MEDICAL SURGICAL NURSING CHAPTER 45

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MEDICAL SURGICAL NURSING CHAPTER 45

• CARING FOR CLIENTS WITH HEAD SPINAL CORD TRAUMA

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HEAD INJURIES

• CONCUSSION
• CONTUSION
• HEMATOMAS
• SKULL FRACTURES

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CONCUSSION

• Results from a blow to the head that jars the
  brain. Results in diffuse microscopic injury to
  the brain, but no serious injury to the brain
  tissue.
• MVA
• falls
• Causes a temporary neurological impairment with
  complete recovery, usually in a short time
• S/S brief lapse in consciousness possible
  followed by temporary disorientation, h/a,
  blurred vision or diplopia, irritablility
  dizziness

• Observe for neurological complications
• Nursing neuro exam, instruct the family to
  observe for signs of IICP
• behavior changes
• sleepiness
• vomiting
• speech or gait distubances

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Contusion (Brain Bruise)

• More serious than a concussion.Results in gross
  structural injury to the brain. May be
  accompanied by skull fx
• Coup injury-head is struck directly
• Contrecoup injury to the brain when it ricochetes
  to other side of the skullsee fig 45-1

• S/S depend on the severity of the blow
• hypotension
• rapid, weak pulse
• shallow resp
• loss of consciousness
• pale, clammy skin
• Hypotension, rapid weak pulse, shallow resp,
  loss of consciousness, pale, clammy skin
• Nursing neuro exam, s/s of IICP, report changes
  to MD teach prevention!!!

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Cerebral Hematomas

• Bleeding within the skull expanding lesion - Fig
  45-3
• Risks anticoagulant therapy, underlying
  bleeding disorder
• Causes head trauma, CV disorders
• Types table 45-1
• Epidural
• Subdural
• Intracerebral

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Cerebral Hematomas

• S/S depends on location of bleed severity
• Medical mgmt if a subdural hematoma may not
  require surgical intervention if resolves on its
  own
• Surgical intervention
• burr holes, fig 45-4
• craniotomy, surgical opening of the skull
• craniectomy, removal of a portion of the cranial
  bone
• cranioplasty repair in a defect in a cranial
  bone usually using a metal or plastic plate or
  wire mesh

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Nursing management

• Hx of injury, perform neuro exam, if trauma
  examine the head for bleeding, abrasions
  lacerations
• Preop care shave area, v/s, cont neuro exams,
  administer meds, insert foley, IV lines
  established, antiembolitic stockings
• Postop see nursing care plan 45-1

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Skull Fractures

• S/S depends on location severity
• Rhinorrhea leakage of CSF from nose
• Otorrhea leakage of CSF from ear fig 45-6
• Periorbital ecchymosis raccoon eyes fig 45-7A
• Battles sign periauricular ecchymosis
  bruising of the mastoid process fig 45-7B

• Open-scalp, bony cranium, dura mater exposed
• Closed-intact layer of scalp covers the fractured
  skull
• Simple, depressed comminuted table 45-2
• Basilar located at base of skull most serious
  with edema at base of brain origin of the spinal
  cord causing CSF circulation blockages, injury
  to nerves and creation of a pathway for infection
  to the brain

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Nursing mgmt

• Test for CSF in drainage see nursing guidelines
  45-1 halo sign, fig 45-8
• Neuro exams ongoing even if the injury appears
  mild
• Prepare for the possiblity of seizures

• Simple skull fx bedrest close observation for
  signs of IICP
• Wound care if the scalp is lacerated
• v/s every 15- 30 minutes seizure precautions

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Spinal Cord Injuries

• Cervical lumbar spines are the most common site
  of injury due to MVA, violence, sports, fall.
• Spinal cord trauma can lead to bleeding within
  the cord where it forms a hematoma that
  compresses the nerve roots

• Spinal cord trauma can severe the cord, if
  complete can result in permanent paralysis loss
  of sensation below the site of injury
• Fig 45-9 table 45-3
• Tetraplegia, quadriplegia results from high
  c-spine injury
• Paraplegia paralysis of lower extremities
  usually due to injury in thoracic level

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Spinal Cord Injuries

• Spinal shock occurs within 30-60 minutes after
  the injury can persist for 1wk to months
• It is the loss of all cord functions below the
  level of injury paralysis, hypotension,
  bradycardia, warm, dry skin and poikilothermia
  body temperature of the environment

• Autonomic Dysreflexia or hyperreflexia can occur
  suddenly after spinal shock is over to those with
  injuries above T6
• An acute emergency that can lead to seizures,
  stroke death
• s/s HTN, bradycardia, pounding ha, nausea, etc
• Causes see box 45-1
• Treatment remove cause treat symptoms

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Spinal Cord Injuries

• Medical mgmt immobilization of the neck back,
  traction, corticosteroids to reduce inflammation,
  cast, braces or surgery. Use of a turning frame
  fig 45-10

• Nursing mgmt maintain good body alignment,
  foley, assist with traction maintenance Never
  lift or remove the wts or increase or decrease
  the amount of wt without MD order
• See nursing process
• Nursing guidelines 45-2

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Spinal Nerve Root Compression

• Intramedullary lesions involve the spinal cord
• Extramedullary lesions involve the tissues
  around the spinal cord
• Most common site is the 3 lower lumbar discs
• Caused by trauma, herniated intervertebral disks
  tumors of the spinal cord surrounding
  structures fig 45-12

• S/S weakness, paralysis, pain paresthesia or
  numbness, tingling
• Medical mgmt conservative treatment rest, skin
  traction, hot moist packs, muscle relaxants,
  analgesics

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Spinal Nerve Root Compression

• Surgical mgmt
• diskectomy
• diskectomy with spinal fusion
• laminectomy
• chemonucleolysis
• See nursing mgmt in nursing guidelines 45-3

• Postop mgmt v/s, deep breathing, assess drsg,
  neuro checks particularly close attention to area
  below the surgery, urine op, use fracture bedpan

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Nutritional Considerations

• Hypercalcemia
• Adequate, regular fluid intake
• High-fiber diet
• Tetraplegics and paraplegics
• Adjust calorie intake to avoid weight gain
• Nutrient needs may be stable or higher
• Clients with skin breakdown
• Increased requirements for protein, vitamin C and
  zinc to promote healing

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Pharmacologic Considerations

• Mannitol Reduction of ICP after surgery
• Respiratory depressant effects less likely with
  codeine
• Antipyretics and other measures relieve elevated
  temperature
• Skeletal muscle relaxant or tranquilizer may lead
  to drowsiness and dizziness
• Medications in liquid form for clients with
  impaired swallowing

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Gerontologic Considerations

• Older adults
• Often respond less favorably to therapies for a
  neurologic deficit
• May incur a chronic fluid volume deficit
• Encourage a fluid intake of 1,500 to 2,000 mL/day