Chapter039

Copyright © 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Timby/Smith: Introductory Medical-Surgical Nursing, 10/e

Chapter 39: Caring for Clients with Head and Spinal Cord Trauma


Concussion Concussion • Pathophysiology, Etiology

– Blow to the head that jars the brain

– Temporary neurologic impairment

• Assessment Findings

– Brief lapse of consciousness; Disorientation

– Headache; Blurred or double vision

– Emotional irritability; Dizziness

• Diagnostic Findings: Skull radiography, CT scan, MRI


Concussion Concussion • Medical Management

– Temporary inactivity

– Mild analgesia

– Observation for neurologic complications

• Nursing Management

– Neurologic assessment

– Close observation: Signs of IICP

– Client instruction: Contact physician, return to ED if symptoms of IICP occur


Contusion Contusion • Pathophysiology, Etiology

– Coup and contrecoup injury

– Cerebral edema


– Hypotension; Rapid, weak pulse; Shallow respirations; Pale, clammy skin

– Temporary amnesia

– Effects of permanent brain damage

• Diagnostic Findings: Skull radiography; CT scan; MRI


Contusion Contusion • Medical Management

– Drug therapy; Mechanical ventilation


– Periodically monitor

• LOC; Neurologic changes; Respiratory distress; Signs of IICP; Vital signs

– Head injury prevention

• Seatbelts; Infant car seats; Protective headgear; Neck restraints; No alcohol or drugs while driving


Cerebral Hematomas Cerebral Hematomas

• Pathophysiology, Etiology

– Head trauma

– Cerebral vascular disorders

– Types: Epidural; Subdural; Intracerebral


– Location dependent; Bleeding rate; Hematoma size; Autoregulation

• Diagnostic Findings: MRI; CT scan; ICP monitoring


Cerebral Hematomas Cerebral Hematomas

Figure 39-3 Location of epidural, subdural, and intracerebral hematomas


Cerebral HematomasCerebral Hematomas• Medical Management

– Indications of surgical emergency: Rapid change in LOC; Signs of uncontrolled IICP

• Surgical Management

– Burr holes

– Intracranial surgery: Craniotomy, craniectomy, and cranioplasty

– Surgical approaches

• Supratentorial

• Infratentorial


Cerebral HematomasCerebral Hematomas


– All head injuries are emergencies

– Nurse’s role

• History; Neurologic examination; Vital signs; LOC

• Limb movement; Pupil reactions

– Trauma

• Head examination; Respiratory status

• Neurologic changes


Cerebral HematomasCerebral Hematomas• Nursing Management

– Preoperative nursing care

• Hair removal; Vital signs; Neurologic assessment; Antiembolism stockings

• Restrict: Fluids

– Post-operative nursing care

• Supine or side-lying position

• Regular monitoring; Observe for IICP

• Control thrombus or embolus; Cerebral edema


Skull Fractures Skull Fractures • Pathophysiology, Etiology

– Head injuries: Open; Closed

– Skull fractures: Simple; Depressed; Basilar

• Assessment Findings: Signs and Symptoms

• Localized headache; Bump, bruise, or laceration; Hemiparesis; Shock

• Rhinorrhea; Otorrhea

• Periorbital ecchymosis; Battle’s sign

• Conjunctival hemorrhages; Seizures


Skull FracturesSkull Fractures• Diagnostic Findings: Skull radiographs; CT scan; MRI

• Medical and Surgical Management

– Simple fracture: Bed rest; Observation for IICP

– Lacerated scalp: Clean, débride, and suture

– Depressed skull fracture

• Craniotomy; Antibiotics

• Osmotic diuretics; Anticonvulsants


Skull FracturesSkull Fractures• Nursing Management

– Signs of head trauma

– Drainage from the nose or ear

– Halo sign

– Neurologic assessments

• Hourly: LOC; Pupil, motor, and sensory status

• Every 15 to 30 minutes: Vital signs

• Prepare for the possibility of seizures


Spinal Cord Injuries Spinal Cord Injuries • Pathophysiology, Etiology

– Accidents (vehicular); Violence

– Spinal shock (areflexia): Poikilothermia

– Autonomic dysreflexia (hyperreflexia)


– Pain; Difficulty breathing; Numbness; Paralysis

– Neurologic examination

• Diagnostic Findings

– Radiography; Myelography; MRI; CT scan


Spinal Cord Injuries Spinal Cord Injuries • Medical Management

– Cervical collar; Cast or brace; Traction; Turning frame

– IV; Vital sign stabilization; Corticosteroids

– Surgical intervention


– Bone fragment removal

– Dislocated vertebrae repair

– Spine stabilization


Nursing ProcessNursing Process• Assessment

– Injury; Treatment at scene

– Neurologic assessment: Document findings

– Vital signs; Respiratory status

– Movement, sensation below injury level

– Signs

• Worsening neurologic damage

• Respiratory distress

• Spinal shock


Nursing ProcessNursing Process

• Diagnosis, Planning, and Interventions

– Ineffective: Breathing pattern; Airway clearance

– Neuropathic pain

– Impaired physical mobility

– Anxiety

– Risks: Impaired gas exchange; Disuse syndrome; Ineffective coping

• Evaluation of expected outcomes


Spinal Nerve Root Compression Spinal Nerve Root Compression

• Pathophysiology, Etiology

– Trauma

– Herniated intervertebral disks

– Tumors of the spinal cord

• Assessment Findings: Weakness; Paralysis; Pain; Paresthesia

• Diagnostic Findings: Spinal radiography; CT; MRI; Myelography; Electromyography


Spinal Nerve Root CompressionSpinal Nerve Root Compression

Figure 39-14 (A) Normal lumbar spine vertebrae, intervertebral disks, and spinal nerve root. (B)

Ruptured vertebral disk.


Spinal Nerve Root Compression Spinal Nerve Root Compression • Medical Management

– Cervical collar or brace; Bed rest; Skin traction; Hot moist packs

– Skeletal muscle relaxants; Drug therapy; Corticosteroids; Analgesics


– Diskectomy

– Laminectomy

– Spinal fusion

– Chemonucleolysis




– Neurologic examination

– Conservative therapy

• Spinal support and alignment; Bed rest in Williams’ position; Tractions

• Proper body mechanics

• Muscle relaxants and analgesics; Moist heat application

• Evaluation of client response to therapy



• Post-surgical Nursing Management

– Monitor vital signs

– Hourly deep breathing exercises

– Examine the dressing for CSF leakage or bleeding

– Assess neurovascular status

– Voiding status

– Fracture bed pan


End of Presentation

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