CNS

BY PN WAN NAPISAH
BINTI WAN OMAR

LEARNING OBJECTIVES

At the end of this session, students will be able
to:
1. Explain the mechanisms of Traumatic Brain Injury.
2. Describe the types of head & brain injury.
3. Explain the causes & effect of Spinal Injury.
4. Define the term of Autonomic Hyperreflexion.
5. Describe signs & symptoms of head & spinal injury.
6. Identify the diagnostic tests & complications for head &

spinal injury.
7. Explain the importance of early treatment for head &

spinal injury in order to reduce the morbidity & mortality.

HEAD INJURY

• Traumatic head injuries are a major cause of
death, and disability.

• Force applied to the head may cause the brain
to be directly injured or shaken, bouncing
against the inner wall of the skull.

• Head injury can be defined as any alteration in
mental or physical functioning related to a
blow to the head.

MECHANISMS OF TRAUMATIC BRAIN INJURY

MECHANISM DEFINITION EXAMPLES
Acceleration
Deceleration Moving object hits stationary head Baseball, fist, hammer
Coup-contrecoup
Moving head hits stationary object Windshield, wall, ground

Results from movement of the Falls, hitting the windshield

intracranial contents within the

cranium; the brain hits the wall of

cranium (coup), then bounces in

the opposite direction & hits the

cranium directly opposite the initial

impact (contrecoup)

Penetrating Object enters the skull & injuries Knives, scissors, gunshot
the brain.





TYPES OF HEAD INJURIES

1. Scalp lacerations
2. Skull fractures
3. Brain injuries
4. Medical conditions

SCALP LACERATIONS

• Can be minor or very
serious.

• May contribute to
hypovolemia.

• Don’t apply excessive
pressure to the open
wound & not to remove
soaked dressing.

• Place a second dressing
over the first & continue
applying manual pressure
until the bleeding is
controlled.

SKULL FRACTURE

• It is due to significant
force on the head.

• May cause open or
closed fracture.

• The presenting signs are
obvious deformity,
visible crack in the skull,
Raccoon eyes & Battle’s
sign.

SKULL FRACTURE

RACCOON EYES BATTLE’S SIGN

BRAIN INJURIES

1. Concussion
2. Contusion
3. Intracranial Bleeding

a. Subdural Hematoma
b. Epidural Hematoma
c. Subarachnoid Haemorrhage

CONCUSSION

• Resulted from a blow to
the head.

• Means temporary loss
of alteration in brain
function without actual
physical damage to the
brain.

• May cause loss of
consciousness,
confusion or amnesia.

Concussion

• Symptoms

- temporary loss of consciousness, confusion,
ringing in the ears, slurred speech, dazed
appearance, fatigue, personality changes,
sensitivity to light, dizziness, headache, and
delayed responses.

- Seek the doctor if loss of consciousness lasts
longer than thirty seconds (30sc) or repeated
vomiting occurs.

Concussion

• Causes

- being hit on a hard surface, fights, or impact
sports
• Risks

- headaches and vertigo

- likely to develop epilepsy

- repeated head injuries. This is most common
in impact sports players like boxers and
football players can cause limited brain
function and ability.

Concussion

• Treatment
- plenty of rest. It is needed in order for your

brain to fully heal and recover.
- Limiting activities is also necessary, especially

things that involve a high level of thinking or
concentration.

CONTUSION

• The brain can sustain a
bruise when the skull is
struck.

• Can cause long lasting
or even permanent
damage of brain tissue.

• ICP may increase due to
bleed & swell.

CONTUSION

• Symptoms

- sleepiness, loss of consciousness, seizures,
coordination problems, memory loss, vision
and speech problems, and a change in
personality or behavior.

• Prognosis

- minor cases can heal on their own with little
to no medical treatment

- In very severe cases herniation of the brain
can result, which will eventually end in a coma
and possibly death.

CONTUSION

• Treatment
- depends largely on how severe the injury is
- Hospitalization.
- Ultrasounds and MRI’s.
- craniotomy may be done to remove the

contusion.
- In mild cases rest and observation

INTRACRANIAL BLEEDING

a. Subdural hematoma

 bridging veins that cross
through the subdural space
tear and bleed.

b. Epidural Hematoma

 blood is trapped in a small
area between dura & skull.

c. Subarachnoid Haemorrhage

 blood accumulates in the
space beneath the inner
arachnoid layer of the
meninges & often associated
with an intracerebral bleed

MEDICAL CONDITION

• Medical condition may
cause spontaneous
bleeding in the brain.

• Such as hypertension,
arteriovenous
malformation.

COMPLICATIONS OF HEAD INJURY

1. Focal neurologic deficits
2. Hydrocephalus
3. Seizure
4. CSF Fistulae
5. Vascular injuries
6. Infections
7. Brain death

SIGNS & SYMPTOMS OF HEAD INJURY

• Laceration, contusions & hematomas to the scalp.
• Soft areas or depression upon palpation.
• Visible skull fractures.
• Ecchymosis around eyes & behind the ear.
• Clear or pink CSF leakage.
• Failure of pupils to respond to light.
• Unequal pupils.
• Loss of sensation & motor function.

SIGNS & SYMPTOMS OF HEAD INJURY

• Period of consciousness.
• Amnesia
• Seizures.
• Numbness or tingling in the extremities.
• Irregular respirations.
• Dizziness
• Visual complaints
• Combative or abnormal behavior
• Nausea or vomiting.

DIAGNOSTIC TESTS

• Physical examination and the history of the
patient.

• Skull X-rays (especially for infant)
• Computerized tomography (CT) scan

MANAGEMENT OF HEAD INJURY

1. Respiratory care – intubation
2. Osmotic diuretic – Mannitol
3. Hypertonic saline – NS 3%
4. ICP monitoring
5. Medication

5. Medication

 Sedative: agitation, painful systemic injuries that require
pain medication Benzodiazepines ,Midazolam

 Corticosteroid : Methylprednisolone ; proved by
research in US( six months patients who had received
corticosteroids within eight hours of injury had greater
improvement in motor function and in sensation to
pinprick and touch.)

 Anticonvulsant - to minimize the brain damage by
preventing early seizures
: Phenytoin (Dilantin)

Medication

 Diuretic – to decrease ICP,brain volume
- Mannitol (osmotic diuretic)
-sugar alcohol that draws water out from the brain into

the intravascular compartment.
- furosemide, glycerol, and urea.

 Monitor intake/output

NURSING MANAGEMENT OF HEAD INJURY

6. Continuous GCS monitoring
7. Nutritional support
8. Pressure area care
9. Positioning (keep prop up to prevent increase

ICP) - normal ICP is 0-10mmHg.
10.Hygiene care
11.Temperature control to prevent hypothermia

Nursing diagnoses (actual)

1. Ineffective airway clearance and impaired gas
exchange related to brain injury.

2. Deficit fluid volume related to decreased LOC and
hormonal dysfunction.

3. Imbalanced nutrition less than body requirements,
related to increased metabolic demands, fluid
restriction and inadequate intake.

4. Disturbed sleep pattern related to brain injury and
frequent neurological checks.

5. Defisit knowledge about brain injury,recovery and
the rehabilitation process.

Nursing diagnose (Potential)

1. Risk for injury related to seizures,
disorientation and restlessness or brain
damage.

2. Risk for imbalanced body temperature
related to damaged temperature regulating
mechanisms in the brain.

3. Risk for impaired skin integrity related to
bedrest, hemiparesis, hemiplegia and
immobility or restlessness.

SPINAL INJURY

• The spinal cord contains the
nerves that carry messages
between your brain and
body. The cord passes
through your neck and back.

• A spinal cord injury is very
serious because it can cause
loss of movement (paralysis)
below the site of the injury.

CAUSES OF SPINAL INJURY

1. Bullet or stab wound
2. Traumatic injury to the face, neck, head,

chest, or back (for example, a car accident)
3. Diving accident
4. Electric shock
5. Extreme twisting of the middle of the body
6. Landing on the head during a sports injury
7. Fall from a great height

SIGNS & SYMPTOMS OF SPINAL INJURY

• Head that is in an unusual position
• Numbness or tingling that spreads down an arm or

leg
• Weakness
• Difficulty walking
• Paralysis (loss of movement) of arms or legs
• No bladder or bowel control
• Shock (pale, clammy skin; bluish lips and fingernails;

acting dazed or semiconscious)
• Lack of alertness (unconsciousness)
• Stiff neck, headache, or neck pain

CERVICAL (NECK) INJURIES

• Symptoms can affect the
arms, legs, and middle of
the body.

• May occur on one or both
sides of the body.

• Symptoms can also include
breathing difficulties from
paralysis of the breathing
muscles, if the injury is high
up in the neck.

THORACIC (CHEST LEVEL) INJURIES

• When spinal injuries occur
at chest level, symptoms
can affect the legs.

• Injuries to the cervical or
high thoracic spinal cord
may also result in blood
pressure problems,
abnormal sweating, and
trouble maintaining
normal body temperature.

LUMBAR SACRAL (LOWER BACK)
INJURIES

• When spinal injuries
occur at the lower back
level, symptoms can
affect one or both legs,
as well as the muscles
that control the bowels
and bladder.

THE
EFFECTS
OF
SPINAL
CORD
INJURY



COMPLICATIONS OF SPINAL INJURY

• Autonomic hyperreflexia ( Dysreflexia)
• Muscle spasticity
• Pain
• Paralysis of breathing muscles
• Paralysis (paraplegia, quadriplegia)
• Pressure sores
• Contractures
• Deep vein thrombosis
• Infections

AUTONOMIC HYPERREFLEXIA

• Autonomic hyperreflexia is a reaction of the
autonomic (involuntary) nervous system to
overstimulation.

• This reaction may include high blood pressure,
change in heart rate, skin color changes (paleness,
redness, blue-grey skin color), and excessive
sweating.

• This condition is life-threatening so it is important to
quickly identify and treat the problem.

AUTONOMIC HYPERREFLEXIA /

AD (DYSREFLEXIA )

• A person with symptoms of autonomic hyperreflexia
should:

– Sit up and raise their head
– Remove tight clothing

• In people with spinal cord injury, the following may
also help prevent this complication:

– Avoid letting the bladder become too full.
– Keep pain levels low.
– Practice proper bowel care to avoid stool impaction.
– Practice proper skin care to avoid bedsores and skin

infections.



DIAGNOSTIC TESTS

• Physical examination
• Neurological examination
• X – ray spine
• CT scan (CT scan is very good to show bony

damage)
• MRI (MRI scan is good for showing soft tissue injury

such as the spinal cord and ligaments as well as any

bleeding)
• Myelogram

MANAGEMENT FOR SPINAL INJURY

ACUTE SITUATION
• Maintaining A, B & C.
• Preventing shock
• Immobilizing neck to prevent further spinal cord

damage.
• Medications

– Corticosteroids, such as dexamethasone or
methylprednisolone, are used to reduce swelling that may
damage the spinal cord.

– Analgesic (Neurontin)
– Muscle relaxer (baclofen)

SURGERY

• Surgery may be needed to:

– Remove fluid or tissue that presses on the spinal
cord (decompression laminectomy)

– Remove bone fragments, disk fragments, or
foreign objects

– Fuse broken spinal bones
or place spinal braces

• Spinal traction

NURSING MANAGEMENT FOR
SPINAL INJURY

• CRIB – to encourage healing process
• Care of the skin, and bowel and bladder

dysfunction.
• Physical therapy, occupational therapy, and

other rehabilitation therapies.