Chapter 45: Head

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Chapter 45 Head Spinal Cord Trauma

• Medical-Surgical II
• Spring Semester
• Karyn Mills, RN, BSN

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Concussion Pg. 721

• Violent jarring of brain after a blow to the head
• temporary loss of cerebral function with no
  damage to cerebral tissue
• Loss of consciousness, followed by headache,
  irritability, dizzy spells, confusion

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Concussion

• Observe for several days for neuro
  symptoms....changes in behavior, speech, gait or
  other abnormality should return to ER
• Recovery is complete and usually occurs in a
  short time
• Must monitor vital signs carefully to prevent
  complications

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Concussion

• May be sent home
• instruct family to check LOC and ability to move
  and talk q hour while awake
• Arouse him q 2 hours during night to determine
  LOC and ability to respond to questions

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Concussion

• Observe for changes in behavior, speech, or other
  abnormality for 2 to 3 days

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Contusion pg 722

• Is more serious than a concussion, results in
  gross structural injury to the brain

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Contussion

• The brain is injured when the head is struck
  directly, a COUP INJURY.
• Dual bruising can result if the force is strong
  enough to send the brain ricocheting to the
  opposite side of the skull, a CONTRECOUP INJURY.

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CONTUSION

• Result in bruising and possibly hemorrhage of
  superficial cerebral tissue.
• Edema develops at the site of injury or in areas
  opposite to the injury.
• A skull fracture can accompany a contusion.

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Contusion S/S

• Hypotension, rapid weak pulse, shallow resp.,
  loss of consciousness pale cool skin
• While unconscious, the client generally responds
  to strong stimuli like pressure applied to the
  sternum.
• On awakening, the client often has temporary
  amnesia (loss of memory) for recent events.
• Permanent brain damage can cause impaired
  intellect, speech difficulty, seizures,
  paralysis, and impaired gait.

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Contusion

• CT or MRI may show bleeding or small hemorrhages,
  a shift in brain tissue edema at injury site
• Nurse observes LOC for ICP and does neuro
  assessment

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Cerebral Hematomas pg 723

• Bleeding within the skull that forms an expanding
  lesion.
• 1. Epidural hematoma
• 2. Subdural hematoma
• 3. Intracerebral hematoma
• Most hematomas are the result of head trauma or a
  cerebral vascular disorder.

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Epidural Hematoma pg 723

• Caused by arterial bleeding and accumulation of
  blood above the dura

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Subdural Hematoma

• Occurs as a result of venous bleeding and the
  accumulation of blood in the space below the
  dura.

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Intracerebral Hematoma

• Is bleeding within the brain that results from an
  open or closed head injury or from a
  cerbrovascular condition such as a ruptured
  cerebral aneurysm

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Those at High Risk

• Receiving anticoagulant therapy
• Underlying bleeding disorders such as hemophilia,
  thrombocytopenia, leukemia, and aplastic anemia
• Bleeding increases the volume of brain contents
  and results in IICP.
• As the ICP increases, cerebral blood flow is
  disrupted and brain becomes hypoxic.

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Cerebral Hematomas

• Unrelieved pressure causes the brain to shift to
  the lateral side (uncal herniation) or herniate
  downward through the foramen magnum.
• The vital centers for respiration, heart rate,
  and blood pressure are affected as well as
  cranial nerve functions.
• Death occurs if the symptoms are not recognized
  and the bleeding is not stopped.

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S/S

• The rapidity and severity of neurologic changes
  depends on the location, the rate of bleeding and
  size of hematoma, and effectiveness of
  autoregulation, the brains ability to provide
  sufficient arterial blood flow despite rising ICP.

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Medical Management

• Some subdural hematomas become walled off and
  absorbed by the body with no treatment.
• However, a rapid change in LOC and signs of
  uncontrolled IICP indicate a surgical emergency.

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Surgical Management

• Surgery consists of drilling holes (burr holes)
  in the skull to relieve pressure, removing the
  clot, and stopping the bleeding.
• If the source of bleeding cannot be located by
  means of burr holes, more invasive surgery is
  performed.
• Intracranial surgery consists of 3 possible
  procedures craniotomy, craniectomy, and
  cranioplasty. (Read on your own)

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Nursing Management pg 725

• Regard a head injury, no matter how mild it
  appears, as an emergency.
• Obtain a history of the injury and perform a
  neurologic examination with particular attention
  to vital signs, LOC, presence or absence of
  movement in the arms and legs, pupil size,
  equality, and reaction to light for evidence of
  IICP.

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Preoperative Nursing Management

• Shave the head in the are where burr holes will
  be drilled (this is sometimes deferred until the
  client is in the operating room)
• Take V/S
• Adm. Prescribed medications such as an
  anticonvulsant like dilantin to reduce the risk
  of seizures before, and after surgery, an osmotic
  diuretic, and corticosterioids.
• Pre-op sedation is generally omitted.

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Preoperative Nursing

• Restrict fluids to avoid intraoperative
  complications, reduce cerebral edema, and prevent
  postoperative vomiting
• Insert indwelling catheter
• Insert IV line
• Apply antiembolism stockings to prevent
  thrombophlebitis and deep vein thrombosis, which
  develop from prolonged immobility during
  neurosurgery.

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Postoperative Nursing Care

• After surgery, place the client in either a
  supine position or a side-lying position on the
  unaffected side
• Postoperative assessments are performed at 15 to
  30 minute intervals and include all areas of
  neurologic function.
• Edema around the eyes (periorbital edema) may
  make examination of the pupils difficult during
  the immediate post-op period

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Postoperative Nursing Care

• Ecchymosis can also be present.
• Maintain a neurologic flow sheet to compare
  assessment findings
• Administer corticosteroids and restrict fluids as
  ordered to control cerebral edema and to increase
  cerebral perfusion
• NEVER GIVE D5W TO A NEURO PT!!!

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Care Plan Family Teaching

• On your own!!!!

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Review Table 45-1 Pg. 724

• Differences in Cerebral Hematomas
• ON YOUR OWN!!

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Skull Fractures pg 725

• A skull fracture is a break in the continuity of
  the cranium.
• A skull fracture is caused by a blow to the head.
  

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Skull Fractures

• The most common types are simple, depressed, or
  comminuted fractures. (Table 45-2 PG. 730)

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Skull Fractures Patho

• The fracture can be associated with an open head
  injury in which the scalp, bony cranium, and dura
  mater (the outer meningeal layer) are exposed.
• There may be a closed head injury in which the
  fractured skull remains covered by an intact
  layer of scalp.

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Skull Fractures Patho

• Open head injuries create a potential for
  infection due to exposure to the environment.
• They are less likely to produce rapid
  intracranial hypertension (IICP) because the
  opening provides some ability for the brain to
  expand as pressure increases.

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Basilar Skull Fractures

• Located at the base of the skull.
• Trauma in this location is especially dangerous
  because it can cause edema of the brain near the
  origin of the spinal cord (foramen magnum),
  interfere with the circulation of CSF, injure the
  nerves that pass into the spinal cord, or create
  a pathway for infection between the brain and the
  middle ear that can result in meningitis.

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S/S

• Simple skull fractures produce few, if any,
  symptoms and heal without complications.
• May c/o of a localized headache. A bump, bruise,
  or laceration may be found on the scalp.

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S/S

• Because basilar skull fractures tend to TEAR the
  dura, rhinorrhea, leaking of CSF from the nose,
  or ottorrhea, leakage of CSF from the ear, may
  occur.
• In some cases periorbital ecchymosis, referred to
  as raccoon eyes, or bruising of the mastoid
  process behind the ear, called Battles sign, can
  be present.

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PG. 730
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S/S

• Conjunctival hemorrhages can occur as well.
• Seizures may occur because of injury to the brain
  tissue.
• Epilepsy can develop as a sequela of head injury.

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Medical Management

• Simple skull fractures require bed rest and close
  observation for signs of IICP.
• If the scalp is lacerated, the wound is cleaned,
  debrided, and sutured.
• Depressed skull fractures require a craniotomy to
  remove bone fragments and control bleeding,
  elevation of the depressed fracture, and repair
  of damaged tissues.

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Medical Management

• Antibiotics to control infection, an osmotic
  diuretic or corticosteroids to prevent or treat
  cerebral edema, and an anticonvulsant to prevent
  or treat seizures.

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Nursing Management pg 731

• Most clients are hospitalized for 24 hours or
  more after a significant head injury
• Use methods described in Nursing Guidelines 45-1
  PG. to test drainage from the nose or ear.
• Look for A HALO sign which indicates the
  presence of CSF in drainage. Fig 45-8)

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Nursing Management

• Evaluate LOC, assess motor and sensory status,
  and check pupils hourly.
• Take V/S every 15 to 30 minutes.
• Prepare for the possibility of seizures

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Spinal Injury

• Head, neck, and back must be immobilized by means
  of a cervical collar and back board
• Spine must be properly aligned at all times to
  prevent further injury to cord
• IV started to prevent shock
• Steroids may be given to reduce edema

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Spinal Injury

• Cervical collar or cervical traction used
• Stryker frame used to turn and body cast may be
  used to immobilize
• Surgery may be done to remove bone fragments or
  repair dislocated vertebrae
• fusion may be done

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Spinal Cord Injury

• Even if no fx has occurred, momentary compression
  of cord because of twisting or severe blow can
  lead to edema and compression
• neuro symptoms may or may not disappear when
  edema subsides
• Trauma may cause

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Spinal Injury

• The most important nursing task immediately after
  injury is to keep his body and head in alignment
  and limiting all movement

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Spinal Cord Injury

• bleeding within cord because it has no place to
  drain, forms a hematoma and compresses cord
• injury may sever nerve fibers partially or
  completely
• spinal cord trauma results in paraplegia (both
  legs) or quadriplegia (arms and legs)

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Symptoms of Spinal Cord Injury

• There may be pain in affected area, difficulty
  breathing, numbness, and paralysis
• If high injury resp failure may occur as
  diaphraghm paralyzed
• Midcervical injury causes paralysis of muscles of
  upper thorax

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symptoms of Spinal Cord Injury

• 5th and 6th cervical and 1st and 5th lumbar are
  especially vulnerable to injury
• If completely severed paralysis occurs
• If minimal damage may have some function

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Care of

• With any spinal cord injury or surgery the
  patient must be log rolled
• It is important to support the back with pillows
  and place a pillow between the legs to avoid back
  strain

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Spinal Shock

• spinal cord injury may result in spinal shock
• Flaccid paralysis, bradycardia and pronounced
  hypotension are symptoms that should be observed
  for in the first few weeks following the accident

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Spinal Shock

• spinal shock, permanent paralysis below level of
  injury, and resp arrest are immediate
  complications of spinal cord injury
• Degree and location of injury determines symptoms
  that occur immediately after injury

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Spinal Shock

• Hypotension, bradycardia, decreased resp rate,
  flaccid paralysis, and warm dry skin
• Bowel and bladder distention may be seen
• Does not perspire below injury so hyperthermia
  can occur
• May persist up to 6 weeks

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Spinal Shock

• GI decompression to relieve gastric and bowel
  distention, foley, suctioning and mechanical
  ventilation may be done

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Autonomic Dysreflexia (Hyperreflexia)

• Acute emergency seen in cervical or high thoracic
  spinal cord injury.
• exaggerated response to sympathetic stimuli (full
  bladder, paralytic ileus or impaction)
• Severe hypertension, bradycardia, pallor, blurred
  vision, or nausea

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Autonomic Dysreflexia

• Seizures and death may occur
• Place in a sitting position to reduce B/P
• May occur over many years and is life threatening
• Full bladder is common cause

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Nursing Care

• Stryker frame or CircOlectric bed used to turn
• Monitor vitals, do neuro checks
• Check for movement below level of injury, look
  for progression of neuro damage and resp distress

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Nursing Care

• Give injections above level of paralysis as
  poorly absorbed
• Rise in temp or accumulation of excessive resp
  secretions may be pneumonia or atelectasis
• Humidify to aid in raising secretions
• Turning prevents pneumonia and atelectasis

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Nursing Care

• assess for paralytic ilius as common
• NG tube may be inserted to prevent distention
• Auscultate bowel sounds, assess urinary and bowel
  function

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Skin Care

• Stryker used to turn from supine to prone and
  back q 2 hours
• Gently massage and give special care to areas
  subject to pressure
• Use lotion but do not use powder as it cakes

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Laminectomy Postop

• Log roll
• Cough increases pressure in spinal canal
• Check dressing for leakage of CSF and bleeding
• Observe for signs of compression caused by edema
  or hemorrhage (change in sensation or motility)

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Laminectomy Postop

• Voiding may be a problem after surg. monitor IO
• Use Fx pan
• Keep bed flat and have him lay on back as much as
  possible
• When allowed up, the head, neck and upper
  shoulders are supported when moving from lying to
  sitting or standing

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TRACTION

• Traction may be continuous or intermittent
• support weights and lower gently so there is not
  a sudden jerking or pulling
• A pillow may be placed under legs to prevent
  heels from rubbing or sheepskin boots used

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Traction

• Roll from side to side to prevent twisting motion
• when out of bed, stand straight, walk slowly, and
  avoid bending forward
• Brace or collar worn continuously unless specific
  order
• avoid hyperextension of neck

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Traction

• Cervical spine injury needs to be stabilized with
  cervical collar or traction
• Crutchfield, Vinke or Gardner-wells tongs or halo
  vest traction used
• Burr holes used and tongs inserted into skull
• Traction by means of weights and pulleys is
  applied to keep alignment and increase space
  between vertebrae

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Traction

• make sure weights hang free
• Never lift or remove weights or decrease or
  increase amount without Drs order
• Ropes must be seated in pulley grooves
• Position must allow correct pull of traction
  apparatus
• padding must be correctly applied
• Check tips of tongs