RESPONSES TO ALTERED PERCEPTION

(Neurologic Alterations) As much as possible, document the patient’s chief

complaint in the patient’s own words. Patients with
neurologic disorders may present common complaints such
Patients with altered neurologic function are
as headache (or pain), motor disturbances (including
frequently encountered by nurses in critical care areas. weakness, paresis, and paralysis) or seizures, sensory
Neurologic alterations are generally defined by problems alterations/deviations (including dizziness, vertigo, and
that derive from the acute aspects of diseases such as visual defects).
traumatic head injury, stroke, and spinal cord injury, among
others.
In general, acute pain may be associated with brain
hemorrhage, spinal disk disease, or trigeminal neuralgia. In
LESSON 1: ASSESSMENT OF NEUROLOGIC contrast, chronic or persistent pain can occur with many
FUNCTION degenerative and chronic neurologic conditions (e.g.,
multiple sclerosis).
On the other hand, muscle weakness frequently
Neurologic assessment is a method of obtaining
coexists with other symptoms of disease and can affect a
specific data in relation to the function of a patient’s nervous
variety of muscles, causing a wide range of disability.
system. It is a comprehensive evaluation that covers several
Weakness can be sudden and permanent, as in stroke, or
areas: mental status, cranial nerve function, motor system,
progressive, as in neuromuscular diseases such as
coordination, sensory system, and various reflexes. The
amyotrophic lateral sclerosis. For other patients, they may
challenges of examining an intubated, restrained, and often
experience seizure, which is a result of abnormal
sedated patient in the intensive care unit (ICU) make
paroxysmal discharges in the cerebral cortex. It may
neurologic assessment difficult in many patients.
manifest as an alteration in sensation, behavior, movement,
perception, or consciousness. The alteration may be short,
LEARNING INPUT such as in a blank stare that lasts only a second, or of longer
duration, such as a tonic–clonic grand mal seizure that can
Proper clinical assessment of the nervous system last several minutes. Seizures can occur as isolated events,
emphasizes the neurologic history and examination. such as when induced by a high fever, or hypoglycemia, or
Obtaining a thorough history from the patient or family it may also be the first obvious sign of a brain lesion.
members can help the clinician characterize the dysfunction,
whereas the neurologic examination will assist in localizing The common symptoms involving altered sensation
and quantifying its severity. As a nurse, it is important that may be caused by a variety of factors including viral
you know the specific components of the assessment. These syndromes, hot weather, and middle ear infections.
are: Assessing dizziness often pose a challenge to the examiner
because of the vague and varied terms that patients use to
PRESENT HEALTH HISTORY. An important describe the sensation. Dizziness is an abnormal sensation
aspect of the neurologic assessment is the history of the of imbalance or movement. On the other hand, vertigo is
present illness. You may begin by asking about the patient’s defined as an illusion of movement, usually rotation.
chief complaint. The initial interview provides an excellent ABOUT 50% OF ALL PATIENTS WITH
opportunity to systematically explore the patient’s current DIZZINESS HAVE VERTIGO. Vertigo is usually a
condition and related events while simultaneously observing manifestation of vestibular dysfunction. The condition can
overall appearance, mental status, posture, movement, and be so severe as to result in spatial disorientation,
affect. lightheadedness, loss of equilibrium (staggering), and
nausea and vomiting. Another altered sensation that patients
Depending on the patient’s condition, you may need may experience is visual defect. Lesions in the visual cortex
to rely on yes-or-no answers to questions or a review of the cause by stroke may interfere with normal visual acuity;
patient’s medical record. You may need to include input nystagmus, an abnormal eye movement, any be associated
from witnesses or the family, or a combination of these. with multiple sclerosis, causing compromised vision.
Abnormal sensation is a neurologic manifestation of both
When interviewing the patient, do not assume that central and peripheral nervous system disease. Patients with
he/she remembers accurately; corroborate with others to get altered sensation are at risk for falls and injury.
a better picture of the patient’s neurologic condition.
Past health, family, and social history. During
Neurologic disease may be stable or progressive, assessment, you need to explore all of the patient’s major
characterized by symptom-free periods as well as illnesses, recurrent minor illnesses, accidents or injuries,
fluctuations in symptoms. surgical procedures, and allergies. In particular, you should
You should, therefore, obtain specific details such as be aware of any history of trauma or falls that may have
the onset, character, severity, location, duration, and involved the head or spinal cord of the patient. Also ask
frequency of symptoms and signs; associated complaints; about the patient’s health and dietary habits including the
precipitating, aggravating, and relieving factors; use of OTC and prescription drugs, alcohol, medications,
progression, remission, and exacerbation; and the presence and illicit drugs. In addition, you may inquire about family
or absence of similar symptoms among family members. history of genetic diseases such as diabetes, cardiovascular
or renal diseases, cancer, or a stroke. When it comes to
social history, always consider the patient’s cultural with very short attentio
background. As you gather data on along this aspect, take Sleep-like state - Persons who are stupo
note of the patient’s self-image.
(not drawing away from pai
unconscious); - Arousal is only thru pai
The history-taking portion of the neurologic Stuporous
assessment is critical and, in many cases of neurologic with little/no
disease, leads to an accurate diagnosis. spontaneous
activity
Physical assessment. A complete neurologic
assessment provides information about the five (5)
Cannot be
categories of neurologic function: cerebral function aroused; - Comatose people do n
(including level of consciousness [LOC], mental status, and Comatose no stimuli, have no cornea
language), cranial nerves, motor system and cerebellar
functions, sensory system, and reflexes.
response to have no pupillary respo
stimuli
Level of consciousness (LOC). Level of
consciousness (LOC) is a measurement of a person's
arousability and responsiveness to stimuli from the The Glasgow coma scale (GCS) was
environment. It is considered to be the most sensitive
indicator of neurologic function. A person’s level of
originally developed so that members of the
consciousness exists along a continuum from full awakening health team can communicate about the level of
to unresponsiveness to any form of external stimuli. Table 1 consciousness of patients with an acute brain
summarizes the levels of consciousness and their injury. It was used to measures 3 different types
description.
of response with different grades. These are: best
motor response - 6 grades; best verbal response -
Table 1. Levels of consciousness. 5 grades; and eye opening - 4 grades. An overall
Level Summary score is made by summing the score in the 3
assessed areas. The lowest possible score is 3, the
- Assessment of LOC involves checking orientation
maximum is 15. Generally in managing patients, a
- A normal sleep stage from which a person is easily
score of 8 is considered to be the threshold; less
awakened is also considered a normal level of
than 8 implies a significant problem in the
Conscious Normal consciousness.
neurologic status of the patient. Other authors
- "Clouding of consciousness" is a term for a mild alteration
agree that a score of 3 or 4 indicates an 85%
of consciousness with alterations in attention
chance of dying and
or remaining vegetative while a
wakefulness. score of 11 or more suggests an 86 % chance of
- People who do not respond good quickly with or
recovery information
with moderate disability.
about their name, location, and the
Overtime, time are
modern considered
structured schema has been
"obtuse" or "confused". developed to reinforce the GCS and the standard
Disoriented;
- A confused person mayapproachbe bewildered, disoriented,
to assessment and,and
hence, to enhance
impaired
Confused have difficulty following instructions.
the consistency The
of person
its use. may
thinking and have slow thinking and possible memory time loss.
responses - This could be caused by sleep deprivation, malnutrition,
allergies, environmental pollution, ADDITIONAL LEARNING.
drugs (prescription and
nonprescription), and infection.
Check the GLASGOW STRUCTURE
- A lethargic person shows excessive drowsiness and
ASSESSMENT of the GLASGOW COMA SCALE
Lethargic Sleepy responds to stimuli only with incoherent mumbles
https://www.glasgowcomascale.org/download
or disorganized movements. Aid-English.pdf?v=3
Obtunded Decreased - In obtundation, a person has a decreased interest in their
alertness; slowed surroundings, slowed responses, and sleepiness.
psychomotor - the person may respond to TOUCH more than VOICE;
Abnormal posture. You should also take
responses may be SLEEPY but easily aroused (there is ready arousal
note that patients with altered neurologic status
and patient responds appropriately when aroused but
may exhibit abnormal postures. These include 2fdecorticatedecerebrate-
decorticate and decerebrate postures. Table 1 position.html/RK=2/RS=.qJXnkJMxxy74drxa0VYf
and Figure 1 present the difference between MghA0E-
these two.

Mental status. A mental status

Table 2. Abnormal postures in patients with nervous system affectation.
Decorticate Posture examination (MSE) is an assessment of a
patient's level of cognitive (knowledge-related)
 the arms are adducted and flexed with  the arms are adducted and extended,
ability, appearance, emotional mood, and speech
the wrists and fingers flexed on the with the wrists pronated and the fingers
and thought patterns at the time of evaluation.
chest. The legs are stiffly extended and flexed. The legs are stiffly extended with
Cognition is a term that refers to the mental
internally rotated, with plantar flexion of plantar flexion of the feet
processes involved in gaining knowledge and
the feet  indicates severe injury toincluding
the brain at the
comprehension, thinking, knowing,
 indicates damage to the corticospinal level ofremembering,
the brainstem judging and problem-solving.
tract, the pathway between the brain  it can occur These onareone side or both
higher-level sides or
functions of the brain and
and the spinal cord just in encompass
the arms language, imagination, perception
 although a serious condition, it is more  it may and occurplanning.
with decorticate posture
There are on areas to be
six (6)
favorable than decerebrate posture the other half ofunder
assessed the body
cognitive aspect and these are:
language and communication, orientation,
memory, attention (including concentration and
calculation), judgment, and reasoning.

Normal cerebral function allows a person

to understand spoken or written words and
express the self through written words or
gestures. There are regions, or language centers,
in the brain that play specific roles to make these
happen. The Wernicke’s area contains sensory
neurons that are involved in the control of speech
and this is located at the posterior section of the
superior temporal gyrus (STG) in the left (or
dominant) cerebral hemisphere. On the other
hand, the Broca’s area contains motor neurons
that are involved in the control of verbal and
expressive speech and it is located in the frontal
part of the left hemisphere of the brain. Damage
to any of these language centers can cause
aphasia.

Aphasia is an acquired language disorder

in which there is an impairment of any language
modality. This may include difficulty in producing
or comprehending spoken or written language.
Figure 2. Comparing decerebrate and decorticate
Depending on the area and extent of brain
postures. Courtesy: damage, a person suffering from aphasia may be
https://r.search.yahoo.com/_ylt=AwrwJUhfQ5Rh. able to speak but not write, or vice versa, or
mUAqEa.Rwx.;_ylu=c2VjA2ZwLWF0dHJpY display any of a wide variety of other deficiencies
gRzbGsDcnVybA-- in language comprehension and production, such
/RV=2/RE=1637135327/RO=11/RU=http%3a%2f as being able to sing but not speak. Read table 2
%2fpgmedic.blogspot.com%2f2010%2f06% for more specific language problems that patients
with Wernicke’s aphasia and Broca’s aphasia may In terms of judgment, assess the patient's
experience. capacity to make sound, reasoned and
Table 2. Language problems in Wernicke’s aphasia and responsible decisions. Currently, there is no clear,
Broca’s aphasia.
Wernicke’s Aphasia satisfactory way to assess judgment.
Nonetheless, you may estimate the patient's
• there is loss of the ability to understand  prevents
judgment based on the history or on an
language imaginary scenario, e.g. What would you do if
• the person can speak clearly, but the  personyoucansmelled
understand
smokelanguage
in a crowded theater?" (good
words that are put together make no  words response
are not properly formed
is "call the Emergency Response
sense. This way of speaking has been  speechHotline"
is slow and
or slurred
"get help"; poor response is "do
called "word salad" because it appears  know “what
nothing"they
orwant
"lighttoa say but they
cigarette").
that the words are all mixed up like the just cannot get it out”.
vegetables in a salad. Reasoning is the act or process of drawing
conclusions from facts, evidence, and other data.
To assess for the patient’s ability to reason out,
Orientation is a function of the mind ask the patient to explain simple, well-known
involving awareness of three dimensions: time, proverbs.
place and person. On the other hand, memory
relates to a person’s ability to store, retain, and For the methods in conducting cranial
recall information and experiences. There are nerve assessment, refer to Table 3 for the
three categories of memory that may need to be summary.
assessed:
Table 3. Methods in conducting cranial nerve assessmen
• Immediate Recall – this may be Cranial Nerve Type Function
elicited by asking the patient to repeat I Olfactory S Ask
a series of numbers in the order that Sense of smell no
they are presented or in reverse order an
• Recent Memory – this may be II Optic S Us
assessed by asking the patient to
to
recall events that occurred earlier Visual acuity
pa
during the day the assessment is being
performed, e.g. What did you eat for use
breakfast? Validate the patient’s III Oculomotor M Extraocular Eye Ass
response with a family member Movement
• Remote Memory – you may ask the IV Trochlear M Pupil constriction and Me
patient to recall past events, e.g. How dilatation an
did you meet your spouse?
Upward and Ass
To assess for the patient’s attention span downward movement
and concentration, you may ask the patient to of eyeball
recite the alphabet or count backward from 100.
V Trigeminal S&M Sensory to skin and Lig
To test the patient’s ability to compute, ask the
face of
patient to perform simple mathematical
sen
computations. In assessing these areas, it is
important to consider the patient’s level of the
knowledge as it may affect the result of the
assessment. Motor nerve to Pal
muscles of the jaw tee
VI Abducens M Lateral movement of Ass
 eyeballs forward flexion of the trunk and knees; gait is
VII Facial S&M Facial expression shuffling with quick and small steps, and
festinating may occur. A spastic gait pattern is
characterized by stiff movements, toes seeming
to catch and drag, legs held together, hip and
knees Figure 2. Antalgic posture. slightly flexed.
Taste

Table 3. Methods in conducting cranial nerve assessment.

VIII Auditory S Hearing Muscle strength. This assessment evaluates
IX S&M Taste the ability of the patient to flex or extend his/her
Glossopharyngeal extremities against gravity and/or resistance. The
muscle strength can be graded as shown in Table
Ability to swallow 4.
X Vagus S&M Sensation of Pharynx
Table 4. Grading motor strength.
Grade Descriptio
0/5 No muscle movement
Movement of vocal 1/5 Visible muscle movement, but no mo
cords 2/5 Movement at the joint, but not again
XI Spinal Accessory M Movement of head 3/5 Movement against gravity, but not ag
and shoulders 4/5 Movement against resistance, but les
XII Hypoglossal M 5/5 strength
Position of tongue
Muscle tone. Muscle tone refers to the
Another component of the neurologic amount of tension or resistance to movement in
assessment is assessing for the patient’s motor a muscle. To assess for muscle tone, check for the
and sensory functions. In assessing the patient’s continuous and passive partial contraction of the
motor function, the following must be muscles and observe for flaccidity, hypotonus,
considered: hypertonus, spasticity, and rigidity.

Gait and stance. To assess gait and stance, Coordination. Muscle coordination can be
you may ask the patient to walk across the room assessed by asking the patient to extend the arms
(if possible). Observe for the motion of the out to the
patient (manner of walking, movement, etc) and sides and
pay particular attention to abnormal gait patterns touch each
such as antalgia, ataxia, hemiplegia, parkinsonian, forefinger
and spastic patterns. An antalgic posture (Figure alternately
2) may be assumed by the patient as a protective to the nose
gait to avoid weight bearing and pain on the
involved side of the body. Ataxia is characterized
by staggering and unsteadiness. There is usually a
wide base of support and movements are
exaggerated. A hemiplegic gait pattern is one in
which the patient abducts the paralyzed limb,
swings it around, and brings it forward so the foot
comes to the ground in front of him/her. A
Parkinsonian gait pattern is marked by increased
(coordination in upper extremities). Alternately, Also, you may need to perform a brief
you may ask the patient to pat the knees with neurologic assessment, called a neuro check. This
both hands, then ask the patient to alternately will enable you to make rapid, repeated
turn up the palm and back of the hands while evaluation of several key indicators of nervous
continuously patting the knees. Be watchful for system status: LOC, pupil size and response,
cues of impaired coordination as well as verbal responsiveness, extremity strength and
involuntary movements. movement, and vital signs. After establishing
baseline values, you may need to regularly
Reflexes. A reflex is an automatic response reevaluate these key indicators to reveal trends
of the body to a stimulus. The deep tendon in the patient’s neurologic function and to help
reflexes (DTR) are assessed by mildly stretching a detect transient changes that can be warning
muscle and tapping a tendon. Like the muscle signs of neurologic problems.
strength, muscle reflexes are also graded (Table
5).

Table 5. Grading muscle reflexes. ADDITIONAL LEARNING

.
Grade Description
0 No response (areflexia)
1+ Sluggish or diminished (hyporeflexia)
2+ Active or expected response (normal)
3+ More brisk than expected, slightly hyperactive
4+ Brisk and hyperactive with intermittent or transient clonus

When performing sensory assessment,

observe the patient’s ability to feel sensations in
various parts of the body and to distinguish Watch the lecture video to add to your le
varying stimuli (temperature, pain, etc). neurological assessment. The video can be acc
Sensation should be equal on both sides of the
body (e.g. equal sensation on both left and right
hand).

A complete neurologic assessment is

complex and time-consuming; hence, some
practitioners may perform a neurologic screening
assessment. The neurologic screening assessment
evaluates some of the key indicators of Finally, in performing neurologic
neurologic function and helps identify areas of assessment to an elderly patient, consider the
dysfunction. The assessment usually includes agerelated changes to the nervous system (e.g.,
evaluation of LOC (including brief mental status slowed nerve conduction and response time) and
examination] and evaluation of verbal integrate possible modifications. The
responsiveness), selected cranial nerves (usually consequences of any neurologic deficit and its
CN II, III, IV, and VI), motor screening (strength, impact on the overall function of the older
movement, and gait), and sensory screening patient such as activities of daily living, use of
(tactile and pain sensation in extremities). If the assistive devices, and individual coping should be
screening assessment reveals areas of neurologic assessed and considered in planning patient care.
dysfunction, you must evaluate those areas in Additionally, you must understand the altered
more detail. responses and the changing needs of the elderly
patient before providing instruction and
education. For example, when using visual
materials for teaching, provide adequate lighting posturing. This finding indicates damage
without glare, contrasting colors, and large print to which part of the brain?
to offset visual difficulties caused by rigidity and
opacity of the lens in the eye and slower pupillary A. Diencephalon
reaction. Teaching the elderly at an unrushed
pace and using reinforcement enhance learning B. Medulla
and retention. The elderly patient requires
adequate time to receive and respond to stimuli, C. Midbrain
learn, and react. These measures allow
comprehension, memory, and formation of D. Cortex
association and concepts.

LEARNING ACTIVITY. Can you

determine the correct answer to
these

problems?

1. The nurse is performing a mental

status examination on a male client

diagnosed with subdural hematoma. This

test assesses which of the following?

A. Cerebellar function

B. Intellectual function

C. Cerebral function

D. Sensory function
This ends our discussion in lesson 1. Check your
understanding of the topics by answering the
short quiz in the learning management system
2. A female client who was trapped inside a car (LMS) of this course. Feedback will be given after
for hours after a head-on collision is the quiz is closed. Good luck!

rushed to the emergency department

with multiple injuries. During the

neurologic examination, the client

responds to painful stimuli with
decerebrate
Instructional Module in NCM 118a |1

LESSON 2: DIAGNOSTIC EVALUATIONS FOR NEUROLOGIC ALTERATIONS

INTRODUCTION OF THE LESSON

AND PRESENTATION OF OUTCOMES

Diagnostic tests and procedures are vital tools that help clinicians confirm or rule out
neurological disorders. A century ago, the only way to make a definite diagnosis for many
neurological disorders was to perform an autopsy after someone had died. Today, new
instruments and techniques allow the healthcare team to assess the living brain and
monitor nervous system activity as it occurs. This lesson describes the common procedures
that may be done to help in the diagnosis of neurologic disorders.

LEARNING OUTCOMES FOR THIS LESSON

At the end of this lesson, you must have:

1. explained the relevance of the diagnostic tests in detecting neurologic

problems; and
2. discussed the relevant nursing interventions in the diagnostic
evaluation of patients.

Chapter 6 Lesson 2: Diagnostic Evaluations for Neurologic Alterations

Instructional Module in NCM 118a |2

CENTRAL ACTIVITIES
This lesson contains one (1) learning input and one (1) learning activity.

LEARNING INPUT

Evaluating and diagnosing damages to the nervous system is complicated

and complex. Many of the symptoms presented by patients may also occur in
other disorders. In addition, many disorders do not have definitive causes,
markers, or tests making the diagnosis even harder.

To diagnose a nervous system disorder, the clinician starts with a complete medical
history and physical exam (discussed in lesson 1). The clinician may also order for the
following tests to aid in the diagnosis of a neurologic problem:

Computed tomography (CT) scanning. This test uses a narrow x-ray beam to scan
body parts in successive layers. The images provide cross-sectional views of the brain,
distinguishing differences in tissue densities of the skull, cortex, subcortical structures, and
ventricles. Usually, an intravenous (IV) contrast agent may be used to highlight differences
further. The brightness of each slice of the brain in the final image is proportional to the
degree to which it absorbs x-rays. The image is displayed on an oscilloscope or TV monitor

Chapter 6 Lesson 2: Diagnostic Evaluations for Neurologic Alterations

Instructional Module in NCM 118a |3

and is photographed and stored digitally. The patient lies on an adjustable table with the
head in a head rest while the scanning system rotates around the head and produces cross
sectional images. The patient must lie with the head held perfectly still without talking or
moving the face, because head motion distorts the image. CT scanning is quick and painless
and uses a small amount of radiation to produce images; it has a high degree of sensitivity
for detecting lesions.

Abnormalities detected on brain CT include tumor or other masses, infarction,

hemorrhage, displacement of the ventricles, and cortical atrophy. CT angiography allows
visualization of blood vessels; in some situations this eliminates the need for formal
angiography. Whole-body CT scanners allow cross sections of the spinal cord to be
visualized. The injection of a water-soluble iodinated contrast agent into the subarachnoid
space through lumbar puncture improves the visualization of the spinal and intracranial
contents on these images.

What are your relevant nursing interventions for patients undergoing CT scan? Your
nursing responsibilities include preparing the patient for the procedure and monitoring the
patient. Preparation includes teaching the patient about the need to lie quietly throughout
the procedure. You may review with the patient different relaxation techniques to alley
anxiety especially when the patient is claustrophobic. For patients who are restless or could
not lie still during the procedure, the doctor may order for sedation to obtain a successful
study. During sedation, on-going patient monitoring is critical.

If a contrast agent is used for the procedure, you must assess the patient for an
iodine/shellfish allergy because the contrast agent used may be iodine based. Also, include
an evaluation of the renal function because the contrast material is cleared through the
kidneys. A suitable IV line for contrast injection and a period of fasting (usually 4 hours) are
required prior to the study. Patients who receive an IV contrast agent are monitored during
and after the procedure for allergic reactions and changes in kidney function.

Magnetic resonance imaging (MRI). This procedure uses a powerful magnetic field to
obtain images of different areas of the body. The magnetic field causes the hydrogen nuclei
(protons) within the body to align like small magnets in a magnetic field. In combination
with radiofrequency pulses, the protons emit
signals, which are converted to images. An
MRI scan can be performed with or without
a contrast agent and can identify a cerebral
abnormality earlier and more clearly than
other diagnostic tests. It is particularly useful
in the diagnosis of brain tumor, stroke, and
multiple sclerosis, and does not involve
ionizing radiation. Newer MRI applications
have added features that allow more
accurate and advanced imaging techniques.

Chapter 6 Lesson 2: Diagnostic Evaluations for Neurologic Alterations

Instructional Module in NCM 118a |4

Nursing interventions to prepare patients for MRI include thorough teaching and
obtaining an adequate history. Ferromagnetic substances in the body may become
dislodged due to the strong magnetic field generated by an MRI, so you must question the
patient about any implants of any metal objects (eg, aneurysm clips, orthopedic hardware,
pacemakers, artificial heart valves, intrauterine devices). These objects could malfunction,
be dislodged, or heat up as they absorb energy. Also, cochlear implants are inactivated by
MRI. For these reasons, other imaging procedures are considered. Instruct the patient that
before he/she enters the room where the MRI is to be performed, all metal objects and
credit cards (the magnetic field can erase them) must be removed. Also, ensure that no
metal objects are brought into the room where the MRI is located.

During the procedure, the patient should lie with the head in a frame on a flat
platform that is moved into a tube housing the magnet (Figure 3). Patients who are unable
to lie flat will not be able to tolerate an MRI. The scanning process is painless, but the
patient may hear grating or knocking noises when the magnetic field direction is flipped.
Earphones or earplugs can help block out the sounds. For patients who may experience
claustrophobia while inside the narrow tube, sedation may be prescribed. The patient may
also be taught to use relaxation techniques while in the scanner. Newer versions of MRI
machines (open MRI) are now available in some locations. However, the images produced
on these machines are often not as detailed and traditional devices are preferable for
accurate diagnosis. The patient is informed that he or she will be able to talk to the staff
during the scan through a microphone inside the scanner.

Positron Emission Tomography. PET scans provide two- and three-dimensional

pictures of brain activity by measuring radioactive isotopes that are injected into the
bloodstream. PET scans of the brain are used to detect or highlight tumors and diseased
tissue, show blood flow, and measure cellular and/or tissue metabolism. PET scans can be
used to evaluate people who have epilepsy or certain memory disorders, and to show brain
changes following injury. PET may be ordered as a follow-up to a CT or MRI scan to give the
physician a greater understanding of specific areas of the brain that may be involved with
problems. A low-level radioactive isotope, also called a tracer, is injected into the
bloodstream and the tracer’s uptake in the brain is measured. The person lies still while
overhead sensors detect gamma rays in the body’s tissues. A computer processes the
information and displays it on a video monitor or on film. Using different compounds, more
than one brain function can be traced simultaneously. PET is painless and uses small
amounts of radioactivity.

Key nursing interventions that relate to PET include patient preparation, which
involves explaining the test and teaching the patient about inhalation techniques and the
sensations (e.g. dizziness, light headedness, and headache) that may occur. The IV injection
of the radioactive substance produces similar side effects. You may also teach relaxation
exercises to the patient to help reduce anxiety during the test.

Chapter 6 Lesson 2: Diagnostic Evaluations for Neurologic Alterations

Instructional Module in NCM 118a |5

Single Photon Emission Computed Tomography (SPECT). SPECT is a threedimensional

imaging technique that captures a moment of cerebral blood flow at the time of injection of
a radionuclide. Gamma photons are emitted from a radiopharmaceutical agent
administered to the patient and are detected by a rotating gamma camera or cameras; the
image is sent to a minicomputer. This approach allows areas behind overlying structures or
background to be viewed, greatly increasing the contrast between normal and abnormal
tissue. SPECT is useful in detecting the extent and location of abnormally perfused areas of
the brain, thus allowing detection, localization, and sizing of stroke; localization of seizure
foci in epilepsy; detection of tumor progression; and evaluation of perfusion before and
after neurosurgical procedures.

The nursing interventions for SPECT primarily include patient preparation and
patient monitoring. You need to teach the patient about what to expect before the test to
allay anxiety and ensure patient cooperation during the test. Pregnancy and breast-feeding
are contraindications to SPECT. You need to advise premenopausal women to practice
effective contraception before and for several days after testing. Also, instruct breastfeeding
women to stop nursing for the time period recommended by the nuclear medicine
department. Monitor the patient during and after the procedure for allergic reactions to the
radiopharmaceutical agent.

Cerebral Angiography. Angiography is a test that involves injecting dye into the
arteries or veins to detect blockage or narrowing (Figure 4). A cerebral angiogram can show
narrowing or obstruction of an artery or blood vessel in the brain, head, or neck. It can
determine the location and size of an aneurysm or vascular malformation. Angiograms are
used in certain strokes where there is a possibility of unblocking the artery using a clot
retriever. Angiograms can also show the blood supply of a tumor prior to surgery or
embolectomy (surgical removal of a blood clot or other material that is blocking a blood
vessel).

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Instructional Module in NCM 118a |6

Prior to the angiography, the patient’s blood urea nitrogen and creatinine should be
checked to ensure the kidneys will be able to clear the contrast agent. The patient should be
well hydrated, and clear liquids are usually permitted up to the time of the test. The patient
is instructed to void immediately before the test, and locations of the appropriate peripheral
pulses are marked with a felt-tip pen. The patient is instructed to remain immobile during
the process and is told to expect a brief feeling of warmth in the face, behind the eyes, or in
the jaw, teeth, tongue, and lips, and a metallic taste when the contrast agent is injected.
After the groin is shaved and prepared, a local anesthetic agent is administered to minimize
pain at the insertion site and to reduce arterial spasm. A catheter is introduced into the
femoral artery, flushed with heparinized saline, and filled with contrast agent. Fluoroscopy is
used to guide the catheter to the appropriate vessels. Neurologic assessment is conducted
during and immediately following cerebral angiography to observe for embolism or arterial
dissection that may occur during the test.

Nursing care after cerebral angiography includes observation of the injection site for
bleeding or hematoma formation (a localized collection of blood). Because a hematoma at
the puncture site or embolization to a distal artery affects the peripheral pulses, peripheral
pulses that were marked prior to the test are monitored frequently. The color and
temperature of the involved extremity are also assessed to detect possible embolism

Noninvasive carotid flow studies and transcranial doppler. Noninvasive carotid flow
studies use ultrasound imagery and Doppler measurements of arterial blood flow to
evaluate carotid and deep orbital circulation. The graph produced indicates blood velocity.
Increased blood velocity can indicate stenosis or partial obstruction. These tests are often
obtained before more invasive tests such as arteriography, or used as screening tools. On
the other hand, transcranial doppler uses the same noninvasive techniques as carotid flow
studies except that it records the blood flow velocities of the intracranial vessels. Arterial
flow velocities can be measured through thin areas of the temporal and occipital bones of
the skull. Transcranial doppler is helpful in assessing vasospasm (a complication following
subarachnoid hemorrhage), altered cerebral blood flow found in occlusive vascular disease,
other cerebral pathology, and brain death.

Part of your nursing intervention is to describe the procedure to the patient. Inform
the patient that it is a noninvasive test, that a handheld transducer will be placed over the
neck and the orbits of the eyes, and that
a water-soluble jelly is used on the
transducer.

Electroencephalography. An
electroencephalogram (EEG) represents
a record of the electrical activity
generated in the brain (Figure 5). It is
obtained through electrodes applied on

Chapter 6 Lesson 2: Diagnostic Evaluations for Neurologic Alterations

Instructional Module in NCM 118a |7

the scalp or through microelectrodes placed within the brain tissue. The amplified activity of
the neurons between any two of these electrodes is recorded on continuously moving
paper. This record is called the encephalogram. This test is a useful tool to detect and
evaluate seizure disorders, coma, or organic brain syndrome. Tumors, brain abscesses,
blood clots, and infection may also cause abnormal patterns in electrical activity. The EEG is
also used in making a determination of brain death.

For a baseline recording, the patient lies quietly with both eyes closed. The patient
may be asked to hyperventilate for 3 to 4 minutes or to look at a bright, flashing light for
photic stimulation. These activation procedures are performed to evoke abnormal electrical
discharges, such as seizure potentials. A sleep EEG may be recorded after sedation because
some abnormal brain waves are seen only when the patient is asleep.

To increase the chances of recording seizure activity, the clinician sometimes

recommend that the patient be deprived of sleep on the night before the EEG. Antiseizure
agents, tranquilizers, stimulants, and depressants should be withheld 24 to 48 hours before
an EEG because these medications can alter the EEG wave patterns or mask the abnormal
wave patterns of seizure disorders. Also, coffee, tea, chocolate, and cola drinks are omitted
in the meal before the test because of their stimulating effect. However, the meal is not
omitted because an altered blood glucose level can cause changes in brain wave patterns.
Inform the patient that the standard EEG takes 45 to 60 minutes while a sleep EEG requires
12 hours. Reassure the patient that the procedure does not cause an electric shock and that
the EEG is a diagnostic test, not a form of treatment. An EEG requires the patient to lie
quietly during the test.

Lumbar puncture and examination of cerebrospinal fluid (CSF). A lumbar puncture

(spinal tap) is carried out by inserting a needle into the lumbar subarachnoid space to
withdraw CSF. The test may be performed to obtain CSF for several purposes including CSF
examination, measurement and reduction of CSF pressure, and administration of intrathecal
(into the spinal canal) medications. The needle is usually inserted into the subarachnoid
space between the third and fourth or fourth and fifth lumbar vertebrae (Figure 6). Because
the spinal cord ends at the first lumbar vertebra, insertion of the needle below the level of
the third lumbar vertebra prevents puncture of the spinal cord. A successful lumbar
puncture requires that the patient be relaxed. An increase in the CSF pressure reading may
be obtained if the patient is anxious and tensed. CSF pressure with the patient in a lateral
recumbent position is normally 50 to 1800 mm H2O. A lumbar puncture may be risky in the
presence of an intracranial mass lesion because intraspinal pressure is decreased by removal
of CSF, and the brain may herniate downward through the foramen magnum. Refer to
Figure 6 for your guide in assisting with lumbar puncture.

Chapter 6 Lesson 2: Diagnostic Evaluations for Neurologic Alterations

Instructional Module in NCM 118a |8

Figure 6. Assisting with a lumbar puncture. Courtesy: Brunner and Suddarth’s

textbook of medical -surgical nursing (12th ed), 2010.

The CSF obtained should be clear and colorless. Pink, blood-tinged, or grossly bloody
CSF may indicate a subarachnoid hemorrhage. The CSF may be bloody initially because of
local trauma but becomes clearer as more fluid is drained. Specimens are obtained for cell
count, culture, glucose, protein, and other tests as indicated. You should send the specimen
to the laboratory immediately because changes will take place and alter the result if the
specimens are allowed to stand.

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Instructional Module in NCM 118a |9

A common side effect of this procedure is post–lumbar puncture headache. A post–

lumbar puncture headache, ranging from mild to severe, may occur a few hours to several
days after the procedure. The headache is characterized as throbbing, dull, and deep along
the bifrontal or occipital areas. It is particularly severe on sitting or standing but lessens or
disappears when the patient lies down. The headache is caused by CSF leakage at the
puncture site. The fluid continues to escape into the tissues by way of the needle track from
the spinal canal. As a result of a leak, the supply of CSF in the cranium is depleted to a point
at which it is insufficient to maintain proper mechanical stabilization of the brain. When the
patient assumes an upright position, tension and stretching of the venous sinuses and
painsensitive structures occur.

Post–lumbar puncture headache may be avoided if a small-gauge needle is used and

if the patient remains prone after the procedure. When more than 20 mL of CSF is removed,
the patient is positioned supine for several hours. Keeping the patient flat overnight may
also reduce the incidence of headaches. A post-puncture headache is usually managed by
bed rest, analgesic agents, and hydration. Occasionally, if the headache persists, the
epidural blood patch technique may be used. Blood is withdrawn from the antecubital vein
and injected into the epidural space, usually at the site of the previous spinal puncture. The
rationale is that the blood acts as a gelatinous plug to seal the hole in the dura, preventing
further loss of CSF.

Herniation of the intracranial contents, spinal epidural abscess, spinal epidural

hematoma, and meningitis are rare but serious complications of lumbar puncture. Other
complications include temporary voiding problems, slight elevation of temperature,
backache or spasms, and stiffness of the neck.

Diagnostic procedures are important clinical tools for detecting a neurological

disorder, charting the disease progression, and monitoring therapeutic effects. As
technology advances, additional and improved screening methods will be developed to
accurately and quickly confirm a specific diagnosis and investigate other factors that might
contribute to the disease without causing much risk to the person.

ADDITIONAL LEARNING.
Watch and learn from this video of
diagnostic tests and ICP monitor ing thru
this site:

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Instructional Module in NCM 118a | 10

LEARNING
ACTIVITY
. Critical Thinking Exercise.

Your patient complains of a headache

lowingfola lumbar puncture. What
resources would you use to identifycurrent
the guidelines for treatment of
headache followingumbar
l puncture? What is the videence base for these
practices? Identify the criteria used to evaluate the strength of the evidence for
these practices.

Chapter 6 Lesson 2: Diagnostic Evaluations for Neurologic Alterations

Instructional Module in NCM 118a | 11

This ends our discussion in lesson 2. Check your understanding of

the topics by answering the short quiz in the learning management
system (LMS) of this course. Feedback will be given after the quiz is
closed.
Good luck!

Chapter 6 Lesson 2: Diagnostic Evaluations for Neurologic Alterations

Instructional Module in NCM 118a |1

LESSON 3: TRAUMATIC ALTERATIONS

INTRODUCTION OF THE LESSON

AND PRESENTATION OF OUTCOMES

Traumatic alterations are common presentations in emergency departments. In particular,

traumatic brain injury (TBI) accounts for more than one million hospital visits annually and it
is a common cause of death and disability among children and adults (Shaikh & Waseem,
2021). This lesson covers TBI, its causes, types, clinical manifestations, complications, and
management.

LEARNING OUTCOMES FOR THIS LESSON

At the end of this esson,

l you must have:
1. explained the types oftraumatic braininjury;
2. related the manifestations to the area and severity of injury;
3. discussed various types of managementorf patients affected bybrain
injury.

Traumatic brain injury occurs when a sudden, external, physical assault damages the
brain. It is a broad term that describes a vast array of injuries that happen to the brain. The
injury can be as mild as a bump, bruise (contusion), or cut on the head, or can be moderate
to severe due to a concussion, deep cut or open wound, fractured skull bone(s), or from
internal bleeding and damage to the brain resulting in coma or even death. Also, the
damage can be focal (confined to one area of the brain) or diffuse (more than one area of
the brain is affected).

The most important consideration in any TBI is whether the brain is injured. Even
seemingly minor injury can cause significant brain damage secondary to obstructed blood
flow and decreased tissue perfusion. The brain cannot store oxygen or glucose to any
significant degree. Because the cerebral cells need an uninterrupted blood supply to obtain
these nutrients, irreversible brain damage and cell death occur if the blood supply is
interrupted for even a few minutes.

Clinical manifestations of brain injury may include the following:

• Altered level of consciousness
• Confusion

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Instructional Module in NCM 118a |2

• Pupillary abnormalities (changes in shape, size, and response to light)

• Altered or absent gag reflex
• Absent corneal reflex
• Sudden onset of neurologic deficits

• Changes in vital signs (altered respiratory pattern, widened pulse pressure,

bradycardia, tachycardia, hypothermia, or hyperthermia)
• Vision and hearing impairment
• Sensory dysfunction
• Headache
• Seizures

A closed (blunt) brain injury occurs when the head accelerates and then rapidly
decelerates or collides with another object (e.g. a wall, the dashboard of a car) and brain
tissue is damaged but there is no opening through the skull and dura. Open brain injury
occurs when an object penetrates the skull, enters the brain, and damages the soft brain
tissue in its path (penetrating injury), or when blunt trauma to the head is so severe that it
opens the scalp, skull, and dura to expose the brain.

Types of Brain Injury

Brain injury may be classified as mild, moderate or severe based on a GCS score of
1315, 9-12, and 3-8, respectively. Based on the extent of neurologic dysfunction, brain injury
may be classified as concussion, contusion, diffuse axonal injury, or intracranial hemorrhage.

Concussion. A concussion (Figure 1) after head injury is a temporary loss of neurologic

function with no apparent structural damage. A concussion (or mild TBI) may or may not
produce a brief loss of consciousness. If brain tissue in the frontal lobe is affected, the
patient may exhibit bizarre irrational behavior, whereas involvement of the temporal lobe
can produce temporary amnesia or disorientation.

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Instructional Module in NCM 118a |3

Figure 1. Concussion injuries

. Concussion may be brought about by direct
hit to the head, car accidents or blast injuries. Courtesy:
https://www.mayoclinic.org/

There are two types of concussion: mild and classic. A mild concussion may lead to a
period of observed or self-reported transient confusion, disorientation, or impaired
consciousness. Other signs and symptoms of neurologic or neuropsychological dysfunction
may include seizures, headache, dizziness, irritability, fatigue, or poor concentration. A
classic concussion is an injury that results in a loss of consciousness; characteristically, this
usually lasts less than 6 hours. This loss of consciousness is always accompanied by some
degree of posttraumatic amnesia.

Diagnostic studies may not be able to detect structural sign of injury, but the duration
of unconsciousness is an indicator of the severity of the concussion. The patient may be
hospitalized overnight for observation or discharged from the hospital in a relatively short
time after a concussion. Monitoring includes observing the patient for headache, dizziness,
lethargy, irritability, emotional lability, fatigue, poor concentration, decreased attention
span, memory difficulties, and intellectual dysfunction that may occur from 1 week to 1 year
after the initial injury. The occurrence of these symptoms after injury is referred to as
postconcussion syndrome.

Recovery from concussion may appear complete, but long-term sequelae are possible.
The family is instructed to observe for the following signs and symptoms and to notify the
physician or clinic (or bring the patient to the emergency department) if they occur:
difficulty in awakening or speaking, confusion, severe headache, vomiting, and weakness of
one side of the body.

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Instructional Module in NCM 118a |4

Contusion. Cerebral contusion (Figure 2) is categorized as moderate to severe head

injury because the brain is damaged in a specific area due to severe
accelerationdeceleration force or blunt trauma. The impact of the brain against the skull
leads to a contusion. Most contusions are usually located in the anterior portions of the
frontal and temporal lobes, around the sylvian fissure, at the orbital areas, and, less
commonly, at the parietal and occipital areas.

Contusions are characterized by loss

of consciousness associated with stupor and
confusion. Other characteristics can include
tissue alteration and neurologic deficit
without hematoma formation, alteration in
consciousness without localizing signs, and
hemorrhage into the tissue that varies in
size and is surrounded by edema. The
effects of injury (hemorrhage and edema)
peak after about 18 to 36 hours. Patient
outcome depends on the area and severity
of the injury. Deep contusions are more
often associated with hemorrhage and Figure 2.MRI showingarge
l left frontal
destruction of the reticular activating fibers cerebral contusion after occipital trauma.
altering arousal. Courtesy: https://www.ncbi.nlm.nih.gov/

Diffuse axonal injury. Diffuse axonal injury (DAI) results from widespread shearing and
rotational forces that produce damage throughout the brain—to axons in the cerebral
hemispheres, corpus callosum, and brain stem. The injured area may be diffuse, with no
identifiable focal lesion. DAI is more serious, is associated with prolonged traumatic coma,
and is associated with a poorer prognosis than a focal lesion or ischemia. The patient with
DAI in severe head trauma experiences no lucid interval, immediate coma, decorticate and
decerebrate posturing, and global cerebral edema. The diagnosis of DAI is made by clinical
signs in conjunction with a CT or MRI scan. Recovery depends on the severity of the axonal
injury.

Intracranial hemorrhage. Hematomas

are collections of blood in the brain that may
be epidural (above the dura), subdural
(below the dura), or intracerebral (within the
brain) (Fig. 3). Major symptoms are
frequently delayed until the hematoma is
large enough to cause distortion of the brain
and increased ICP. The signs and symptoms
of cerebral ischemia resulting from

Chapter 6 Lesson 3: Traumatic Alterations

 Figure 3. Epidural, subdural, and
intracerebral hematoma. Courtesy:
Instructional Module in NCM 118a Brunner & Suddarth’s textbook of | 5
medical-surgical nursing, 2010

compression by a hematoma are variable and depend on the speed with which vital areas
are affected and the area that is injured. In general, a rapidly developing hematoma, even
if small, may be fatal, whereas a larger but slowly developing one may allow compensation
for increases in
ICP.

Epidural hematoma may occur as a result of a skull fracture that causes a rupture or
laceration of the middle meningeal artery, the artery that runs between the dura and the
skull inferior to a thin portion of temporal bone. Hemorrhage from this artery causes rapid
pressure on the brain. Symptoms are caused by the expanding hematoma. Epidural
hematomas are often characterized by a brief loss of consciousness followed by a lucid
interval in which the patient is awake and conversant. During this lucid interval,
compensation for the expanding hematoma takes place by rapid absorption of CSF and
decreased intravascular volume, both of which help maintain a normal ICP.

When the mechanisms that maintain the ICP can no longer compensate, even a small
increase in the volume of the blood clot produces a marked elevation in ICP. The patient
then becomes increasingly restless, agitated, and confused as the condition progresses to
coma. Then, often suddenly, signs of herniation appear (usually deterioration of
consciousness and signs of focal neurologic deficits, such as dilation and fixation of a pupil or
paralysis of an extremity), and the patient’s condition deteriorates rapidly.

The most common type of herniation syndrome associated with an epidural

hematoma is uncal herniation. An epidural hematoma is considered an extreme emergency;
marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment
consists of making openings through the skull (burr holes) to decrease ICP emergently,
remove the clot, and control the bleeding. A craniotomy may be required to remove the clot
and control the bleeding. A drain is usually inserted after creation of burr holes or a
craniotomy to prevent reaccumulation of blood.

A subdural hematoma is a collection of blood between the dura and the brain, a space
normally occupied by a thin cushion of fluid. The most common cause of subdural
hematoma is trauma, but it can also occur as a result of coagulopathies or rupture of an
aneurysm. A subdural hemorrhage is more frequently venous in origin and is caused by the
rupture of small vessels that bridge the subdural space. The subdural hematoma that results
may be acute, subacute, or chronic, depending on the size of the involved vessel and the
amount of bleeding.

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Instructional Module in NCM 118a |6

Acute subdural hematomas are associated with major head injury involving contusion
or laceration. Clinical symptoms develop over 24 to 48 hours. Signs and symptoms include
changes in LOC, pupillary signs, and hemiparesis. There may be minor or even no symptoms
with small collections of blood. Coma, increasing blood pressure, decreasing heart rate, and
slowing respiratory rate are all signs of a rapidly expanding mass requiring immediate
intervention.

Subacute subdural hematomas are the result of less severe contusions and head
trauma. Clinical manifestations usually appear between 48 hours and 2 weeks after the
injury. Signs and symptoms are similar to those of an acute subdural hematoma. If the
patient can be transported rapidly to the hospital, an immediate craniotomy is performed to
open the dura, allowing the subdural clot to be evacuated. Successful outcome also depends
on the control of ICP and careful monitoring of respiratory function. The mortality rate for
patients with acute or subacute subdural hematoma is high because of associated brain
damage.

Chronic subdural hematomas can develop from seemingly minor head injuries and are
seen most frequently in the elderly. The elderly are prone to this type of head injury
secondary to brain atrophy, which is a frequent consequence of the aging process. A chronic
subdural hematoma can resemble other conditions; for example, it may be mistaken for a
stroke. The bleeding is less profuse, but compression of the intracranial contents still occurs.
The blood within the brain changes in character in 2 to 4 days, becoming thicker and darker.
In a few weeks, the clot breaks down and has the color and consistency of motor oil.
Eventually, calcification or ossification of the clot takes place. The brain adapts to this
foreign body invasion, and the clinical signs and symptoms fluctuate. Symptoms include
severe headache, which tends to come and go; alternating focal neurologic signs;
personality changes; mental deterioration; and focal seizures. Treatment consists of surgical
evacuation of the clot. The procedure may be carried out through multiple burr holes, or a
craniotomy may be performed for a sizable subdural mass that cannot be suctioned or
drained through burr holes.

Intracerebral hemorrhage is bleeding into the substance of the brain. It is commonly

seen in head injuries when force is exerted to the head over a small area. These
hemorrhages within the brain may also result from systemic hypertension, rupture of a
saccular aneurysm, vascular anomalies, intracranial tumors, bleeding disorders and many
more.

The onset may be insidious, beginning with the development of neurologic deficits
followed by headache. Management includes supportive care, control of ICP, and careful
administration of fluids, electrolytes, and antihypertensive medications. Surgical
intervention by craniotomy or craniectomy permits removal of the blood clot and control of
hemorrhage but may not be possible because of the inaccessible location of the bleeding or
the lack of a clearly circumscribed area of blood that can be removed.

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Instructional Module in NCM 118a |7

Assessment and diagnosis of the extent of injury are accomplished by the initial
physical and neurologic examinations. Diagnostic tests such as CT and MRI scans are useful
in evaluating the brain structure. Any patient with a head injury is presumed to have a
cervical spine injury until proven otherwise. The patient is transported from the scene of the
injury on a board with the head and neck maintained in alignment with the axis of the body.
A cervical collar should be applied and maintained until cervical spine x-rays have been
obtained and the absence of cervical spinal cord injury documented.

All therapy is directed toward preserving brain homeostasis and preventing secondary
brain injury. Common causes of secondary injury are cerebral edema, hypotension, and
respiratory depression that may lead to hypoxemia and electrolyte imbalance. Treatments
to prevent secondary injury include stabilization of cardiovascular and respiratory function
to maintain adequate cerebral perfusion, control of hemorrhage and hypovolemia, and
maintenance of optimal blood gas values.

As the damaged brain swells with edema or as blood collects within the brain, an
increase in ICP occurs. If the ICP remains elevated, it can decrease the cerebral perfusion
pressure (CPP). Initial management is based on the principle of preventing secondary injury
and maintaining adequate cerebral oxygenation. Surgery is required for evacuation of blood
clots, débridement and elevation of depressed fractures of the skull, and suture of severe
scalp lacerations. ICP is monitored closely; if increased, it is managed by maintaining
adequate oxygenation, elevating the head of the bed, and maintaining normal blood
volume. Devices to monitor ICP or drain CSF can be inserted during surgery or at the bedside
using aseptic technique. The patient is cared for in the intensive care unit, where expert
nursing care and medical treatment are readily available.

Supportive measures for patients with rain injury includes ventilatory support, seizure
prevention, fluid and electrolyte maintenance, nutritional support and management of pain
and anxiety. Comatose patients are intubated and mechanically ventilated to ensure
adequate oxygenation and protect the airway. Because seizures can occur after head injury
and can cause secondary brain damage from hypoxia, antiseizure agents may be
administered. If the patient is very agitated, benzodiazepines may be prescribed to calm the
patient without decreasing LOC. These medications do not affect ICP or CPP, making them
good choices for the patient with head injury. A nasogastric tube may be inserted, because
reduced gastric motility and reverse peristalsis are associated with head injury, making
regurgitation and aspiration common in the first few hours.

When a patient has sustained a severe head injury incompatible with life, the patient
may be a potential organ donor. The nurse may assist in the clinical examination for
determination of brain death and in the process of organ procurement. The three cardinal
signs of brain death on clinical examination are coma, the absence of brain stem reflexes,
and apnea. Adjunctive tests, such as cerebral blood flow studies, electroencephalogram
(EEG), transcranial are often used to confirm brain death. The health care team provides

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Instructional Module in NCM 118a |8

information to the family and assists them with the decision-making process about end-
oflife care.

Nursing Process in the Care of Patients with TBI

Assessment. Depending on the patient’s neurologic status, the nurse may elicit
information from the patient, from the family, or from witnesses or emergency rescue
personnel. Immediate health history, although it may not be elicited initially, should include
the following questions:
• When did the injury occur?
• What caused the injury?
• What was the direction and force of the blow?

A history of unconsciousness or amnesia after a head in jury indicates a significant

degree of brain damage, and changes that occur minutes to hours after the initial injury can
reflect recovery or indicate the development of secondary brain damage. You should
determine if there was a loss of consciousness, the duration of the unconscious period, and
if the patient could be aroused.

In addition to asking questions that establish the nature of the injury and the
patient’s condition immediately after the injury, you should examine the patient thoroughly.
Assessment includes determining the patient’s LOC using the Glasgow Coma Scale (GCS) and
assessing the patient’s response to tactile stimuli (if unconscious), pupillary response to
light, corneal and gag reflexes, and motor function. Baseline and ongoing assessments are
critical in nursing assessment of the patient with brain injury, whose condition can worsen
dramatically and irrevocably if subtle signs are overlooked.

Diagnosis. Based on the assessment data, the patient’s major nursing diagnoses may
include the following:
• Ineffective airway clearance and impaired gas exchange related to brain injury
• Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP, and
possible seizures
• Deficient fluid volume related to decreased LOC and hormonal dysfunction
• Imbalanced nutrition, less than body requirements, related to increased
metabolic demands, fluid restriction, and inadequate intake
• Risk for injury (self-directed and directed at others) related to seizures,
disorientation, restlessness, or brain damage
• Risk for imbalanced body temperature related to damaged temperatureregulating
mechanisms in the brain
• Risk for impaired skin integrity related to bed rest, hemiparesis, hemiplegia,
immobility, or restlessness
• Disturbed thought processes (deficits in intellectual function, communication,
memory, information processing) related to brain injury

Chapter 6 Lesson 3: Traumatic Alterations

Instructional Module in NCM 118a |9

• Interrupted family processes related to unresponsiveness of patient,

unpredictability of outcome, prolonged recovery period, and the patient’s
residual physical disability and emotional deficit
• Deficient knowledge about brain injury, recovery, and the rehabilitation process

Likewise, based on all the assessment data, the major complications of the injury
include the following:
• Decreased cerebral perfusion
• Cerebral edema and herniation
• Impaired oxygenation and ventilation
• Impaired fluid, electrolyte, and nutritional balance
• Risk of posttraumatic seizures

Planning and goals. The goals for the patient with TBI may include:
• maintenance of a patent airway, adequate CPP, fluid and electrolyte balance,
adequate nutritional status
• prevention of secondary injury
• maintenance of normal body temperature
• maintenance of skin integrity
• improvement of cognitive function
• effective family coping
• increased knowledge about the rehabilitation process
• absence of complications

Nursing interventions. The nursing interventions for the patient with a head injury
are extensive and diverse including constant monitoring, setting priorities for nursing
interventions, anticipating needs and complications, and initiating rehabilitation.

Monitoring neurologic function. The importance of ongoing assessment and

monitoring of the patient with brain injury cannot be overstated. Certain parameters are
assessed initially and as frequently as the patient’s condition requires. As soon as the initial
assessment is made, the use of a neurologic or critical care flow chart is started and
maintained.

The GCS is used to assess LOC at regular intervals, because changes in the LOC
precede all other changes in vital and neurologic signs. The vital signs also are monitored at
frequent intervals to assess the intracranial status. Signs of increasing ICP include
bradycardia, increasing systolic blood pressure, and widening pulse pressure (Cushing’s
reflex). As brain compression increases, respirations become rapid, the blood pressure may
decrease, and the pulse slows further. A rapid increase in body temperature is regarded as
unfavorable because hyperthermia increases the metabolic demands of the brain and may
indicate brain stem damage, a poor prognostic sign. The temperature is maintained at less

Chapter 6 Lesson 3: Traumatic Alterations

Instructional Module in NCM 118a | 10

than 38 C (100.4 F). Tachycardia and arterial hypotension may indicate that bleeding is
occurring elsewhere in the body.

Motor function is assessed frequently by observing spontaneous movements, asking

the patient to raise and lower the extremities, and comparing the strength and equality of
the upper and lower extremities at periodic intervals. To assess upper extremity strength,
instruct the patient to squeeze your fingers tightly. Assess the lower extremity motor
strength by placing your hands on the soles of the patient’s feet and asking the patient to
push down against your hands. The presence or absence of spontaneous movement of each
extremity is also noted, and speech and eye signs are assessed. If the patient does not
demonstrate spontaneous movement, responses to painful stimuli are assessed.

Motor response to pain is assessed by applying a central stimulus, such as pinching

the pectoralis major muscle, to determine the patient’s best response. Peripheral
stimulation may provide inaccurate assessment data because it may result in a reflex
movement rather than a voluntary motor response. Abnormal responses (lack of motor
response; extension responses) are associated with a poorer prognosis.

In addition to the patient’s spontaneous eye opening, evaluated with the GCS, the
size and equality of the pupils and their reaction to light are assessed. A unilaterally dilated
and poorly responding pupil may indicate a developing hematoma, with subsequent
pressure on the third cranial nerve due to shifting of the brain. If both pupils become fixed
and dilated, this indicates overwhelming injury and intrinsic damage to the upper brain stem
and is a poor prognostic sign. The patient with a head injury may develop deficits such as
anosmia (lack of sense of smell), eye movement abnormalities, aphasia, memory deficits,
and posttraumatic seizures or epilepsy. Patients may be left with residual psychological
deficits (impulsiveness, emotional lability, or uninhibited, aggressive behaviors) and, as a
consequence of the impairment, may lack insight into their emotional responses.

Maintaining the airway. One of the most important nursing goals in the management
of head injury is to establish and maintain an adequate airway. The brain is extremely
sensitive to hypoxia, and a neurologic deficit can worsen if the patient is hypoxic. Therapy is
directed toward maintaining optimal oxygenation to preserve cerebral function. An
obstructed airway causes carbon dioxide retention and hypoventilation, which can produce
cerebral vessel dilation and increased ICP. Interventions to ensure an adequate exchange of
air in an unconscious patient include the following:
• Maintaining the unconscious patient in a position that facilitates drainage of oral
secretions, with the head of the bed elevated about 30 degrees to decrease
intracranial venous pressure
• Establishing effective suctioning procedures (pulmonary secretions produce
coughing and straining, which increase ICP)
• Guarding against aspiration and respiratory insufficiency

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• Closely monitoring arterial blood gas values to assess the adequacy of ventilation.
The goal is to keep blood gas values within the normal range to ensure adequate
cerebral blood flow
• Monitoring the patient who is receiving mechanical ventilation for pulmonary
complications such as acute respiratory distress syndrome (ARDS) and pneumonia

Monitoring fluid and electrolyte balance. Brain damage can produce metabolic and
hormonal dysfunctions. The monitoring of serum electrolyte levels is important, especially in
patients receiving osmotic diuretics, those with syndrome of inappropriate antidiuretic
hormone (SIADH) secretion, and those with posttraumatic diabetes insipidus. Serial studies
of blood and urine electrolytes and osmolality are carried out because head injuries may be
accompanied by disorders of sodium regulation. Hyponatremia is common after head injury
due to shifts in extracellular fluid, electrolytes, and volume. Hyperglycemia, for example, can
cause an increase in extracellular fluid that lowers sodium. Hypernatremia may also occur as
a result of sodium retention that may last several days, followed by sodium diuresis.
Increasing lethargy, confusion, and seizures may be the result of electrolyte imbalance.
Endocrine function is evaluated by monitoring serum electrolytes, blood glucose values, and
intake and output. Urine is tested regularly for acetone. A record of daily weights is
maintained, especially if the patient has hypothalamic involvement and is at risk for the
development of diabetes insipidus.

Promoting adequate nutrition. Head injury results in metabolic changes that can
increase calorie consumption and nitrogen excretion. Protein demand increases. Early
initiation of nutritional therapy has been shown to improve outcomes in patients with head
injury. Patients with brain injury are assumed to be catabolic and nutritional support
consultation should be considered as soon as the patient is admitted. Parenteral nutrition
via a central line or enteral feedings administered via a nasogastric or nasojejunal feeding
tube should be considered. If CSF rhinorrhea occurs, an oral feeding tube should be inserted
instead of a nasal tube. Laboratory values should be monitored closely in patients receiving
parenteral nutrition. Elevating the head of the bed and aspirating the enteral tube for
evidence of residual feeding before administering additional feedings can help prevent
distention, regurgitation, and aspiration. A continuous drip infusion or pump may be used to
regulate the feeding. Enteral or parenteral feedings are usually continued until the
swallowing reflex returns and the patient can meet caloric requirements orally.

Preventing injury . Often, as the patient emerges from coma, a period of lethargy and
stupor is followed by a period of agitation. Each phase is variable and depends on the
individual person, the location of the injury, the depth and duration of coma, and the
patient’s age. Restlessness may be caused by hypoxia, fever, pain, or a full bladder. It may
indicate injury to the brain but may also be a sign that the patient is regaining
consciousness. Agitation may also be the result of discomfort from catheters, intravenous
(IV) lines, restraints, and repeated neurologic checks.

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Strategies to prevent injury include the following:

• The patient is assessed to ensure that oxygenation is adequate and the bladder is
not distended
Dressings and casts are checked for constriction
Padded side rails are used or the patient’s hands are wrapped in mitts to protect
the patient from self-injury and dislodging of tubes
• Restraints are avoided, because straining against them can increase ICP or cause
other injury.
• Opioids are avoided as a means of controlling restlessness, because they depress
respiration, constrict the pupils, and alter responsiveness
• Environmental stimuli are reduced by keeping the room quiet, limiting visitors,
speaking calmly, and providing frequent orientation information
• Adequate lighting is provided to prevent visual hallucinations
• Efforts are made to minimize disruption of the patient’s sleep–wake cycles
• The patient’s skin is lubricated with oil or emollient lotion to prevent irritation due
to rubbing against the sheet
• If incontinence occurs, an external sheath catheter may be used on a male
patient. Because prolonged use of an indwelling catheter inevitably produces
infection, the patient may be placed on an intermittent catheterization schedule

Maintaining body temperature. Fever in TBI patients can be the result of damage to
the hypothalamus, cerebral irritation from hemorrhage, or infection. Monitor the patient’s
temperature every 2 to 4 hours. If the temperature increases, identify the cause and control
it using acetaminophen and cooling blankets to maintain normothermia. If infection is
suspected, potential sites of infection are cultured and antibiotics are administered as
ordered.

Maintaining skin integrity. Patients with TBI often require assistance in turning and
positioning because of immobility or unconsciousness. Prolonged pressure on the tissues
decreases circulation and leads to tissue necrosis. Potential areas of breakdown need to be
identified early to avoid the development of pressure ulcers. Specific nursing measures
include the following:
• Assessing all body surfaces and documenting skin integrity every 8 hours
• Turning and repositioning the patient every 2 hours
• Providing skin care every 4 hours
• Assisting the patient to get out of bed to a chair three times a day

Improving cognitive functioning. Although many patients with head injury survive
because of resuscitative and supportive technology, they frequently have significant
cognitive sequelae that may not be detected during the acute phase of injury. Cognitive
impairment includes memory deficits, decreased ability to focus and sustain attention to a

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task (distractibility), reduced ability to process information, and slowness in thinking,

perceiving, communicating, reading, and writing. Psychiatric, emotional, and relationship
problems develop in many patients after head injury. Resulting psychosocial, behavioral,
emotional, and cognitive impairments are devastating to the family as well as to the patient.
Cognitive rehabilitation activities may help the patient to devise new problem-solving
strategies. Assistance from many disciplines is necessary.

Supporting family coping. Having a loved one sustain a TBI produces a great deal of
stress in the family. This stress can result from the patient’s physical and emotional deficits,
the unpredictable outcome, and altered family relationships. Families report difficulties in
coping with changes in the patient’s temperament, behavior, and personality. Such changes
are associated with disruption in family cohesion, loss of leisure pursuits, and loss of work
capacity, as well as social isolation of the care taker.

To promote effective coping, you can ask the family how the patient is different now,
what has been lost, and what is most difficult about coping with this situation. Helpful
interventions include providing family members with accurate and honest information and
encouraging them to continue to set well-defined short-term goals. Family counseling helps
address the family members’ overwhelming feelings of loss and helplessness and gives them
guidance for the management of inappropriate behaviors. Support groups help the family
members share problems, develop insight, gain information, network, and gain assistance in
maintaining realistic expectations and hope.

Many patients with severe head injury die from their injuries, and many of those
who survive experience long-term disabilities that prevent them from resuming their
previous roles and functions. During the most acute phase of injury, family members need
factual information and support from the health care team. Many patients with severe head
injuries that result in brain death are young and otherwise healthy and are therefore
considered for organ donation. Family members of patients with such injuries need support
during this extremely stressful time and assistance in making decisions to end life support
and permit donation of organs. They need to know that the patient who is brain dead and
whose respiratory and cardiovascular systems are maintained through life support is not
going to survive and that the severe head injury, not the removal of the patient’s organs or
the removal of life support, is the cause of the patient’s death.

Monitoring and managing potential complications. Because of the seriousness of the

TBI patient’s condition, intensive care is needed and they are monitored very closely. The
following complications should also be monitored:

Decreased cerebral perfusion pressure. Maintenance of adequate CPP is important

to prevent serious complications of head injury due to decreased cerebral perfusion.
Adequate CPP is greater than 60 mm Hg. A decrease in CPP can impair cerebral perfusion

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and cause brain hypoxia and ischemia, leading to permanent brain damage. Once the
threshold CPP is reached, vasoconstriction of the cerebral blood vessels occurs, causing ICP
to decrease. Therapy is directed toward decreasing cerebral edema and increasing venous
outflow from the brain. Systemic hypotension, which causes vasoconstriction and a
significant decrease in CPP, is treated with increased IV fluids or vasopressors.

Cerebral edema and herniation. The patient with a head injury is at risk for additional
complications such as increased ICP and brain stem herniation. Cerebral edema is the most
common cause of increased ICP in the patient with a head injury, with the swelling peaking
approximately 48 to 72 hours after injury. Bleeding also may increase the volume of
contents within the rigid, closed compartment of the skull, causing increased ICP and
herniation of the brain stem and resulting in irreversible brain anoxia and brain death.
Measures to control ICP include the following:

Elevate the head of the bed as prescribed

Maintain the patient’s head and neck in neutral alignment (no twisting or flexing
the neck)
• Initiate measures to prevent the Valsalva maneuver
• Maintain normal body temperature
• Administer O2 to maintain PaO2 >90 mm Hg
• Maintain fluid balance with normal saline solution
• Avoid noxious stimuli (e.g., excessive suctioning, painful procedures)
• Administer sedation to reduce agitation
• Maintain cerebral perfusion pressure >70 mm Hg.

Impaired oxygenation and ventilation. Impaired oxygen and ventilation may require
mechanical ventilatory support. The patient must be monitored for a patent airway, altered
breathing patterns, and hypoxemia and pneumonia. Interventions may include endotracheal
intubation, mechanical ventilation, and positive end-expiratory pressure.

Impaired fluid, electrolyte, and nutritional balance. Fluid, electrolyte, and nutritional
imbalances are common in the patient with a head injury. Common imbalances include
hyponatremia, hypokalemia, and hyperglycemia. Modifications in fluid intake with tube
feedings or IV fluids may be necessary to treat these imbalances. Insulin administration may
be prescribed to treat hyperglycemia. Undernutrition is also a common problem in response
to the increased metabolic needs associated with severe head injury. Decisions about early
feeding should be individualized; options include IV hyperalimentation or placement of a
feeding tube. Feeding tubes should be placed 3 to 7 days after neurologic injury to replace
energy and nitrogen losses, prevent increased mortality, and improve outcomes.

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Posttraumatic seizures. TBI patients are at an increased risk for posttraumatic

seizures. Posttraumatic seizures are classified as immediate (within 24 hours after injury),
early (within 1 to 7 days after injury), or late (more than 7 days after injury). Seizure
prophylaxis is practiced by administering antiseizure medications. It is important to prevent
posttraumatic seizures, especially in the immediate and early phases of recovery, because
seizures may increase ICP and decrease oxygenation. However, many antiseizure
medications impair cognitive performance and can prolong the duration of rehabilitation.
Therefore, it is important to weigh the overall benefit of these medications against their side
effects. Research evidence supports the use of prophylactic antiseizure agents to prevent
immediate and early seizures after head injury, but not for prevention of late seizures.

Promoting home and community-based care. Relevant patient and family instruction is
paramount to promote care when patient is discharged from the hospital. Discuss with the
patient and family aspects of care that they need to focus on such as performing selfcare,
complying with the therapeutic regimen, and preventing complications.

Teaching patients self-care. Teaching early in the course of head injury often focuses
on reinforcing information given to the family about the patient’s condition and prognosis.
As the patient’s status and expected outcome change over time, family teaching may focus
on interpretation and explanation of changes in the patient’s physical and psychological
responses. If the patient’s physical status allows discharge to home, the patient and family
are instructed about limitations that can be expected and complications that may occur.
Explain how to monitor for complications that merit contacting the neurosurgeon.
Depending on the patient’s prognosis and physical and cognitive status, the patient may be
included in teaching about self-care management strategies. If the patient is at risk for late
posttraumatic seizures, antiseizure medications may be prescribed at discharge. Provide
instruction about the side effects of these medications and the importance of continuing to
take them as prescribed.

Continuing care. The rehabilitation phase of care for the patient with a TBI begins at
hospital admission. The goals of rehabilitation are to maximize the patient’s ability to return
to his or her highest level of functioning and to his or her home and the community, address
concerns before discharge for a smooth transition to home or rehabilitation, and promote
independence with adaptation to deficits. The patient is encouraged to continue the
rehabilitation program after discharge, because improvement in status may continue 3 or
more years after injury. Continued teaching and support of the patient and family are
essential as their needs and the patient’s status change.

Depending on their status, TBI patients are encouraged to return to normal activities
gradually. Referral to support groups and to the Brain Injury Association may be war ranted.
During the acute and rehabilitation phases of care, the focus of teaching is on obvious
needs, issues, deficits, and complications. Complications after TBI include infections (e.g.,

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pneumonia, UTI, septicemia, wound infection, brain abscess) and heterotrophic ossification
(painful bone overgrowth in weight-bearing joints). The need for continuing health
promotion and screening practices after the initial phase of care must be emphasized.

Evaluation. Expected patient outcomes may include the following:

• Attains or maintains effective airway clearance, ventilation, and brain oxygenation
a. Achieves normal blood gas values and has normal breath sounds on
auscultation
b. Mobilizes and clears secretions
• Achieves satisfactory fluid and electrolyte balance
a. Demonstrates serum electrolytes within normal range
b. Has no clinical signs of dehydration or overhydration
• Attains adequate nutritional status
a. Has less than 50 mL of aspirate in stomach before each tube feeding
b. Is free of gastric distention and vomiting
c. Shows minimal weight loss
• Avoids injury
a. Shows lessening agitation and restlessness
b. Is oriented to time, place, and person
• Maintains normal body temperature
a. Absence of fever
b. Absence of hypothermia
• Demonstrates intact skin integrity
a. Exhibits no redness or breaks in skin integrity
b. Exhibits no pressure ulcers
Shows improvement in cognitive function and improved memory
Demonstrates absence of complications
a. Exhibits normal vital signs and body temperature, and increasing orientation to
time, place, and person
b. Demonstrates normal or reduced ICP
• Experiences no posttraumatic seizures
a. Takes antiseizure medications as prescribed
b. Identifies side effects/adverse effects of antiseizure medications
• Family demonstrates adaptive family processes
a. Joins support group
b. Shares feelings with appropriate health care personnel
c. Makes end-of-life decisions, if needed
• Participates in rehabilitation process as indicated for patient and family members
a. Takes active role in identifying rehabilitation goals and participating in
recommended patient care activities
b. Prepares for discharge.

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LEARNING ACTIVITY. Critical thinking exercise.

A 65-year-old man is brought to the emergency department by his

family, who report that he fell approxi mately 2 weeks ago in the bathroom. The
patient does not recall the event. His family states that he is sleeping more than
usual and seems forgetful. The patient is prescribed warfarin (Coumadin) daily.
What type of injury has he most likely sustained? What type of medical
treatment might he undergo? What discharge instructions are war ranted for
this patient’s family or caregiver?

This ends our discussion in lesson 3. Check your understanding of the topics by answering
the short quiz in the learning management system (LMS) of this course. Feedback will be
given after the quiz is closed.
Good luck!

Chapter 6 Lesson 3: Traumatic Alterations