MedicalSurgical Nursing Concepts Practice 3 rd edition Chapter

Head Injuries Etiology Pathophysiology Older adult considerations Signs and symptoms Diagnosis Treatment Surgical intervention

Hematomas From Black JM, Hawks JH: Medical-surgical nursing: clinical management for positive outcomes, ed.

Pathophysiology of Head Injuries Closed injury versus open injury Contusion Coup-contrecoup injury Subdural hematoma

Electroencephalography (EEG) From Fuller G, Manford M: Neurology, ed. 3, London, 2011, Churchill Livingstone.

Copyright © 2017, Elsevier Inc. All rights reserved. 1

Magnetic Resonance Imaging Midline Sagittal View of the Brain From Chipps E, Clanin N,

Surgical Interventions on Head Injuries Preoperative period Postoperative period Nursing management Copyright © 2017,

Postoperative Care: Special Considerations Positioning Keep the neck in midline and prevent excessive hip

Nursing Management Special precautions Ø Ø Absolute bed rest Cover draining ear with sterile

Head injury-priority assessments Respiratory status- changes in LOC, GCS Cranial nerve function-eye blink response,

Increased Intracranial Pressure Etiology Pathophysiology Signs and symptoms Diagnosis Treatment Complications Copyright © 2017,

Causes of increased ICP Hypercarbia Endotracheal intubation Coughing or blowing the nose Extreme neck

Pathophysiologic Changes from Brain Injury Copyright © 2017, Elsevier Inc. All rights reserved. 17

Common Abnormal Respiratory Patterns Associated with Coma From Lewis SL, Dirksen SR, Heitkemper MM,

Treatment and Care of Increased ICP Supportive care Osmotic diuretics Furosemide (Lasix) Dexamethasone (Decadron)

Actions that decrease ICP Elevate HOB to at least 30 degrees Avoid extreme flexion/motion

Complications Hydrocephalus Diabetes insipidus Copyright © 2017, Elsevier Inc. All rights reserved. 21

Nursing Management Assessment (data collection) Ø Ø Ø Perform careful neurologic assessment. Monitor level

Immediately Report Increasing ICP Extreme restlessness or excitability following a period of apparent calm

Immediately Report Increasing ICP (Cont. ) Unequal size of pupils and other abnormal pupillary

Goals of Nursing Care Maintain cerebral perfusion. Reduce ICP. Maintain adequate respiration. Protect from

Injuries of the Spine and Spinal Cord Etiology Pathophysiology Signs and symptoms Diagnosis Treatment

Vertical Compression From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care,

Level of Spinal Cord Damage C 1 to C 3 C 4 C 5

Four Main Objectives Save the victim’s life. Prevent further injury to the spinal cord

Treatment and Nursing Management Respiratory management Immobilization and surgery Urinary management Psychological care Grief

Crutchfield Tongs for Cervical Traction Courtesy of Michael S. Clement, MD, Mesa, AZ. Copyright

Halo Traction Vest for Cervical Stabilization Modified from Urden LD, Stacy KM, Lough ME:

Roto. Rest Delta Advanced Kinetic Therapy System Courtesy of Kinetic Concepts, Inc. , San

Complications Spinal shock and neurogenic shock Muscle spasms Autonomic dysreflexia (hyperreflexia) Orthostatic hypotension Deep

Nursing Management Assessment (data collection) Nursing diagnosis Planning Implementation Evaluation Rehabilitation Copyright © 2017,

Back Pain and Ruptured Intervertebral Disk (“Slipped Disk”) Etiology Ø Ø Ø Acute lumbosacral

Back Pain and Ruptured Intervertebral Disk (“Slipped Disk”) (Cont. ) Pathophysiology Signs and symptoms

Herniated Disk (Nucleus Pulposus) with Compression of Spinal Cord From Lewis SL, Heitkemper MM,

Complementary and Alternative Therapies Acupuncture—chronic back pain Acupressure—relieves muscle spasms Massage therapy—relieves muscle spasms

Surgical Procedures Diskectomy Spinal fusion Laminectomy Nursing management Ø Ø Preoperative care Postoperative care

Log-Rolling Procedure From de. Wit SC, O’Neill P: Fundamental concepts and skills for nursing,

Guidelines for the Patient with Low Back Pain or Spinal Surgery Do Ø Ø

Guidelines for the Patient with Low Back Pain or Spinal Surgery (Cont. ) Do

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Pathophysiology of Head Injuries Closed injury versus open injury Contusion Coup-contrecoup injury Subdural hematoma Epidural hematoma Intracerebral hematoma Copyright © 2017, Elsevier Inc. All rights reserved. 4

Postoperative Care: Special Considerations Positioning Keep the neck in midline and prevent excessive hip flexion. Use caution when performing nasal suctioning. Watch for cerebrospinal fluid (CSF) leakage from nose, ear, and operative site. Quiet, nonstimulating environment Prompt reporting Copyright © 2017, Elsevier Inc. All rights reserved. 9

Nursing Management Special precautions Ø Ø Absolute bed rest Cover draining ear with sterile gauze. Avoid nose blowing and picking. Do not block drainage. Copyright © 2017, Elsevier Inc. All rights reserved. 10

Head injury-priority assessments Respiratory status- changes in LOC, GCS Cranial nerve function-eye blink response, gag and cough reflexes, tongue and shoulder movements Check pupils for PERRLA 1

Causes of increased ICP Hypercarbia Endotracheal intubation Coughing or blowing the nose Extreme neck or hip flexion/extension HOB less than 30 degrees Increasing intra-abdominal pressure, ie, restrictive clothing or Valsalva maneuver 1

Common Abnormal Respiratory Patterns Associated with Coma From Lewis SL, Dirksen SR, Heitkemper MM, et al: Medicalsurgical nursing: assessment and management of clinical problems, ed. 9, St. Louis, 2014, Mosby. Copyright © 2017, Elsevier Inc. All rights reserved. 18

Treatment and Care of Increased ICP Supportive care Osmotic diuretics Furosemide (Lasix) Dexamethasone (Decadron) Ventilator and oxygenation Barbiturates and antiseizure medications Temperature control Copyright © 2017, Elsevier Inc. All rights reserved. 19

Actions that decrease ICP Elevate HOB to at least 30 degrees Avoid extreme flexion/motion of the head Ø Maintain head in neutral, midline position Maintain a patent airway Administer O 2 as ordered Administer stool softeners to lessen straining of the Valsalva maneuver Report any CSF drainage from ears/nose Maintain calm, quiet environment Maintain normal body temp 1

Nursing Management Assessment (data collection) Ø Ø Ø Perform careful neurologic assessment. Monitor level of consciousness (LOC), pupillary reactions, level of neuromuscular activity, and vital signs. “Neuro checks” are performed every 15 minutes to every 2 hours for the acute patient. Copyright © 2017, Elsevier Inc. All rights reserved. 22

Immediately Report Increasing ICP Extreme restlessness or excitability following a period of apparent calm Deepening stupor and decreasing LOC Headache that is unrelenting and increasing in intensity Vomiting, especially persistent, projectile vomiting Copyright © 2017, Elsevier Inc. All rights reserved. 23

Immediately Report Increasing ICP (Cont. ) Unequal size of pupils and other abnormal pupillary reactions Leakage of CSF from the nose or ear Changes in the patient’s blood pressure, pulse, or respiration; widening pulse pressure; a slow, bounding pulse Copyright © 2017, Elsevier Inc. All rights reserved. 24

Goals of Nursing Care Maintain cerebral perfusion. Reduce ICP. Maintain adequate respiration. Protect from injury. Maintain normal body functions. Prevent complications. Copyright © 2017, Elsevier Inc. All rights reserved. 25

Vertical Compression From Ignatavicius DD, Workman ML: Medical-surgical nursing: critical thinking for collaborative care, ed. 7, Philadelphia, 2013, Saunders. Copyright © 2017, Elsevier Inc. All rights reserved. 27

Four Main Objectives Save the victim’s life. Prevent further injury to the spinal cord by carefully handling the patient. Repair as much of the damage to the spinal cord as possible. Establish a routine of care that will improve and maintain the patient’s state of health and prevent complications, so that eventual physical, mental, and social rehabilitation is possible. Copyright © 2017, Elsevier Inc. All rights reserved. 31

Treatment and Nursing Management Respiratory management Immobilization and surgery Urinary management Psychological care Grief and mourning response Sexual concerns Copyright © 2017, Elsevier Inc. All rights reserved. 32

Halo Traction Vest for Cervical Stabilization Modified from Urden LD, Stacy KM, Lough ME: Priorities in critical care nursing, ed. 6, St. Louis, 2012, Mosby. In Lewis SL, Heitkemper MM, Dirksen SR, et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 9, St. Louis, 2013, Mosby. Copyright © 2017, Elsevier Inc. All rights reserved. 34

Complications Spinal shock and neurogenic shock Muscle spasms Autonomic dysreflexia (hyperreflexia) Orthostatic hypotension Deep venous thrombosis Infection Skin breakdown Renal complications Heterotopic ossification Copyright © 2017, Elsevier Inc. All rights reserved. 36

Back Pain and Ruptured Intervertebral Disk (“Slipped Disk”) Etiology Ø Ø Ø Acute lumbosacral strain Instability of lumbosacral spine Osteoarthritis of the spine Intervertebral disk degeneration and spinal stenosis Herniation of the intervertebral disk Copyright © 2017, Elsevier Inc. All rights reserved. 39

Herniated Disk (Nucleus Pulposus) with Compression of Spinal Cord From Lewis SL, Heitkemper MM, Dirksen SR, et al: Medical-surgical nursing: assessment and management of clinical problems, ed. 7, St. Louis, 2007, Mosby. Copyright © 2017, Elsevier Inc. All rights reserved. 41

Guidelines for the Patient with Low Back Pain or Spinal Surgery Do Ø Ø Ø Ø Bend your knees with your back straight and crouch to lift an item off the floor. Carry items close to the center of your body. Perform your back exercises twice a day; periodically review the correct way to do them. Maintain appropriate body weight; lose weight if overweight. Use a lumbar pillow or roll when sitting and particularly when driving for long distances. Stop and walk around at least every 2 hours when on long trips. Consider how to safely perform a task before starting to do it. Copyright © 2017, Elsevier Inc. All rights reserved. 45

Guidelines for the Patient with Low Back Pain or Spinal Surgery (Cont. ) Do not Ø Ø Ø Lean over without bending the knees. Reach to lift items or lift heavy items higher than the elbows. Stand or sit for long periods. Sleep with your legs out straight without a pillow cushioning under the thighs or between the legs when on the side. Bend from the waist to pick up an item. Twist to the side to lift things (e. g. , groceries or things in the car or trunk). Copyright © 2017, Elsevier Inc. All rights reserved. 46