PNCM 1169- Module 15 Neurologic Trauma
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School
University of Notre Dame**We aren't endorsed by this school
Course
NURSING MISC
Subject
Medicine
Date
Dec 16, 2024
Pages
32
Uploaded by GrandHyenaPerson1179
Module 15: PNCM 1169- Medical Surgical Nursing II| 1 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.UNIVERSITY OF SAINT LOUIS Tuguegarao City SCHOOL OF HEALTH AND ALLIED SCIENCES First Semester S.Y. 2021-2022 CORRESPONDENCE LEARNING MODULE Care of Clients with Problems in Nutrition, Gastrointestinal, Metabolic and Endocrine, Perception and Coordination, Acute and Chronic (Medical Surgical Nursing II) Prepared by: Jonalyn P. Santos, MSN Instructor/s Reviewed by: Janina C. Abad, MSN Program Chair Recommended by: Dindo V. Asuncion, PhD. Academic Dean Approved by: Emmanuel James P. Pattaguan, PhD VP for Academics Finals Duration: Week 15
Module 15: PNCM 1169- Medical Surgical Nursing II| 2 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.November 22-26, 2021 Set 1 (137): Wed-Thu 3:30-6:00 PM Set 2 (138): Fri 1:00-6:00 PM I.Introduction This will be your guide for the topics and activities for the fifteenth week Date Topic Activities or Tasks III. PERCEPTION AND COORDINATION b.Neurologic Function iii. Neurologic trauma 1. Risk factors and screening 2. Assessment findings: subjective data and results of physical assessment 3. Results and implications of diagnostic or laboratory examinations 4. Pathophysiologic mechanisms a. Head injury Asynchronous learning: resources will be uploaded in the LMS Synchronous sessionswith recitation: for online mode Self-directed learningof the provided materials and resources for the correspondence mode Nursing Care PlanHello again student nurses! Nurse Missy here. Welcome to the next module where we will continue our discussion of the disorders neurologic function. We will discuss the management of patients experiencing neurologic trauma. Are you ready?-----------------------------------------LET’S GO MEDICAL-SURGICAL NURSES!
Module 15: PNCM 1169- Medical Surgical Nursing II| 3 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.b. Spinal cord injury c. Traumatic Brain Injury 5. Nursing diagnosis 6. Management a. Pharmacologic actions b. Nursing responsibilities For this week of this term, the following shall be your guide for the different lessons and tasks that you need to accomplish. Be patient, read it carefully before proceeding to the tasks expected of you. GOOD LUCK! Content III. PERCEPTION AND COORDINATION b. Neurologic Function iii. Neurologic trauma 1. Risk factors and screening 2. Assessment findings: subjective data and results of physical assessment 3. Results and implications of diagnostic or laboratory examinations 4. Pathophysiologic mechanisms a. Head injury b. Spinal cord injury c. Traumatic Brain Injury 5. Nursing diagnosis 6. Management a. Pharmacologic actions b. Nursing responsibilities Learning Outcomes At the end of the lesson, the students will be able to: ●Identify significant subjective and objective data from the client’s history, physical assessment ●Identify implications of relevant diagnostic tests and procedures for clients with reference to neurologic function ●Trace the pathophysiological process involved in neurologic disorders ●Determine the purpose, indications, nursing responsibilities of treatment management and modalities for neurologic disorders ●Integrate bioethical concepts in the planning, implementation and evaluation of care of clients with neurologic disorders
Module 15: PNCM 1169- Medical Surgical Nursing II| 4 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.●Develop appropriate outcome criteria for the care of clients with neurologic disorders II.LEARNING CONTENTAre you ready Medical-Surgical Nurses! Neurologic Trauma Head Injury ●Any degree of injury to the head ranging from scalp laceration to loss of consciousness to focal neurological deficits ●Traumatic brain injury (TBI) oA non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness Neurological trauma is an injury to the brain, spine or nerves. Accidents involving vehicles, bikes, sports or falls usually cause these types of injuries. Neurological trauma can often affect many areas of the body —including the organs, blood vessels, muscles and bones —so care requires a team of specialists.
Module 15: PNCM 1169- Medical Surgical Nursing II| 5 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.https://lh3.googleusercontent.com/proxy/guJpSU2tdLjec1yJQGYbicjcWrp0c5YKnfD-e47qz5AULUUfCDpjgMIPDVkGEogSWdBMacECeIOfclvSOWtO0N3kFL8UNrMq2hy09NojyIXsuSUAOfYR ●Etiology oMotor vehicle accidents- 44% oFalls- 26% oAssaults- 13% oSports-related injuries oFirearm-related injuries- 8% oOther/Unknown ●Head Trauma Types TBI is highest among adolescents, young adults, and those older than 75. Vehicle crashes are the leading cause of brain injury. Falls are the second leading cause wherein 50% of major trauma deaths are due to TBITBI has a high potential for poor outcome. Deaths occur at three points in time after injury: Immediately after the injury, within 2 hours after injury and 3 weeks after injury. This implies proper monitoring and follow-up of the patient during this time.
Module 15: PNCM 1169- Medical Surgical Nursing II| 6 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.oLacerations ▪Easily recognized ▪The most minor type of head trauma ▪Scalp is highly vascular which causes profuse bleeding ▪Major complication is infection oSkull Fractures ▪Linear ●Break in the continuity of bone without alteration of relationship of parts ●Low velocity injuries ▪Depressed ●Inward indentation of skull cause ●Powerful blow https://lh3.googleusercontent.com/proxy/ZhczZwC9DGAXJFAZ7BEzW-9zWX1t7zaBefH0q2JIGkzp4dX_iDfZsz5UiZoNmni_KwIBdPJjUt8Xs1lZDFaR5_Cx2XSIoVHN4Q ▪Comminuted ●Multiple linear fractures with fragmentation of bones into pieces ▪Compound ●Depressed skull fractures and scalp laceration communicating with intracranial cavity ▪According to location ●Frontal fracture ●Temporal fracture oBoggy temporal muscle because extravasation of blood oOval shaped bruise behind the ear in mastoid region (battle sign) oOtorrhoea ●Parietal bone fracture oDeafness
Module 15: PNCM 1169- Medical Surgical Nursing II| 7 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.oCSF otorrhoea oBulging of tympanic membrane by blood or CSF oFacial paralysis ●Posterior fossa fracture ●Orbital fracture oPeriorbital ecchymosis (RACCOON EYES) oOptic nerve injury ●Basilar skull fracture oOtorrhoea, rhinorrhoea oBulging of tympanic membrane oBattle’s sign oFacial paralysis oTinnitus , vertigo https://d3i71xaburhd42.cloudfront.net/4a8f1f120bcf71f394d23705e8a2e1b56dd0d8ad/5-Figure1-1.png ●Test to determine CSF leakage oCheck for presence of glucose ▪Dextrostrip/ Tes-Tape strip ▪If blood is present in the fluid ▪The test become unreliable; perform second method oHalo ring sign ▪Allow leaking fluid drip onto a white pad/towel ▪Observe the drainage ▪Within a few minutes the blood coalesces into center and a yellowish ring encircles the blood
Module 15: PNCM 1169- Medical Surgical Nursing II| 8 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.https://www.cmaj.ca/content/cmaj/185/5/416/F1.large.jpg https://static.cambridge.org/binary/version/id/urn:cambridge.org:id:binary:20190815062525287-0430:9781108647397:45028fig8_7.png?pub-status=live Brain Injury ●Concussion oA sudden transient mechanical head injury with disruption of neuronal activity and a change in the LOC oOccurs when the brain suddenly shifts inside the skull and knocks against the skulls bony surface oManifestations ▪Brief disruption of LOC ▪Concussions can last from a few moments, to an unconscious state for over 3 min ▪Amnesia regarding event ▪Headache ●Contusion oIt is the bruising of the brain tissue within a focal area oIt is usually associated with a closed head injury
Module 15: PNCM 1169- Medical Surgical Nursing II| 9 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.●Coup-Contrecoup oIn this type of injury contusion occur both at the site of direct impact of the brain on the skull (coup) and at the a secondary area of damage on the opposite side away from injury (contrecoup) leading to multiple contusion areas ●Diffuse Axonal Injury oInvolves widespread damage to axons in the cerebral hemispheres, corpus callosum, and brain stem. oCan be mild, moderate, or severe head trauma oResults in axonal swelling and disconnection oIn severe injury, the patient has no lucid intervals and experiences immediate coma, decorticate and decerebrate posturing, and global cerebral edema. oDiagnosis: Clinical signs, CT scan or MRI. oRecovery depends on the severity of the axonal injury Concussion is a result of violent jarring of the brain. The brain is suspended in fluid within the skull, so violent jarring of the head can cause violent movement of the brain within the skull (which the brain is not accustomed to) leading to a temporary disruption in function. In contusion on the other hand, there is bruising of the brain on the point of impact leading to some form of brain tissue damage.
Module 15: PNCM 1169- Medical Surgical Nursing II| 10 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.https://www.frontiersin.org/files/Articles/455362/frym-07-00093-HTML/image_m/figure-2.jpg ●Brain Lacerations oIt involve actual tearing of brain tissue and often occur in association with depressed, open fractures and penetrating injuries oIntracerebral hemorrhage is commonly observed ●Intracranial Hemorrhages https://www.thoughtco.com/thmb/oKb2u8R9ZiPpvqxC1TvrCfReTlw=/1500x1000/filters:no_upscale():max_bytes(150000):strip_icc()/meninges-56f99a4f5f9b5829866fe6a7.png
Module 15: PNCM 1169- Medical Surgical Nursing II| 11 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.https://www.clevelandclinic.org/healthinfo/ShowImage.ashx?PIC=4514&width=420 oEpidural Hemorrhage ▪A neurologic emergency ▪Most common type of intracranial hemorrhage ▪Results from bleeding between the dura and the inner surface of the skull ▪May be caused by blow to the temporal, parietal bone ▪Commonly bleeding by arterial in origin due to breakage to middle meningeal artery ▪May be venous from dural venous sinus ▪Clinical manifestation ●The patient is initially unconscious after the trauma ●The patient then awakens and has a lucid interval followed by a decrease in LOC ●Headache ●Nausea and vomiting ●On head CT the clot (hematoma) is bright, biconvex shaped clot and has a well-defined border that usually respects cranial suture lines ▪Management ●A rapid Open craniotomy for evacuation of the congealed clot and hemostasis is indicated for EDH ●Prevention of cerebral herniation can dramatically improve outcome
Module 15: PNCM 1169- Medical Surgical Nursing II| 12 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.oSubdural Hematoma ▪Occurs from bleeding between the dura mater and the arachnoid layer of the meninges ▪SDH usually results from venous bleeding, usually from tearing of a bridging vein running from the cerebral cortex to the dural sinuses. ▪Hematoma may be slower to develop ▪Types ●Acute subdural hemorrhage oIt develops 24-48 hrs after the severe head trauma oCommonly related to acceleration- deceleration injury oClinical manifestations as same as elevated ICP ▪The size of hematoma determines the patient clinical presentation ▪Decreasing LOC from drowsy and confused to unconsciousness ▪Headache ▪Ipsilateral pupil dilation ▪Motor signs ▪On head CT scan, the clot is bright or mixed-density, crescent-shaped (lunate), may have a less distinct border oManagement ▪Open craniotomy for evacuation of the clot and decompression is indicated for any acute SDH more than 1 cm in thickness, or smaller hematomas that are symptomatic ●Subacute Subdural Hematoma oUsually occurs within 2-14 days of the injury oThe alteration in mental status as hematoma develops oProgression depends on the size and location of hematoma ●Chronic Subdural Hematoma oIt develops over weeks or months after seemingly minor head injury oThe peak incidence of chronic SDH is in 50-60 Years of age oClinical manifestations is progressive alteration in LOC oSubarachnoid Hemorrhage ▪Bleeding occurs between the arachnoid and pia mater ▪Etiology ●Rupture of Berry aneurysm ●Trauma (fracture at the base of the skull leading to internal carotid aneurysm) ▪Clinical manifestations ●Explosive headache, “worst headache of my life”●Nausea and vomiting, decreased LOC or coma. ●Signs of meningeal irritation ●Increased attenuation is seen in the CSF Spaces over the cerebral hemisphere oIntracerebral Hemorrhage (ICH)
Module 15: PNCM 1169- Medical Surgical Nursing II| 13 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.▪Intra Axial hemorrhage is hemorrhage that occurs within the brain tissue itself ▪Two main types ●Intraparenchymal hemorrhage- ICH extending into brain parenchyma ●Intraventricular hemorrhage- ICH extending into ventricles; ▪Etiology ●Hypertensive vasculopathy (70-80%) ●Ruptured Aneurysm Trauma- 16% ▪Clinical manifestation ●Rapidly progressive severe headache, building over several minutes, often accompanied by focal neurological deficits ●Nausea and vomiting ●Decreased level of consciousness. ●S/S depend site of hemorrhage oBasal ganglia/internal capsule - hemiparesis,dysphasia oCerebellum - ataxia, vertigo oPons - cranial nerve deficits, coma oCerebral cortex - hemiparesis, hemisensory loss, hemianopsia, dysphasia oDiagnostic evaluation ▪Taking a history in head injury ●Mechanism of injury ●Loss of consciousness or amnesia ●Level of consciousness at scene and on transfer ●Evidence of seizures ●History of vomiting ●Pre-existing medical conditions ●Medications (especially anticoagulants) ●Illicit drugs and alcohol ▪Physical examination ●Glasgow Coma Score ●Pupil size and response ●Signs of skull fracture: oBilateral periorbital edema (raccoon eyes) oBattle’s sign (bruising over mastoid) oCerebrospinal fluid rhinorrhoea or otorrhoea oHemotympanum or bleeding from ear ●neurological examination: tone, power, sensation, reflexes ▪Computerised tomography ●CT scan is considered the best diagnostic test to evaluate for cranio-cerebral trauma because it allows rapid diagnosis and intervention in the setting
Module 15: PNCM 1169- Medical Surgical Nursing II| 14 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.https://bmjopen.bmj.com/content/bmjopen/6/12/e013742/F1.large.jpg oMRI scan to detect small lesions oCervical spine X-ray indicated to detect any cervical injury oTranscranial doppler allow the measurement of CBF oManagement ▪Severe head injury is best managed in a neurointensive care setting ▪The patient should be positioned with the head up 30 degree ▪It is important to ensure that the cervical immobilisation collar does not obstruct venous return from the head ▪Airway and ventilation ●Patient in traumatic coma is unable to protect their airway and is at risk for aspiration ●Maintain a normocapnia ▪Circulation and cerebral perfusion pressure ●Hypotension and hypoxia as a major cause of secondary brain injury. ●A systolic BP < 90 mmHg worse outcome in traumatic coma ●Cerebral perfusion pressure should be maintained at > 65 mmHg in severely head-injured patients. ▪Control of intracranial pressure ●Position head up 30º ●Avoid obstruction of venous drainage from head ●Sedation +/–muscle relaxant ●Normocapnia ●Diuretics: furosemide, mannitol ●Seizure control
Module 15: PNCM 1169- Medical Surgical Nursing II| 15 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.oNormothermia oBarbiturates ▪Medications ●Osmotic Diuretics oMannitol 25% o1.5-2 g/kg IV infused over 30-60 minutes ●Anticonvulsants: Phenytoin oMay inhibit spread of seizure activity in motor cortex oDosage: Loading dose of 10-15 mg/kg then maintenance of 100 mg IV/PO q6-8hr PRN ●Barbiturates: Pentobarbital oIt will reduce the brain metabolic rate and help reduce ICP. oDosage- 100 mg IV OR 150-200 mg IM ●Calcium channel blockers oTo prevent cerebral vasospasm after injury, maintain blood flow to the brain and so prevent further damage. ▪Surgical management ●No surgical intervention if collection <10ml ●Indication of surgical decompression oThe GCS score decreases by 2 or more points between the time of injury and hospital evaluation oThe patient presents with fixed and dilated pupils oThe intracranial pressure (ICP) exceeds 20 mm Hg
Module 15: PNCM 1169- Medical Surgical Nursing II| 16 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.https://neupsykey.com/wp-content/uploads/2016/06/B9781437702736000592_f059-003-9781437702736.jpg ●Types oBurr-hole- opening into cranium with a drill oCraniotomy- bone flap is temporarily removed from the skull to access the brain oCraniectomy –Incision into the cranium to cut away a bone flap oCranioplasty - surgical repair of a defect or deformity of a skull oNursing management ▪Nursing assessment: ●ABC ●GCS Score ●Neurologic examination ●Signs of elevated ICP ●Signs of CSF leakage ▪Nursing diagnosis
Module 15: PNCM 1169- Medical Surgical Nursing II| 17 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.●Ineffective tissue perfusion (cerebral) related to interruption of CBF associated with cerebral hemorrhage and edema ●Acute pain (headache) related to trauma and cerebral edema ●Hyperthermia related to increased metabolism, and loss of cerebral integrative function secondary to possible hypothalamus injury ●Impaired physical mobility related to decreased LOC and treatment –imposed bedrest ●Anxiety related to abrupt change in health status, hospital environment and uncertain future ●Risk for complication related cerebral edema and hemorrhage ▪Monitoring neurologic function ●LOC/ GCS ●Vital signs ●Motor function ▪Maintaining airway patency ●To prevent brain hypoxia ●Maintaining adequate oxygenation ●Position to facilitate drainage of secretions; HOB at 30 degrees to prevent increased ICP ●Adequate and effective suctioning as needed ●Aspiration precautions ●Monitor ABGs ●Monitor mechanical ventilation ●Assess and monitor for pulmonary complications ▪Monitor F&E balance ●Especially for diuretic therapy ▪Maintain adequate nutrition ●Administer parenteral nutrition as prescribed ●NGTs should not be inserted if with CSF rhinorrhea, OGT is inserted instead ▪Preventing injury ●Institute safety precautions ●Seizure precautions ●Minimize environmental stimulation to prevent agitation and irritability ●Always reorient client if possible ●Provide adequate lighting to prevent visual hallucinations ●Assist with physical mobility when able ▪Maintain normal body temperature ▪Maintain skin integrity ●Turning and repositioning to prevent skin breakdown and ulcer formation ●Frequent skin care ▪Improve cognitive functioning ●Assess presence and extent of impairment ●Refer to appropriate health care provider for collaborative management ▪Preventive Measures ●Health Promotion ●Prevent car and motorcycle accidents
Module 15: PNCM 1169- Medical Surgical Nursing II| 18 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.●To Wear safety helmets ▪Rehabilitation Ambulatory and Home Care ●Nutrition ●Bowel and bladder management ●Seizure disorders ●Family participation and education ▪Unconscious stages ●Stupor is a state of partial or near complete unconsciousness in which the patient is lethargic, immobile, and has a reduced response to stimuli. ●Coma is a state in which the patient is totally unconscious and cannot be aroused even with strong stimuli. ▪Persistent vegetative state ●Condition in which awake patients are unconscious and unaware of their surroundings and the cerebral cortex is not functioning. ●A vegetative state can result from diffuse injury to the cerebral hemispheres of the brain without damage to the lower brain and brainstem. ●The vegetative state is considered permanent if it persists for 12 months after TBI Spinal Cord Injury (SCI) ●Damage to the spinal cord that results in a loss of function such as mobility or feeling. ●Can cause temporary or permanent changes in SC function. Symptoms may include loss of muscle function, sensation, or autonomic function in the parts of the body served by the spinal cord below the level of the injury. ●Risk factors oHighest among persons age 16-30 (53.1%) oMales (81.2 %) ▪Sports-related injuries (89.8%) oBoth genders: auto accidents, falls and gunshots are the three leading causes of SCI. ●Etiology oRoad Traffic accidents. oBullet or stab wound oTraumatic injury oElectric shock oExtreme twisting of the middle of the body oLanding on the head during a sports injury oFall from a great height ●Clinical manifestations oDepend on the types of spinal cord injury oComplete Spinal Cord Injuries ▪May result in either paraplegia or paraparesis ▪Quadriplegia ●Spinal cord injury above the first thoracic vertebra, or within the cervical sections of C1-C8. ●Result is some degree of paralysis in all four limbs—the legs and arms.
Module 15: PNCM 1169- Medical Surgical Nursing II| 19 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.▪Paraplegia ●Spinal cord injuries below the first thoracic spinal levels (T1-L5). ●Paraplegics are able to fully use their arms and hands, but the degree to which their legs are disabled depends on the injury. ●Complete paraplegia oPermanent loss of motor and nerve function at T1 level or below ▪Results in loss of sensation and movement in the legs, bowel, bladder, and sexual region. https://www.u3anetcant.nz/stalbans/speakers/images/Spinal-Cord-Injury.jpg oIncomplete spinal cord injuries
Module 15: PNCM 1169- Medical Surgical Nursing II| 20 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.https://i.pinimg.com/originals/ef/ba/94/efba9458e12f253e5b9873ea653f1a57.png ▪Classified according to the area of spinal cord damage: central, lateral, anterior, or peripheral. ▪Central Cord Syndrome ●Cause: Injury or edema of the central cord, usually of the cervical area and cervical lesions ●Characteristics: oMotor deficits (in the upper extremities compared to the lower extremities oSensory loss varies but is more pronounced in the upper extremities oBowel/bladder dysfunction is variable, or function may be completely preserved.
Module 15: PNCM 1169- Medical Surgical Nursing II| 21 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.▪Anterior Cord Syndrome ●Cause: The syndrome may be caused by acute disk herniation or hyperflexion injuries associated with fracture-dislocation of vertebra. oIt also may occur as a result of injury to the anterior spinal artery, which supplies the anterior two thirds of the spinal cord. ●Characteristics: Loss of pain, temperature, and motor function is noted below the level of the lesion; light touch, position, and vibration sensation remain intact. ▪Posterior Cord Syndrome
Module 15: PNCM 1169- Medical Surgical Nursing II| 22 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.●Cause: an infarct in the posterior spinal artery and is caused by lesions on the posterior portion of the spinal cord ●Characteristics: loss of proprioceptive sensation, fine touch, pressure, and vibration below the lesion; deep tendon areflexia. ▪Brown- Sequard syndrome/ Lateral Cord Syndrome. ●Cause: The lesion is caused by a transverse hemisection of the cord (half of the cord is transected from north to south), usually as a result of a knife or missile injury, fracture dislocation of a unilateral articular process, or possibly an acute ruptured disk ●Characteristics: Ipsilateral paralysis or paresis is noted, together with ipsilateral loss of touch, pressure, and vibration and contralateral loss of pain and temperature. ▪Conus Medullaris syndrome ●Cause: blow to the back- such as Gunshot and spinal tumor.
Module 15: PNCM 1169- Medical Surgical Nursing II| 23 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.●Characteristics: oBowel and bladder dysfunction oFlaccid lower extremities oSexual dysfunction (saddle anesthesia) ▪Cauda Equina Syndrome/ Horse tail Syndrome. ●Cause: Injury or lesion at the lumbosacral nerve root below the conus medullaris. ●Causes loss of function of the lumbar plexus ●Characteristics: oAreflexia loss of reflexes (Lower Extremities). oLeg weakness oBladder/bowel dysfunction https://pbs.twimg.com/media/DrDzw6PW4AEKfxc.jpg https://image.slidesharecdn.com/28caudaconusbladder-161124063259/95/cauda-equina-vs-conus-medullaris-syndrome-18-638.jpg?cb=1480314626 oManifestations depending on level of injury
Module 15: PNCM 1169- Medical Surgical Nursing II| 24 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.▪Cervical (neck) injuries ●Breathing difficulties ●Loss of normal bowel and bladder control ●Numbness ●Sensory changes ●Spasticity (increased muscle tone) ▪Thoracic (chest level) injuries ●Loss of normal bowel and bladder control ●Numbness ●Sensory changes ●Spasticity (increased muscle tone) ●Weakness, paralysis ▪Lumbar sacral (lower back) injuries ●Loss of normal bowel and bladder control (you may have constipation, leakage, and bladder spasms) ●Numbness ●Pain ●Sensory changes ●Weakness and paralysis oOther manifestations ▪Spinal Shock ●Clinical syndrome characterized by a reversible loss of reflex, motor and sensory function below the level of a spinal cord injury (SCI). ●When lesion is T6 or higher: associated with loss of autonomic tone leading to hypotension, hypothermia and ileus. ●Manifestations oTransient increase in blood pressure due to the release of catecholamines oHypotension oFlaccid paralysis oUrinary retention, and fecal incontinence. oSymptoms may last a few hours to several days/week ●Management oCorrection of hypotension oFluid resuscitation oOxygen therapy oCorrection of bradycardia with atropine oIntake and output monitoring ▪Autonomic Dysreflexia ●Syndrome in which there is a sudden onset of excessively high blood pressure. ●It is more common in people with spinal cord injuries that involve the thoracic nerves of the spine or above (T6 or above). ●May lead to seizures, stroke, and even death when left untreated ●Causes/ triggers oBowel distention oBladder distention (most common)
Module 15: PNCM 1169- Medical Surgical Nursing II| 25 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.●Manifestations oA severe headache oProfuse diaphoresis above the level of injury oFlushing above the level of injury oPiloerection above the level of injury oDry and pale skin because of vasoconstriction below the level of injury oVisual disturbances oNasal stuffiness oAnxiety or feelings of doom oNausea and vomiting ●Management oClose monitoring of patient oCorrection of hypertension oBladder drainage o10 ml of 2% lidocaine administered intravesically 4-6 minutes prior to routine Foley catheter oBotox for chemodenervation of the bladder ▪Pain ▪Breathing difficulty ▪Sensitivity to stimuli ●Diagnostic evaluation oComplete blood count (e.g. Hb, RBC, WBC) oArterial blood gas level oX- rays oComputerized Tomography (CT) scans oMagnetic Resonance Imaging (MRI): oMyelography ●Management: oWhole blood oHydrocortisone oNorepinephrine action: adrenergic drug oEpinephrine action: α and β adrenergic drug oDopamine action: adrenergic, anti-shock drug oEmergency management ▪Initial treatment of patients with cord injury focuses on two aspects -preventing further damage and resuscitation. ▪Immobilization with a hard cervical collar (in case of cervical spine injuries) and care in transportation of patients is of paramount importance if the spine is unstable. ▪Resuscitation is aimed at airway maintenance, adequate oxygen saturation of peripheral blood, restoring blood pressure to acceptable limits, preventing bradycardia, done simultaneously to prevent any ischemic damage to the already compromised cord. ●Nursing management oNursing diagnosis ▪Impaired physical mobility related to loss of motor function ▪Fluid volume deficit related to decreased LOC
Module 15: PNCM 1169- Medical Surgical Nursing II| 26 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.▪Risk for injury related to loss of motor function. ▪Urinary retention related to level of injury ▪Risk for Impaired skin integrity related to trauma ▪Knowledge deficit regarding the treatment modalities and current situation. ▪Anxiety related to outcome of diseases as evidenced by poor concentration on work, isolation from others, rude behavior oNursing Goal ▪Resuscitation according to ATLS guidelines ▪Determination of neurological injury ▪Prevention of neurological deterioration ▪Ongoing assessment and treatment of associated injuries ▪Prevention of complications ▪Initiation of definitive management for vertebral column injury. oRespiratory management ▪Closely monitor the patient’s respiratory rate, depth, and pattern, staying alert for paradoxical breathing. ▪Maintain continuous pulse oximetry; when possible, use end-tidal capnography as part of routine monitoring. ▪Intubation. ●Patients with respiratory failure require mechanical ventilation. ●If your patient needs intubation, take care to maintain spinal alignment by using a cervical collar, manual inline traction oCardiovascular management ▪Patients with significant cervical and high thoracic injuries (T6 level and above) may develop ▪Neurogenic shock. ●Caused by loss of sympathetic tone, this distributive shock state results in vasodilation, profound bradycardia, and hypothermia. ▪Hypotension, temperature dysregulation, venous stasis, and autonomic dysregulation (AD) may occur. oGI management ▪Acute GI problems in SCI patients may include paralytic ileus with associated abdominal distention, gastric ulcers, and constipation. ▪Monitor the patient’s bowel sounds and abdominal distention at least every 4 hours. If indicated and ordered, insert a decompressive gastric tube to reduce aspiration risk and restore diaphragm position and lung size to normal. ▪To aid bowel regulation, the patient may need a bowel regimen of stool softeners and a high-fiber diet along with low-volume enemas, glycerin, or bisacodyl suppositories or digital rectal stimulation to cause reflexive evacuation after the morning meal. oGenitourinary management Many patients with injuries at the C3 vertebral level or higher are ventilator dependent. Those with an intact phrenic nerve may qualify for diaphragmatic pacer implantation, which may allow weaning from mechanical ventilation.
Module 15: PNCM 1169- Medical Surgical Nursing II| 27 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.▪A patient in neurogenic shock experiences abrupt loss of voluntary muscle control and reflexes, resulting in acute urinary retention. ▪An indwelling urinary catheter must be placed to decompress the bladder and allow close urinary output monitoring. ▪SCI can cause neurogenic or aneurogenic bladder. ▪In neurogenic bladder, reflex-initiated voiding may occur when the patient has a full bladder. ▪In aneurogenic bladder, such voiding doesn’t occur, potentially causing overflow urine leakage. ▪Planned intermittent catheterization can reduce incontinence. Long term bladder management varies with the patient’s bladder type, needs, and lifestyle.oMusculoskeletal management ▪Patients with SCIs typically experience muscle spasticity as spinal shock recedes and reflexes return. ▪Non-pharmacologic strategies to manage spasticity include ●Range-of motion exercises ●Positioning techniques ●Weight-bearing exercises ●Electrical stimulation, and orthoses or splinting to prevent loss of muscle length and contractures. ▪Pharmacologic therapy may include baclofen, benzodiazepines, alpha2-adrenergic agonists, and regional botulism toxin or phenol injection. oDermatologic management ▪Prevention and early detection are the cornerstones of pressure ulcer management. ▪An established skin risk assessment tool, such as the Braden scale. ▪Turning the patient every 2 hours or more (depending on risk assessment findings) ▪Avoiding positioning the patient on bony prominences, such as the trochanters, sacrum, and heels ▪Minimizing moisture ▪Frequently inspecting the skin under braces and splints ▪Establishing a pressure-release regimen (manual or automated) for wheelchair sitting
Module 15: PNCM 1169- Medical Surgical Nursing II| 28 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.https://o.quizlet.com/Amx.4a9cFmsxqskaJbs1Xw.png oRehabilitation ▪Cognitive Rehabilitation Therapy ▪Speech Therapy ▪Mental Rehabilitation ▪Physical Exercise ▪Occupational Therapy oPossible complications ▪Blood pressure changes - can be extreme (autonomic hyperreflexia) ▪Chronic kidney disease ▪Complications of immobility: Deep vein thrombosis; Pulmonary infections; Skin breakdown ▪Contractures ▪Increased risk of urinary tract infections ▪Loss of bladder control ▪Loss of bowel control ▪Loss of sensation ▪Loss of sexual functioning (male impotence) ▪Muscle spasticity ▪Paralysis of breathing muscles ▪Paralysis (paraplegia, quadriplegia) ▪Pressure sores III.EVALUATION
Module 15: PNCM 1169- Medical Surgical Nursing II| 29 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.●For online learners: Multiple choice type questions will be given. To be uploaded in LMS. ●For correspondence learner: Case analysis IV.APPLICATION Finals: Nursing Care Plan●This will be group activity that will be accomplished throughout the duration of the final term. The class will be divided into groups with at most 5 members. Each group will be assigned a disease process that they will study wherein each member of the group should prepare what is asked for for the week. Outputs will be compiled and submitted at the end of the term. ●All outputs must be evidence-based and supported by credible research or scholarly articles. ●The following will be submitted per week: oWeek 15- Actual Nursing Diagnosis in the community setting Rubrics CATEGORY 5 = exemplary 4 = accomplished 3 = developing 2 = beginning Assessment Includes all pertinent data related to nursing diagnosis and does not include data that is not related to nursing diagnosis. Labs are noted with appropriate rationales. Subjective and objective data support nursing diagnosis Includes all pertinent data related to nursing diagnosis, but also includes data not related to nursing diagnosis. Labs present with inappropriate rationale. Subjective and objective data support nursing diagnosis with inconsistencies Does not include all pertinent data related to nursing diagnosis. May also include data that does not relate to nursing diagnosis. Missing important labs with rationales. Subjective and objective data do not support nursing diagnosis Assessment portion is incomplete. Does not include lab results and pertinent subjective and objective data Case analysisJoel sustained a traumatic brain injury following a road traffic accident on his motorcycle. His motorcycle was hit side on by a car, which propelled James off the vehicle and into oncoming traffic. His helmet was broken during the impact. Paramedics assessed GCS 6 at the scene and required intubation prior to transfer to the emergency room. What important assessment findings must be checked on Joel upon admission to the emergency department? Which of the following findings would indicate the need for emergency surgery? How will you prepare the patient and his family for the prognosis and condition of the patient?
Module 15: PNCM 1169- Medical Surgical Nursing II| 30 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.Diagnosis Diagnosis is appropriate for patient and ordinal level, and diagnosis is NANDA approved. Diagnosis also includes all parts and information is listed in the correct part of diagnosis. Includes 5 diagnosis and selects one "priority" and "actual” diagnosisDiagnosis is appropriate for patient and ordinal level, and diagnosis is NANDA approved, but does not include all parts or information listed in the wrong part of diagnosis. Only list 2-4 appropriate diagnosis and select one priority “actual” diagnosis Diagnosis is not appropriate for patient and ordinal level (first diagnosis, second diagnosis, etc). May also not be NANDA and may not include all parts. Only list 1-2 appropriate diagnosis and does not select a priority “actual” diagnosisDiagnosis portion is incomplete Planning and Evaluation Goal statement is patient or family oriented, and contains two measurable criteria and a target date or time. Goal statement is patient or family oriented, and contains at least one measurable criteria or a target date/time. Goal statement is not patient or family oriented and does not have measurable criteria for a target date or time. Goals and outcomes are incomplete and do not address the diagnosis. Implementation Interventions portion contains adequate number of interventions to help patient/family meet goal, and interventions are specific in action and frequency, labeled with independent, dependent or collaborative and are listed with referenced rationales. Interventions portion contains adequate number of interventions to help patient/family meet goal, but interventions may not be specific, labeled or listed with rationales. Interventions portion does not include an adequate number of interventions to help patients/family meet goals. Interventions may also not be specific, labeled or listed with rationales The Intervention portion is incomplete. Interventions included are inappropriate and do not contribute to the attainment of client goals. Originality Plagiarism scan score is not more than 5% Plagiarism scan score is not more than 10% Plagiarism scan score is not more than 15% Plagiarism scan score is not more than 20%
Module 15: PNCM 1169- Medical Surgical Nursing II| 31 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.References Printed ReferencesBooks1.Gilbert, Julia, and Elisabeth Coyne, eds. Acute care nursing. Cambridge University Press, 2018. 2.Gulanick, M., & Myers, J. L. (2017). Nursing care plans: Diagnoses, interventions, and outcomes. Elsevier Health Sciences. 3.Urden, L. D., Stacy, K. M., & Lough, M. E. (2016). Priorities in Critical Care Nursing. Elsevier Health Sciences. 4.Hinkle, J. L., & Cheever, K. H. (2018). Brunner and Suddarth’s textbook of medical-surgical nursing. Wolters kluwer india Pvt Ltd. 5.Molina, P. E. (2018). Endocrine physiology 5thEd. New York, NY, USA: Lange Medical Books/McGraw-Hill. 6.Pedrotti, F. L., Pedrotti, L. M., & Pedrotti, L. S. (2017). Introduction to optics. Cambridge University Press. Electronic Resources1.Chang, E. (2017). Living with Chronic Illness and Disability-EBook: Principles for Nursing Practice. Elsevier Health Sciences. 2.Chaudhury, A., Duvoor, C., Reddy Dendi, V. S., Kraleti, S., Chada, A., Ravilla, R., ... & Mirza, W. (2017). Clinical review of antidiabetic drugs: implications for type 2 diabetes mellitus management. Frontiers in endocrinology, 8, 6. 3.DeWit, S. C., Stromberg, H., & Dallred, C. (2016). Medical-surgical nursing: concepts & practice. Elsevier Health Sciences. 4.Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-Surgical Nursing-E-Book: Assessment and Management of Clinical Problems, Single Volume. Elsevier Health Sciences. 5.McKee, K., Glass, S., Adams, C., Stephen, C. D., King, F., Parlman, K., ... & Kontos, N. (2018). The inpatient assessment and management of motor functional neurological disorders: an interdisciplinary perspective. Psychosomatics, 59(4), 358-368. 6.Naidoo, J., & Wills, J. (2016). Foundations for Health Promotion-E-Book. Elsevier Health Sciences. 7.Newman, C. B., Blaha, M. J., Boord, J. B., Cariou, B., Chait, A., Fein, H. G., ... & Tannock, L. R. (2020). Lipid management in patients with endocrine disorders: an endocrine society clinical practice guideline. The Journal of Clinical Endocrinology & Metabolism, 105(12), 3613-3682. 8.Priyadi, A., Muhtadi, A., Suwantika, A. A., & Sumiwi, S. A. (2019). An economic evaluation of diabetes mellitus management in South East Asia. Journal of Advanced Pharmacy Education & Research| Apr-Jun, 9(2), 53-74. 9.Urden, L. D., Stacy, K. M., & Lough, M. E. (2019). Priorities in Critical Care Nursing-E-Book. Elsevier Health Sciences.
Module 15: PNCM 1169- Medical Surgical Nursing II| 32 Academic Intellectual Property Rights: Materials posted over NEO-LMS are the properties of USL and the Facilitators. Students are not allowed to share it to any third-party individuals not part of the class without any permission from the owners.10.Yaccob, A., & Mari, A. (2019). Practical clinical approach to the evaluation of hepatobiliary disorders in inflammatory bowel disease. Frontline gastroenterology, 10(3), 309-315 Congratulations for conquering this module Med-Surg Nurses. See you in the next module where we will continue to talk about disorders of the neurologic function.