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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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