse briefs the family about the paralysis
Modify nursing care based on paralysis
b. Conserve energy Limit mobility of client
c. Help prolong independence in ambulation
Use assistive devices (Crutches, braces, wheelchairs)
d. Encourage fluid intake

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To prevent complications associated with immobility
e. Small frequent feedings High nutrient (Caloric) feedings
f. Speech Therapy

Care of Clients with Neurological Trauma
Brain Injury
Definition: Any insult to the brain capable of producing physical, intellectual, emotional,
social and vocational changes
Incidence:
^ 50% - Associated with alcoholism
^ More on Males; 30 years or younger
^ More on weekends
^ Motor vehicular accidents Leading cause
^ More common on night time

Mechanism That Controls Head Injuries
1. Acceleration Injury
. Occurs when an immobile head is struck by a moving object
. Examples:
The immobile head gets hit by a mobile ball
A person waiting for a car gets hit by a coconut on the head
2. Deformation Injury
. Force results in deformation and disruption of the integrity of the impacted body part
. Example: Getting hit on the head by a coconut, the skull gets depressed
3. Deceleration Injury
. Head is moving and hits an immobile object
. Example: A person who is driving hits the steering wheel
4. Acceleration-Deceleration Injury
. Moving object hits the immobile head and head hits an immobile object
. Example: Object hits immobile head and head hits another immobile object
5. Rotation Injury
. Due to acceleration-deceleration in which the brain is twisted within the skull
. Example: Being punched and the person twists

CAUSES OF BRAIN INJURY
1. Blunt Trauma Head strikes an immobile head (No penetration)
> Example: Acceleration / Deceleration
2. Penetrating Injury
> Those made by foreign bodies as knives / bullets
3. Coup-contrecoup (Coup Blow; Contrecoup Opposite)
> Same blow causes injury on the opposite side
> Example: Gets hit by a flying object and hits the forehead, same effect on the other side
(back)

TYPES OF SKULL INJURY
1. Scalp Injury
- Can cause lacerations, hematomas / contusions / abrasions to the skin
2. Skull Fracture Theres a break in the skull
a. Linear
i. Appears as a thin line
ii. Does not require treatment unless brain is injured
iii. Theres just a line / mirror but didnt separate
b. Depressed
i. Example: Bump on the head, theres a depression of the skull
c. Basilar Occurs in bones over the base of the FRONTAL and TEMPORAL bones

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i. Worst of the three
ii. If in the Event client presents a history of basilar fracture, assess for fluid from
ear / nose (It may be CSF!)
iii. To confirm, assess for the presence of GLUCOSE from the discharge
3. Brain Injury
a. Open Head Injury Penetrates the Skull!
Example: Characterized / exemplified by a penetrating object (knife / bullet)
b. Closed Head Injury Arises from BLUNT TRAUMA, HEAD IS NOT OPENED
Example: Bumped head, the insides are injured
c. Concussion
No break or no evidence of fracture in the skull
No visual trauma (As if nothing happened)
Less severe than Contusion
d. Contusion
Associated with extensive damage
Brain is damaged with hemorrhage / petechiae and bruising
4. Diffuse Axonal Injury
MORE SEVERE! No FOCAL LESION, appears only at a microscopic level
Cant pinpoint the exact part of the brain that was specifically damaged
Damage occurs at a tissue level, therefore it occurs at a microscopic level
5. Focal Injury
~ You can pinpoint where the damage is
a. Epidural / Extradural Forms BETWEEN the SKULL and DURA MATER
b. Subdural Collection of blood BETWEEN the DURA MATER and SUBARACHNOID
due to tearing of veins over the brain
c. Intracerebral Hematoma
Caused by bleeding directly into the brain tissue and may occur at the area of
injury
Blood clot is confined in the brain tissue

INDICATION OF HEAD INJURY
Scalp Wound (Bruise / Laceration)
Presence of swelling
May / may not have loss of consciousness
Fracture: If in the Event it is a BASILAR FRACTURE, SUSPECT fluid from the ear/nose
Nuchal Rigidity (Stiff neck)

MANAGEMENT
1. Medical
a. Initial Immobilize client
i. Airway
ii. Breathing
iii. Circulation
iv. Monitor Vital Signs
b. On-going Management
Decrease ICP
Cerebral metabolic rate
2. Nursing Care
a. Risk for Ineffective Airway Clearance
Clean mouth
Suction client on a PRN basis
Position Keep neck on a neutral position
b. Altered cerebral tissue perfusion
3. Surgical Intervention
a. Craniotomy To remove a part of a cranium
Immediately AFTER the INJURY!
The primary concern is the NECK of the
client, because the medulla oblongata is
located there (Vital Centers!)
- 1
st
Objective = Immobilize
head part
- Never transport client on the
hospital immediately
(Immobilize head FIRST!)
- Apply Neck Collar! And DO
NOT JACK-KNIFE the client
- Immobilize first neck and
spinal cord
***There is no exact borderline between a
client with Brain Injury and Spinal Cord
Injury
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Rationale: Immobilize to ABC-VS
Airway Give O2, but NEVER
HYPEREXTEND the neck!
Breathing By O2 inhalation
Circulation
Monitor VS

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b. Creating a burr to drain out the drainage
If the client has internal bleeding, the head is drained to ICP
If there is the presence of swelling, increase the space to the ICP

Spinal Cord Trauma
Spinal Cord Injury and Brain Injury GO HAND IN HAND!!
Incidence:
^ Males: 18 25 years old
^ Same with Brain Injury
^ Seen on younger individuals

SITE
Lower Cervical Region = Common between C8 T1
Junction on lower Thorax and Upper Lumbar = Between T12 and L1

CAUSES
1. Motor Vehicular Accidents 44% (Put on helmet and seatbelt!)
2. Violence 24%
3. Fall 22%
4. Sports 8%
5. Other 2%

MECHANISMS THAT INJURE VERTERBRAL COLUMN
1. Hyperextension / Whiplash
Results from falling; chin hits an object and head is thrown back
ANTERIOR LIGAMENT is ruptured torn with fracture of POSTERIOR ELEMENT
OF VERTEBRAL BODY

Example: Client fell from the stairs and chin hits the floor
2. Hyperflexion
Common site is C5 C6, T12 L1
Results from STRETCH COMPRESSION AND DEFORMITY of the Spinal Cord
Example: Client is driving a car, and suddenly goes a complete STOP! And the head
strikes the steering wheel / wind shield
3. Vertical Compression
Occurs at T12 L1
Force applied downward from the cranium as in falls/jumps; person lands on head,
sacrum or feet
4. Rotation Injury
May involve all parts of the vertebra

LEVELS OF SPINAL CORD INJURY
Spinal nerves carries impulses into the spinal cord
The spinal cord serves as a super highway for impulses back
and forth
If the spinal cord is impaired, it would not be able to send
impulses

1. Refers to the vertebra that the injury is closest to
2. Principle: The higher (closer to the brain) the injury, the
greater the area of the body affected
a. If C8 is damaged, T1 is damaged also
b. The functions below the level of the injury will be
impaired (Both motor and sensory)


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Cervical
Supplies the neck part
If in case damaged, there would be QUADRIPLEGIA (Paralysis f the upper and lower
extremities)
The nerves that supply spinal nerves would be affected also
Thoracic
Supplies a part of the upper and back
T1 T2, upper portion is affected
PARAPLEGIA (Loss of sensory motor of lower half of the body)
Lumbar
Affected: Lower back and lower extremities
PARAPLEGIA still
Sacral
Provides senses to the PERI-ANAL Area
Process of voiding and defecation is affected

CLASSIFICATION OF SPINAL CORD INJURY
1. Complete
Most debilitating
Complete loss of sensation and muscle control below the level of injury
May recover some motor function (Rehabilitation) but sensory function is not recovered
2. Incomplete (A part is damaged only)
Typically retains varying levels of movement and function below the location of injury
Have some function below level of injury though not normal
Sensory function is most commonly lost but can feel and move but impaired (slight)

CLINICAL SYNDROMES CAUSING PARTIAL PARALYSIS
1. Anterior Cord Syndrome (HYPEREXTENSION)
W Damaged is towards the front of the spinal cord (FROM HYPEREXTENSION)
W Manifestation:
Loss of motor function associated with loss of temperature and pain sensation
below the location of injury
2. Central Cord Syndrome
W The center part of the spinal cord is damaged
W Damage is located in the center of the spine resulting to loss of function in the upper
body and weakness in the upper region
3. Brown Sequard Syndrome
W Damage is limited to one side of the spine
Ipsilateral Motor Paralysis (Same Side!)
Contralateral Sensory Loss (Loss of pain and temperature on opposite sides)
4. Posterior Cord Syndrome (HYPERFLEXION)
W Rare type
W Difficulty of movement coordination but general function is retained
W Motor function is affected (Coordination, client can walk but gait)
5. Conus Medullaris
W Affectation of the LUMBAR NERVE
W Follow damage to the LUMBAR NERVE ROOT!!
W Manifested by:
Bowel and Bladder AREFLEXIA and FLACCID (Gelatin) Lower Extremity
(Client cant VOID and DEFECATE VOLUNTARILY) Ew
Penile Erection and Micturation Reflexes may be preserved
(Depends on the severity of the trauma)
6. Cauda Equina Syndrome
W Due to injury to the LUMBOSACRAL NERVE ROOTS
W Similar to Conus Medullaris syndrome (Areflexia)


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Impairment Scale (From A E)
A. Complete No motor / sensory loss
B. Incomplete Sensory is intact, but no motor function available
C. Incomplete Motor function is preserved and more than half of key muscles have severely limited
use
D. Incomplete Motor function is preserved and more than half of the key muscles have basic
functionality
E. Normal Sensory and motor function are functioning normally

Grade Complete/Incomplete/Normal Interpretation
A Complete No motor / sensory loss
B Incomplete Sensory is intact, but no motor
function available
C Incomplete Motor function is preserved and
more than half of key muscles
have severely limited use

D Incomplete Motor function is preserved and
more than half of the key muscles
have basic functionality

E Normal Sensory and motor function are
functioning normally

CLINICAL MANIFESTATIONS
1. Level of Injury
a. Below level of injury, the following are lost
Voluntary movement
Sense of pain, temperature and proprioception (client can relay within the
environment)
Bowel and bladder function
Spinal and autonomic reflexes
b. Level of injury may be described
Skeletal Injury Refers to vertebral damage
Neurologic level of injury Lowest segment of the spinal cord with bilateral
intact sensory and motor function

Cervical Cord
a) Quadriplegia
b) Above C4 Fatal (Muscles of respiration are innervated there!)
c) C5 Maintains shoulder and bicep control, but have no control on wrist and
hands
d) C7 Able to lift shoulders, elbows and wrist and with some hand
movement
e) Below C7
^ No motor function and sensation
^ Lumbar Paraplegia
T9 and Below Lower portion
Thoracic Vertebra Supplies the back (Upper portion of the body) T1 T8
a) T1 Can strengthen arm***







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Lumbar
a) Have functions of upper extremities
b) L5 Have no sensation in perianal area, heels and small toe
c) Ambulate with a wheel chair

Spinal Shock
Whenever the Spinal Cord is damaged, all functions will be lost, when all functions are
lost it is called as SPINAL SHOCK
^ Areflexia (Absence of reflexes)
^ Loss of sensation
^ Takes place (Days Weeks Months)
Significance: Difficult to assess spinal cord injury if in the state of SPINAL SHOCK
Phases: IF RECOVERING
1. Phase I
Complete loss / weakening of all reflexes below level of spinal cord
injury (SCI)
2. Phase II
Occurs over next 2 days
Characterized by the return of some part, but not all reflexes
First to appear is BULBOCAVERNOSUS REFLEX
o Assessed by touching the glans penis
The ANAL SPHINCTER will CONTRACT!
If (+), client is regaining reflexes
3. Phase III
Characterized by HYPERREFLEXIA
Exaggerated reflexes
Presence of HYPERREFLEXIA is AUTONOMIC DYSREFLEXIA
Autonomic Dysreflexia
Definition: Overactivity of the autonomic nervous conduction
Incidence: Those with levels of injury ABOVE T5!
REMEMBER: NOT ALL CLIENTS WILL EXPERIENCE AUTONOMIC
DYSREFLEXIA

What Stimulates Autonomic Dysreflexia?
- Activities/situations that used to be VERY uncomfortable to the client before the injury
- Examples:
o Bowel impaction
o Bladder Distention
o Bed sore

Bladder Distention Sympathetic Nervous System Vasoconstriction

Spinal Cord

Brain

Compensatory mechanism, stimulates the sympathetic nervous
system which will cause VASOCONSTRICTION

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AUTONOMIC DYSREFLEXIA MANIFESTATIONS
- Hypertension = 200/100
- Severe headache (Bounding HEADACHE)
- Goose pimples
- Sweating but only seen above the injury
- Rest lessens
- Reddened skin ABOVE level of Spinal Cord Injury
- Cold Clammy Skin BELOW level of Spinal Cord Injury

CAUSES
- Full bladder
- Bowel fullness
- Skin related
- Sexual-activity

TREATMENT
1. Avoiding / removing offending agent
2. If BP shoots up, let client sit up to let pooling of blood on the lower extremities
3. Loosen any constrictive clothes
4. Drugs as anti-hypertensive drugs and vasodilators

MANAGEMENT
1. Medical Management
a. Client Moved with adequate number of persons (2 4)
b. Care of Neck Neutral position!
c. Care of Spine Place on spine board with neck collar
d. Turn by log rolling (Client is seen as one piece)
2. Nursing Care of Spinal Cord Injury
a. Risk for Hypotension Flat on bed, head is neutral
b. Inability to Sustain Spontaneous Ventilation Put on mechanical ventilator
c. Risk for Aspiration Suction PRN
d. Risk for Thermoregulation Hypothermic, monitor temperature
3. Surgery
a. Surgical fusion Combining of 2 or 3 vertebra
4. Use of Halo Jacket
5. Body cast