Intracranial Disorders
Spinal Cord Disorders
Spring 2015
Winship
9 Differences between the Male Brain
and the Female Brain
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Brain Size
Brain Hemispheres
Relationships
Mathematical Skills
Stress
Language
Emotions
Spatial abilities
Susceptibility to brain function disorders
NCLEX-RN® REVIEW
Test Question 1
1.
Which of the following pathophysiologic events
results in irregular respiratory patterns as LOC
decreases?
1.
2.
3.
4.
pressure on the meninges
reflexive motor responses
loss of the oculocephalic reflex
brainstem responses to changes in PaCO2
NCLEX-RN® REVIEW
Test Question 1 Response
1.
Which of the following pathophysiologic events
results in irregular respiratory patterns as LOC
decreases?
1.
2.
3.
4.
pressure on the meninges
reflexive motor responses
loss of the oculocephalic reflex
brainstem responses to changes in PaCO2
NCLEX-RN® REVIEW
Test Question 1 Rationale
Normally the RAS and cerebral hemispheres
control respirations with a regular pattern;
however, when they are damaged, the lower
brainstem responds to changes in PaCO2, resulting
in irregular respiratory patterns.
NCLEX-RN® REVIEW
Test Question 2
2. The unconscious patient has depressed or
absent gag and swallowing reflexes. Which
nursing diagnosis would be appropriate?
1. Decreased Intracranial Adaptive Capacity
2. Risk for Aspiration
3. Imbalanced Nutrition: Less than Body
Requirements
4. Ineffective Breathing Pattern
NCLEX-RN® REVIEW
Test Question 2 Response
2. The unconscious patient has depressed or
absent gag and swallowing reflexes. Which
nursing diagnosis would be appropriate?
1. Decreased Intracranial Adaptive Capacity
2. Risk for Aspiration
3. Imbalanced Nutrition: Less than Body
Requirements
4. Ineffective Breathing Pattern
NCLEX-RN® REVIEW
Test Question 2 Rationale
The unconscious patient with impaired gag or
swallowing reflexes would be at risk for aspiration
since saliva and any fluids taken by mouth could
not be swallowed normally
NCLEX-RN® REVIEW
Test Question 3
3. What is the rationale for the use of osmotic
diuretics to treat IICP?
1.
Hyperthermia increases the cerebral metabolic rate
and exacerbates IICP.
2. Increased blood osmolality draws edematous fluid
into the vascular system.
3. Patients with ICP are at increased risk for
gastrointestinal hemorrhage.
4. Brain injury and IICP often cause seizures.
NCLEX-RN® REVIEW
Test Question 3 Response
3. What is the rationale for the use of osmotic
diuretics to treat IICP?
1.
Hyperthermia increases the cerebral metabolic rate
and exacerbates IICP.
2. Increased blood osmolality draws
edematous fluid into the vascular system.
3. Patients with ICP are at increased risk for
gastrointestinal hemorrhage.
4. Brain injury and IICP often cause seizures.
NCLEX-RN® REVIEW
Test Question 3 Rationale
Osmotic diuretics increase the osmolality of blood
by excreting water and leaving solutes; as a result,
the water in the brain would is drawn into the
vascular space.
NCLEX-RN® REVIEW
Test Question 4
4. On admission to the ED, a patient who has
altered LOC has a variety of laboratory tests to
facilitate the diagnosis of the etiology of the
condition. Which tests would likely be performed?
Select all that apply.
1.
2.
3.
4.
5.
blood glucose
serum electrolytes
blood and urine toxicology
urine for WBCs
spinal fluid osmolarity
NCLEX-RN® REVIEW
Test Question 4 Response
4. On admission to the ED, a patient who has
altered LOC has a variety of laboratory tests to
facilitate the diagnosis of the etiology of the
condition. Which tests would likely be performed?
Select all that apply.
1.
2.
3.
4.
5.
blood glucose
serum electrolytes
blood and urine toxicology
urine for WBCs
spinal fluid osmolarity
NCLEX-RN® REVIEW
Test Question 4 Rationale
A patient with an altered LOC would probably have
blood glucose to check for hypoglycemia,
electrolytes to check for metabolic disturbances
(especially sodium), and toxicology to test for drug
or alcohol toxicity
Chapter 42
Intracranial Disorders
Altered LOC
• Arousal
▫ Alertness
▫ Depends on the RAS
• Cognition
▫ Mental activity controlled by the cerebral
hemispheres
 Thought processes, Memory, Perception, Problem
solving and Emotion
Causes of Altered LOC
• Damage to the RAS
▫ Stroke, Demyelinating diseases, Tumors,
Abscesses and Head injuries
▫ Pressure and compression of the brainstem
• Cerebral blood flow disruptions
▫ Hypoxia, Ischemia, Seizures, Metabolic alterations
Patterns of Respirations
• Cheyne-Stokes respirations
• Neurogenic hyperventilation
• Apneustic respirations
• Ataxic/apneic respirations
Pupillary and Oculomotor Responses
• Pupillary/oculomotor manifestations
▫ Oval
▫ Eccentric (off center)
▫ Fixed and dilated
• Spontaneous eye movement/ocular reflex
manifestations:
▫ Doll’s eyes movements
▫ Fixation
Motor Responses
• Motor manifestations:
▫ Responses to stimuli
 Appropriate response
 Flaccidity
▫ Reflexive responses
 Decorticate posturing
 Decerebrate posturing
 Flaccidity
Figure 41–19 Decorticate posturing.
Figure 41–20 Decerebrate posturing.
Coma States and Brain Death
• PVS
• Locked - In Syndrome
• Brain Death
Persistent Vegetative State
• Death of cerebral hemispheres
• Continued brainstem/cerebellum function
• Characteristics of PVS:
▫ Sleep–wake cycles
▫ Basic functions, but without interaction
• Diagnosis:
▫ Condition must persist for at least 1 month
Locked-In Syndrome
• Blocked efferent pathways
• Intact cognitive abilities
• Unable to communicate through speech or
movement
Brain Death
• Cessation of all brain functions, including
brainstem
• Diagnostic criteria:
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Unresponsive coma
Absent motor/reflex movements
No spontaneous respirations
Pupils fixed and dilated
Absent ocular responses
Flat EEG
No cerebral blood flow
Brain Death
• Manifestations must persist
▫ 30 minutes to 1 hour
▫ 6 hours after onset of coma and apnea
Cerebral or Brainstem Dysfunction
• Interdisciplinary Care:
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Medications
Surgery
Support of airway and respirations
Maintaining nutritional status
Diagnosis
• Blood Glucose
• Serum Electrolytes
• Serum Osmolality
• ABG
• Liver function tests (Ammonia)
• Toxicology
Nursing Diagnosis
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Family Coping
Ineffective Airway Clearance
Risk for Aspiration
Risk for Impaired Skin Integrity
Impaired Physical Mobility
Risk for Imbalanced Nutrition: Less than Body
Requirements
Increased Intracranial Pressure
• Noncompressible Components
▫ Brain (80%)
▫ CSF (8%)
▫ Blood (12%)
• Normal ICP
▫ 5 – 10 mmHg – intracranial
▫ 60 – 180cm H2O – lying down
• IICP – sustained elevated pressure > 10mmHg
Causes of IICP
• Cerebral edema
• Hydrocephalus
• Brain Herniation
Increased Intracranial Pressure
• Manifestations: pg 1439
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Behavior/personality changes, decreased LOC
Hemiparesis, hemiplegia
Abnormal motor responses
Altered vision, papillary/oculomotor changes
Cushing’s response
Headache, papilledema, vomiting
Increased Intracranial Pressure
• Interdisciplinary Care:
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Finding underlying cause
Preventing herniation syndrome
Medications, chemical restraints
Intracranial surgery
Assessment/monitoring ICP
Mechanical ventilation
Seizures
• Abnormal, sudden, excessive
uncontrolled electrical discharge of
neurons within the brain; may result
in alteration in consciousness, motor
or sensory ability, and/or behavior
Types of seizures
• Partial
• Generalized
• Unclassified
Partial Seizures
Partial or focal due to the fact they
begin in a part of one hemisphere
• Simple Partial
• Complex Partial
Generalized Seizures
Six types that involve both cerebral hemispheres
• Tonic-Clonic
• Tonic
• Clonic
• Absence
• Myoclonic
• Atonic
Figure 42–4 Tonic-clonic seizures in
grand mal seizures. A, Tonic phase. B,
Clonic phase.
Figure 42–4 (continued) Tonic-clonic
seizures in grand mal seizures. A,
Tonic phase. B, Clonic phase.
Idiopathic Seizures
• Not associated with any brain lesion
• May be caused by:
Metabolic disorders
Acute alcohol withdrawal
Electrolyte disturbances
Heart disease
Emotional upheavals
High fever
Epilepsy
• Chronic disorder with recurrent unprovoked
seizures; may be caused by abnormality in
electrical neuron activity, and/or imbalance of
neurotransmitters
• Epilepsy information
Assessment
Diagnostic
• EEG
• MRI
• CT
• PET
Labs
• Genetic
• Electrolyte
imbalances
Interventions
• Antiepileptic drugs (AEDs)
Pg 1445
• Commonly used to control chromic seizures
and involuntary muscle movements. The
AED’s act in the motor cortex to reduce the
electrical discharges
Box 42-1 Drug Interactions
with AEDs
Table 42-3 Nursing Assessments
Before, During, and After a Seizure
Seizure Precautions
• O2 and suction readily available
• Saline lock for IV access
• Side rails up at all times
• Padded side rails controversial
• Bed in lowest position
• Never insert padded tongue blade
Seizure Management
• If simple partial seizure, observe
patient and document seizure
• Turn patient on side during
generalized tonic-Clonic seizureturning head helps to prevent
aspiration
• Do not restrain
Status Epilepticus Management
• Prolonged seizure lasting more than
5 minutes or repeated seizures over
the course of 30 minutes
• Neurologic emergency that must be
treated promptly and aggressively
Treatment
• Establish airway
• If needed administer O2
• Establish IV access
• Give IV diazepam, lorazepam,
phenytoin, or general anesthesia
Status Epilepticus Complications
• Metabolic changes
• Hypoxia
• Hypotension
• Cardiac dysrhythmias
• Lactic acidosis
• Brain damage
• Death
SE
Stroke/ Brain Attack
• A disruption in the normal blood
supply to the brain may lead to
death after a few minutes
• The brain is unable to store
oxygen or glucose and must
receive a constant flow of blood
to function.
Contralateral deficit
• A stroke in one hemisphere of the brain is
manifested by deficits in the opposite side of the
body.
• Ischemic stroke is caused by the
occlusion of a cerebral artery by either a
thrombus or an embolus
• 87% of all strokes are ischemic
TIA
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Mini stroke
Less than 24 hours
Warning signs for a larger stroke
Manifestations
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Contralateral numbness or weakness
Aphasia
Blurred vision
Amaurosis fugax
Large vessel (thrombotic) Stroke
• Commonly effect a single cerebral artery
supplying the cerebral cortex
• Causes
▫ Aphasia
▫ Neglect syndrome
▫ Visual field defects
Small Vessel stroke (Lacunar infarct)
• The infarcted areas slough off
• Leaves a small cavity or lake
• Occurs deep in the brain
• Causes
▫ Motor hemiplegia
▫ Sensory hemiplegia
▫ Dysarthria
Cardiogenic Embolic stroke
• Blood clot from A Fib, Ventricular thrombi, MI,
CHD or plaque
• Usually at bifurcations of vessels in the middle
cerebral artery
• Occurs when a blood vessel ruptures
• Types
▫ Intracerebral hemorrhage
▫ Subarachnoid hemorrhage
• Most often Fatal
Contributing Factors
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HTN (↑ chance for stroke 4x)
Rupture of vessel r/t plague
Aneurysms
Trauma
Tumor erosion
AVM
Afib
Anticoagulant therapy
Blood disorders
DM
Hypertension
• Elevated systolic and diastolic blood
pressures cause changes within the
arterial wall leaving it susceptible to
rupture
• More likely with sudden episodes of
dramatic B/P elevation, i.e. cocaine
intoxication
Aneurysm
• Ballooning or blistering of artery
• Congenital or traumatic
• Aneurysm is when the vessel
ruptures
• Intracerebral hematoma
• Blood pools in brain – irritation to
healthy tissue
• Leads to ischemia and infarction
Arteriovenous Malformation
• Congenital defect
• Tangled, spaghetti like mass of
malformed dilated vessels with
thin walls
• May eventually rupture due to
arterial pressure
Strokes
• Stroke Overview
Health Promotion and Illness
Prevention
• Avoidance of smoking,
sedentary lifestyle, high fat diet
• Moderate alcohol consumption
• Weight control
• Control of hypertension
Assessment
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History of activity when stroke began
How the symptoms progressed
Onset of stroke
Severity of the symptoms
Due the symptoms come and go
Observe LOC
Assess for memory impairment, difficulty with
speech
• Past medical history/Social history
• Medication
Neurologic Assessment
• LOC may vary depending on the
extent of increased ICP caused by the
stroke and on the location of the
stroke.
Right Cerebral Hemisphere
• Visual, spatial awareness
• Proprioception
• May be unaware of changes
• Disoriented to time/place
• Impulsivity
• Poor Judgment/Decisions
• Short Attention span
Left Cerebral Hemisphere
• Dominant in 85% of people
• Language/Speech
• Math
• Analytic thinking
• Aphasia
• Agraphia
• Alexia
• Slow and cautious
Motor Changes
• Hemiplegia- paralysis
• Hemiparesis- weakness
• Hypertonia /Flaccid paralysisExtremities fall to the side
• Hypertonia/Spastic paralysisfixed position, ROM restricted
Sensory Changes
• Agnosia
• Apraxia
• Neglect Syndrome
• Ptosis
• Retinal ischemia- causes a brief
episode of blindness
• Hemianopia
Cranial Nerve Assessment
• CN II. IV. VI – Oculomotor
movements
• CN V- ability to chew
• CN IX and X – ability to swallow
• CN VII- facial paralysis
• CN IX- absent gag reflex
• CN XII Impaired tongue
movement
Diagnostic Assessment
CT and CT angiography
• Identify hemorrhage
• Cerebral aneurysms if large enough
• Baseline information for future
comparison
• Identify pathologic changes mimic
stroke
• After 24 hours can show ischemia
Diagnostic Assessment
MRI
• Presence of edema, ischemia and tissue
necrosis earlier than a CT
Angiography
• Status of cerebral vessels and narrowing can be
treated with papaverine
Cardiac cause
• ECG
• Holter monitor
• Cardiac enzymes
• Echocardiogram
Ineffective Cerebral Tissue
Perfusion Interventions
• Administer systemic
thrombolytic therapy
• Neurologic assessment
• Monitor ICP
• Avoid activities/procedures that
may increase ICP
• Assess need for suctioning
Drug Therapy
• Thrombolytic
• Anticoagulants
• Lorazepam/AED
• Calcium channel blockers
• Stool softeners
• Analgesics for pain
• Antianxiety drugs
Complications
• Hydrocephalus
• Vasospasms
• Rebleeding or rupture
Surgical Management
• Carotid angioplasty
• Endarterectomy
• Extracranial-intracranial bypass
Management of Arteriovenous
Malformations
• Interventional therapy to occlude
abnormal arteries or veins and
prevent bleeding from the vascular
lesion
• Gamma radiation to produce fibrous
thickening of the endothelial lining
Management of cerebral
Aneurysms
• Craniotomy when stable- the
aneurysm is clipped or clamped at
the base or neck to prevent bleeding
• Interventional radiology- small
catheter through the femoral artery
into the aneurysm platinum wire
coils placed inside aneurysm, which
creates a clot that makes a seal
Aneurysm
• Stroke clipping of aneurysm and coiling
procedures…
• Aneurysm clipping
• Aneurysm Coiling
Management of Intracranial
Bleeding
• Craniotomy to remove clots and
relieve ICP
Indications
• Worsening of neurologic status
• Extension of intracranial lesion
with significant increases in ICP
Impaired Physical Mobility and
Self Care
Interventions
• ROM exercises for the involved
extremities
• Frequent position changes
• Prevention of DVT
• Therapy focused on patient
performance of ADL's
Disturbed Sensory Perception
Interventions Right hemisphere
• Damage difficulty in the performance of
visual perceptual or spatial-perceptual
tasks
• Activities of ADL’s / Ambulation
Left hemispheric
• Memory deficits
• Changes in ability to carry out simple
tasks
Impaired Verbal
Communication
• Language or speech problems, result
of damage to the dominant
hemisphere
• Expressive aphasia, damage in
Broca’s area of the frontal lobe
Expressive aphasia
• Receptive (Wernicke’s or sensory)
aphasia, injury in the temporoparietal
area Receptive aphasia
Impaired Swallowing
Interventions
• Assess patients ability to swallow
• Facilitate swallowing through
positioning the patient
• Appropriate diet: semisoft or liquid
food
• Aspiration precautions
Urinary and Bowel Incontinence
• Altered level of consciousness
may cause incontinence or
impaired innervation, or inability
to communicate need
• Develop a bladder and bowel
training program
Traumatic Brain Injury
• External force to the head
• Altered LOC
• Increased ICP
• May be temporary or permanent
• May be partial or total disability
• High incidence of death
TBI – Open Head injury
• Penetration to the head results in opening of
skull
• Skull fractures
• Hemorrhage may occur
• CSF leakage from ears or nose
▫ Clear
▫ Can be tested for Glucose to determine
• Increased risk for infection
TBI – Closed Head Injury
• Blunt trauma to head
• Concussion
• Diffuse axonal injury
▫ MVA
• Contusion
▫ Coup/Contrecoup
• Laceration
TBI - Hemorrhage
• Epidural Hematoma
▫ Lucid periods then unconsciousness
▫ Neurosurgical emergency
• Subdural Hematoma
▫ Slow
▫ Tearing
▫ Highest mortality rate
• Intracerebral Hemorrhage
▫ Accumulation of blood within brain tissue
TBI - Hemorrhage
• Monitor ABC’s
• Vital Sign Assessment
• Neurologic Assessment
▫ Glasgow
Brain Tumors
• Primary
▫ Occur within CNS
• Secondary
▫ Metastasis from other
parts
Brain Abscess
•Purulent infection of the
brain
HEADACHES
• Types
Migraine
Tension
Cluster
MIGRAINES
• Episodic familiar disorder
manifested by unilateral,
frontotemporal, throbbing pain in the
head, often worse behind one eye or
ear.
• Often accompanied by a sensitive
scalp, anorexia, photophobia, nausea
• Aura: sensation that signals the onset
MIGRAINES
Causes
• Vascular
• Genetic
• Central Neuronal Hyper excitability
• Chemical Factors
MIGRAINES
Types
• Migraine with an Aura
Light changes, flashes, double vision
• Migraine without an Aura
More common
• Atypical Migraine
Last more than 72 hours
Can’t find definitive reason for
Migraine
SYMPTOMS
• Sensitivity to light: Photophobia
• Irritability
• Nausea, Vomiting
• Sensitivity to sounds: Phonophobia
INTERVENTIONS
Goal Pain Management
• Abortive Therapy
• Preventative Therapy
• Alternative Therapy
INTERVENTIONS
Preventive Therapy
• Beta Blockers
• Ca+ Channel Blockers
• Tricyclic – SSRI
• Antiepileptic
• Riboflavin
INTERVENTIONS
Alternative Therapies
• Massage
• Cold cloth
• Acupressure/Acupuncture
• Nutritional changes
• Relaxation/Biofeedback techniques
CLUSTER HEADACHES
Histamine Cephalagia
• Causes are unknown; attributed to
vasoreactivity and oxyhemoglobin
desaturation
• Studies suggest it may be related to
hypothalamic hyperactivity
• Intense pain on one side radiating to
forehead, temple, or cheek
Interventions
• Medications that are used for
migraines
• Wear sunglasses to avoid sunlight
• Oxygen via mask
• Avoidance of precipitating factors,
anger excitement
• Surgical management if resistant to
medications
TENSION HEADACHES
• Neck and shoulder muscle
tenderness and bilateral pain at the
base of the skull and in the forehead
• Treatment: non-opioids analgesics,
muscle relaxants, occasional
opioids
Spinal Cord Disorders
Chapter43
Spinal Cord Injury
• Spinal cord injury (SCI) can not
be reversed
• Complete- spinal cord severed or
damaged so all innervations
below the level of injury are
eliminated
• Incomplete – some function or
movement below level of injury
Spinal Cord Injury
• Primary mechanisms
• Secondary mechanisms
Primary Mechanisms
• Hyperflexion
• Hyperextension
• Axial loading or vertical
compression
• Excessive rotation
• Penetrating injuries
Secondary Mechanisms
• Neurogenic shock
• Vascular insult
• Hemorrhage
• Ischemia
• Fluid and electrolyte imbalance
Cervical Injuries
• Anterior cord syndrome
• Posterior cord lesion
• Brown-Sequard syndrome
• Central cord syndrome
Assessment
• Gather as much data as possible about the
accident
• How the accident occurred
• Position after the accident
• Symptoms after the injury
• Type of immobilizers used if any
• Problems that may have occurred during
stabilization
Initial Assessment
• First Priority assessment of
respiratory pattern
• Assess for indications of intraabdominal hemorrhage or
hemorrhage or bleeding around
fracture sites
• Level of consciousness
Initial Assessment
Establish level of injury
• Tetraplegia/Quadriplegia
• Quadriparesis
• Paraplegia
• Paraparesis
Spinal Shock
Condition is characterized by:
• Flaccid paralysis
• Loss of reflex activity below the level of
the lesion
• Bradycardia
• Paralytic ileus
• Hypotension
Sensation Assessment
• Sensation is carried from the
peripheral nerves to the spinal cord
and up to the cerebral cortex via
sensation-specific tracts.
• The injury may inhibit this
transmission
Sensation Assessment
• Have the patient close his or her
eyes touch the skin with a sharp
object and a soft object.
• Compare bilateral responses
• Use a skin dermatome staring in the
area of loss of sensation and ending
where sensations become normal
Motor Ability Assessment
• Systematic assessment of the
patients muscles
• American Spinal Injury Association
(ASIA) Five point grading scale
• DTRs
Cardiovascular Assessment
• Cardiovascular dysfunction is usually
the result of disruption of the
autonomic nervous system
• Bradycardia, hypotension, and
hypothermia result from loss of
sympathetic input and may lead to
cardiac arrest
Cardiovascular Assessment
• Systolic blood pressure lower than
90 mm Hg requires treatment
because lack of perfusion to the
spinal cord worsens the condition
Assessments
• Respiratory
• Gastrointestinal
• Genitourinary
Assessments
•Musculoskeletal
•Psychosocial
•Laboratory
•Diagnostic imaging
Interventions
• Reduction and immobilization
of the fracture to prevent
further damage to the spinal
cord from bone fragments
• Nonsurgical techniques:
traction, external fixation
Immobilization for
Cervical Injuries
• Halo fixation and cervical
tongs
• Stryker frame, rotational bed,
kinetic treatment table
• Pin site care and monitoring
of traction ropes
• Immobilization techniques
Immobilization of Thoracic and
Lumbar Injuries
• Thoracic: Bedrest and possible
immobilization with a fiberglass or
plastic body cast
• Lumbar and sacral: immobilization
of spine with brace/corset worn
when out of bed
• Custom fit
Drug Therapy
• Methylprednisolone
• Dextran
• Atropine sulfate
• Dopamine hydrochloride
• Naloxone or THR
• Sygen
Drug Therapy
• 4-AP potassium channel
blocker
• Dantrolene
• Baclofen
• Etidronate disodium
Surgical Management
• Emergency surgery necessary for
spinal cord decompression
• Decompressive Laminectomy
• Spinal fusion
• Harrington rods to stabilize
thoracic spinal injuries
Autonomic Dysreflexia
• Common in patients with upper
SCI
• Severe hypertension
• Bradycardia
• Severe headache
• Nasal stuffiness
• Flushing
Autonomic Dysreflexia
• Treatment
▫ Elevate HOB
▫ Remove compression stockings
▫ Assess for stimuli that cause AD &
Treat
▫ Administer Emergency antihypertensives
Spinal Cord Tumors
• Pathologic effects related to
compression of the cord,
displacement , disruption of vascular
supply and obstruction of CSF
• Symptoms are related to growth
Spinal Cord Tumors
• Surgical management: goal
remove as much of the tumor as
possible
• Nonsurgical management:
radiation, chemotherapy and
pain control