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Subarachnoid Hemorrhage
Traumatic subarachnoid hemorrhage occurs with tearing or
shearing of microvessels in the arachnoidlayer, resulting in
hemorrhage into the subarach- noid space (which contains the
CSF). Blood in the subarachnoid space irritates the brainstem,
causing abnormal activity in the autonomic nervous system that
may produce cardiac dysrhythmias and hyper- tension.
Hydrocephalus may result when blood in the subarachnoid space
impedes reabsorption of CSF. Cerebral vasospasm, a less common
complication, may also occur.
Diffuse Axonal Injury(dai)
DAI is characterized by a direct tearing or shearing of axons,
which worsens during the rst 12 to 24 hours as cerebral edema
develops. DAI is thought to occur with rotational and acceleration
deceleration forces. DAI can be classied as mild, moderate, or
severe:
patients who are declared brain dead are candidates for organ
donation. Discussions about brain death should be separated in
time from conversations regarding the opportunities for organ
donation.
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occur. A collaborative care guide for the patient with a spinal cord
injury is given in Box 23-12.
Prevention of respiratory compromise.
Patients with a spinal cord injury, especially injuries above T6, are
at risk for respiratory compromise. Respiratory failure is
anticipated if the patients vital capacity is less than 15 to 20
mL/kg and the respiratory rate is greater than 30 breaths/min. If
the oxygen saturation value is less than 90% or if the PaCO2 is
greater than 45 mm Hg, intubation may be required. Routine
bronchial hygiene therapy (BHT) and kinetic therapy using a
specialty bed that rotates a minimum of 40 degrees on a
continuous basis helps prevent pulmonary complications.
RED FLAG! Respiratory complications are the leading cause of
death in the acute and chronic phases of spinal cord injury,
especially in patients with higher-level injuries.
Prevention of cardiovascular compromise. The patient is at risk
for bradycardia, hypotension, and dysrhythmias because of
disruption in the autonomic nervous system. When the blood
pressure is not high enough to sustain vital organ perfusion, lowdose dopamine may be administered after adequate uid
resuscitation. Symptomatic bradycardia may require the
administration of atropine or the use of a transcutaneous or
transvenous pacemaker. Left ventricular dysfunction may occur
secondary to the release of -endorphins; cardiac enzymes should
be obtained if there are ECG changes.
Pain management. Pain management is essential in caring for
patients with spinal cord injuries. It is not unusual for the patient
to report pain, frequently severe pain. The source of the pain may
be neuropathic, musculoskeletal, central, or visceral. Abnormal
sensation may occur at the level of the lesion in injuries caused
by nerve root damage.
Thermoregulation. Ineffective thermoregulation is common in
patients with spinal cord injuries above the thoracolumbar area.
Interruption of the sympathetic nervous system inhibits thalamic
thermoregulatory mechanisms. As a result, the patient cannot
sweat to get rid of body heat, and there is an absence of
vasoconstriction, result- ing in an inability to shiver to increase
body heat. Hypothermia is usually managed by using warmed
blankets, and the room temperature is adjusted to maintain
patient comfort. The goal is to stabilize the patients temperature
above 96.5F (35.8C).
Mobilization and positioning. Attention to mobilization and
positioning is important to pre- vent complications of immobility. A
turn schedule for the patient is important, even if the patient has
not had stabilizing surgery. It may take three staff members to
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INTERVENTIONS
Oxygenation/Ventilation
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Circulation/Perfusion
Serum electrolytes are within normal limits. Serum osmolality remains within
prescribed range.
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Assume that the patient can understand all that is said. Converse with, not
about, the patient.
Do not overwhelm the patient with talking. Leave some moments of silence
between verbal stimuli.
Manage the environment to provide only one source of stimulation at a
time. If talking is taking place, the radio or television should be turned off.
Provide short, random periods of sensory input that are meaningful to the
patient. A favorite television program or tape recording or 30 min of music
from the patients favorite radio station will provide more meaningful
stimulation than constant radio accompaniment, which becomes as
meaningless as the continual bleep of the cardiac monitor.
4. Confusedagitated. Stimulus response is primarily to internal confusion with
increased state of activity; behavior may be bizarre or aggressive; patient may
attempt to remove tubes or restraints or crawl out of bed; verbalization is
incoherent or inappropriate; patient shows minimal awareness of environment and
absent short-term memory.
Be calm and soothing when handling the patient. Approach with gentle
touch to decrease the occurrence of defensive emotional and motor reexes.
Watch for early signs that the patient is becoming agitated (eg, increased
movement, vocal loudness, resistance to activity).
When the patient becomes upset, do not try to reason with him or her or
talk him or her out of it. Talking will be an additional external stimulus that
the patient cannot handle.
If the patient remains upset, either remove him or her from the situation or
remove the situation from him or her.
5. Confused, inappropriatenonagitated. Patient is alert and responds consistently to
simple commands; however, patient has a short attention span and is easily
distracted; memory is impaired and patient exhibits confusion of past and present
events; patient can perform previously learned tasks with maximal structure but is
unable to learn new information; may wander off with vague intention of going
home.
Present the patient with only one task at a time. Allow time to complete it
before giving further instructions.
Make sure that you have the patients attention by placing yourself in view
and touching the patient before talking.
If the patient becomes confused or resistant, stop talking. Wait until he or
she appears relaxed before continuing with instruction or activity.
6. Confusedappropriate. Patient shows goal- directed behavior but still needs
external direction; can understand simple directions and reasoning; follows simple
directions consistently and requires less supervision for previously learned tasks;
has improved past memory depth and detail and basic awareness of self and
surroundings.
Use gestures, demonstrations, and only the most necessary words when
giving instructions.
Maintain the same sequence in routine activities and tasks. Describe these
routines to the patient and relate them to time of day.
7. Automaticappropriate. Patient is able to complete daily routines in structured
environment; has increased awareness of self and surroundings but lacks insight,
judgment, and problem-solving ability.
Supervision is still necessary for continued learning and safety.
Reinforce the patients memory of routines and schedules with clocks,
calendars, and a written log of activities.
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8. Purposefulappropriate. Patient is alert, oriented, and able to recall and integrate
past and recent events; responds appropriately to environment; still has decreased
ability in abstract reasoning, stress tolerance, and judgment in emergencies or
unusual situations.
The patient should be able to function without supervision.
Consideration should be given to job retraining or a return to school.
INTERVENTIONS
Oxygenation/Ventilation
ABGs are within normal limits. Airway patency is maintained. The patient
does not aspirate.
The patient does not develop pulmonary complications (eg, infection,
atelectasis).
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levels.
Mobility/Safety
Joint range of motion is maintained and contractures prevented.
Muscle tone is maintained. The patient ambulates in a safe manner to
the best of his or her ability.
Position in correct alignment.
Begin range-of-motion exercises early after admission.
Maintain splint, brace, and adaptive device schedule; check for pressure
ulcers q4h or more often if indicated.
Consult with physical and occupational therapy.
Skin Integrity
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Teach patient/family:
Bowel program and training
Dietary habits to maintain bowel function
Bladder training/intermittent catheterization
Prevention of, and signs/symptoms of autonomic dysre exia
Complications of immobility are prevented.
Teach patient/family:
Positioning to prevent skin breakdown
Physical therapy exercises
BHT
Patient is discharged to appropriate postacute setting.