`NEURO
cause fatal haemorrhage.
7 Common TBI’s
1. Concussion
- A mild non-penetrating head injury
without any gross structural
damage to the brain. It usually
results from
acceleration/deceleration forces
occurring secondary to a direct
blow to the head.
2. Contusion
- A blow that causes a bruise of the
brain. Contusion can be a coup or
contrecoup type. Coup contusions
occur at the site of impact,
whereas contrecoup injuries
typically take place on the
contralateral side of impact, usually
the basi-frontal lobe & anterior
temporal lobe.
3. Epidural Hematoma
- An extra-axial collection of blood
within the potential space between
the outer layer of the dura mater &
the inner table of the skull. Majority
of cases result from MVA, physical
assaults, or accidental falls.
4. Subdural Hematoma
- An abnormal collection of blood
from ruptured or torn vein between
the arachnoid & dura mater.
5. Subarachnoid Hge (SAH)
- SAH is most caused by trauma &
result from the tearing of small
capillaries with blood subsequently
entering into the subarachnoid
space (SAS). It commonly occurs
over the convexity, whereas SAH
secondary to aneurysmal rupture
occurs in the basal cisterns.
6. Arteriovenous Malformation (AVM)
- AVM’s are abnormal fistulas
between arteries & veins without
an intervening capillary bed. High
arterial flow directly into venous
structures can lead to disruption of
the venous walls & ultimately
The most frequent presentation of brain
AVMs is a haemorrhage in the SAS.
7. Intracerebral Hge (ICH)
- ICH, a subtype of stroke, is a
devastating condition whereby a
hematoma is formed within the
brain parenchyma with or without
blood extension into the ventricles.
Non-traumatic ICH comprises 10-15% of
all strokes & is associated with high
morbidity and mortality.
Risk factors of ICH
● Chronic hypertension
● Amyloid angiopathy
● Anticoagulants
● Vascular malformations
Diagnostic evaluation to detect TBIs
Non-contrast CT head remains the
gold-standard imaging modality in the
initial diagnosis of ICH.
Surgical Management of TBIs
A craniotomy is a surgical procedure in
which a part of the skull is temporarily
removed to expose the brain & perform an
intracranial procedure.
Indications for craniotomy:
● Brain tumors
● Aneurysm
● AVM
● Subdural empyemas
● Subdural hematomas
● Intracerebral hematomas
Nursing Management for Post
Craniotomy
1. Position head and body of client
appropriately based on the craniotomy
approach
2. Keep the incision clean
3. Watch for signs of infection or
complications
4. Control pain
Medical Management of TBIs
1. ABC’s (manage like a stroke patient)
2. Minimize the risk of rebleeding &
hematoma expansion within the first 24-72
hours
3. Patients taking Vit K antagonist are
managed by using fresh frozen plasma,
Vit K, prothrombin complex concentrates
& recombinant activated factor VIIa
Nursing Diagnosis of TBIs
● Risk for injury related to
complications of head injury
● Acute pain related to altered brain
or skull tissue
● Risk for seizures
● Decreased Intracranial Adaptive
Capacity related to increased ICP
Nursing Interventions for TBIs
1. Monitor the patient’s neurological
status including LOC
2. Monitor ICP
3. Maintain patent airway; assist with
intubation & ventilation
4. Assess for fluid leakage from the
ears and nose (rhinorrhea &
otorrhea might be CSF after head
trauma caused by fractures)
5. DBCT
6. Suction PRN
7. Institute measures to prevent
increased ICP
8. Administer histamine-2 blockers
9. If the patient is unable to swallow,
provide enteral feedings after
bowel sound has returned.
10. Elevate HOB even during feedings
11. Monitor V/S qH especially RR &
depth
Cerebral Aneurysm
There are outpouching of artery dilations
that occur at weak points along the arterial
circulation within the brain
Risk Factors:
● Age
● Uncontrolled hypertension
● Smoking
● Alcohol abuse
● Atherosclerosis
● Congenital defect of the vessel
wall
● Family history of aneurysm
Classifications of Cerebral Aneurysm:
1. Saccular (Berry)
2. Fusiform
3. Giant
4. Dissecting
Clinical Manifestations:
Unruptured cerebral aneurysm are
asymptomatic.
When ruptured, the following may be
observed:
1. Sudden onset, severe headache.
This is classically described as a
“thunderclap headache” or “worst
headache of my life”
2. Loss of consciousness
3. Nausea and vomiting
4. Hypertension
5. Mydriasis
6. Visual field &/ Cranial nerve
deficits
7. Mental status changes such as
drowsiness, photophobia
8. Motor or sensory deficits, neck
stiffness, & lower back pain with
neck flexion
Surgical Management of Cerebral
Aneurysm
Aneurysm clipping and Coil Embolization
(or Endovascular Coiling) can be used to
seal off an unruptured brain aneurysm &
help prevent a future rupture.
Nursing Diagnosis for Cerebral
Aneurysm
1. Ineffective tissue perfusion related
to bleeding or vasospasm
2. Disturbed sensory perception
related to medically imposed
restrictions
Nursing Management for Cerebral
Aneurysm
1. Monitor closely for neurologic
deterioration & maintain a
neurologic flow record
2. Monitor LOC, VS especially BP &
PR, pupillary response, respiratory
rate & depth
3. CBR in a non-stressful
environment
4. Elevate HOB 30 degrees to 45
5. AVOID: heavy lifting, valsalva
maneuver, caffeine, alcohol &
other stimulants
6. Apply sequential compression
devices
7. Place on seizure precaution
SPINAL CORD INJURY
Types:
1. Incomplete (partial damage)
example: whiplash
2. Complete injury (total & permanent
damage)
example: total cord transection
(paraplegia or tetraplegia are
results of complete SCI)
Etiology:
1. MVA (30%)
2. Falls (30%)
3. Acts of Violence (13%)
4. Sports-related (9%)
5. Medical and Surgical Etiologies
(5%)
Risk Factors:
1. Being a make
2. Age between 16 and 30 y/o
3. Older than 65 y/o
4. Engaging in risky behavior
5. Having a bone or joint disorder
Clinical Manifestation
Cervical SCI:
● Above c4 = fatal
● Quadriplegia
● Respiratory muscle paralysis
● Bowel & bladder retention
Thoracic SCI:
● Paraplegia
● Poor control of upper trunk
● Bowel & bladder retention
Lumbal SCI:
● Flaccid paraplegia
● Bowel & bladder retention
Sacral SCI:
● Above S2: with erection but no
ejaculation
● Between S2-S4: no erection & no
ejaculation; paraplegia; and bowel
& bladder incontinence
Summary of Physical Findings
● C-1 to C-3: Tetraplegia with total
loss of muscular/respiratory
function
● C-4 to C-5: Tetraplegia with
impairment, reduced pulmonary
capacity complete dependency for
ADL’s
● C-6 to C-7: Tetraplegia with some
arm/hand movement allowing
some independence of ADL’s
● C-7 to T-1: Tetraplegia with limited
use of thumb/fingers, increasing
independence
● T-2 to L-1: Paraplegia with intact
arm function and varying function
of intercostal & abdominal muscles
● L-1 to L-2 or below: Mixed
motor-sensory loss; bowel and
bladder dysfunction
Surgical Management
1. Spinal decompression surgery
2. ORIF
Medical Management
1. High dose methylprednisolone
therapy
2. Maintain hemodynamic stability &
BP (hypotension and shock will
worsen the impact of any existing
SCI and worsen the likelihood of
neurologic recovery)
3. Rehabilitation
Nursing Management in Acute Phase
1. Immobilization of entire spine (to
prevent further trauma)
Immobilization of neck with cervical
collar (maintain neutral position)
2. Log roll the patient with adequate
personnel in turning the patient
while maintaining spine alignment.
For children <8 years old, use an
airway pad to promote neutral
cervical spine position
3. Maintain patent airway & breathing
4. Administration of high-dose
corticosteroids
(methylprednisolone)
5. O2 therapy
Complications of Spinal Cord Injury
1. Neurogenic shock
2. Spinal shock
3. Autonomic dysreflexia
American Spinal Injury Association (ASIA)
and International Spinal Cord Society
(ISCoS)
● Defines Neurogenic Shock as a
general autonomic nervous system
dysfunction that include symptoms
such as:
- Orthostatic hypotension
- Autonomic dysreflexia
- Temperature dysregulation
Seen with SCIs above the level of T6
Emergency response for patients with
Spinal Cord Injury
Initial assessment = A, B, C
Initial intervention = minimize movement
of spine
> A rigid cervical collar & supportive
blocks on a backboard with straps are
recommended
Succeeding interventions:
1. Use log-roll technique to move the
patient
2. If mechanical ventilation is
required, rapid-sequence
intubation with in-line spinal
immobilization. However,
intubation over a flexible fiberoptic
laryngoscope is the preferred
method if the clinical situations
allows.
3. Profound hypotension is treated
immediately with a crystalloid fluid
bolus. If hypotension is due to
spinal shock (as opposed to
volume depletion from hemorrhage
due to other injuries), repittitive
fluid boluses are not recommended
and the patient should be started
on inotropes to maintain arterial
blood pressure.
4. Urinary retention should be
assessed & a urinary catheter
should be placed immediately.
Medical Management of Neurogenic
Shock
Initial management = hemodynamic
stabilization
Hypotension should be treated first to
prevent secondary injury.
Step 1: IV infusion/ resuscitation
Step 2: vasopressor and inotropes. (No
single agent is recommended).
● 1st line - phenylephrine; WOF
bradycardia
● 2nd line - noreponephrine;
epinephrine
Step 3: Treatment for bradycardia:
● 1st line: Atropine & glycopyrrolate
to oppose vagal tone
● 2nd line: isoproterenol,
theophylline and aminophylline
Step 4: Initial c-spine immobilization using
Miami J or Philadelphia collar (to prevent
further damage)
Surgical Management of Neurogenic
Shock
Decompression Surgery
- Example: laminectomy with spinal
fusion (creates space by removing
the lamina - the back part of a
vertebra that covers your spinal
canal
Spinal Shock
● Also known are “neural shock or
areflexia”
● A short term temporary physiologic
disorganization of SC fxn that can
start 30-60 mins after a SCI
resulting in a transient increase in
BP due to the release of
catecholamines. This is
immediately followed by
hypotension, flaccid paralysis, &
urinary retenrion
● Deficits after a spinal shock are still
permanent: loss of neurological
activity including loss of motor,
sensory, reflex & autonomic fxn
below the level of the SCI or lesion
Clinical Manifestations
1. Absence of sweating above the
level of the injury
2. Bladder retention
3. Hypotension
4. Areflexia below the level of the
injury
Note: If the lumbo-sacral segment are
undamaged, S/Sx wears off in 2-3 weeks
The 1st sign of resolution is: contraction of
the quadriceps (hamstring) muscles &
flexion or extension of toes on plantar
stimulation
Medical Management of Spinal Shock
1. Inotropes & chronotropes:
dopamine or phenylephrine &
norepinephrine
2. For bradycardia, atropine is
indicated
3. Patients with spinal shock will
usually develop paralytic ileus and
require decompression
4. Thermoregulation is also altered
5. Venous thromboembolism (VTE)
prophylaxis as untreated SCI
patients can develop
thromboembolism within 72 H of
admission
6. Prevention of pressure ulcers
(regular turning using log-roll)
7. Urinary retention is managed by
intermittent catheterization.
Indwelling cath is less preferred
because of UTI
8. Gastric ulcer prophylaxis using
proton-pump inhibitors for 4weeks
Nursing Diagnosis
● Impaired breathing pattern r/t
impairment of innervation of
diaphragm (lesions at or above
C-5)
● Impaired physical mobility r/t
neuromuscular impairment
● Disturbed sensory perception r/t
destruction of sensory tracts with
altered sensory reception,
transmission & integration
Nursing Management
1. Maintain patent airway. Monitor RR
& depth
Provide O2, using face mask or
nasal cannula
2. Keep patient’s head head in
neutral position
 3. Elevate HOB
4. Maintain alignment of vertebra
(immobilization & traction)
5. Avoid urinary & fecal retention
6. Applying anti-embolism stockings
& elevating the foot of the bed may
help minimize pooling of the blood
in the legs & prevent thrombus
formation
7. Administer methylprednisolone as
prescribed
Autonomic Dysreflecia
- A condition that emerges after a
SCI, usually when the injury has
occurred above the T6 level.
- Dysregulation of the ANS leads to
an uncoordinated autonomic
response that may result in a
potentially life-threatening
hypertensive episode when there
is a noxious stimulus below the
level of the spinal cord injury.
6. Dry &/ pale skin (because of
vasoconstriction below the level of
injury)
Nursing Diagnosis
● Ineffective breathing pattern r/t
neuromuscular impairment
● Risk for Autonomic dysreflexia r/t
bladder or bowel distention
Nursing Management
1. Elevate HOB
2. Maintain a patent airway (ABCs),
Administer oxygen
3. Maintain patency of catheter
4. Maintain elimination
5. Suction secretions PRN
6. Prevent decubitus ulcer (avoid and
limit prone position when indicated)

Etiology
1. Distended bladder, clogged FBC,
UTI
2. Impacted rectum

Epidemiology
- Develops in 20% to 70% of
patients with SCI above the T6
level & unlikely to develop if the
injury is below T10

Clinical Manifestation
1. Extreme hpn (as high as
300mmHg) & exaggerated
autonomic response to stimuli
2. Severe, pounding headache
3. Flushing & diaphoresis above the
level of injury
4. Blurred vision
5. Piloerection above the level of
injury