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Topics: care of the neurological patient. Head trauma Spinal cord injury Cranial nerve evaluation. Part One: Head Trauma (Traumatic Brain Injury aka TBI). Physical injury to brain tissue Temporary or permanent impairment of brain function All involve some form of structural damage

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topics care of the neurological patient

Topics: care of the neurological patient

Head trauma

Spinal cord injury

Cranial nerve evaluation

part one head trauma traumatic brain injury aka tbi
Part One: Head Trauma(Traumatic Brain Injury aka TBI)
  • Physical injury to brain tissue
  • Temporary or permanent impairment of brain function
  • All involve some form of structural damage
  • Nursing involvement is critical for
    • Support of respiration and oxygenation
    • Support of blood pressure
    • Prevent further injury
    • Rehabilitation
head injury
Head injury

National Head Injury Foundation:

  • Traumatic insult to the brain…
  • Capable of producing physical, intellectual, emotional, social, and vocational changes
  • Highest risk individuals are
    • Those 15-24 years
    • Infants
    • School aged children
    • Elderly
slide4
Rates of TBI-related Emergency Department Visits, Hospitalizations, and Deaths by Sex — United States, 2001–2010
mechanism and force of injury
Mechanism and force of injury
  • The mechanism and force determines the degree of structural damage:
concussion
Concussion
  • Posttraumatic alteration in mental status
  • Transient, reversible
  • From seconds to minutes
  • Defined as <6 hours (arbitrary)
  • No gross

structural brain

lesions

diffuse axonal injury dai
Diffuse axonal injury (DAI)
  • Caused by deceleration
  • Causes shear-type forces
  • Damage to axonal fibers and myelin sheaths
diffuse axonal injury dai1
Diffuse axonal injury (DAI)
  • Edema from injury increases intracranial pressure
  • Sometimes defines as loss of consciousness >6 hours
  • Typically underlying

injury in Shaken

Baby Syndrome

brain contusion
Brain contusion
  • Bruise of the brain
  • Can occur with open, penetrating, or closed injury
  • Can impair wide range of brain functions
brain hematoma
Brain hematoma
  • Collection of blood in or around the brain
  • Can occur with penetrating or closed injury
  • May be epidural, subdural, or intracerebral
  • Subarachnoid hemorrhage (SAH) is common in TBI
skull fractures
Skull fractures
  • Penetrating injuries involve fractures by definition
  • Closed injuries may also cause skull fractures
  • Presence of fracture suggests significant force was involved
pathophysiology of tbi
Pathophysiology of TBI
  • Trauma produces direct damage to brain tissue
  • Edema produced in damaged tissues
  • Cranial vault is fixed in size
  • Fluid (CSF) is noncompressible
  • Brain tissue is somewhat compressible
  • Intracranial pressure increases
  • Cerebral perfusion pressure decreases
  • Brain tissue can become ischemic
treatment of tbi
Treatment of TBI
  • Focused on restoring normal ICP
  • Evacuation of hematoma through burr holes
  • Ligation of bleeding vessels
  • May allow hematoma to reabsorb slowly
  • Debridement of traumatized tissue in open head injury to prevent infection
  • Steroids to minimize swelling, diuretics
  • Cranioplasty, possible grafting
monitoring intracranial pressure
Monitoring intracranial pressure
  • Catheter placed in OR or at bedside in ICU
  • Assist physician with placement
  • Maintain asepsis
  • Monitor pressure at appropriate intervals
  • Drain CSF as indicated
  • Monitor patient tolerance
  • Monitor of neuro status
  • Rezero at least every 12 hours
  • Maintain at level of tragus to correspond with Foramen of Monro
markedly increased icp
Markedly increased ICP
  • Hypertension
  • Bradycardia
  • Respiratory depression
  • Decorticate or

decerebrate

posturing are

bad prognostic

signs

herniation
Herniation
  • Brain is squeezed across skull structures
  • Caused by TBI, intracranial hemorrhage, or brain tumor
  • Extreme pressure placed on parts of the brain at site of herniation
  • Blood supply cut off
  • Often fatal
part 2 spinal cord trauma
Part 2: Spinal Cord Trauma
  • Trauma may produce

injuries to spinal cord,

vertebrae, or both

  • 40% cord injuries from

motor vehicle accidents

  • 25% from violent crime
  • 35% from falls, sports,

work-related accidents

  • 80% of patients are male
level of injury and resulting dysfunction
Level of injury and resulting dysfunction
  • Spinal cord level identified

by corresponding vertebrae

  • Vertebrae can be grouped

into segments

  • The higher the injury, the

greater potential dysfunction

high cervical nerves c1 4
High cervical nerves: C1-4
  • Most severe
  • Paralysis of upper and lower extremities, trunk
  • No breathing control, no

cough

  • No bowel, bladder

control

  • Dependent for all ADLs
  • 24/7 care required
low cervical nerves c5 8
Low cervical nerves: C5-8
  • Nerves control arms

and hands

  • May be able to breathe

independently

  • May be able to speak
c 5 injury
C-5 Injury
  • Person can raise arms,

bend elbows

  • Some or total paralysis of

wrists, hands, trunk, legs

likely

  • Can speak, use diaphragm,

but breathing is weak

  • ADL assistance required
  • Can use power wheelchair
c 6 injury
C-6 Injury
  • Wrist extension affected
  • Paralysis of hands, trunk,

legs usual

  • May be able to bend wrists back
  • Can speak, breathing is weak
  • May be able to use equipment to

move in & out of wheelchair, bed

  • May be able to drive adapted vehicle
  • Little to no control of bowel or bladder, may be able to use adaptive equipment
c 7 injury
C-7 Injury
  • Elbow extension,

finger extension

  • Usually can straighten

arm, normal shoulder

movement

  • Can perform most ADLs, may need assistance with more difficult tasks
  • May be able to drive an adapted vehicle
  • Little, no voluntary control of bowel or bladder
c 8 injury
C-8 Injury
  • Some hand movement
  • Able to grasp,

release objects

  • Can perform most ADLs,

may need assistance with

more difficult tasks

  • May be able to drive an adapted vehicle
  • Little, no voluntary control of bowel or bladder
t1 5 injury
T1-5 Injury
  • Nerves affect upper chest, mid-back, abdominal muscles
  • Arm, hand function usually normal
  • Affect the trunk, legs(paraplegia)
  • May use manual wheelchair
  • Can drive a modified car
  • Can stand in standing frame, may

walk with braces

t6 12 injury
T6-12 Injury
  • Nerves affect muscles of the trunk
  • Usually paraplegia
  • Normal upper-body

movement

  • Able to control, balance trunk

while seated

  • Usually can cough productively
  • Little, no voluntary control of bowel or bladder
  • Can use manual wheelchair
  • Can drive a modified car
  • Can stand in standing frame, may walk with braces
l1 5 injury
L1-5 Injury
  • Some loss of function

in the hips, legs

  • Little, no voluntary

control of bowel

or bladder

  • May need wheelchair,

braces

s1 5 injury
S1-5 Injury
  • Some loss of function in the

hips and legs.

  • Little or no voluntary control

of bowel or bladder

  • Most likely will be able to walk
part 3 cranial nerves
Part 3: Cranial nerves
  • 12 pairs of nerves—above level of C-1
  • Emerge from brain or brainstem
  • Seen on ventral surface of brain
  • Some are sensory
  • Some are motor
  • Some connected

to glands or other

organs

mnemonics for memorizing cns
Mnemonics for memorizing CNs
  • Standard: “On old Olympus’ towering top, a Finn and German viewed some hops.”
  • Sensory, motor, or both: “Some say marry money, but my brother says big brains matter more.”*

(*Rude version also available)

more fun mnemonic
More fun mnemonic
  • “Oh, Oh, Oh, They Traveled And Found Voldermort* Guarding Very Secret Horcruxes”

(*vestibulocochlear aka auditory)

  • Sensory, motor, or both: “Severus Snape Meets Malfoy, But Mad Bellatrix Stays Behind Bushes Misusing Magic”
testing cranial nerves
Testing cranial nerves
  • Part of any complete

physical assessment

  • Often CN I dismissed

clinically

  • Charted as, “CN II-XII intact”
  • Particularly important in head trauma
  • Testing pupils alone is not enough!
cn i olfactory nerve
CN I: Olfactory Nerve
  • Fibers originate from nasal olfactory epithelium
  • Purely sensory
  • Carries impulses for sense of smell
  • HOW TO TEST: Ask patient to sniff something aromatic—vanilla, coffee, cloves
cn 2 optic
CN 2: Optic
  • Fibers originate in retina
  • Purely sensory
  • Carries impulse for vision
  • HOW TO TEST: Visual acuity and visual field
cn 3 4 6 oculomotor trochlear and abducens
CN 3, 4, 6: Oculomotor, Trochlear, and Abducens
  • Tested together
  • CN 3 and 4 emerge from midbrain, exit skull to eye
  • CN 6 leaves from pons, exits to eye
  • Oculomotor—superior, inferior, medial rectus muscles of eye
  • Trochlear—superior oblique muscles of eye
  • Abducens—lateral rectus muscles of eye
  • HOW TO TEST: pupil reaction, cardinal positions
cn 5 trigemina l
CN 5: Trigeminal
  • Exit from pons,

form 3 divisions on face

  • Both motor and sensory for face
  • Sensory impulses from mouth, nose, surface of eyes
  • Fibers stimulate chewing muscles
  • HOW TO TEST: Safety pin on skin surface, corneal reflex with cotton wisp; ask to clench teeth, open mouth against resistance, move jaw side to side
cn 7 facial
CN 7: Facial
  • Origin in pons, through temporal bone to face
  • Both motor and sensory
  • Expression
  • Lacrimal and salivary glands
  • Taste
  • HOW TO TEST: Can ask to

taste substances; ask to squint, smile, whistle;

may test tearing with ammonia

cn 8 acoustic vestibulocochlear
CN 8: Acoustic (Vestibulocochlear)
  • Originates in inner ear, enters brainstem
  • Purely sensory
  • Sense of equilibrium, hearing
  • HOW TO TEST: Air and bone conduction with tuning fork
cn 9 and 10 glossopharyngeal and vagus
CN 9 and 10: Glossopharyngeal and Vagus
  • Glossopharyngeal fibers leave midbrain to throat, vagus fibers leave medulla throughneck into thorax and abdomen
  • Both motor and sensory—pharynx and salivary glands, impulses from pharynx, pressure receptors from carotid artery; vagussupples smooth muscles of

abdominal organs

  • HOW TO TEST: Gag,

swallow, cough, speak

cn 11 spinal accessory
CN 11: Spinal accessory
  • Originates in medulla and superior spinal cord, travels to muscles of neck and back
  • Both sensory and motor
  • Sternocleidomastoid and trapezius muscles
  • HOW TO TEST: Ask to rotate head, shrug shoulders against resistance
cn 12 hypoglossal
CN 12: Hypoglossal
  • Arise from medulla to tongue
  • Motor to muscles of tongue, sensory from tongue to brain
  • HOW TO TEST: Ask to stick out tongue
principles of cn testing
Principles of CN testing
  • Indicates specific neurological

dysfunction rather than a

systemic disorder

  • Develop your own method of

testing quickly and efficiently

  • In normal, healthy patient, may screen with less detail
  • Regardless, important to know structure and function as you perform CN testing!