Intracranial DisordersSpinal Cord Disorders

Spring 2015Winship

9 Differences between the Male Brain and the Female Brain

•Brain Size•Brain Hemispheres•Relationships•Mathematical Skills•Stress•Language•Emotions•Spatial abilities•Susceptibility to brain function disorders

NCLEX-RN® REVIEWTest Question 11. Which of the following pathophysiologic

events results in irregular respiratory patterns as LOC decreases?

1. pressure on the meninges2. reflexive motor responses3. loss of the oculocephalic reflex4. brainstem responses to changes in PaCO2

NCLEX-RN® REVIEWTest Question 1 Response1. Which of the following pathophysiologic

events results in irregular respiratory patterns as LOC decreases?

1. pressure on the meninges2. reflexive motor responses3. loss of the oculocephalic reflex4. brainstem responses to changes in

PaCO2

NCLEX-RN® REVIEWTest Question 1 RationaleNormally the RAS and cerebral hemispheres control respirations with a regular pattern; however, when they are damaged, the lower brainstem responds to changes in PaCO2, resulting in irregular respiratory patterns.

NCLEX-RN® REVIEWTest Question 22. The unconscious patient has depressed

or absent gag and swallowing reflexes. Which nursing diagnosis would be appropriate?

1. Decreased Intracranial Adaptive Capacity2. Risk for Aspiration3. Imbalanced Nutrition: Less than Body

Requirements4. Ineffective Breathing Pattern

NCLEX-RN® REVIEWTest Question 2 Response2. The unconscious patient has depressed

or absent gag and swallowing reflexes. Which nursing diagnosis would be appropriate?

1. Decreased Intracranial Adaptive Capacity2. Risk for Aspiration3. Imbalanced Nutrition: Less than Body

Requirements4. Ineffective Breathing Pattern

NCLEX-RN® REVIEWTest Question 2 RationaleThe unconscious patient with impaired gag or swallowing reflexes would be at risk for aspiration since saliva and any fluids taken by mouth could not be swallowed normally

NCLEX-RN® REVIEWTest Question 33. What is the rationale for the use of

osmotic diuretics to treat IICP?1. Hyperthermia increases the cerebral

metabolic rate and exacerbates IICP.2. Increased blood osmolality draws edematous

fluid into the vascular system.3. Patients with ICP are at increased risk for

gastrointestinal hemorrhage.4. Brain injury and IICP often cause seizures.

NCLEX-RN® REVIEWTest Question 3 Response3. What is the rationale for the use of

osmotic diuretics to treat IICP?1. Hyperthermia increases the cerebral

metabolic rate and exacerbates IICP.2. Increased blood osmolality draws

edematous fluid into the vascular system.

3. Patients with ICP are at increased risk for gastrointestinal hemorrhage.

4. Brain injury and IICP often cause seizures.

NCLEX-RN® REVIEWTest Question 3 RationaleOsmotic diuretics increase the osmolality of blood by excreting water and leaving solutes; as a result, the water in the brain would is drawn into the vascular space.

NCLEX-RN® REVIEWTest Question 44. On admission to the ED, a patient who has altered LOC has a variety of laboratory tests to facilitate the diagnosis of the etiology of the condition. Which tests would likely be performed? Select all that apply.

1. blood glucose2. serum electrolytes3. blood and urine toxicology4. urine for WBCs5. spinal fluid osmolarity

NCLEX-RN® REVIEWTest Question 4 Response4. On admission to the ED, a patient who has altered LOC has a variety of laboratory tests to facilitate the diagnosis of the etiology of the condition. Which tests would likely be performed? Select all that apply.

1. blood glucose2. serum electrolytes3. blood and urine toxicology4. urine for WBCs5. spinal fluid osmolarity

NCLEX-RN® REVIEWTest Question 4 RationaleA patient with an altered LOC would probably have blood glucose to check for hypoglycemia, electrolytes to check for metabolic disturbances (especially sodium), and toxicology to test for drug or alcohol toxicity

Chapter 42Intracranial Disorders

Altered LOC

•Arousal▫Alertness▫Depends on the RAS

•Cognition▫Mental activity controlled by the cerebral

hemispheres Thought processes, Memory, Perception,

Problem solving and Emotion

Causes of Altered LOC

•Damage to the RAS▫Stroke, Demyelinating diseases, Tumors,

Abscesses and Head injuries▫Pressure and compression of the brainstem

•Cerebral blood flow disruptions▫Hypoxia, Ischemia, Seizures, Metabolic

alterations

Patterns of Respirations

•Cheyne-Stokes respirations

•Neurogenic hyperventilation

•Apneustic respirations

•Ataxic/apneic respirations

Pupillary and Oculomotor Responses

•Pupillary/oculomotor manifestations ▫Oval▫Eccentric (off center)▫Fixed and dilated

•Spontaneous eye movement/ocular reflex manifestations:▫Doll’s eyes movements▫Fixation

Motor Responses

•Motor manifestations:▫Responses to stimuli

Appropriate response Flaccidity

▫Reflexive responses Decorticate posturing Decerebrate posturing Flaccidity

Figure 41–19 Decorticate posturing.

Figure 41–20 Decerebrate posturing.

Coma States and Brain Death

•PVS

•Locked - In Syndrome

•Brain Death

Persistent Vegetative State

•Death of cerebral hemispheres•Continued brainstem/cerebellum function•Characteristics of PVS:

▫Sleep–wake cycles▫Basic functions, but without interaction

•Diagnosis:▫Condition must persist for at least 1 month

Locked-In Syndrome

•Blocked efferent pathways•Intact cognitive abilities•Unable to communicate through speech

or movement

Brain Death

•Cessation of all brain functions, including brainstem

•Diagnostic criteria:▫Unresponsive coma▫Absent motor/reflex movements▫No spontaneous respirations▫Pupils fixed and dilated▫Absent ocular responses▫Flat EEG▫No cerebral blood flow

Brain Death

•Manifestations must persist▫30 minutes to 1 hour▫6 hours after onset of coma and apnea

Cerebral or Brainstem Dysfunction•Interdisciplinary Care:

▫Medications▫Surgery▫Support of airway and respirations▫Maintaining nutritional status

Diagnosis• Blood Glucose

• Serum Electrolytes

• Serum Osmolality

• ABG

• Liver function tests (Ammonia)

• Toxicology

Nursing Diagnosis

•Family Coping•Ineffective Airway Clearance•Risk for Aspiration•Risk for Impaired Skin Integrity•Impaired Physical Mobility•Risk for Imbalanced Nutrition: Less than

Body Requirements

Increased Intracranial Pressure

•Noncompressible Components▫Brain (80%)▫CSF (8%)▫Blood (12%)

•Normal ICP▫5 – 10 mmHg – intracranial▫60 – 180cm H2O – lying down

•IICP – sustained elevated pressure > 10mmHg

Causes of IICP

•Cerebral edema

•Hydrocephalus

•Brain Herniation

Increased Intracranial Pressure

•Manifestations: pg 1439▫Behavior/personality changes, decreased

LOC▫Hemiparesis, hemiplegia▫Abnormal motor responses▫Altered vision, papillary/oculomotor

changes▫Cushing’s response▫Headache, papilledema, vomiting

Increased Intracranial Pressure

•Interdisciplinary Care:▫Finding underlying cause▫Preventing herniation syndrome▫Medications, chemical restraints▫Intracranial surgery▫Assessment/monitoring ICP▫Mechanical ventilation

Seizures

Seizures

•Abnormal, sudden, excessive uncontrolled electrical discharge of neurons within the brain; may result in alteration in consciousness, motor or sensory ability, and/or behavior

Types of seizures

•Partial

•Generalized

•Unclassified

Partial Seizures

Partial or focal due to the fact theybegin in a part of one hemisphere

•Simple Partial

•Complex Partial

Generalized Seizures

Six types that involve both cerebral hemispheres

• Tonic-Clonic

• Tonic

• Clonic

• Absence

• Myoclonic

• Atonic

Figure 42–4 Tonic-clonic seizures in grand mal seizures. A, Tonic phase. B, Clonic phase.

Figure 42–4 (continued) Tonic-clonic seizures in grand mal seizures. A, Tonic phase. B, Clonic phase.

Idiopathic Seizures•Not associated with any brain lesion

•May be caused by: Metabolic disorders Acute alcohol withdrawal Electrolyte disturbances Heart disease Emotional upheavals High fever

Epilepsy

•Chronic disorder with recurrent unprovoked seizures; may be caused by abnormality in electrical neuron activity, and/or imbalance of neurotransmitters

•Epilepsy information

Assessment

Diagnostic•EEG•MRI•CT•PET

Labs•Genetic •Electrolyte imbalances

Interventions

•Antiepileptic drugs (AEDs)Pg 1445

•Commonly used to control chromic seizures and involuntary muscle movements. The AED’s act in the motor cortex to reduce the electrical discharges

Box 42-1 Drug Interactions with AEDs

Table 42-3 Nursing Assessments Before, During, and After a Seizure

Seizure Precautions

•O2 and suction readily available

•Saline lock for IV access

•Side rails up at all times

•Padded side rails controversial

•Bed in lowest position

•Never insert padded tongue blade

Seizure Management

•If simple partial seizure, observe patient and document seizure

•Turn patient on side during generalized tonic-Clonic seizure- turning head helps to prevent aspiration

•Do not restrain

Status Epilepticus Management

•Prolonged seizure lasting more than 5 minutes or repeated seizures over the course of 30 minutes

•Neurologic emergency that must be treated promptly and aggressively

Treatment

•Establish airway

•If needed administer O2

•Establish IV access

•Give IV diazepam, lorazepam, phenytoin, or general anesthesia

Status Epilepticus Complications •Metabolic changes

•Hypoxia

•Hypotension

•Cardiac dysrhythmias

•Lactic acidosis

•Brain damage

•Death SE

CVA

Stroke/ Brain Attack

•A disruption in the normal blood supply to the brain may lead to death after a few minutes

•The brain is unable to store oxygen or glucose and must receive a constant flow of blood to function.

Contralateral deficit

•A stroke in one hemisphere of the brain is manifested by deficits in the opposite side of the body.

Ischemic Strokes

•Ischemic stroke is caused by the occlusion of a cerebral artery by either a thrombus or an embolus

•87% of all strokes are ischemic

TIA

•Mini stroke•Less than 24 hours•Warning signs for a larger stroke•Manifestations

▫Contralateral numbness or weakness▫Aphasia▫Blurred vision▫Amaurosis fugax

Large vessel (thrombotic) Stroke•Commonly effect a single cerebral artery

supplying the cerebral cortex

•Causes ▫Aphasia▫Neglect syndrome▫Visual field defects

Small Vessel stroke (Lacunar infarct)

•The infarcted areas slough off•Leaves a small cavity or lake•Occurs deep in the brain

•Causes▫Motor hemiplegia▫Sensory hemiplegia▫Dysarthria

Cardiogenic Embolic stroke

•Blood clot from A Fib, Ventricular thrombi, MI, CHD or plaque

•Usually at bifurcations of vessels in the middle cerebral artery

Hemorrhagic Strokes

•Occurs when a blood vessel ruptures

•Types▫Intracerebral hemorrhage▫Subarachnoid hemorrhage

•Most often Fatal

Contributing Factors•HTN (↑ chance for stroke 4x)•Rupture of vessel r/t plague•Aneurysms•Trauma•Tumor erosion•AVM•Afib•Anticoagulant therapy•Blood disorders•DM

Hypertension

•Elevated systolic and diastolic blood pressures cause changes within the arterial wall leaving it susceptible to rupture

•More likely with sudden episodes of dramatic B/P elevation, i.e. cocaine intoxication

Aneurysm

•Ballooning or blistering of artery

•Congenital or traumatic•Aneurysm is when the vessel ruptures

•Intracerebral hematoma•Blood pools in brain – irritation to healthy tissue

•Leads to ischemia and infarction

Arteriovenous Malformation

•Congenital defect•Tangled, spaghetti like mass of malformed dilated vessels with thin walls

•May eventually rupture due to arterial pressure

Strokes

•Stroke Overview

Health Promotion and Illness Prevention

•Avoidance of smoking, sedentary lifestyle, high fat diet

•Moderate alcohol consumption

•Weight control•Control of hypertension

Assessment•History of activity when stroke began•How the symptoms progressed•Onset of stroke•Severity of the symptoms•Due the symptoms come and go•Observe LOC•Assess for memory impairment, difficulty

with speech•Past medical history/Social history•Medication

Neurologic Assessment•LOC may vary depending on the extent of increased ICP caused by the stroke and on the location of the stroke.

Right Cerebral Hemisphere•Visual, spatial awareness•Proprioception•May be unaware of changes•Disoriented to time/place•Impulsivity•Poor Judgment/Decisions•Short Attention span

Left Cerebral Hemisphere•Dominant in 85% of people•Language/Speech•Math •Analytic thinking•Aphasia•Agraphia•Alexia•Slow and cautious

Motor Changes

•Hemiplegia- paralysis•Hemiparesis- weakness•Hypertonia /Flaccid paralysis-

Extremities fall to the side•Hypertonia/Spastic paralysis- fixed position, ROM restricted

Sensory Changes

•Agnosia•Apraxia•Neglect Syndrome•Ptosis•Retinal ischemia- causes a brief episode of blindness

•Hemianopia

Cranial Nerve Assessment

•CN II. IV. VI – Oculomotor movements

•CN V- ability to chew•CN IX and X – ability to swallow

•CN VII- facial paralysis•CN IX- absent gag reflex•CN XII Impaired tongue movement

Diagnostic AssessmentCT and CT angiography

•Identify hemorrhage•Cerebral aneurysms if large enough

•Baseline information for future comparison

•Identify pathologic changes mimic stroke

•After 24 hours can show ischemia

Diagnostic AssessmentMRI•Presence of edema, ischemia and tissue

necrosis earlier than a CTAngiography•Status of cerebral vessels and narrowing

can be treated with papaverineCardiac cause•ECG•Holter monitor•Cardiac enzymes•Echocardiogram

Ineffective Cerebral Tissue Perfusion Interventions

•Administer systemic thrombolytic therapy

•Neurologic assessment•Monitor ICP•Avoid activities/procedures that may increase ICP

•Assess need for suctioning

Drug Therapy

•Thrombolytic•Anticoagulants•Lorazepam/AED•Calcium channel blockers•Stool softeners•Analgesics for pain•Antianxiety drugs

Complications

•Hydrocephalus•Vasospasms•Rebleeding or rupture

Surgical Management

•Carotid angioplasty

•Endarterectomy

•Extracranial-intracranial bypass

Management of Arteriovenous Malformations•Interventional therapy to occlude abnormal arteries or veins and prevent bleeding from the vascular lesion

•Gamma radiation to produce fibrous thickening of the endothelial lining

Management of cerebral Aneurysms

•Craniotomy when stable- the aneurysm is clipped or clamped at the base or neck to prevent bleeding

•Interventional radiology- small catheter through the femoral artery into the aneurysm platinum wire coils placed inside aneurysm, which creates a clot that makes a seal

Aneurysm

• Stroke clipping of aneurysm and coiling procedures…

•Aneurysm clipping•Aneurysm Coiling

Management of Intracranial Bleeding

•Craniotomy to remove clots and relieve ICP

Indications•Worsening of neurologic status

•Extension of intracranial lesion with significant increases in ICP

Impaired Physical Mobility and Self Care

Interventions•ROM exercises for the involved extremities

•Frequent position changes•Prevention of DVT•Therapy focused on patient performance of ADL's

Disturbed Sensory PerceptionInterventions Right hemisphere •Damage difficulty in the performance of visual perceptual or spatial-perceptual tasks

•Activities of ADL’s / AmbulationLeft hemispheric•Memory deficits•Changes in ability to carry out simple tasks

Impaired Verbal Communication

•Language or speech problems, result of damage to the dominant hemisphere

•Expressive aphasia, damage in Broca’s area of the frontal lobe

Expressive aphasia•Receptive (Wernicke’s or sensory) aphasia, injury in the temporoparietal area Receptive aphasia

Impaired Swallowing

Interventions•Assess patients ability to swallow

•Facilitate swallowing through positioning the patient

•Appropriate diet: semisoft or liquid food

•Aspiration precautions

Urinary and Bowel Incontinence

•Altered level of consciousness may cause incontinence or impaired innervation, or inability to communicate need

•Develop a bladder and bowel training program

TBI

Traumatic Brain Injury

•External force to the head•Altered LOC•Increased ICP•May be temporary or permanent

•May be partial or total disability

•High incidence of death

TBI – Open Head injury

•Penetration to the head results in opening of skull

•Skull fractures•Hemorrhage may occur•CSF leakage from ears or nose

▫Clear▫Can be tested for Glucose to determine

•Increased risk for infection

TBI – Closed Head Injury

•Blunt trauma to head•Concussion•Diffuse axonal injury

▫MVA•Contusion

▫Coup/Contrecoup•Laceration

TBI - Hemorrhage

•Epidural Hematoma▫Lucid periods then unconsciousness▫Neurosurgical emergency

•Subdural Hematoma▫Slow▫Tearing▫Highest mortality rate

•Intracerebral Hemorrhage▫Accumulation of blood within brain tissue

TBI - Hemorrhage

•Monitor ABC’s•Vital Sign Assessment•Neurologic Assessment▫Glasgow

Brain Tumors/Abscess

Brain Tumors

•Primary▫Occur within CNS

•Secondary▫Metastasis from other parts

Brain Abscess

•Purulent infection of the brain

Headaches

HEADACHES•Types Migraine Tension Cluster

MIGRAINES

•Episodic familiar disorder manifested by unilateral, frontotemporal, throbbing pain in the head, often worse behind one eye or ear.

•Often accompanied by a sensitive scalp, anorexia, photophobia, nausea

•Aura: sensation that signals the onset

MIGRAINES

Causes•Vascular

•Genetic

•Central Neuronal Hyper excitability

•Chemical Factors

MIGRAINESTypes•Migraine with an Aura Light changes, flashes, double vision

•Migraine without an Aura More common•Atypical Migraine Last more than 72 hours Can’t find definitive reason for Migraine

SYMPTOMS•Sensitivity to light: Photophobia

•Irritability

•Nausea, Vomiting

•Sensitivity to sounds: Phonophobia

INTERVENTIONS

Goal Pain Management•Abortive Therapy

•Preventative Therapy

•Alternative Therapy

INTERVENTIONS

Preventive Therapy•Beta Blockers•Ca+ Channel Blockers•Tricyclic – SSRI•Antiepileptic•Riboflavin

INTERVENTIONSAlternative Therapies•Massage•Cold cloth•Acupressure/Acupuncture•Nutritional changes•Relaxation/Biofeedback techniques

CLUSTER HEADACHESHistamine Cephalagia•Causes are unknown; attributed to vasoreactivity and oxyhemoglobin desaturation

•Studies suggest it may be related to hypothalamic hyperactivity

•Intense pain on one side radiating to forehead, temple, or cheek

Interventions

•Medications that are used for migraines

•Wear sunglasses to avoid sunlight

•Oxygen via mask•Avoidance of precipitating factors, anger excitement

•Surgical management if resistant to medications

TENSION HEADACHES•Neck and shoulder muscle tenderness and bilateral pain at the base of the skull and in the forehead

•Treatment: non-opioids analgesics, muscle relaxants, occasional opioids

Spinal Cord DisordersChapter43

SCI

Spinal Cord Injury• Spinal cord injury (SCI) can

not be reversed• Complete- spinal cord

severed or damaged so all innervations below the level of injury are eliminated

• Incomplete – some function or movement below level of injury

Spinal Cord Injury

•Primary mechanisms

•Secondary mechanisms

Primary Mechanisms

•Hyperflexion

•Hyperextension

•Axial loading or vertical compression

•Excessive rotation

•Penetrating injuries

Secondary Mechanisms

•Neurogenic shock

•Vascular insult

•Hemorrhage

•Ischemia

•Fluid and electrolyte imbalance

Cervical Injuries

•Anterior cord syndrome

•Posterior cord lesion

•Brown-Sequard syndrome

•Central cord syndrome

Assessment•Gather as much data as possible about the

accident

•How the accident occurred

•Position after the accident

•Symptoms after the injury

•Type of immobilizers used if any

•Problems that may have occurred during stabilization

Initial Assessment•First Priority assessment of respiratory pattern

•Assess for indications of intra-abdominal hemorrhage or hemorrhage or bleeding around fracture sites

•Level of consciousness

Initial Assessment

Establish level of injury•Tetraplegia/Quadriplegia

•Quadriparesis

•Paraplegia

•Paraparesis

Spinal ShockCondition is characterized by:•Flaccid paralysis

•Loss of reflex activity below the level of the lesion

•Bradycardia

•Paralytic ileus

•Hypotension

Sensation Assessment

•Sensation is carried from the peripheral nerves to the spinal cord and up to the cerebral cortex via sensation-specific tracts.

•The injury may inhibit this transmission

Sensation Assessment•Have the patient close his or her eyes touch the skin with a sharp object and a soft object.

•Compare bilateral responses

•Use a skin dermatome staring in the area of loss of sensation and ending where sensations become normal

Motor Ability Assessment

•Systematic assessment of the patients muscles

•American Spinal Injury Association (ASIA) Five point grading scale

•DTRs

Cardiovascular Assessment

•Cardiovascular dysfunction is usually the result of disruption of the autonomic nervous system

•Bradycardia, hypotension, and hypothermia result from loss of sympathetic input and may lead to cardiac arrest

Cardiovascular Assessment

•Systolic blood pressure lower than 90 mm Hg requires treatment because lack of perfusion to the spinal cord worsens the condition

Assessments

•Respiratory•Gastrointestinal•Genitourinary

Assessments

•Musculoskeletal•Psychosocial•Laboratory•Diagnostic imaging

Interventions

•Reduction and immobilization of the fracture to prevent further damage to the spinal cord from bone fragments

•Nonsurgical techniques: traction, external fixation

Immobilization for Cervical Injuries

•Halo fixation and cervical tongs

•Stryker frame, rotational bed, kinetic treatment table

•Pin site care and monitoring of traction ropes

•Immobilization techniques

Immobilization of Thoracic and Lumbar Injuries

•Thoracic: Bedrest and possible immobilization with a fiberglass or plastic body cast

•Lumbar and sacral: immobilization of spine with brace/corset worn when out of bed

•Custom fit

Drug Therapy

•Methylprednisolone•Dextran•Atropine sulfate•Dopamine hydrochloride•Naloxone or THR•Sygen

Drug Therapy

•4-AP potassium channel blocker

•Dantrolene•Baclofen•Etidronate disodium

Surgical Management

•Emergency surgery necessary for spinal cord decompression

•Decompressive Laminectomy•Spinal fusion•Harrington rods to stabilize thoracic spinal injuries

Autonomic Dysreflexia

•Common in patients with upper SCI

•Severe hypertension•Bradycardia•Severe headache•Nasal stuffiness•Flushing

Autonomic Dysreflexia

•Treatment▫Elevate HOB▫Remove compression stockings

▫Assess for stimuli that cause AD & Treat

▫Administer Emergency anti- hypertensives

Spinal Cord Tumors

•Pathologic effects related to compression of the cord, displacement , disruption of vascular supply and obstruction of CSF

•Symptoms are related to growth

Spinal Cord Tumors

•Surgical management: goal remove as much of the tumor as possible

•Nonsurgical management: radiation, chemotherapy and pain control