Learning Objectives
By the end of this section, you will be able to:
- Discuss the pathophysiology, risk factors, and clinical manifestations for traumatic brain injuries and spinal cord injuries
- Describe the diagnostics and laboratory values in traumatic brain injuries and spinal cord injuries
- Describe the medical therapies that apply to the care of traumatic brain injuries and spinal cord injuries
- Apply nursing concepts and plan associated nursing care for the patient with traumatic brain injuries and spinal cord injuries
- Evaluate the efficacy of nursing care for the patient with traumatic brain injuries and spinal cord injuries
Traumatic brain and spinal cord injuries occur when the brain and/or spinal cord are damaged by trauma. Such trauma may include a forceful blow to the head and/or body that happens when an individual falls, or trauma may result when an object slams into the head and/or body. Although some patients may be able to recover from brain or spinal cord injuries, in some cases, these injuries cause permanent disability and even death.
Traumatic Brain Injury
Damage that results when the brain experiences a sudden assault from an external source is called traumatic brain injury (TBI). The external source can be a variety of things, including a powerful blow to the head from falling, as well as something like a bullet that shatters the skull and pierces the brain. Incidents that may lead to traumatic brain injuries include automobile accidents, blunt force trauma, and being struck by a flying object.
Pathophysiology
TBI may cause temporary or long-term problems, depending on the nature and severity of the injury. TBIs may be penetrating, which occurs when the skull is pieced by a sharp object that enters brain tissue. Other TBIs are nonpenetrating, which occurs when the assault is strong enough to move the brain around inside the skull, but the skull is not broken.
The problems caused by TBIs may include cognitive difficulties, such as the inability to think, communication issues, and/or struggling to move body parts. A primary injury occurs immediately, whereas a secondary injury occurs gradually in response to reactive processes in the brain that are caused by the trauma. Secondary injuries may take days, or even weeks, to appear.
Link to Learning
Read this article for more information about TBI from Mayfield Brain & Spine.
Clinical Manifestations
TBIs have symptoms in three areas: physical, cognitive and behavioral, and perception and sensation. Physical symptoms may include headaches, double or blurred vision, seizures, convulsions, tremors, nausea and vomiting, slurred speech and/or difficulty swallowing, muscle weakness, paralysis, balance and coordination issues, drainage in the ears or nose, and bowel and/or bladder control issues. Cognitive and behavioral symptoms may include lack of consciousness, coma, disorientation and confusion, concentration issues, loss of memory, difficulty thinking, short attention span, mood changes, irritability, frustration, loss of inhibitions, and sleep disorders. Perception and sensation symptoms may include ringing in the ears, sensitivity to sound and/or light, vertigo and dizziness, fatigue and lack of energy, anxiety, depression, foul tastes in the mouth, and decreased understanding of time and/or space. Typically, symptoms, such as headache and confusion, tend to occur immediately following a TBI, whereas symptoms that involve moods and emotions may take longer to develop.
Assessment and Diagnostics
To assess and diagnose a TBI, patients should undergo a physical examination that gathers information about the type of injury the patient has, including whether the injury is penetrating or nonpenetrating. The examination should also review the patient’s symptoms, which may include physical, cognitive and behavioral, and/or perception and sensation symptoms. If a TBI diagnosis cannot be confirmed through a physical examination, patients should undergo MRIs, CTs, and/or other neuropsychological tests.
Diagnostics and Laboratory Values
To confirm a TBI diagnosis, patients may need to be tested. Options for testing include MRIs, CTs, and neuropsychological tests. The Glasgow Coma Scale (GCS) can be used to assess the patient’s consciousness level. MRIs and CTs will show evidence of injury, such as skull fractures and swelling, bruising, and/or bleeding on the brain. Neuropsychological tests will reveal problems the patient may be having with concentration, memory, problem-solving, and other cognitive skills. As noted previously, a GCS score lower than eight indicates problems with a patient’s consciousness level. The highest possible score on the GCS is 15. Patients with higher scores have less severe injuries.
Nursing Care of the Patient with Traumatic Brain Injury
Nursing care for a patient with TBI should focus on helping the patient recover if possible. If the patient has permanent health issues as a result of the injury, nursing care should focus on helping the patient adjust and learn to manage the new health issues, which may include problems such as nerve damage and seizures. Patients may also experience issues such as memory loss, a decline in cognitive thinking abilities, double vision, and headaches. If needed, the patient and their family should be provided with mental health support.
Recognizing Cues and Analyzing Cues
The cues of TBI will be found in the patient’s physical examination and test results. The findings should reveal whether the patient has TBI, and if so, the nature and severity of the injury.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
TBI treatment should be prioritized based on the severity of the symptoms. The nursing interventions appropriate for patients with TBI may include those in Table 17.23.
| Nursing Care | Rationale |
|---|---|
| Complete focused neurological assessments. | The patient’s pain levels, cognitive abilities, and other symptoms may indicate TBI. |
| Monitor vital signs. | Changes in the patient’s vital signs such as heart rate and blood pressure may indicate health issues. Patient may also show signs of infection. |
| Provide care before and after surgery. | Some patients with TBI may need surgery. Nurses should help patients prepare for surgery and provide care after surgery, such as dressing patients’ wound(s), maintaining oxygenation, positioning the patient, monitoring ICP, and assessing with GCS. |
| Administer medications. | Patients may need medication to help with pain relief. Other medications that can help limit additional damage to the brain following an injury include antiseizure and coma-inducing drugs. Some patients may need diuretics to help with fluid retention. |
| Help prevent seizures and provide seizure care. | In some patients, traumatic brain injuries can cause seizures. Nurses should take actions to help prevent seizures, such as low lighting, and provide care to help patients during a seizure, such as safe bedding and pillows. |
| Coordinate with therapists. | As they recover, some patients need therapy to regain skills and overcome problems incurred by traumatic brain injury. This may include speech, physical, and/or occupational therapists. |
Evaluation of Nursing Care for the Patient with Traumatic Brain Injury
The desired outcome for patients with TBI is recovery from the injury and relief of their symptoms. If their symptoms cannot be relieved, the desired outcome is to help them control and manage their symptoms, overcoming any losses in skills and functioning.
Medical Therapies and Related Care
The medical therapies used to help patients with TBI may include surgery, medications, and therapy. Depending on the severity of their injury and symptoms, some patients may need rehabilitation and long-term care to recover.
Spinal Cord Injuries
A spinal cord injury is damage to any area of the spinal cord, including the nerves and nerve fibers that transmit signals from the brain. Spinal cord injuries may involve the spinal cord and/or the bones and tissues that surround the spinal cord. As with TBIs, spinal cord injuries can be caused by various events, including automobile accidents, falls, sports injuries, and violence. Infections that cause abscesses on the spinal cord can also result in spinal cord injuries.
Pathophysiology
Like TBIs, spinal cord injuries may cause temporary or permanent damage to the body. Depending on the nature of a spinal cord injury, the patient may experience issues with strength, movement, feeling, and functioning in areas of the body below the injured area.
Spinal cord injuries fall into two categories—incomplete and complete. With incomplete injuries, the spinal cord retains some capability to communicate with the brain, enabling patients to maintain some functioning, muscle control, and feeling below the injured area. In complete injuries, patients lose all nerve communication below the injured area, leading to a total loss of functioning, muscle control, and feeling below the injured area.
Spinal cord injuries may also lead to paralysis. A form of paralysis from a spinal cord injury known as paraplegia affects some or all of the truck, pelvic organs, and legs. But with paraplegia, patients can still move their arms. A form of paralysis from a spinal cord injury that is known as tetraplegia, or quadriplegia, affects patients’ arms and hands, as well as their trunk, pelvic organs, and legs.
Clinical Manifestations
Typically, the symptoms of a spinal cord injury include the inability to move, pain and/or stinging sensations, muscle weakness, numbness and tingling, balance and coordination difficulties, spasms and/or exaggerated reflexes, loss of bladder and/or bowel control, decreased or lost sensations, and sexual dysfunction. Some patients also experience difficulty breathing.
Assessment and Diagnostics
To assess and diagnose a spinal cord injury, patients should undergo a physical examination that gathers information about the incident that led to the injury and the symptoms the patient is experiencing. This includes impairments, such as the patient’s range of motion, muscle weakness, and level of sensations. This also includes the patient’s sensory functions as determined by pinpricks and touching. Patients may also need tests such as x-rays, MRIs, and CTs to reveal fractures and other damage to the spine.
Nursing Care of the Patient with Spinal Cord Injury
As with patients who have TBIs, nursing care for the patient with a spinal cord injury should focus on helping the patient recover if possible. If the patient has permanent health issues as a result of the injury, nursing care should focus on helping the patient adjust and learn to manage the new health issues. If needed, the patient and their family should be provided with mental health support.
Recognizing Cues and Analyzing Cues
The cues of a spinal cord injury will be found in the patient’s physical examination and test results. In addition to the patient’s symptoms, such as pain and inability to move, the findings may include results such as bone fractures and swelling that reveal whether the patient has a spinal cord injury, and if so, the nature and severity of the injury.
Prioritizing Hypotheses, Generating Solutions, and Taking Action
Spinal cord injuries should be prioritized based on the severity of the symptoms. The nursing interventions appropriate for patients may include those in Table 17.24.
| Nursing Care | Rationale |
|---|---|
| Complete focused neurological assessments. | The patient’s pain levels and other symptoms, such as ability to move, indicate if a spinal cord injury is present and its severity. |
| Monitor vital signs. | Changes in the patient’s vital signs such as heart rate and blood pressure may indicate health issues. In particular, patients may exhibit signs of shock. |
| Provide care before and after surgery. | Some patients with spinal cord injury may need surgery. Nurses should help patients prepare for surgery and provide care after surgery, such as dressing patients’ wound(s). |
| Administer medications. | Patients may need medication to help with pain relief. |
| Assist with traction. | Some patients may need to be placed in traction to keep them immobile and help realign their spine. |
| Coordinate with therapists. | As they recover, some patients need therapy to regain skills and overcome problems incurred by spinal cord injury. This may include physical and/or occupational therapists. |
Evaluation of Nursing Care for the Patient with Spinal Cord Injuries
The desired outcome for patients with spinal cord injuries is relief of their symptoms. If their symptoms cannot be relieved, the desired outcome is to help them control and manage their symptoms.
Medical Therapies and Related Care
The medical therapies used to help patients with spinal cord injuries may include surgery, medications, and therapy. The medications that may be useful include steroid injections to reduce swelling, as well as nonsteroidal anti-inflammatory drugs, which can also relieve pain and swelling. Some patients may benefit by taking corticosteroids for swelling, and for short-term pain relief, opioids may benefit some patients. For muscle pains and spasms, patients may benefit from drugs such as tizanidine and diazepam. To deal with pain, as well as depression, some patients may find serotonin-norepinephrine reuptake inhibitors helpful. Depending on the severity of their injury and symptoms, some patients may need rehabilitation and long-term care to recover.