1. concept map: selected topics in neurological nursing pathophysiology traumatic brain injury...
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Concept Map: Selected Topics in Neurological Nursing
PATHOPHYSIOLOGY
Traumatic Brain InjurySpinal Cord Injury
Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntington’s Disease Alzheimer’s Disease Huntington’s Disease Myasthenia Gravis Guillian-Barre’ Syndrome Meningitis Parkinson’s Disease
PHARMACOLOGY
--Decrease ICP--Disease / Condition Specific Meds
ASSESSMENTPhysical Assessment Inspection Palpation Percussion Auscultation
ICP Monitoring“Neuro Checks” Lab Monitoring
Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, Discharge Planning, more…basedOn Nursing Process: A_D_P_I_E
Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary
ObjectivesObjectivesExplain pathophysiology of various SCIs and
related conditions
Detail signs & symptoms and functionality of different level SCIs
Differentiate between Neurogenic Shock and Spinal Shock
Explain Autonomic Dysreflexia / Autonomic Dysreflexia / HyperreflexiaHyperreflexia and list appropriate nursing interventions
Discuss overall medical & nursing management of SCIs
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SCI Involves loss of:
Motor functionSensory function
ReflexesControl of elimination
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Common Causes SCICommon Causes SCI
Motor vehicle accidents (MVAMVA) - Auto and motorcycle accidents the leading cause of spinal cord injuries
Acts of ViolenceViolence – mostly gunshot wounds
FallsFalls – SPI after age 65 is often caused by a fall
SportsSports and recreation injuries - Impact sports and diving in shallow water * ATV *
Diseases - Cancer, infections, arthritis and inflammation
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Breakdown of Fall Statistics
Breakdown of Sports Statistics
Breakdown of Road Traffic Accident Statistics
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SCI TypeSCI Type
Incomplete / Partial spinal cord injuryIncomplete / Partial spinal cord injury- Spinal cord is able to convey some messages
to or from the brain. Therefore, retain some sensation and possibly some motor function below the affected area
Complete injuryComplete injury- Complete loss of motor function and Complete loss of motor function and
sensationsensation below the area of injury
**** Even in a complete injury, the spinal cord is almost never completely cut in half. Doctors use the term "complete" to describe a large amount of damage to the spinal cord.
It's a key distinction becausekey distinction because many people with partial spinal cord injuries are able to experience significant recovery, while those with complete injuries are not
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Complete or Partial ?
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Compressison / Wedge Fracture Compressison / Wedge Fracture As the forces push
forwards and backwards, pressure is applied to the front and/or back of the spinal bones causing damage in these areas as indicated by the arrow
In these injuries, direct compression forces downwards literally squash the bones, resulting in a loss of height seen on x-ray. This x-ray also shows a chipchip fracture at the front of the lumbar vertebrae (green green arrowarrow) (See how much bigger and stronger this bone is compared to the cervical bone in the picture on the left)
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Spinal Cord InjurySpinal Cord Injury
Most trauma to the spinal cord causes permanent disabilitydisability or loss of movement (paralysis) and sensation below the site of below the site of the injurythe injury
Paralysis can involve all four extremities, a condition called quadriplegiaquadriplegia or tetraplegia, or only the lower body, a condition called paraplegiaparaplegia
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C4
C6
T6
L1
SCI Causal CategoriesSCI Causal Categories
Traumatic spinal cord injury may stem from:- Sudden, traumatic blow that fractures,
dislocates, crushes or compresses one or more of vertebrae
- Gunshot or knife wound that penetrates and cuts your spinal cord
- Additional (secondary) damage usually occurs over days or weeks because of bleeding, swelling, inflammation and fluid accumulation in and around spinal cord
Non-traumatic spinal cord injury may be caused by arthritis, cancer, blood vessel problems or bleeding, inflammation or infections, or disk degeneration of the spine
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Risk factorsRisk factorsGenderGender - Spinal cord injury affects a disproportionate
amount of men
AgeAge – (Young adults and seniors)- Between ages 16 and 35 / MVA leading cause - Another peak in people older than 60 / falls leading
cause
People active in sportsPeople active in sports – High risk athletic activities include football, rugby, wrestling, gymnastics, diving, surfing, ice hockey and downhill skiing
Predisposing conditionsPredisposing conditions - A relatively minor injury can cause spinal cord injury in people with conditions that affect their bones or joints, such as arthritis or osteoporosis
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At At thethe Scene Scene
Priorities1. Maintaining ability to breathe2. Preventing shock3. Immobilization to prevent further spinal cord damage (Backboard & C-Collar)
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Vertebrae Commonly InvolvedVertebrae Commonly Involved
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C5
T12
Baseline Assessment At Scene & Baseline Assessment At Scene & Upon Arrival to ERUpon Arrival to ER
ABCs / ATLS assessment includes Vital Signs & Glasgow Coma Score
Neck / Spine stabilization
Maintaining BP
Multisystem support
May be sedated
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DiagnosisDiagnosis
X-Ray
C-Spine
FIRST
!!
Swimmer’s View
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Be Vigilant !Be Vigilant !Spinal cord injury isn't always obvious
Numbness or paralysis may result immediatelyimmediately after a spinal cord injury or graduallygradually as bleeding or swelling occurs in or around the spinal cord
In either case, time between injury and treatment time between injury and treatment is a criticalis a critical factor that can determine the extent of complications and the level of recovery
It's safest to assumeassume that trauma victims have a spinal cord injuryspinal cord injury until proved otherwise
If you suspect that someone has a back or neck injury
Spinal Immobilization STAT !
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History of InjuryHistory of InjuryLoss of Consciousness?
Other victims seriously hurt?
Mechanism of injury?
Driver / passenger / seatbelt ?Fall height / what caused fall?Hit where and with what?Gunshot / impaled object ?
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Mechanism of Injury Mechanism of Injury
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Different mechanism
of injury
CT ScanCT Scan
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MRIMRI
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Continued…Continued…MRI – For identifying herniated disks, blood
clots or other masses that may be compressing the spinal cord. But… MRI can't be used on people with pacemakers or on trauma victims who need certain life-support machines or cervical traction devices
Myelography - Dye injected into spinal canal then X-rays or CT scan can suggest a herniated disk or other lesions. Used when MRI isn't possible
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PrimaryPrimary Spinal Injury Spinal Injury
Result of initial trauma
Injury usually permanent
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©2000 Brian SmithGreg Louganis's Diving Accident, 1988 Sports Illustrated
SecondarySecondary Spinal Injury Spinal Injury
Occurs after Spinal cord trauma
Damage at cellular level
Necrosis (Cells swell, burst and leak toxic substances to other cells)
Apoptosis (Programmed cell death / cell suicide to prevent bursting)
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Secondary SCI
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Secondary SCI
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SCI DisabilitySCI Disability
1. Depends on Location1. Depends on Location
Injuries (lesion) higher in the spinal cord produce more paralysis
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SCI DisabilitySCI Disability
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2. Depends on type of injury2. Depends on type of injury
Spinal Cord - Horizontal ViewSpinal Cord - Horizontal View
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American Spinal Injury Association (ASIA) ClassificationAmerican Spinal Injury Association (ASIA) Classification
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Incomplete / Partial SCIIncomplete / Partial SCICentral
Lateral / Brown-Sequard Syndrome
Anterior
Posterior
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Anterior Cord SyndromeAnterior Cord SyndromeDamage o front 2/3 of spinal cord, loss of pain and
temperature sensation, and motor function below level of injury
Light touch (pressure) and position and vibration sensation preserved
Possible for some people with this injury to later recover some movement
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Central Cord SyndromeCentral Cord SyndromeUsually with unbelted MVA and falls of elderly
Typically results greater weakness in arms vs lower extremities
Sensory loss varies but more severe in upper extremities
Control over the bowel and bladder varies and may be preserved
Possible for some recovery from this type of injury, usually starting in the legs, gradually progressing upwards
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Brown-Sequard SyndromeBrown-Sequard SyndromeUsually stab or GSW
Damage is towards one side of the spinal cord
Ipsilateral (same side as the cord injury) Impaired or loss of movement, touch, pressure and vibration
** (Hemiparaplegia)
Contralateral (opposite side of cord injury) loss of pain and temperature sensation ** (Hemianesthesia)
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Posterior Cord SyndromePosterior Cord SyndromeDamage is towards the back of the spinal
cord
May leave the person with good muscle power, pain and temperature sensation
However they may experience difficulty coordinating movement of their limbs
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MotorMotor (blue) and SensorySensory (red) axons in the spinal cord and peripheral nerves.
Sensory neurons reside in the dorsal root ganglia (DRG) while MotoneuronsMotoneurons reside in the spinal cord and innervate muscle (yellow).
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SCI Goals of CareSCI Goals of CareThere's no way to reverse damage
Treatment focuses on:
1. Preventing further injury
2. Enabling people to return to an active and productive life within the limits of their disability
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