Neurological Disorders

1
Neurological Disorders

• Sherry Burrell, RN, MSN
• Rutgers University
• Nursing III

2
General Neuro Signs / Symptoms

• Fainting
• Dizziness
• Seizures
• Headache
• Memory Loss
• Weakness

• Pain
• Numbness / Tingling
• Speech changes
• Vision changes
• Tremors
• Paralysis

3
Neurological History

• Explore presenting compliant(s)
• Precipitating events
• Progression of signs / symptoms
• Client Information
• Allergies
• Medical, surgical and / or traumatic history
• Medications
• Habits
• Lifestyle changes
• Family History

4
Neurologic Assessment

• Physical Examination Components
• Level of consciousness
• Motor function
• Pupillary function / eye movements
• Respiratory pattern
• Vital signs changes

5
Level of Consciousness

• Most important aspect of neurologic examination
• Level of consciousness first to deteriorate
  (often subtle)
• Consciousness
• Arousal (alertness) and Awareness (content)
• Levels of Consciousness
• Alert
• Lethargic
• Obtunded
• Stuporous
• Comatose

Thalen Box 24-2 pp. 647
6
LOC Assessment Tools

• Glasgow Coma Scale (GCS)
• Three Categories
• Eye opening, verbal response and motor response
• Scoring
• Highest or best possible score 15
• A score of lt 7 indicates coma (generally)
• Lowest or worst possible score 3
• Not appropriate for use in
• Children, intoxicated clients or spinal cord
  injuries

Thalen Table 24-1 pp.647
7
Motor Assessment

• Steps of examination
• Observe for spontaneous movement
• Elicit motor movement in response to stimuli
• Type of Stimuli
• Verbal
• Simple and direct statements no visual or
  tactile stimuli
• Reduce environmental stimuli or distractions
• Noxious (painful)
• When no response to verbal stimuli
• Acceptable methods nail bed pressure and
  trapezius pinch

8
Motor Responses

• Level of Motor Movements Strength
• Evaluate each extremity compare with opposite
  side and record separately
• Other considerations Seizure activity
• Abnormal Motor Responses
• In the unconscious client noxious stimuli may
  elicit abnormal posturing
• Decorticate (abnormal flexion)
• Decerebrate (abnormal extension)
• Flaccidity

9
Abnormal Posturing
? Decorticate Posturing
? Decerebrate Posturing
10
Motor Reflexes

• Deep Tendon Reflexes (DTR)
• Tap appropriate tendon with percussion or reflex
  hammer usually done by MD
• Achilles (ankle), quadriceps (knee jerk), biceps
  and triceps
• Graded 0-4 ( 0 none? 2 normal ? 4
  hyperactive)
• Superficial Reflexes
• Corneal
• Gag
• Swallowing
• Oculocephalic (Dolls eyes)
• Abnormal Adult Reflexes
• Babinski

11
Pupillary Function Eye Movement

• Evaluate both pupils for equality
• Size (mm)
• Shape
• Response to light note consensual response
• Extraocular movements (EOM)
• CN III, CN IV and CN VI

12
Respiratory Alterations

• Cheyne-Stokes
• Rhythmic crescendo decrescendo rate and depth
  of respiration brief periods of apnea
• Central Neurogenic Hyperventilation
• Very deep, very rapid respirations no apnea
• Apneustic
• 2-3 second inspiratory and / or expiratory pause
• Cluster Breathing
• Groupings of irregular, gasping respirations
  separated by long periods of apnea
• Ataxic Respirations
• Irregular, random pattern deep and shallow
  respirations with periods of apnea (irregular
  too).

Thalen table 24-2 pp. 655
13
Vital Sign Changes

• Cushings Triad
• Severe elevations in intracranial pressure result
  in classic clinical manifestation of Cushings
  Triad
• Bradycardia
• Systolic hypertension (with widened pulse
  pressure)
• Bradypnea
• Grave occurrence, if increased ICP is not
  addressed herniation will result.

14
Diagnostics

• X-rays
• CT Scans
• MRI
• Cerebral angiography
• Evoked potentials
• Myelography
• Lumbar puncture
• Laboratory testing
• Serum, CSF, tissue biopsies and urine

15
Intracranial Pressures (ICP)

• Brain contained within the skull (closed
  container)
• Intracranial space is occupied by three
  components
• Blood (arterial venous) 150 ml
• Cerebral Spinal Fluid (CSF) 150 ml
• Brain Tissue / Substance 1400 ml
• Normal physiologic conditions ICP lt 15 mmHg
• Increased ICP
• Any value sustained at 20 mmHg requires medical
  intervention.

16
Increased Intracranial Pressures

• Monro-Kellie Hypothesis
• Increase in one intracranial component must be
  compensated by a decrease in one or more of the
  other components.
• Closed container compensation is limited once
  exhausted the result is a rapid increase in ICP
• Causes of Increased ICP
• Trauma
• Head injuries (most common)
• Intracranial Tumors
• Space occupying lesions
• Other Causes

17
Cerebral Perfusion Pressure

• Cerebral perfusion pressure (CPP) is the pressure
  needed to ensure blood flow to the brain
• CPP MAP- ICP
• The brain needs a cerebral perfusion pressure
  (CPP) of 80-100mmHg.
• Below 30 mmHg (sustained) irreversible neurologic
  damage occurs.
• If CPP equals to SBP cerebral blood flow will
  cease.

18
Increased ICP

• A pathologic condition altering the relationship
  between intracranial volume and pressure.
• Leading to
• Decrease in cerebral blood flow and tissue
  perfusion
• Stimulation of cerebral swelling (edema)
• Shifts in brain tissue (herniation)

19
Stages of Increased ICP

• Stage I
• Headache
• History of head injury
• Vital signs / pupillary responses normal
• Stage II
• Mental Status Changes (first change)
• Vital signs / pupillary responses normal

Thalen figure 24-7 pp.657
20
Increased ICP

• Stage III
• Decreased LOC (lethargy ?obtunded ?stupor)
• Vomiting (maybe projectile)
• Small pupils sluggish responses to light
• Cushings Triad systolic HTN (widening pulse
  pressure), bradypnea and bradycardia (bounding,
  slow pulse)
• Stage IV
• Comatose
• Pupils dilated ? fixed
• Abnormal posturing decorticate / decerebrate?
  flaccidity
• Cushings triad progresses ?herniation ? brain
  death

21
ICP Monitoring

• Four Methods of ICP Monitoring
• Intraventricular
• A small catheter is placed within the ventricular
  system (ventriculostomy)
• Subarachnoid
• Hollow bolt or screw into the subarachnoid space
• Epidural
• Small fiberoptic sensor into epidural space
  (between skull dura)
• Intraparechymal
• Small fiberoptic catheter into the white matter
  of brain tissue (parenchyma)

22
Management of Increased ICP

• Nursing Activities and Positioning
• HOB elevated to 30 degrees
• Trendelenburg, prone positions should be avoided
  / limited
• Head should be maintained neutral position
  (midline)
• Avoid extreme neck flexion or rotation and hip
  flexion
• Identify daily care activities that increase ICP
• Avoid Valsalva maneuver turning or straining
  with BM
• Provide rest periods
• Reduce environmental stimuli
• Encourage significant other contact and
  therapeutic touch

23
Management of Increased ICP

• Nursing Activities and Positioning Cont.,
• Respiratory / Ventilator Considerations
• Suctioning
• Hyperoxygenate before and after each pass
• Limit the number of passes (1 to 2) and duration
  (lt 10 seconds)
• Ensure tracheostomy ties are not too tight
• Limit / avoid coughing
• Avoid PEEP gt 20 cm H2O
• Hyperventilation
• PaCO2 low end of normal current trend ( 35 mmHg)

24
Management of Increased ICP

• Nursing Activities and Positioning Cont.,
• Prevention Infection
• Aseptic techniques ICP catheter, other invasive
  lines and foley
• Temperature Regulation
• Hyperthermia antipyretics and cooling blankets
• Blood Pressure Control
• Delicate balance in neurologic patient
• Sedatives used first then antihypertensives
• Seizure Control
• Anticonvulsants Prophylactic
• i.e. Dilantin until therapeutic levels reached
  Ativan
• Seizure Precautions

25
Management of Increased ICP

• Nursing Activities and Positioning Cont.,
• Volume Control
• CSF Drainage (ventriculostomy)
• Osmotic Diuretics
• Control of Metabolic Demand
• Barbiturate Therapy / Coma
• Control of Cerebral Edema
• Steroids (i.e. dexamethasone)
• Nutrition Support
• High protein
• Parenteral nutrition
• Pain / Anxiety Management
• Benzodiazepines to clam without decreasing LOC

26
Management of Increased ICP

• Nursing Activities and Positioning Cont.,
• Monitoring Considerations
• Vital Signs
• Neurological exams
• Trends of signs and symptoms paramount
• ICP monitoring device
• Note amount and appearance of CSF drainage
• Strict I O
• Daily weights
• Laboratory values

27
Management of IICP

• Surgical Considerations
• Craniotomy
• Removal of tumor, relieve increased ICP, evacuate
  a hematoma and /or control hemorrhage.
• Surgical Approaches
• Transcranial
• Transsphenoidal

28
Craniotomy Considerations

• Pre-operative Nursing Care
• Baseline assessment data
• Laboratory data sent and monitored
• Diagnostics completed
• Prep surgical site (shave hair)
• Support
• Education
• Post-operative Nursing Care
• Neurological checks hourly or more!
• Vital signs hourly
• Maintain ICP monitoring device

29
Post Craniotomy

• Nursing Prevention / Management
• Increased ICP
• i.e. vomiting
• Hemorrhage
• Fluid and electrolyte imbalance (check labs.)
• CSF leak
• Deep vein thrombosis (DTV) prevention
• Gastric ulcerations
• Pulmonary infections
• Seizures
• Air embolism

30
Complications of Increased ICP

• Diabetes Insipidus
• SIADH
• Herniation
• Brain Death

31
Diabetes Insipidus

• Decreased secretion of antidiuretic hormone (ADH)
• Clinical Manifestations
• Hypernatremia (serum)
• Excessive water losses via urine (very dilute
  urine)
• Client may become hypovolemic or dehydrated
• Management
• Fluid volume
• Encourage oral intake of fluids (if possible)
• I.V. fluids careful monitoring laboratory
  results and BP
• Electrolyte replacements
• Vasopressin therapy
• Pitressin or Desmopression DDAVP

32
SIADH

• Increased secretion of antidiuretic hormone (ADH)
• Clinical Manifestations
• Decreased urinary output (very concentrated
  urine)
• Hyponatremia (serum)
• Further increase in ICP
• Volume overload
• i.e. peripheral edema and weight gain
• Management
• Fluid restriction

33
Herniation Brain Death

• Herniation
• Result of excessive ICP result cessation of CBF
• Leads to irreversible brain anoxia and brain
  death
• Brain Death
• Complete, irreversible cessation of function of
  the entire brain and brain stem.
• Mechanical support sustaining life
• Nursing Considerations
• Organ Donation

34
Head Injuries

• Broad term to classify sudden trauma to head
  including injuries sustained to the scalp, skull
  or brain.
• Most common causes
• MVA motor vehicle accidents (50)
• Falls (21)
• Violence (12)
• Sports related-injuries (10)

35
Mechanisms of Head Injuries

• Closed Injuries
• Blunt, Nonmissile Injuries
• Coup and Contrecoup
• Direct injury at site of initial impact of trauma
  (Coup)
• Indirect injury at opposite pole (Contrecoup)
• Open Injuries
• Penetrating, missile injuries
• Communication of intracranial contents with
  external environment
• Increase risk of infection

36
Clinical Manifestations

• Neurological deficits
• Altered LOC
• Confusion
• Vital sign changes
• Altered reflexes
• Gag
• Corneal

• Headache
• Dizziness
• Impaired hearing or vision
• Sensory or motor dysfunction
• Seizures

37
Scalp Injuries

• Isolated scalp injuries usually classified as
  minor head injuries.
• The scalp is highly vascular with poor
  constrictive abilities bleeding is often profuse
• Infection is a major concern, which must be
  prevented!!

38
Skull Fractures

• Actual break in continuity of skull
• Cause is extreme, forceful trauma
• Brain injury may or may not occur
• Types of Skull Fractures
• Linear
• Basilar
• Depressed

39
Skull Fractures Cont.,

• Basilar
• Fracture at base of skull usually temporal or
  frontal areas
• Bleeding from nose, pharynx, ears or into
  conjunctiva
• Bruising
• Battles sign ecchymosis over mastoid
• Raccoon (eyes) sign bilateral periorbital
  ecchymosis
• CSF leak from nose or ears
• Watch for Infection !!
• Depressed
• Downward depression of bone into intracranial
  cavity
• Maybe comminuted shattering or fragmenting of
  bone

40
Cerebral Concussion

• Head injury with temporary loss of neurological
  function with no (gross or microscopic)
  structural damage.
• Cause jarring of the brain closed (nonmissile)
  injuries
• Clinical Manifestations
• Loss of consciousness usually brief
• S/Sx Dependent on location of injury to brain
  tissue
• Post concussion syndrome
• Usually occurs within 24 to 48 hours after injury
  but, may present up to several months later.
• S/Sx HA, dizziness, lethargy, irritability and
  anxiety
• May affect everyday home or work-related
  activities

41
Cerebral Contusion

• More severe injury than concussion
• Bruising of the brain
• Maybe caused by both open and closed injuries
• Initial loss of consciousness
• Clinical Manifestations
• Alterations in level of consciousness
• Focal neurological deficits
• Seizures
• Vomiting (maybe projectile)
• Increased ICP

42
Intracranial Hemorrhage (ICH)

• Trauma can cause bleeding within the brain tissue
  or within the spaces surrounding the brain
• The result is hematomas or collections of blood
  within cranial vault most serious of brain
  injuries
• Classified according to location
• Epidural hematoma
• Subdural hematoma
• Intracerebral hematoma

43
Epidural Hematoma

• Blood collects between skull and dura mater
• Most often arise from arterial hemorrhage
• Cause usually is injury of middle meningeal
  artery in the temporal region
• Clinical Manifestations
• LOC after initial trauma (immediate at site of
  injury)
• Lucid interval
• Rapid deterioration in neurologic respiratory
  function
• Medical Emergency rapid surgical intervention

44
Subdural Hematoma

• Blood collects between dura arachnoid maters
• Often venous in origin
• Cause is usually injury to bridging veins
• Associated with coup / contrecoup injuries
• Can occur
• Acute (less than 48 hours after injury)
• Subacute (48 hours- 2 weeks)
• Chronic (over 2 weeks)

45
Subdural Hematoma Cont.,

• Acute Subdural hematoma
• Loss of consciousness
• Pupil sluggish ? dilatation and becomes fixed
• Requires rapid surgical intervention
• Subacute Subdural Hematoma
• May or may not have loss of consciousness
• Chronic Subdural Hematoma
• Often forget actual injury common in elderly
• S/Sx fluctuate or come and go
• Severe headache personality changes mental
  deterioration and focal neurologic deficits

46
Intracerebral Hematoma

• Blood collects within the cerebral tissue
  (parenchyma)
• Most common with open (missile) injuries
• Result in increased ICP secondary to bleed which
  is accompanied by cerebral edema displacing
  tissue from within the brain structure
• Other S/Sx Specific to location and size of
  bleed
• Small bleeds can cause changes in neurologic
  status
• Deterioration is often sudden surgical and
  medical interventions.

47
Head Injury Considerations

• Management
• Frequent neurologic assessments / vital signs
• I O and daily weights
• Increased ICP
• Fluid and electrolyte balances
• Pharmacologic
• Positioning
• Nursing Activities
• Maintain skin integrity
• Protection from injury
• Prevent infection / provide rest

48
Brain Tumors

• Space-occupying intracranial lesions
• Benign or malignant.
• Clinical manifestations differ according to area
  of lesion and rate of growth
• Common Signs / Symptoms
• Alterations in consciousness
• Decreased neurologic functioning
• Headaches
• Seizures
• Vomiting (maybe sudden and projectile)

49
Types of Brain Tumors

• Brain tumors within the brain tissue
• Gliomas Most common type of brain tumor
• Astrocytomas
• Most common type of Glioma
• Slow growing malignant
• Invasive (difficult to surgically remove entire
  tumor)
• Glioblastomas Mulitforme
• Is a advanced stage of Astrocytomas
• Rapid growing malignant invasive
• Poorest prognosis

50
Types of Brain Tumors Cont.,

• Brain tumors arising from supporting structures
• Meningiomas
• Encapsulated, non-invasive usually benign
• Slow growing well defined
• Compresses rather than invades
• Acoustic Neuromas
• Non- malignant slow growing
• CN VIII affected HA, tinnitus, hearing loss,
  impaired balance, unsteady gait facial pain /
  numbness on the side of tumor
• Developmental Tumors
• Angiomas
• A benign mass of abnormal blood vessels with thin
  walls prone to rupture

51
Brain Tumor Considerations

• Management
• Increased ICP
• Corticosteroids (dexamethasone and prednisone)
• H2 blocker must accompany
• Osmotic Diuretics
• Anti-seizure medications
• Tumor removal / destruction
• Craniotomy
• ICP monitoring
• Radiation
• Chemotherapy
• Small role poor penetration of blood-brain
  barrier

52
Spinal Cord Injury (SCI)

• In the United States
• 10,000 spinal cord injuries occur annually.
• 200,000 people live with disabilities from spinal
  cord injuries.
• Most prevalent between the ages of 16 and 30
  years of age.
• Higher incidents in
• Males vs. Females
• African American vs. Caucasians
• Most prevalent causes of traumatic spinal cord
  injuries
• MVA (35)
• Violence (30)
• Falls (19)
• Sports-related injuries (8)

53
Spinal Cord Injuries

• Spinal cord itself ends at L2 but, the vertebral
  column continues to the coccyx.
• Most often occur in areas of the spinal cord that
  have the greatest range of mobility
• Cervical 5th-7th
• Thoracic 12th
• Lumbar 1st

54
Pathophysiology

• Primary Injury
• Spinal cord damage occurring at the moment of
  impact.
• Secondary Injury
• Spinal cord damage occurring as a result of
  ongoing cellular change from edema, ischemia and
  hemorrhage.
• Can continue for weeks after the initial impact.

55
Classification of SCI

• Complete Injuries
• Loss of voluntary motor activity and sensation
  below the level of injury
• Quadriplegia (C1 T1)
• Paraplegia (T2-L1)
• Incomplete Injuries
• Variable or mixed losses of voluntary activity
  motor and sensation below the level of injury.
• Anterior Cord Syndrome
• Posterior Cord Syndrome
• Brown-Sequard Syndrome
• Central Cord Syndrome

(SB Chart 63-8 pp. 1928)
56
Acute Spinal Cord Injuries

• Pharmacologic Management
• High-dose corticosteroids Methylpredinsolone
• H2 Blocker prevent gastric ulcerations
• Medical Management
• Cervical Fractures
• Fixed Skeletal Fracture Traction
• Realign the vertebrae, facilitate bone healing
  prevent further injury.
• Halo Device
• Cervical spine immobilization allows for
  ambulation self care
• Thoracic Lumbar Fractures
• Body cast (plastic or fiberglass)
• Immobilization of thoracic lumber spine
  bedrest supine position

57
Surgical Management

• Laminectomy
• Removal of a portion of the vertebral ring called
  the lamina
• Allowing for expansion from edema or for removal
  of boney fragments / disk material.
• Spinal Fusion
• Fusion of vertebral bodies to prevent movement
  and increase stability of the spinal column.
• Spinal Rodding
• Use of metal rods stabilize and realign the
  spine.
• Nursing Surgical Considerations
• Post Operative Braces

58
Acute Complications in SCI

• Spinal Shock
• Autonomic Dysreflexia
• Deep Vein Thrombosis

59
Spinal Shock

• A state of shock occurring shortly after injury
  to the spinal cord injury may last for up to a
  month.
• Occurs most often with a spinal cord injury at T6
  or above
• A sudden loss of reflexes, sensory, motor and
  autonomic nervous system activity below the level
  of spinal cord injury.

60
Spinal Shock Cont.,

• Clinical Manifestations
• Hypotension
• Bradycardia
• Loss of bladder tone urinary retention
• Loss of bowel tone paralytic ileus
• Nursing Considerations
• Frequent monitoring
• Blood pressure support care with repositioning
• Bowel and bladder support
• Return of spinal reflexes indicate the resolution
  of spinal shock.

61
Autonomic Dysreflexia

• A life threatening condition that occurs with
  SCI.
• It generally occurs after spinal shock has
  resolved and spinal reflexes return but, may
  persist throughout lifespan.
• The cause is a massive sympathetic response to
  noxious stimuli.
• Noxious stimuli often includes
• Distended bladder (most common)
• Bowel constipation or impaction
• Other pressure ulcers or cold drafts
• Usually occurs with SCI at T6 or above

62
Autonomic Dysreflexia Cont.,

• Clinical Manifestations
• Hypertension (sudden)
• Bradycardia
• Serve, pounding headache
• Facial flushing
• Nasal congestion
• Chills and fever
• Nausea
• Profuse sweating

63
Autonomic Dysreflexia Cont.,

• Nursing Management
• Identify and remove noxious stimuli if possible
• Bladder
• Bowel
• Skin or cold drafts
• Loosen constrictive clothing or devices
• Raise the head of the bed or sit the client up
• Other Considerations
• Antihypertensive Medications
• Maintain appropriate room temperature

64
Deep Vein Thrombosis (DVT)

• High risk due to immobility
• Nursing Assessment
• Inspect both lower extremities for redness or
  localized swelling
• Measuring calf circumference (compare
  bilaterally)
• Collaborative Prevention
• Pharmacologic Low-dose Heparin or Lovenox
• Elastic compression stockings
• Compression boots
• Encourage fluid intake
• ROM exercises
• Prevention is essential a DTV can lead to a
  pulmonary embolism

65
Acute Assessment in SCI

• ABCs
• Immobilize head, neck and spine!!
• Neurologic examination
• Motor
• Reflexes
• Sensory
• Dermatomes (Thalen pp. 641 figure 23-26)

66
Nursing Management

• The complete spinal cord injured client
• Goal of nursing management
• Attain some form of mobility
• Maintain skin integrity
• Bladder and bowel management
• Address psychosocial needs
• Preserve sexual function
• Prevention complications

67
Nursing Considerations

• Respiratory Status
• Ventilator care if necessary
• Administer supplemental oxygen as needed
• Assist in clearing bronchial secretions
• Suctioning hyperoxygenate
• Chest PT
• Add humidity to supplement oxygen
• Encourage liquids
• Cough assistance (Quad coughing)
• Monitor Frequently
• Prevent Infection

68
Nursing Considerations Cont.,

• Immobility
• Proper body alignment and transfer of client
• Repositioning every two hours turn clock
• Prevent pressure ulcers
• Wheelchair weight shifts /cushions
• Passive ROM 4-5x day begin as soon as possible
• Maintain joint mobility prevent contractures
• Reduce spasticity (meds help i.e. Baclofen)
• Encourage mobility as soon as possible
• Wheelchair Manual or electronic (oral / thumb
  controlled)

69
Nursing Considerations Cont.,

• Pressure Ulcers
• The spinal cord injured client can develop
  pressure ulcers rapidly.
• Turn, turn, turn every two hours !!
• Locations common to assess
• Ischial tuberosity
• Greater trochanter
• Sacrum
• Heels
• Always check under braces and other devices for
  skin integrity keep skin dry

70
Nursing Considerations Cont.,

• Skin Integrity
• Assessment of skin with every position change
• Meticulous skin assessments
• Observe for any redness or skin breakdown break
  down
• Frequent turning !!
• Common causes of alterations
• Immobility
• Wheelchair trauma
• Urinary or bowel incontinence

71
Nursing Considerations Cont.,

• Neurogenic Bladder
• Two main types seen with spinal cord injuries
• Reflex or Spastic Bladder
• Most common with complete cord injuries
• Loss of the sensation to void, bladder fills and
  empties automatically it may or may not be
  completely empty.
• Non-reflexive or Flaccid Bladder
• Bladder fills and becomes greatly distended which
  results in overflow incontinence
• Bladder unable to contract and no discomfort
  associated with fullness overstretching of
  bladder and detrusor muscle may lead to reflux

72
Nursing Considerations Cont.,

• Neurogenic Bladder Cont.,
• Adhere to client normal bladder program
• Often established by frequent reflex stimulation
  or intermittent catheterization
• Client or Caregiver Education
• Intermittent / straight catheterization
• Record fluid intake
• Voiding patterns
• Signs and symptoms of UTI autonomic dysreflexia
• Urinary Diversion Procedures

73
Nursing Considerations Cont.,

• Bowel Elimination
• Diet
• High in fiber encourage fluids
• Bowel program
• Every 48 hours after meals (same time) Proper
  positioning
• Reflex stimulation / manual removal of stool
• Stool softeners or laxatives enemas only when
  necessary
• Teach signs and symptoms of impaction
• Contractures
• Splints / passive ROM

74
Nursing Considerations Cont.,

• Reproductive / Sexual Function
• Women with spinal cord injuries can become
  pregnant but, face life-threatening complications
• Men with spinal cord injuries prosthetic penile
  implants Viagra
• Climax may or may not be achieved
• Psychosocial
• Coping with disability important to set
  short-term realistic goals
• Coping with lifestyle, role and financial changes
• Depression
• Support groups, social work
• Allow to express concerns, fears and frustration

75
Chronic SCI Complications

• Autonomic dysreflexia
• Bladder and kidney infections
• Spasticity
• Contractures
• Pressure ulcers
• Can lead to sepsis and osteomyelitis
• Depression
• Bone and joint disorders