Download NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS and more Exams Nursing in PDF only on Docsity! NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS COPING Exemplar: Dissociative Disorders • Giddens: Concept 32 Coping • Psych: Dissociative Disorders in Chapter 16 Key terms • Appraisal: Coping appraisal is how one responds to a situation • Cognitive restructuring: A core part of cognitive behavioral therapy (CBT). CBT is one of the most effective psychological treatments for common problems like depression, anxiety disorders. Process of learning to identify and dispute irrational or maladaptive thoughts known as cognitive distortions, such as all-or-nothing thinking (splitting), magical thinking, over-generalization, magnification, and emotional reasoning, which are commonly associated with many mental health disorders. DISSOCIATIVE DISORDERS • Occur after significant adverse experiences/trauma • Individuals respond to stress with severe interruption of consciousness • Dissociation is an unconscious defense mechanism • Protects individual against overwhelming anxiety through emotional separation • However, this separation results in disturbances in memory, consciousness, self-identity, and perception Reality testing: Patients with dissociative disorders have intact reality testing • This means that although the person may have flashbacks or images, these are triggered by current events, relate to the past trauma, and are not delusions or hallucinations NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS Mild fleeting dissociative experiences are relatively common to all of us • For example, we say we are on “auto pilot” when we drive home from work and cannot recall the last 15 minutes before reaching the house • These common experiences are distinctly different from the processes of pathological dissociation Dissociation is involuntary and results in failure of the normal control over a person’s mental processes and normal integration of conscious awareness o Dimensions of a memory that should be linked are not and are fragmented ▪ For example, a person may be aware of a sound or smell, but these sensations would not be linked to the actual event itself, leaving the person fearful and/or confused ▪ The person may reenact, as well as re-experience, trauma without consciously knowing why Symptoms: May be either positive or negative • Positive symptoms refer to unwanted additions to mental activity such as flashbacks • Negative symptoms refer to deficits such as memory problems or the ability to sense or control different parts of the body • Dissociation decreases the immediate subjective distress of the trauma and also continues to protect the individual from full awareness of the disturbing event Protective for children • Dissociation can also be somewhat protective for a child to maintain an attachment with abusive or neglectful caregivers • This highlights the importance of attachments and relationships in allowing the child to grow socially, intellectually, and cognitively NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS pleasure- seeking and nonconforming o The alter personalities may behave as individuals of a different sex, race, or religion o The dominant hand and the voice may also be different; intelligence and electroencephalographic findings may also be altered • The primary personality or host is usually not aware of the alters and is perplexed by lost time and unexplained events • Experiences such as finding unfamiliar clothing in the closet, being called a different name by a stranger, or not having childhood memories are characteristic of dissociative identity disorder • Alters may be aware of the existence of each other to some degree • Transition from one personality to another (switching) occurs during times of stress and may range from a dramatic to a barely noticeable event • Some patients experience the transition when awakening • Shifts may last from minutes to months, although shorter periods are more common • Borderline personality disorder is the most common disorder that accompanies DID Epidemiology: The lifetime prevalence of dissociative disorders ranges from 2% to 10% • Depersonalization/derealization disorder is about 2% o Females and males are equally affected by this problem • Dissociative amnesia is also fairly common with a prevalence of about 2% to 7% o Females are affected at more than twice the rate of men • Dissociative identity disorder has a 12-month prevalence of 1.5% o Males and females are equally represented in this disorder Comorbidity: Common with dissociative disorders NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • Major depressive disorder, panic attacks, eating disorders, PTSD is common, somatoform symptoms, eating disorders, obsessive-compulsive disorder (OCD), reactive attachment disorder, and attention-deficit disorder commonly co-occur with the dissociative disorders • Personality disorders such as borderline personality disorder, substance-use disorders, and sexual and sleep disorders, are also comorbid with dissociative disorders • Dissociative amnesia may be comorbid with conversion disorder or a personality disorder • Dissociative fugue may co-occur with PTSD • Depersonalization and derealization also occur in hypochondriasis, mood and anxiety disorders, obsessive- compulsive disorder, and schizophrenia Risk Factors • Childhood physical, sexual, or emotional abuse and other traumatic life events are associated with adults experiencing dissociative symptoms • Dissociative symptoms, or “mindflight,” actually reduce disturbing feelings and protect the person from full awareness of the trauma Biological Factors • Genetic: Although genetic variability is thought to play a role in stress reactivity, dissociation is largely due to extreme stress or environmental factors • Neurobiological: The limbic system is involved in the development of dissociative disorders o Animal studies show that early and prolonged detachment from the caretaker negatively affects the development of the limbic system o Traumatic memories are processed in the limbic system, and the hippocampus stores this information o Individuals with dissociative disorders have altered communication between higher and lower NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS brain structures due to the massive release of endogenous opioids at the time of severe threat o This inhibits the thalamus from connecting with the limbic area with the neocortex and integration across the hemispheres through the corpus callosum o People with temporal lobe epilepsy experience depersonalization, derealization, anxiety, and dissociation o This overlap of symptoms results in people without epilepsy being treated with anticonvulsants o Conversely, but less likely, people with epilepsy may be treated for a psychiatric disorder Psychological Factors • One of the most primitive ego defense mechanisms is dissociation • The theory of structural dissociation of the personality proposes that patients with complex trauma have different parts of their personality—the apparently normal part and the emotional part—that are not fully integrated with each other *3 PARTS • Each part has its own responses, feelings, thoughts, perceptions, physical sensations, and behaviors • These different parts may not be aware of one another with only one dominant personality operating depending on the situation and circumstance of the moment Environmental Factors • Dissociative disorders are responses to acute overwhelming trauma and as such are due to environmental factors • These may include any experience that is overwhelming to the person such as a motor vehicle accident, combat, emotional/verbal abuse, incest, neglectful or abusive caregivers, imprisonment, and many other types of traumatic events Cultural Considerations NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS perceive their appearance as distorted and may avoid being seen in public o Patients with dissociative amnesia and identity disorder often have employment and family problems o Memory loss often renders them unable to work and impairs normal relationships o Employers dislike the lost time that may occur due to dissociative symptoms o Families often direct considerable attention toward the patient but may express concern over having to assume roles that were once assigned to the patient o Families find it difficult to accept the seemingly erratic behaviors of the patient o The high anxiety that accompanies dissociative disorders makes it difficult to keep relationships stable Assessment Tools: Scales have been developed to assess dissociation • The Cambridge Depersonalization Scale measures both depersonalization and derealization • Dissociative Experience Scale: Used to assess for general dissociation • The Somatoform Dissociation Questionnaire: Used to assess for general dissociation General Guidelines for Assessment 1. Assess for a history of self-harm 2. Evaluate level of anxiety and signs of dissociation 3. Identify support systems through a psychosocial assessment 4. Refer patient to therapist Planning • Phase 1: Establishing safety, stabilization, and symptom reduction • Phase 2: Confronting, working through, and integrating traumatic memories • Phase 3: Identity integration and rehabilitation NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS The nurse will most often encounter the patient in times of crisis (i.e., when the patient is admitted to the hospital for suicidal or homicidal behavior) Implementation: Anxiety reduction, coping enhancement, self-awareness enhancement, self-esteem enhancement, and emotional support • Psychoeducation o Patients with dissociative disorders need to learn about their illness and be given ongoing instruction about coping skills and stress management o Normalizing experiences by explaining symptoms as adaptive responses to overwhelming events is important o Often the victim of childhood trauma grows up with the false negative belief that the abuse was deserved punishment o Grounding techniques promote the individual’s ability to be “in the moment” and help counter dissociative episodes ▪ For example, dissociation can be disrupted by: stomping feet, taking a shower, holding an ice cube, exercising, deep breathing, or touching the upholstery on a chair o Patients can learn to keep a daily journal to increase awareness of feelings and to identify triggers to dissociation ▪ If a patient has never written a journal, the nurse should suggest beginning with a 5- to 10- minute daily writing exercise • Pharmacological Interventions o There are no specific medications for patients with dissociative disorders, but appropriate medications are often prescribed for the hyperarousal and intrusive symptoms that accompany PTSD and dissociation NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o These might include antidepressant medication, antianxiety agents, and antipsychotics o Substance-use disorders and suicidal risk, which are common, must be assessed carefully in selecting safe and appropriate pharmacotherapy o In the acute setting, the nurse may witness dramatic memory retrieval in patients with dissociative amnesia or fugue after treatment with intravenous benzodiazepines Advanced Practice Interventions: • CBT, psychodynamic psychotherapy, exposure therapy, modified EMDR therapy, hypnotherapy, neurofeedback, ego state therapies, somatic therapies, and medication Somatic Therapy • Dissociation causes people to experience a distressing fragmentation of consciousness and a sense of separation from themselves • Disturbances of perception, sensation, autonomic regulation, and movement are common for those who have suffered significant trauma because trauma is often stored physically in the body • Verbal and bodily psychotherapies are seen as complementary by the discipline of Dance Movement Therapists in working with traumatized dissociative patients in emotional recovery • Sensorimotor psychotherapy combines talk therapy with body-centered interventions and movement to address dissociative symptoms o This therapy is based on the premise that the body, mind, emotions, and spirit are interrelated, and a change at one level results in changes in the others o Awareness, focusing on the present, and recognizing touch as a means of communicating are some of the principles of this therapy o During psychotherapy sessions, the patient describes current physical sensations. NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS C. Thyroid dysfunction D. Eating disorder SEXUALITY Exemplar: Gender Dysphoria Readings: • Giddens: 22 • Psych: Gender Dysphoria in Chapter 20 • Maternal: Read Development of Gender Identity in Chapter 32 Key terms • Sex: is assigned at birth, refers to one’s biological status as either male or female, and is associated primarily with physical attributes • Gender refers to the socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for boys and men or girls and women • Transgender or trans: denoting or relating to a person whose sense of personal identity and gender does not correspond with their birth sex NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • Cisgender or Cis: denoting or relating to a person whose sense of personal identity and gender corresponds with their birth sex • Gender Identity: a person's perception of having a particular gender, which may or may not correspond with their birth sex • Sexual Orientation: a person's sexual identity in relation to the gender to which they are attracted; the fact of being heterosexual, homosexual, or bisexual (or other, different from ender identity) Gender Dysphoria (Formerly gender identity disorder) • The distress a person experiences as a result of the sex and gender they were assigned at birth • Feelings of unease about maleness or femaleness • Gender identity: The sense of “maleness” or “femaleness” is usually not established until a child is 3 years old • People tend to be comfortable with the fact that they are male or female • Unfortunately, biological assignment does not necessarily determine whether individuals think of themselves as male or female • When biological sex differs from gender identity, the individual may suffer from gender dysphoria, or feelings of unease about their incongruent maleness or femaleness • A man might describe himself as “a woman trapped in a man’s body.” • It should be noted that gender dysphoria is no longer considered a psychiatric disorder • Until quite recently, this problem was known as gender identity disorder, and all transgender people would be considered mentally ill based on the disorder’s criteria Signs and symptoms in children: • Expressions of desire to be the opposite sex • Some children insist that they are the opposite sex and ask their families to call them by another name • Only a small percentage of children who display gender dysphoria characteristics will continue to show NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS these characteristics into adolescence or adulthood • More intense childhood symptoms are associated with persistence of the dysphoria into adulthood Signs and symptoms in teenagers and adults • May verbalize a desire to be the other sex and to be treated as such • Dressing up and passing for the opposite sex is common • Adolescents may dread the appearance of secondary sexual characteristics and (along with adults) may seek hormones or surgery to alter their masculinity or femininity • These individuals do not usually consider themselves to be homosexual • The biological female who falls in love with a woman believes she is actually a man who loves a woman Epidemiology • Gender dysphoria is extremely uncommon • For adult individuals born male, the prevalence is estimated from 0.005% to 0.014% • For adult individuals born female, the prevalence is lower ranging from 0.002 to 0.003% Comorbidity • Children with gender dysphoria may also have anxiety, disruptive and impulse-control problems, and depressive disorders • Autism spectrum disorder has also been associated with gender dysphoria • In adolescents and adults, anxiety disorders are most common followed by mood disorders • Substance use and self-destructive behavior are also common parallels found in people suffering from gender dysphoria Biological Factors • While biological factors are not thought to cause this problem, they are believed to influence its development • Hormones may play a role as decreased levels of testosterone in males and increased levels in women NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS related issues • Adults with gender dysphoria may choose to take hormones to alter their chemistry toward their preferred gender • A female who would like to become a male takes testosterone o This results in more muscle, facial hair, clitoral enlargement, amenorrhea, and increased sex drive • When a male takes estrogen, it results in decreased penis and testicles size, less muscle, more fat on the hips, less facial and body hair, and slight increase in breast size Surgical: Sex reassignment surgery criteria • When severe and intractable sex reassignment surgery is an option • If the patient is considered appropriate for sex reassignment, psychotherapy is usually initiated to prepare the patient for the cross-gender role • The patient is then instructed to live in the cross-gender role before surgery—including going to work or attending school—to help the individual determine whether he or she can interact successfully with members of society in the cross-gender mode • Legal and social arrangements are made such as changing names on legal documents • New employment may be sought if it is necessary to leave a former job because of discrimination • Relationship issues, such as what to tell parents, children, and former spouses, must be addressed • Males are instructed to have electrolysis and to practice female behaviors • Females are instructed to cut their hair, bind or conceal their breasts, and similarly take on the identity of a man • If these measures have been successful and the patient still wishes reassignment, hormone treatment is begun • After a period of time on hormone therapy, the patient may be considered for surgical reassignment if it NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS is still desired Sex reassignment surgery • In men, surgery may include removal of the penis (penectomy) and testes (orchiectomy) and the addition of a vagina (vaginoplasty) • In females, surgical procedures may include the removal of the breasts (mastectomy), optional removal of the uterus (hysterectomy) and ovaries (oophorectomy), and the construction of a penis (phalloplasty) in females o Efforts to create an artificial penis have met with mixed results. • In a study, regret for the surgery was found in only about 2% of people • Still psychotherapy is indicated after surgery to help the patient adjust to the surgical changes MOBILITY Exemplar: Spinal cord injury Readings • Meg surge: Chapter 60 Spinal Cord and Peripheral Nerve Problems • Med surge: Neurogenic Shock in Chapter 66 • Maternal: Spinal Cord Injuries in Chapter 49 NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS Key terms • Anterior cord syndrome: Localized injury to the anterior portion of the spinal cord, characterized by complete paralysis and hypalgesia and hypesthesia to the level of the lesion • Paraplegia: Paralysis of the legs and lower body • Tetraplegia: Another term for quadriplegia, paralysis of all four limbs Spinal Cord Injury • Caused by trauma or damage to the spinal cord • It can result in temporary or permanent alteration in the function of the spinal cord • Young adult men ages 16 to 30 years have the greatest risk for SCI • With improved treatment strategies, even the very young patient with SCI can anticipate a long life • SCI has increased in older adults, related to people with SCI living longer and older age at the time of injury Etiology and Pathophysiology: SCI is usually a result of trauma • Motor vehicle accidents: 50%, Falls: 22%, Acts of violence: 15%, Recreation/sports: 8%, Diseases: 5% Types of injury • Primary Injury: Result of the initial trauma (physical disruption) to spinal cord o The initial mechanical disruption of axons as a result of stretch or laceration o Cord compression by bone displacement, interruption of blood supply to the cord, traction from pulling on the cord, penetrating trauma such as gunshot, stab wounds (tearing and transection) • Secondary injury: The result of progressive damage following the initial injury o The ongoing, progressive damage that occurs after the primary injury o From processes such as ischemia, hypoxia, hemorrhage, and edema NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS Level of Injury • Skeletal level of injury is the vertebral level with the most damage to vertebral bones and ligaments • Neurologic level is the lowest segment of the spinal cord with normal sensory and motor function on both sides of the body • The level of injury may be cervical, thoracic, lumbar, or sacral o Cervical and lumbar: Most common because those areas are associated with the greatest flexibility and movement o Cervical cord: If the cervical cord is involved, paralysis of all four extremities occurs ▪ Resulting in tetraplegia (formerly termed quadriplegia) ▪ The degree of impairment in the arms following the injury depends on the level of injury ▪ The lower the level, the more function is retained in the arms ▪ Above C4 can be fatal (phrenic nerve) innervates the diaphragm- this means quadriplegia ▪ C5 and below: Various patterns of motor loss NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o If the thoracic, lumbar, or sacral spinal cord is damaged, the result is paraplegia (paralysis and loss of sensation in the legs) o Injury to vertebra, sites that are most common: C1-C2, C4-C6, T11-L2 (These are the most mobile) Degree of Injury • The degree of spinal cord involvement may be complete or incomplete (partial) • Complete cord involvement results in total loss of sensory and motor function below the level of injury • Incomplete cord involvement results in a mixed loss of voluntary motor activity and sensation and leaves some tracts intact • The degree of sensory and motor loss depends on the level of injury and reflects specific damaged nerve tracts Incomplete injuries: Five major syndromes are associated with incomplete injuries • Central Cord Syndrome: Caused by damage to central spinal cord (most commonly the cervical cord region) o More common in older adults o S&S: Motor weakness and altered sensation present in upper extremities, Lower extremities not usually affected, Dysesthetic burning pain in upper extremities • Anterior Cord Syndrome: Caused by damage to anterior spinal artery o Results in compromised blood flow to anterior spinal cord o Typically results from compression of anterior portion of the spinal cord, often due to flexion injury o S&S: Motor paralysis & loss of pain and temperature sensation below level of injury, because posterior cord tracts are not injured, sensations of touch, position, vibration, & motion remain intact • Brown-Séquard Syndrome: Results from damage to one half of the spinal cord o Typically results from penetrating injury to spinal cord o S&S: Ipsilateral (same side as injury): Loss of motor function and pressure, position, and NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS vibratory sense, Contralateral (opposite side of injury): Loss of light touch, pain, and temperature sensation below level of injury • Conus Medullaris Syndrome: Results from damage to the conus medullaris (lowest portion of spinal cord) o S&S: Motor function in legs may be preserved, weak, or flaccid, Decrease in or loss of sensation in perianal area, Areflexic bowel and bladder, Impotence, Pain uncommon • Cauda Equina Syndrome: Results from damage to cauda equina (lumbar and sacral nerve roots) o S&S: Asymmetric distal weakness, patchy sensation in lower extremities, may cause flaccid paralysis of lower extremities, Complete loss of sensation between legs and over buttocks, inner thighs, and backs of legs (saddle area), Areflexic (flaccid) bladder and bowel, Severe, radicular, asymmetric pain Clinical Manifestations in the ACUTE period: Related to the direct trauma, level and degree The patient with an incomplete injury may demonstrate a mixture of manifestations Motor and Sensory Effects • The sensory regions are called dermatomes, with each segment of the spinal cord innervating a particular area of skin o Each dermatome has a specific point recommended for testing • The American Spinal Injury Association (ASIA) Impairment Scale is recommended for classifying the severity of impairment from SCI (Grade A- Worst, Grade 5- best) o It combines assessments of motor and sensory function to determine neurologic level and completeness of injury o Useful for recording changes in neurologic status and identifying appropriate rehabilitation goals Respiratory System: Respiratory complications closely correspond to the level of injury • Cervical injuries above C4 present special problems because of the total loss of respiratory muscle function • Injury or fracture below C4 results in diaphragmatic breathing if the phrenic nerve is functioning NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS ▪ The defecation reflex may be damaged and anal sphincter tone relaxed (retention) ▪ This leads to constipation, increased risk of incontinence, and possible impaction, ileus, or megacolon ▪ Hemorrhoids can occur over time Integumentary System • The risk for skin breakdown over bony prominences in areas of decreased or absent sensation is a major consequence of immobility related to SCI • Pressure ulcers can occur quickly and lead to major infection and sepsis Thermoregulation • Poikilothermism is the adjustment of body temperature to room temperature o It occurs in SCI because interruption of the sympathetic nervous system prevents peripheral temperature sensations from reaching the hypothalamus o Spinal cord disruption is also marked by decreased ability to sweat or shiver below the level of injury, which affects the ability to regulate body temperature o The degree of poikilothermism depends on the level of injury o High cervical injuries are associated with a greater loss of ability to regulate temperature than are thoracic or lumbar injuries Metabolic Needs • Nasogastric suctioning may lead to metabolic alkalosis • It’s important to monitor sodium and potassium until suctioning is discontinued and a normal diet is resumed • This person has increased nutritional needs due to increased metabolism and more protein breakdown • Lean body mass is lost and muscle atrophy leads to weight loss • Nutritional support should focus on a diet that addresses the person's caloric and nitrogen needs • Adequate nutrition helps to prevent skin breakdown, reduce infection, and decrease muscle atrophy NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS Peripheral Vascular Problems • Venous thromboembolism (VTE) is a common problem accompanying SCI during the first 3 months • Detecting deep venous thrombosis (DVT) may be difficult in a person with SCI because usual signs and symptoms, such as pain and tenderness, are not present • Pulmonary embolism is a leading cause of death in patients with SCI Pain • Differs in type and severity, and is influenced by the patient's physical functioning and emotions • The pain can be nociceptive or neuropathic • Nociceptive: Can develop from musculoskeletal, visceral, or other types of injury (skin ulceration, headache) o Patients often describe musculoskeletal pain as dull or aching. It starts or worsens with movement o Visceral pain is located in the thorax, abdomen, and/or pelvis, and may be dull, tender, or cramping • Neuropathic: Occurs from damage to the spinal cord or nerve roots o The pain can be located at or below the level of injury o Hot, burning, tingling, pins and needles, cold, and/or shooting o Patients may be extremely sensitive to stimuli and even light touch can cause significant pain Emergency management: Airway, breathing, circulation, disability, environment NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS Injury process: • Edema forms: After incident, spinal cord edema occurs o This causes flaccid paralysis and loss of reflex activity below the level of the lesion • Spinal shock: Attributed to cord edema from the time of injury o May occur following acute SCI *Immediately after spinal cord injury o Characterized by decreased reflexes, Loss of sensation, absent thermoregulation, and flaccid paralysis below the level of injury ▪ Complete loss of skeletal muscle function: Flaccid paralysis ▪ Loss of reflexes: Areflexia ▪ Loss of bowel and bladder tone: Urinary retention ▪ Loss of venous return: Hypotension, bradycardia (loss of sympathetic input) ▪ Loss of ability to regulate body temperature by hypothalamus (patient assumes environment temperature) o S&S: Hypotension, bradycardia, flaccid paralysis, warm dry skin, loss of spinal reflex activity NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS ▪ Perform a digital rectal examination (if trained) only after application of an anesthetic ointment to decrease rectal stimulation and avoid increasing symptoms o Check for other noxious stimuli: Remove all skin stimuli, such as constrictive clothing and tight shoes • Drug therapy: If symptoms persist after the source has been relieved, administer a rapid onset and short duration agent such as nitroglycerin, nitroprusside, or hydralazine • Patient & Caregiver Teaching: Autonomic Hyperreflexia o Signs and symptoms: Sudden onset of acute headache, Elevation in BP and/or reduction in pulse rate, Flushed face and upper chest (above level of injury) and pale extremities (below level of injury), Sweating above level of injury, Nasal congestion, Feeling of apprehension o Immediate interventions: Raise the person to a sitting position, Remove the noxious stimulus (fecal impaction, kinked urinary catheter, tight clothing), Call the HCP if above actions do not relieve the signs and symptoms o Measures to decrease the incidence of autonomic hyperreflexia: Maintain regular bowel function, use a local anesthetic to prevent autonomic hyperreflexia if manual rectal stimulation is used to promote bowel function, Monitor urine output, Encourage the patient to wear a Medic Alert bracelet NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS Prehospital: Always assume every patient has a SCI in trauma situation • ABC’s and preventing extension of spinal cord damage (secondary injury) • Immobilization: Recommended immobilization includes a combination of a rigid cervical collar and supportive blocks on a backboard with straps o Spinal immobilization in patients with penetrating trauma is also not recommended because of increased mortality o The concern during initial management of patients with potential cervical spinal injuries is impairment of neurologic function due to movement of the injured vertebrae • Systemic and neurogenic shock must be treated to maintain systolic BP greater than 90 mm Hg Diagnostic Tests & Labs • CT scan: The preferred imaging study to diagnose the location and degree of injury as well as the degree of spinal canal compromise • Spinal X-Ray: Anteroposterior, lateral, and odontoid spinal x-rays • Cervical x-rays are obtained when CT scan is not readily available, However, visualizing C7 and T1 on NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS cervical x-rays is often difficult, and the ability to fully evaluate cervical spine injury is compromised • MRI is used to assess soft tissue injury, neurologic changes, unexplained neurologic deficits, or worsening neurologic condition • CT angiogram: Patients with cervical injuries who demonstrate altered mental status may also need a CT angiogram to rule out vertebral artery damage • EMG (measure evoked potentials): Brain activity • Duplex Doppler ultrasound: Used to diagnose DVT • ECG (EKG): Monitor for heart dysrhythmias • Bloodwork: CMP, CBC, Coagulation profile, ABGs, UA, electrolytes, serum glucose, hemoglobin and hematocrit • Urinalysis: Baseline since UTI big complication • Serial bedside Pulmonary function tests (PFTs) • Complete neurologic examination: Perform a comprehensive neurologic examination with assessment of the head, chest, and abdomen for additional injuries or trauma Acute care assessment • Obtain a history, with emphasis on how the incident occurred • Initial assessment (which usually occurs in the emergency department) includes managing the person's ABCs and vital signs to ensure the airway is secure, oxygenation saturation (SaO2) is greater than 90%, and SBP is greater than 90 mm Hg • Interventions and diagnostics are implemented to ensure the patient is hemodynamically stable • A complete neurologic assessment is completed using the ASIA tool o Muscle groups are tested with and against gravity, alone and against resistance, on both sides of the body NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS and degree of compression • Early spinal cord decompression may reduce secondary injury and thus improve the patient's outcome • Surgery within the first 24 hours after SCI is safe and associated with improved neurologic outcome • Surgery to stabilize the spine can be performed from the back of the spine (posterior approach) or from the front of the spine (anterior approach)- In some cases, both approaches may be needed • Fusion involves attaching metal screws, plates, or other devices to the bones of the spine to keep them aligned o This procedure is usually done when two or more vertebrae have been injured o Small pieces of bone may also be attached to the injured bones to help them fuse into one solid piece o The bone used for this procedure can be obtained from the patient's spinal bone harvested during surgery, from another bone in the patient's body (autologous), or from donor bone (allograft) Drug Therapy • Methylprednisolone (MP): Was used for many years to treat acute SCI, is no longer approved by the FDA o No evidence suggests clinical benefit of MP to treat acute SCI o High-dose MP is associated with harmful side effects: Immunosuppression with increased risk of infection, increased frequency of upper GI bleeding, sepsis, longer stays in the ICU, and even death • Low-molecular-weight heparin (Enoxaparin [Lovenox]) is used to prevent VTE unless contraindicated o Contraindications include internal bleeding, abnormal kidney function, and recent surgery o Oral anticoagulation alone is not recommended as a prophylactic treatment strategy o VTE prophylaxis for 3 months following injury • Vasopressor agents (phenylephrine or norepinephrine (Levophed)): Improves hypotension NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o Used in the acute phase as adjuvants to treatment o Used to maintain the mean arterial pressure (MAP) greater than 85 to 90 in order to improve perfusion to the spinal cord o Use of vasopressors has significant risk of complications, including ventricular tachycardia, troponin elevation, metabolic acidosis, and atrial fibrillation o Dopamine has been shown to have more complications than phenylephrine in SCI o Because drug metabolism is altered in patients with SCI, drug interactions may occur o Differences in drug metabolism correlate with level and completeness of injury, with greater change apparent following cervical cord injury than injury at lower spinal levels o Midodrine may be given to promote blood vessel contraction and increase venous return for patients experiencing orthostatic hypotension • Corticosteroid (fludrocortisone): Used to increase intravascular volume and help with orthostatic hypotension • Anticholinergics (Atropine): For bradycardia • Histamine (H2)-receptor blockers (ranitidine [Zantac], famotidine [Pepcid]) or proton pump inhibitors (e.g., pantoprazole [Protonix], omeprazole [Prilosec]): To prevent stress ulcers • To maintain blood pressure and pulse rate: Atropine sulfate, Intropin (dopamine), Dobutrex (dobutamine) Acute Care: High cervical cord injury caused by flexion-rotation is the most complex SCI Interventions for this type of injury can be modified for patients with less severe injuries Immobilization: Proper immobilization of the neck involves the maintenance of a neutral position • Cervical injuries: Closed reduction with skeletal traction used for early realignment (reduction) of the injury o Crutchfield or Gardner-Wells tongs or halo (halo ring) can provide this type of traction, using a NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS rope that extends from the center of the device over a pulley to weights attached at the end ▪ Traction must be maintained at all times ▪ Possible displacement of the skull pins is a disadvantage of tongs, if this happens remove weights and notify the HCP ▪ If displacement occurs, hold the head in a neutral position and get help ▪ Immobilize the head while the surgeon reinserts the tongs ▪ No specific recommendations are available regarding maximum weight for traction ▪ The surgeon may start with 10 pounds and add 5 pounds for each level to the injury ▪ The goal is spinal reduction ▪ Pin care is important for infection prevention • Awake patients are monitored with x-ray as well as neurologic and pain assessment • Comatose patients require serial x-rays to evaluate the effects of traction • The need for surgery is determined after the spine is reduced • After cervical fusion or other stabilization surgery, the patient may wear a hard cervical collar or sternal- occipital-mandibular immobilizer brace • Patients with stable thoracic or lumbar spine injuries may be immobilized with a custom thoracolumbar orthosis (TLSO or body jacket) to inhibit spinal flexion, extension, and rotation • Immobilization of the neck of the patient with SCI prevents further injury, but the effects of immobility are profound • When a patient can begin to mobilize after a stable injury (for which surgery is not needed), the halo frame can be attached to a special vest (Halo vest) o Infection at the sites of tong or halo pin insertion is another potential problem o Preventive care is based on hospital protocol o A common protocol involves cleansing sites twice a day with half strength peroxide and normal NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o The patient may complain of light-headedness, dizziness, and nausea, and lose consciousness when moved from a bed to a chair o Assess orthostatic BP when mobilizing the patient o For symptomatic patients, use an abdominal binder and graduated compression stockings to promote venous return o Drugs used to increase intravascular volume include salt tablets and fludrocortisone o Midodrine may be given to promote blood vessel contraction and increase venous return • DVT prophylaxis: Use low-molecular-weight heparin or low-dose heparin in combination, sequential compression devices (SCDs), or graduated compression stockings to promote venous return and prevent VTE o Venous duplex studies may be performed before applying compression devices o Regularly perform range of motion (ROM) exercises and stretching o Continue VTE prophylaxis for 3 months following injury Fluid and Nutritional Management • During the first 48 to 72 hours after the injury, the GI tract may stop functioning (paralytic ileus) • A nasogastric tube must be inserted if ileus occurs • Because the patient cannot have oral intake, carefully monitor fluid and electrolyte status • Nutrition should be started within the first 72 hours following injury • Due to severe catabolism, a high-protein, high-calorie diet is needed for energy and tissue repair • Patient is in hypermetabolic state • Once bowel sounds are present or flatus is passed, and the patient is not receiving mechanical ventilation, a formal swallow evaluation should be done, If no risk of aspiration is identified, gradually introduce oral food and fluids NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • If the patient fails the swallow evaluation or is unable to eat due to an endotracheal tube or tracheostomy, a more secure feeding tube may be placed in the stomach or jejunum Bladder and Bowel Management • Neurogenic bladder: Immediately after injury, loss of autonomic and reflex control of bladder and sphincter o Due to this, urine is retained o Since there is no sensation of fullness, overdistention of the bladder can result in reflux into the kidney and cause renal failure o Bladder overdistention may even result in rupture of the bladder o An indwelling catheter may be inserted as soon as possible after injury ▪ Ensure patency of the catheter by frequent inspection and irrigation if necessary ▪ Strict aseptic technique for catheter care is essential to prevent infection ▪ During the period of indwelling catheterization, encourage a large fluid intake ▪ Check the catheter to prevent kinking and ensure free flow of urine ▪ Catheter-acquired urinary tract infection (CAUTI) is a common problem • The best method for preventing UTI is regular and complete bladder drainage • Intermittent catheterization should be done four to six times daily to prevent bacterial overgrowth from urinary stasis • If the urine is cloudy or has a strong, or if the patient develops symptoms of a UTI (e.g., chills, fever, malaise), send a specimen for culture • Urinary diversion surgery may be needed for repeated UTI with renal involvement or repeated stones, or if therapeutic interventions have been unsuccessful ▪ Age related changes that affected renal function, older adults more likely to develop NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS renal calculi and older men may have benign prostatic hyperplasia • May interfere with urinary flow and complicate management o Drug therapy: Various drugs can be used to treat the patient with a neurogenic bladder ▪ Anticholinergic drugs (oxybutynin [Ditropan XL], tolterodine [Detrol]) may be used to suppress bladder contraction ▪ α-Adrenergic blockers (terazosin, doxazosin [Cardura]) to relax the urethral sphincter ▪ Antispasmodic drugs (baclofen) used to decrease spasticity of pelvic floor muscles o Surgical treatment: Bladder neck revision (sphincterotomy), bladder augmentation (augmentation cystoplasty), penile prosthesis, artificial sphincter, perineal ureterostomy, cystotomy, vesicotomy, and anterior urethral transplantation • Neurogenic bowel: Problem during spinal shock due to no voluntary or involuntary (reflex) evacuation o Constipation is generally a problem, start a bowel program during acute care o This involves choosing a rectal stimulant (suppository or small-volume enema) to be inserted daily at a regular time, followed by gentle digital stimulation or manual evacuation until evacuation is complete o Suppositories (bisacodyl or glycerin) or small-volume enemas and digital stimulation o Constipation can be reduced with adequate fluid intake, a healthy diet of fiber and vegetables, and increased activity and exercise o A stool softener such as docusate sodium can be used to regulate stool consistency o Oral stimulant laxatives should be used only if absolutely necessary and not on a regular basis o Valsalva maneuver and manual stimulation are useful in patients with lower motor neuron injuries Temperature Control • Because the patient has no vasoconstriction, piloerection (erection of body hair), or heat loss NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • Protein important- Regularly assess nutritional status. Both weight loss and gain can contribute to skin breakdown. Adequate intake of protein is essential for skin health. Evaluation of prealbumin, total protein, and albumin can help identify inadequate protein intake. Stress the importance of nutrition for skin health. Reflexes: Once spinal shock is resolved, return of reflexes may complicate rehabilitation • Lacking control from the higher brain centers, reflexes are often hyperactive and produce exaggerated • Penile erection can occur from a variety of stimuli, causing embarrassment and discomfort • Spasms ranging from mild twitches to convulsive movements below the level of injury may also occur • The patient or caregiver may interpret this reflex activity as a return of function, explain the reason • Inform the patient of the positive use of these reflexes in sexual, bowel, and bladder retraining • Spasms may be controlled with the use of antispasmodic drugs such as baclofen, dantrolene (Dantrium), and tizanidine (Zanaflex). Botulism toxin injections may also be given to treat severe spasticity. Nursing Diagnoses • Ineffective breathing pattern related to respiratory muscle fatigue, neuromuscular paralysis, and/or retained secretions • Imbalanced nutrition: less than body requirements related to paralytic ileus and metabolic demands of body • Ineffective peripheral tissue perfusion related to hypotension and lack of mobility • Impaired skin integrity related to immobility and/or poor tissue perfusion • Impaired urinary elimination related to spinal injury and/or limited fluid intake • Constipation related to neurogenic bowel, inadequate fluid intake, and/or immobility • Risk for autonomic hyperreflexia (dysreflexia) related to reflex stimulation of sympathetic nervous system Chronic problems with SCI NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • Mobility: Disuse syndrome (ROM helps), Spasticity (neuron issue) • Perfusion: Orthostatic hypotension (Due to pooling of blood), DVT (Immobility) • Gas exchange: Pneumonia (Due to ab muscle dysfunction, unable to clear secretions) • Elimination: Bowel & bladder dysfunction (Due to nerves being caught off from brain) • Tissue integrity: Pressure ulcers (AKA dermal ulcers, from immbolity) • Psychosocial adjustment Nursing interventions: Respiratory precautions, Immobility precautions, Nutritional measures, Bowel and bladder training, Include family in planning and care Areas of concern in SCI rehab • Mobility/Locomotion: PT, Functional electrical stimulation systems • Self-care: OT • Continence of the bowel and/or bladder • Sexuality • Coping Rehabilitation and Home Care • Many of the problems identified in the acute period become chronic and continue throughout life • Rehabilitation focuses on retraining physiologic processes as well as extensive patient, caregiver, and family teaching about how to manage the physiologic and life changes resulting from the injury • Rehabilitation is an interprofessional team effort • Team members include rehabilitation nurses, HCPs, physical therapists, occupational therapists, speech therapists, vocational counselors, psychologists, therapeutic recreation specialists, prosthetists, orthotists, NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS case managers, social workers, and dietitians Respiratory Rehabilitation NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS ▪ Signals from the brain are sent through the nerves of the spinal cord to the T10-L2 levels ▪ The signals are then relayed to the penis and trigger an erection ▪ Men with low-level incomplete injuries are more likely to have psychogenic erection than men with higher-level incomplete injuries ▪ Men with complete injuries are less likely to experience psychogenic erection. o A reflex erection occurs with direct physical contact to the penis or other erotic areas ▪ A reflex erection is involuntary and can occur without sexually stimulating thoughts ▪ These reflex erections are often short lived and uncontrolled and cannot be maintained or summoned at the time of coitus ▪ The nerves that control a man's ability to have a reflex erection are located in the sacral nerves (S2-4) of the spinal cord ▪ Most men with SCI are able to have a reflex erection with physical stimulation regardless of the extent of the injury if the S2-4 nerve pathways are not damaged • Treatment for erectile dysfunction includes drugs, vacuum devices, and surgical procedures o Phosphodiesterase inhibitors such as sildenafil (Viagra) have become the first-line treatment in men with SCI o Sexual stimulation is required to get an erection after taking the medication o Penile injection of vasoactive substances (papaverine, prostaglandin E) is another medical treatment o Risks include prolonged penile erection (priapism) and scarring, so these substances should be considered only after failure of sildenafil o Vacuum suction devices use negative pressure to encourage blood flow into the penis o Erection is maintained by a constriction band placed at the base of the penis o The main surgical option is implantation of a penile prosthesis NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • SCI affects male fertility, causing low sperm quality and ejaculatory dysfunction o Recent advances in methods of sperm retrieval include penile vibratory stimulation and electroejaculation • The effect of SCI on female sexual response is less clear o A woman of childbearing age with SCI usually remains fertile o The injury does not affect the ability to become pregnant or to deliver normally through the birth canal o Menses may cease for as long as 6 months after injury o If sexual activity is resumed, protection against unplanned pregnancy is needed o A normal pregnancy may be complicated by UTI, anemia, and autonomic hyperreflexia o Because uterine contractions are not felt, precipitous delivery is always a danger • Care should be taken not to dislodge an indwelling catheter during sexual activity • Open discussion with the patient regarding sexual rehabilitation is essential Grief and Depression • Depression after SCI is common and disabling • Working through grief is a difficult, lifelong process for which the patient needs support and encouragement • The goal of recovery is related more to adjustment than to acceptance o Adjustment implies the ability to go on with living with certain limitations o Although the patient who is cooperative and accepting is easier to treat, expect a wide fluctuation of emotions from a patient with SCI o Your role in grief work is to allow mourning as part of the rehabilitation process o Maintaining hope is important during the grieving process and should not be interpreted as denial • When the patient is depressed, sympathy is not helpful NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o Treat the patient as an adult and encourage participation in care planning o A primary nurse relationship is helpful. Staff planning and sessions in which staff members can express their feelings help to provide consistency of care o To adjust, the patient needs continual support throughout the rehabilitation process in the form of acceptance, affection, and caring o Be attentive when the patient needs to talk and sensitive to needs at various stages of the grief process • Although depression during the grief process usually lasts days to weeks, some individuals may become clinically depressed and require treatment for depression Rehabilitation and Home Care • Physical therapy (ROM, mobility, strength, equipment) to maintain muscle mass and prevent contractures • Occupational therapy (splints, ADLs training): For functional ability • Speech therapy (swallow and cognition) • Pain management • Spasticity management • Bowel and bladder training • Autonomic hyperreflexia prevention • Pressure ulcer prevention • Recreational therapy • Patient and caregiver teaching NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS of the neck; usually attributed to meningeal irritation. a resistance to flexion of the neck, a condition seen in patients with meningitis. • Agnosia: The inability to process sensory information Traumatic brain injury • A serious form of head injury is traumatic brain injury (TBI) • TBI leading cause of death from trauma – responsible for 30% injury related deaths • Males are twice as likely to sustain a TBI as females Leading causes of traumatic brain injury • Falls 35% • Traffic incidents 17% • Struck by or against 16.5% • Assault 10% Risk factors: Very young, very old, high risk behaviors – drug use, sports Prognosis • Head trauma has a high potential for a poor outcome • Deaths from head trauma occur at three points after injury o Immediately after the injury: The majority of deaths occur immediately after the injury ▪ Either from the direct head trauma or from massive hemorrhage and shock o Within 2 hours after injury: Deaths occurring within a few hours of the trauma are caused by progressive worsening of the brain injury or internal bleeding NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o Approximately 3 weeks after injury: Deaths occurring 3 weeks or more after the injury result from multisystem failure • Expert care in the weeks after is crucial in decreasing the mortality risk and in optimizing patient outcomes Common symptoms: Headache, neck stiffness, confusion, drowsiness, nausea/vomiting, seizure, coma Types of Head Injuries • Scalp Lacerations: Easily recognized type of external head trauma *Open o Because the scalp contains many blood vessels with poor constrictive abilities, most scalp lacerations are associated with profuse bleeding o Even relatively small wounds can bleed significantly o The major complications associated with scalp laceration are blood loss and infection • Skull Fractures: More serious *Closed o Skull fractures frequently occur with head trauma o Categorized as (1) linear or depressed; (2) simple, comminuted, or compound; and (3) closed or open o Fractures may be closed or open, depending on the presence of a scalp laceration or extension of the fracture into the air sinuses or dura o The type and severity of a skull fracture depend on the velocity, momentum, direction and NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS shape (blunt or sharp) of the injuring agent, and site of impact o The location of the fracture determines the clinical manifestations o Basilar skull fracture is a specialized type of linear fracture involving the base of the skull ▪ Manifestations can evolve over several hours, vary with the location and severity ▪ May include cranial nerve deficits ▪ Battle's sign (postauricular ecchymosis), and periorbital ecchymosis (raccoon eyes) ▪ This fracture generally is associated with a tear in the dura and subsequent leakage of CSF ▪ In cases where a basilar skull fracture is suspected, an orogastric tube should be inserted rather than a nasogastric tube o Cerebral spinal fluid Leakage: Indicates tear in dura mater ▪ Confirmation that the fracture has traversed the dura: • Rhinorrhea (CSF leakage from the nose), may also manifest as postnasal sinus drainage- can be overlooked. • Otorrhea (CSF leakage from the ear) ▪ The risk of meningitis is high with a CSF leak, antibiotics should be administered as a preventive measure ▪ Testing to determine whether the fluid leaking from the nose or ear is CSF • Dextrostix or Tes-Tape strip to determine whether glucose is present o CSF gives a positive reading for glucose o If blood is present, testing for glucose is unreliable because blood also contains glucose o In this event, look for the halo or ring sign NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o The clinical signs of DAI are varied but may include a decreased LOC, increased ICP, decortication or decerebration, and global cerebral edema o Patients with DAI who survive the initial event are rapidly triaged to an ICU, where they will be vigilantly watched for signs of increased ICP and treated accordingly o Approximately 90% of patients with DAI remain in a persistent vegetative state o These patients make reflective movements, not intentional o They are completely unaware of self and environment o Distinguishing feature is that there is no behavioral expression of self-awareness or recognition or external stimuli o If they come out of persistent vegetative state you can see that they are actually tracking a person in the room o Initially the most threatening complication is increased ICP- Patient may present in a decorticate or decerebrate position- which indicates severe brain injury Focal Injury: Damage that can be localized to a specific area of the brain • Direct impact of skull into brain causing contusion, laceration, or hemorrhage • Can be minor to severe and can be localized to an area of injury • Focal injury consists of lacerations, contusions, hematomas, and cranial nerve injuries • Lacerations involve actual tearing of the brain tissue o Often occur in association with depressed and open fractures and penetrating injuries o Tissue damage is severe, and surgical repair of the laceration is impossible because of the nature of brain tissue o Medical management consists of antibiotics (until meningitis is ruled out) and prevention of secondary injury related to increased ICP NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o If bleeding is deep into the brain tissue, focal and generalized signs develop o Intracerebral hemorrhage is generally associated with cerebral laceration ▪ This hemorrhage manifests as a space-occupying lesion accompanied by unconsciousness, hemiplegia on the contralateral side, and a dilated pupil on the ipsilateral side ▪ As the hematoma expands, signs of increased ICP become more severe • Cerebral hemorrhage can happen with major head trauma o Other delayed responses, including hemorrhage, hematoma formation, seizures, cerebral edema o Hemorrhage is common with blood occupying space in the skull- which would be a closed system- as there is more blood, brain mater is compressed, this causes unconsciousness, hemiplegia, and an increase in ICP o Subarachnoid hemorrhage and intraventricular hemorrhage can also occur secondary to head trauma • Contusion: Bruising of the brain tissue with a focal area, usually associated with a closed head injury o Loss of consciousness, brain tissue bruising w/ cerebral edema o Contusion is a more serious problem than concussion and the outcome is less predictable o Due to close head trauma where there has been bruising of the brain tissue o A contusion may contain areas of hemorrhage, infarction, necrosis, and edema, and it frequently occurs at a fracture site ▪ With contusion, the phenomenon of coup-contrecoup injury is often noted • Coup-contrecoup injuries are often the precipitating factor that cause contusion – the site of impact is affected as well as the opposite site • Consequently, cerebral hemorrhage occurs with rebleeding possible- the greater the bleed the greater the neurological deficit • Damage from coup-contrecoup injury occurs when the brain moves inside the skull due NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS to high-energy or high-impact injury mechanisms • Results from strong blow to the head, causing the brain to slam against the side of the skull • Contusions or lacerations occur both at the site of the direct impact of the brain on the skull (coup) and at a second area of damage on the opposite side away from injury (contrecoup), leading to multiple contused areas • Coup injuries are brain contusions occurring at the point of impact • Contrecoup injuries result when the brain impacts the side of the skull opposite the point of impact o Contrecoup injuries tend to be more severe, and overall patient prognosis depends on the amount of bleeding around the contusion site o Caused by automobile accidents or abusive or violent events such as shaking a baby o Complications such as hematomas, brain swelling, disruptions to the flow of cerebral spinal fluid and problems with skull fragments compressing or entering brain tissue o Shaken baby syndrome is a serious form of child abuse caused by violent shaking of infants- a large head in proportion to the body, coupled with weak neck muscles places the baby at significant risk for coup-contrecoup injuries ▪ Blood vessels sheer which results in intracranial bleeding and retinol hemorrhage ▪ The baby may present with vomiting, irritability, poor feeding, and listlessness ▪ In more serious injuries, present with seizures, abnormal posturing, altered level of consciousness, apnea, or bradycardia NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o Mo st fre que ntly a tea r of the mid dle me nin gea l art ery tea r due to te mp oral skull fracture but may also be frontal or occipital o An epidural hematoma is a neurologic emergency and is usually associated with a linear fracture crossing a major artery in the dura, causing a tear (skull fracture tears blood vessels) o It can have a venous or an arterial origin ▪ Venous tears develop slowly, arterial tears develop quickly o Signs and symptoms: LOC, dizziness, headache, nausea and vomiting, confusion, focal findings ▪ Present as unconscious, then conscious, then unconscious “talk and die syndrome” ▪ A period of unconsciousness after the injury, followed by some lucidity, then decreased in the level of consciousness ▪ As hematoma is enlarging the patient will experience headache, nausea, vomiting, ↓ in LOC o If left untreated there will be herniation, which is an abnormal protrusion of brain tissue leaving its original position through an opening o Diagnosis: CT- early diagnosis based on CT scan o Treatment: Burr Holes and craniotomy ▪ Immediate treatment necessary to prevent permanent damage – one or more burr holes are drilled into the skull to relieve the increasing intracranial pressure and to drain excess blood ▪ Rapid surgical intervention to evacuate the hematoma and NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS pre ve nt cer ebr al her nia tio n, alo ng wit h me dic al ma na ge me nt for inc rea sing ICP, can dramatically improve outcomes ▪ Surgeon might also seek the source of bleeding to stop it • Subdural hematoma: Bleeding between the dura mater and arachnoid layer of the meninges o Slowly expanding with venous blood o Caused by venous bleeding between the dura mater and the meninges o Usually results from injury to the brain tissue and its blood vessels o Because it is usually venous in origin, the subdural hematoma may be slower to develop o However, can be caused by an arterial hemorrhage, in which case it develops more rapidly o Can be acute, subacute, or chronic ▪ Acute: Manifests within 24 to 48 hours of the injury • Rapid bleeding after severe head injury can cause acute subdural hematomas • Symptoms can develop in minutes to hours • Symptoms: Headache, decrease in level of consciousness o The size of the hematoma determines the clinical presentation and prognosis o Appearance may range from drowsy and confused to unconscious o The larger the bleed the more serious the presentation will be because the blood is occupying space in the closed skull NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o ▪ ▪ increase in ICP from the cerebral edema can cause an increased morbidity and mortality risk despite surgical intervention to evacuate the hematoma • Blunt force injuries that produce acute subdural hematomas may also cause significant underlying brain injury, resulting in cerebral edema ▪ Subacute: Develops over several hours or days, not as serious as acute • Usually occurs within 2 to 14 days of the injury • After the initial bleeding, a subdural hematoma may appear to enlarge over time as the breakdown products of the blood draw fluid into the subdural space ▪ Chronic: Develops over weeks, months, or years after a seemingly minor head injury • By the time symptoms occur with chronic, the hematoma may be quite large • More common with elderly and alcoholics NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS Treatment • Skull fractures: The treatment of skull fractures is usually conservative o For depressed fractures and fractures with loose fragments, a craniotomy is necessary to elevate the depressed bone and remove the free fragments o If large amounts of bone are destroyed, the bone may be removed (craniectomy), and a cranioplasty will be needed later • Large acute subdural and epidural hematomas (or those associated with significant neurologic impairment) o The blood must be removed through surgical evacuation o A craniotomy is generally performed to visualize and allow control of the bleeding vessels o Burr-hole openings may be used in an extreme emergency for a more rapid decompression, followed by a craniotomy ▪ A drain may be placed postoperatively for several days to prevent reaccumulation of blood • Cases of extreme swelling (e.g., DAI, hemorrhage): A craniectomy may be performed, which involves removing a piece of skull to reduce the pressure inside the cranial vault, thus reducing the risk of herniation Nursing Assessment • Mechanism of injury: motor vehicle collision, sports injury, industrial incident, assault, falls • Medications: Anticoagulant medications • General: Altered mental status • Integumentary: Lacerations, contusions, abrasions, hematoma, Battle's sign, periorbital edema and ecchymosis, otorrhea, exposed brain matter • Respiratory: Rhinorrhea, impaired gag reflex, inability to maintain a patent airway. Impending NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS herniation: altered/irregular respiratory rate and pattern • Cardiovascular: Impending herniation: Cushing's triad • Gastrointestinal: Vomiting, projectile vomiting, bowel incontinence • Urinary: Bladder incontinence • Reproductive: Uninhibited sexual expression • Neurologic: Altered level of consciousness, seizure activity, pupil dysfunction, cranial nerve deficit(s) • Musculoskeletal: Motor deficit/impairment, weakness, palmar drift, paralysis, spasticity, decorticate or decerebrate posturing, muscular rigidity or increased tone, flaccidity, ataxia Possible Diagnostic Findings • CT/MRI: Hematoma, edema, skull fracture, and/or foreign body • EEG: Abnormal • Positive toxicology screen or alcohol level • Blood glucose: ↓ or ↑ • ↑ ICP Nursing Diagnoses • Risk for ineffective cerebral tissue perfusion related to interruption of CBF associated with cerebral hemorrhage, hematoma, and edema • Hyperthermia related to increased metabolism, infection, and hypothalamic injury • Impaired physical mobility related to decreased LOC • Anxiety related to abrupt change in health status, hospital environment, and uncertain future • Potential complication: Increased ICP related to cerebral edema and hemorrhage Acute Care: The general goal of nursing management of the head-injured patient is to maintain cerebral NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS oxygenation and perfusion and prevent secondary cerebral ischemia • Frequent neurologic assessments: Surveillance or monitoring for changes in neurologic status is critically important because the patient's condition may deteriorate rapidly, necessitating emergency surgery o The GCS is useful in assessing the LOC o Report any indications of a deteriorating neurologic state, no matter how subtle, such as a decreasing LOC or decreasing motor strength, to the HCP • Eye care: Eye problems may include loss of the corneal reflex, periorbital ecchymosis and edema, diplopia o Loss of the corneal reflex may necessitate administering lubricating eye drops or taping the eyes shut to prevent abrasion o Periorbital ecchymosis and edema decrease with time, but cold and, later, warm compresses provide comfort and hasten the process o Diplopia can be relieved by use of an eye patch, consider a consult with an ophthalmologist • Temperature management: Hyperthermia may occur from injury to or inflammation of the hypothalamus o Elevations in body temperature can result in increased CBF, cerebral blood volume, and ICP o Increased metabolism secondary to hyperthermia increases metabolic waste, which in turn produces further cerebral vasodilation o Avoid hyperthermia with a goal of a temperature of 96.8° to 98.6° F (36° to 37° C) o Use interventions to reduce temperature in conjunction with sedation as necessary to prevent shivering • Management of CSF: If CSF rhinorrhea or otorrhea occurs, inform the HCP immediately o The head of the bed may be raised to decrease the CSF pressure so that a tear can seal o A loose collection pad may be placed under the nose or over the ear o Do not place a dressing in the nasal or ear cavities and document the amount of drainage each shift NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • Check with your HCP before taking drugs that may increase drowsiness, including muscle relaxants, tranquilizers, and opioid pain medications • Avoid driving, using heavy machinery, playing contact sports, and taking hot baths Intracranial Pressure • The skull has three essential volume components: brain tissue, blood, and cerebrospinal fluid (CSF) • The intracellular and extracellular fluids of brain tissue make up approximately 78% of this volume • Blood in the arterial, venous, and capillary network makes up 12% of the volume, and the remaining 10% is the volume of the CSF Primary versus secondary injury: Important in understanding ICP • Primary injury: Occurs at the initial time of an injury (impact of car accident, blunt-force trauma) o Resulting in displacement, bruising, or damage to any of the three components NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • Secondary injury: The resulting hypoxia, ischemia, hypotension, edema, or increased ICP that follows the primary injury o Secondary injury, which could occur several hours to days after the initial injury, is a primary concern when managing brain injury o Nursing management of the patient with an acute intracranial problem must include management of secondary injury and thus increased ICP Regulation and Maintenance of Intracranial Pressure NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • Normal Intracranial Pressure o Intracranial pressure (ICP) is the hydrostatic force measured in the brain CSF compartment o Under normal conditions balance among the three components (brain tissue, blood, CSF) o Factors that influence ICP under normal circumstances are changes in (1) arterial pressure; (2) venous pressure; (3) intraabdominal and intrathoracic pressure; (4) posture; (5) temperature; and (6) blood gases, particularly CO2 levels • Monro-Kellie doctrine: o The skull is a rigid structure with 3 components: the brain, blood, & CSF o If any one of these increases, another compartment must decrease in order to maintain ICP o If this does not happen, there will be an increase in ICP o This hypothesis is only applicable in situations in which the skull is closed ▪ The hypothesis is not valid in persons with displaced skull fractures or hemicraniectomy • Normal ICP ranges from 5 to 15 mm Hg o A sustained pressure greater than 20 mm Hg is considered abnormal and must be treated • Normal Compensatory Adaptations o In applying the Monro-Kellie doctrine, the body can adapt to volume changes within the skull in three different ways to maintain a normal ICP ▪ First, compensatory mechanisms can include changes in the CSF volume • The CSF volume can be changed by altering CSF absorption or production and by displacing CSF into the spinal subarachnoid space ▪ Second, changes in intracranial blood volume can occur through the collapse of cerebral veins and dural sinuses, regional cerebral vasoconstriction or dilation, and changes in venous outflow ▪ Third, brain tissue volume compensates through distention of the dura or compression NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS Pressure Changes: Based on stages • Stage 1: High compliance o The brain is in total compensation, with accommodation and autoregulation intact o An increase in volume (brain tissue, blood, or CSF) does not increase the ICP • Stage 2: The compliance is beginning to decrease o An increase in volume places the patient at risk of increased ICP and secondary injury • Stage 3: Significant reduction in compliance o Any small addition of volume causes a great increase in ICP o Compensatory mechanisms fail, there is a loss of autoregulation, and the patient exhibits manifestations of increased ICP (headache, changes in level of consciousness or pupil responsiveness o When loss of autoregulation: Body attempts to maintain cerebral perfusion by increasing systolic BP ▪ However, decompensation is imminent ▪ The patient's response is characterized by systolic hypertension with a widening pulse pressure, bradycardia with a full and bounding pulse, and altered respirations ▪ This is known as Cushing's triad and is a neurologic emergency • Stage 4: As the patient enters stage 4, the ICP rises to lethal levels with little increase in volume o Herniation occurs as the brain tissue is forcibly shifted from the compartment of greater pressure to a compartment of lesser pressure o In this situation, intense pressure is placed on the brainstem, and if herniation continues, brainstem death is imminent Factors Affecting Cerebral Blood Flow • CBF can be affected by cardiac or respiratory arrest, systemic hemorrhage, and other pathophysiologic NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS states (e.g., diabetic coma, encephalopathies, infections, toxicities) • Regional CBF can also be affected by trauma, tumors, cerebral hemorrhage, or stroke o When regional or global autoregulation is lost, CBF is no longer maintained at a constant level but is directly influenced by changes in systemic BP, hypoxia, or catecholamines Increased Intracranial Pressure • Any patient who becomes unconscious acutely, regardless of the cause, should be suspected of having increased ICP Mechanisms of Increased Intracranial Pressure • Increased ICP is a potentially life-threatening situation that results from an increase in any or all of the three components (brain tissue, blood, CSF) within the skull • Elevated ICP is clinically significant because it diminishes cerebral perfusion pressure which increases risks of brain ischemia and infarction, and is associated with a poor prognosis • Elevated ICP also decreases cerebral blood flow, which increases the risk of ischemia • There is an increase in edema and tissue pressure Common causes of increased ICP: A mass and cerebral edema • A mass: Hematoma, contusion, abscess, tumor • Cerebral edema: Brain tumors, hydrocephalus, head injury, or brain inflammation • These cerebral insults (mass/cerebral edema), can may result in hypercapnia, cerebral acidosis, impaired autoregulation, and systemic hypertension, increase the formation and spread of cerebral edema • This edema distorts brain tissue, further increasing the ICP, leads to even more tissue hypoxia and acidosis • It is critical to maintain CBF to preserve tissue and thus minimize secondary injury NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • Sustained increases in ICP result in brainstem compression and herniation of the brain from one compartment to another • Displacement and herniation of brain tissue can cause a potentially reversible process to become irreversible • Ischemia and edema are further increased, compounding the preexisting problem • Compression of the brainstem and cranial nerves may be fatal • Herniation forces the cerebellum and brainstem downward through the foramen magnum • If compression of the brainstem is unrelieved, respiratory arrest will occur due to compression of the respiratory control center in the medulla Progression of increased ICP • Insult to brain causes tissue edema which increases ICP then compression of ventricles and blood vessels which lowers cerebral blood flow then lowers oxygen with death to brain cells and edema around necrotic tissue results in increased ICP with compression of brainstem and respiratory center this results in an accumulation of CO2 which causes vasodilation which further increases ICP resulting from higher blood volume and ultimately death Cerebral Edema: Results in an increase in tissue volume that can increase ICP • The extent and severity of the original insult are factors that determine the degree of cerebral edema • Causes of Cerebral Edema o Mass Lesions: Brain abscess, Brain tumor, Hematoma, Hemorrhage o Head Injuries and Brain Surgery: Contusion, Hemorrhage, Posttraumatic brain swelling o Cerebral Infections: Encephalitis, Meningitis o Vascular Insult: Anoxic and ischemic episodes, Cerebral infarction, Venous sinus thrombosis o Toxic or Metabolic Encephalopathic Conditions: Hepatic encephalopathy, Lead or arsenic NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o Patho of Cushing’s Triad Opposite vitals of shock NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS ▪ When compensatory mechanisms fail there is a loss of autoregulation, which enables an increase in intracranial pressure ▪ Eventually the situation does not improve and the increase in ICP and perfusion declines to the point where the brain mass will herniate and there is resulting compression of the brain stem, which causes death o Manifestations: Headache, decreased LOC, and pupillary response changes Clinical Manifestations: In more detail • When ICP increases to the point at which the brains’ ability to adjust has reached its limits, neural function is impaired. Manifested by clinical changes in o Any sudden change in patients’ condition such as restlessness (without cause), confusion, or increasing drowsiness is a neurological significance o ICP up= patient becomes stuporous reacting only to loud auditory or painful stimuli o This stage- serious impairment of brain circulation is taking place and immediate intervention is needed o Neurological function deteriorates further, patient becomes comatose and exhibits abnormal motor response in the form of decortication, decerebration or flaccidity o When come is profound, pupils dilated and fixed, respirations impaired, death usually inevitable • Change in Level of Consciousness o The level of consciousness is the most sensitive and reliable indicator of neuro status o Electroencephalogram (EEG): Can show patterns of brain activity o A change in consciousness may be dramatic (as in coma) or subtle (such as a flattening of affect, change in orientation, or decrease in level of attention) o In the deepest state of unconsciousness (i.e., coma), the patient does not respond to painful stimuli NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • Changes in Vital Signs o Caused by increasing pressure on the thalamus, hypothalamus, pons, and medulla • Ocular Signs o Dilation of the pupil on the same side (ipsilateral) as the mass lesion o Sluggish or no response to light o Inability to move the eye upward and adduct o Ptosis of the eyelid o A fixed, unilateral, dilated pupil is considered a neurologic emergency that indicates herniation of the brain o Blurred vision, diplopia, and changes in extraocular eye movements o Sluggish but equal pupil response o A dilated unilateral pupil o Papilledema (an edematous optic disc seen on retinal examination) • Decrease in Motor Function: As the ICP continues to rise, the patient manifests changes in motor ability o The patient cannot swallow or cough and is incontinent of urine and feces o Hemiparesis: On opposite side of the mass lesion o Hemiplegia: Sign of worsening ICP o Decorticate posture: Internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers as a result of interruption of voluntary motor tracts in the cerebral cortex. Extension of the legs may also be seen o A decerebrate posture: Indicates more serious damage and results from disruption of motor fibers in the midbrain and damage to the brainstem. In this position, the arms are stiffly extended, adducted, and hyperpronated. There is also hyperextension of the legs with plantar flexion of the feet NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS tissue and bone. Blood from intracranial hematomas absorbs the light differently than other areas of the brain. Monitoring ICP and Cerebral Oxygenation • Indications for Intracranial Pressure Monitoring o ICP should be monitored in patients admitted with a Glasgow Coma Scale (GCS) score of 8 or less and an abnormal CT scan or MRI ▪ These results indicate that the patient may have bleeding, contusion, edema, or other problems • Methods of Measuring ICP o Ventriculostomy: The gold standard for monitoring ICP ▪ This technique directly measures the pressure within the ventricles, facilitates removal and/or sampling of CSF, and allows for intraventricular drug administration o Other methods: The fiberoptic catheter, The air pouch/pneumatic technology o Inaccurate ICP readings: Can be caused by CSF leaks around the monitoring device, obstruction of the intraventricular catheter (from tissue or blood clot), a difference between the height of the catheter and the transducer, kinks in the tubing, and incorrect height of the drainage system relative to the patient's reference point. Bubbles or air in the tubing can also dampen the waveform. o Complications from monitoring ICP: Infection is a serious complication with ICP monitoring ▪ Factors that contribute to the development of infection include ICP monitoring more than 5 days, use of a ventriculostomy, a CSF leak, and a concurrent systemic infection ▪ Routinely assess the insertion site, use aseptic technique, and monitor the CSF for a change in drainage color or clarity • Cerebrospinal Fluid Drainage o With the ventricular catheter, it is possible to control ICP by removing CSF NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS o The two options for CSF drainage are intermittent or continuous o Strict aseptic technique during dressing changes or sampling of CSF is imperative to prevent infection o Complications of this type of drainage system include ventricular collapse, infection, and herniation or subdural hematoma formation from rapid decompression Cerebral Oxygenation Monitoring: Measure cerebral oxygenation and assess perfusion • Three intracranial devices used in ICU settings are the LICOX catheter, Neurovent catheter, and jugular venous bulb catheter Interprofessional Care • The underlying cause of increased ICP is usually an increase in blood (hemorrhage), brain tissue (tumor or edema), or CSF (hydrocephalus) in the brain • For any patient with increased ICP, it is important to maintain adequate oxygenation to support brain function and prevent secondary injury • An endotracheal tube or tracheostomy may be necessary to maintain adequate ventilation • Arterial blood gas (ABG) analysis guides the O2 therapy • The goal is to maintain the PaO2 at greater than or equal to 100 mm Hg and to keep PaCO2 in normal range at 35 to 45 mm Hg • The patient may need to be on a mechanical ventilator to ensure adequate oxygenation • If increased ICP is caused by a mass lesion (tumor, hematoma) surgical removal of mass is the best treatment • In aggressive situations, a craniectomy (removal of part of skull) may be performed to reduce ICP and prevent herniation Drug Therapy: An important part in the management of increased ICP NURS EXAM NOTES 4 BEST STUDY GUIDE WITH COMPLETE SOLUTIONS • Vasopressors and IV fluid boluses to keep systolic pressure above 90 • Osmotic diuretic: Mannitol (Osmitrol) (25%): Given IV o Mannitol decreases the ICP in two ways: plasma expansion and osmotic effect o The immediate plasma-expanding effect reduces the hematocrit and blood viscosity, thereby increasing CBF and cerebral O2 delivery o A vascular osmotic gradient is created by mannitol o Fluid moves from the tissues into the blood vessels, reducing the ICP because of the decrease in the total brain fluid content o Monitor fluid and electrolyte status when osmotic diuretics are used o Mannitol may be contraindicated if renal disease is present and if serum osmolality is elevated • Hypertonic saline solution o It produces massive movement of water out of edematous swollen brain cells and into blood vessels o This movement of water out of the brain can reduce swelling and improve cerebral blood flow o Hypertonic solution infusion requires frequent monitoring of BP and serum sodium levels because intravascular fluid volume excess can occur o Hypertonic saline infusion has been shown to be just as effective as mannitol when treating increased ICP, and both are often used concurrently when caring for a patient with a severe brain injury • Corticosteroids (Dexamethasone): Used to treat vasogenic edema surrounding tumors and abscesses o Not recommended for traumatic brain injury o Prevent the formation of proinflammatory mediators o Corticosteroids also improve neuronal function by improving CBF and restoring autoregulation o Complications associated with the use of corticosteroids include hyperglycemia, increased incidence of infections, and gastrointestinal (GI) bleeding