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Nursing Care of Patients with
Neurological Dysfunction
Elaine Harris, RN, MS, CCRN
Care of Adults with High AcuityNeeds
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Goals of Nursing Assessment
Gather data a!out functioning of the ner"ous
system in an un!iased, orderly manner and
clearly record it
#ollow data o"er time, loo$ing for
correlations and trends
Analy%e the data to de"elo& a list of
&otential or actual diagnoses Determine effects of dysfunction on daily
li"ing and a!ility to &erform self'care
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Mental Status Assessment
(ests to e"aluate le"el of consciousness
and arousal, orientation to en"ironment
and thought content
)*C is the most critical &arameter and
e"aluates function of the cere!ral
hemis&here
Res&onsi"eness is categori%ed according
to the &atient+s arousal to eternal stimuli
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)e"els of Arousal
Awa$e'''the &atient may
slee& more than usual or
!e confused when first
awa$ening
)ethargic'''drowsy !utfollows sim&le commands
when stimulated
*!tunded'''arousa!le with
stimuli- Res&onds "er!allywith .ust one or two words-
#ollows sim&le commands
!ut otherwise drowsy
Stu&orous'''"ery hard to
arouse/ inconsistently may
follow commands or s&ea$ a
single word with much
stimulation Semi'Comatose'''mo"ements
are &ur&oseful when
stimulated/ does not follow
commands or s&ea$
coherently Comatose'''may res&ond with
reflei"e &osturing !ut limited
s&ontaneous mo"ement
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*rientation to En"ironment
0hat is your name1 0here are you now1
0hat is the month, year, date, time1
An increase in wrong answers indicatesincreasing confusion and &ossi!le
deterioration
2ncrease in correct res&onses may
indicate im&ro"ement
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Assessment of Cogniti"e A!ility
Maimum score 3 45- 65 or lower 3 neuro im&airment
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Assessment of Motor #unction
(ests of strength and coordination
0hat elicits motor res&onse1 0ords1 Pain1
E"aluate the a!ility to follow commands
As$ &atient to mo"e etremity against gra"ity
7Noious stimuli8 3 eliciting &ain !y &inching
tra&e%ius muscle, &ressure on su&raor!ital
ridge, sternal ru!, or com&ressing nail!eds
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Motor Assessment, continued
7)ocali%ation8 means the &atient tries to
remo"e the stimulus in an organi%ed way
70ithdrawal8 means the &atient sim&ly
&ulls away from the noious stimuli
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Decere!rate Rigidity
Etension, adduction and hy&er&ronation
of the u&&er etremities- Etension of
lower etremities with &lantar fleion of the
feet- May clinch teeth-
Denotes mid!rain or &ons in.ury
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Decorticate Rigidity
#leion of the arms, wrists, fingers
Adduction of u&&er etremities and
etension of legs- Cere!ral hemis&here
in.ury
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Assessment of Strength, Coordination
7Pronator Drift8
As$ &atient to lift legs one at a time
straight off !ed against your resistance
0ea$ness indicates damage to motor
neuron &athways
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Motor Strength, Coordination, cont
Hemi&aresis 9wea$ness:
Hemi&legia 9&aralysis:
Remem!er the cere!ellum is res&onsi!lefor smooth synchroni%ation, !alance, and
ordering of mo"ement-
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Assessment of ;ital Signs
(em&, HR,
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Assessment of Res&irations
Shallow, ra&id res&irations can indicate a
&ro!lem with maintenance of the airway or
need for suctioning
Snoring or stridor can indicate &artiallyo!structed airways
Cheyne'Sto$es Res&irations'''crescendo'
decrescendo alternating with &eriods of a&nea Hy&o"entilation must !e a"oided for
res&iratory acidosis occurs-
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*ther Assessment Areas
Pu&il changes 9si%e and sha&e:
Cranial ner"e function
Sensation 9&erce&tion of !eing touched:
Pro&rioce&tion 970hich way am 2 mo"ing your
finger1:
Stereognosis 9a!ility to recogni%e o!.ects !y
touch: Gra&hestesia 9a!ility to recogni%e num!ers or
letters traced lightly on the s$in:
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Signs of 2ncreased 2ntracranial Pressure
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2ncreased 2CP, continued
Manifested !y deterioration in all as&ects of
neurological functioning
)*C decreases as 2CP increases- May !egin
with restlessness, confusion, com!ati"enessand decom&ensate =uic$ly
Pu&il reactions !egin to diminish 9&u&il
i&silateral to the in.ury will dilate first: Motor function declines, may &osture
Changes in ;S come late
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Cushing+s (riad
A cluster of changes that indicate "ery
high 2CP and im&ending herniation>
2ncreased systolic
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Nursing Care During Diagnostic Studies
Com&uter (omogra&hy 9C(:
Measures density of tissues, !lood and !one
Cere!ral edema a&&ears less dense and therefore
is lighter in color than normal Always used =uic$ly in trauma setting, sei%ures,
headaches, )*C, diagnosis of sus&ected stro$es
0ill show s$ull fractures, tissue swelling,
hematomas, tumors
Patient education> lie still, may ha"e
claustro&ho!ia
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Diagnostics, con+t
Magnetic Resonance 2maging 9MR2:
More detailed images that loo$ li$e anatomy
Does N*( show !ony anomalies as well as
C(
Can interfere with &acema$ers, and &atients
with surgical cli&s and &rostetic im&lants
made of ferrous materials can+t !e scanned ;entilators, monitors may !e &ro!lematic
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Diagnostics, con+t
Cere!ral Angiogra&hy
Gold standard for e"aluating "ascular &ro!lems
Can re"eal large and small aneurysms and A;
malformations
Radiogra&hic catheter is &assed through
femoral artery to each of the arterial "essels
!ringing !lood to the !rain and s&inal cord Radio&a=ue contrast is in.ected and ra&id
images are ta$en
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Diagnostics, con+t
Cere!ral !lood flow studies
Radioisoto&e is in.ected 2; and the !rain is
scanned to determine which areas show
accumulation
Can determine cere!ral "asos&asms and
!rain death 9no !lood flow:
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Head 2n.uries
2n.ury to scal&, s$ull, or !rain
Most serious is 7closed head in.ury8 with
traumatic !rain in.ury 9(
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Head 2n.ury, continued
M;C and falls are the most common causes
#irearms, assaults, s&orts'related in.uries,
recreational in.uries, and war'related in.uries
High &otential for &oor outcomes
GCS on arri"al at the hos&ital is a strong
&redictor of sur"i"al, with GCS !elow ?
indicating only a 45'@5 chance of sur"i"al
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S$ull #ractures
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S$ull #racture, con+t
Rhinorrhea 9CS# lea$ing from nose: or *torrhea
9CS# lea$ing from ear: confirm torn dura
Ris$ of meningitis is great
(est fluid to see if it is CS#> glucose test stri&will !e &ositi"e if it is CS#-
2f there is !loody drainage, do 7halo test8> let
drainage dri& on a BB-
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S$ull #ractures, con+t
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Concussion
A diffuse in.ury to the head- May or may
not lose consciousness
*ften a !rief disru&tion of )*C and
amnesia regarding the e"ent- Headache,
lethargy can &ersist u& to 6 months
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Cere!ral Contusion
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E&idural Hematoma
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Su!dural Hematoma
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Su!dural, con+t
(he i&silateral &u&il dilates and !ecomes
fied if 2CP is significantly ele"ated
Chronic, su!'acute hematomas can occur
6'FB days after in.ury and are common in
older adults 9!rain atro&hy 3 more s&ace:
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Su!dural Hematoma, con+t
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Emergency Nursing Care for Head
2n.uries
Assure &atent airway
Assume cer"ical
s&ine in.ury A)0AS
2mmediate C( *ygen "ia non'
re!reather or
intu!ation
2; access with 6 large
!ore catheters
Em&loy all measures
to reduce 2CP
9ele"ate head of !ed
45 degrees: Control eternal
!leeding with
&ressure dressing !ut
N* firm &ressure untilde&ressed s$ull
fracture ruled out
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Emergency, con+t
N* NG (
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Nursing Diagnoses for Head 2n.uries
Ris$ for ineffecti"e cere!ral tissue
&erfusion R( interru&tion of cere!ral !lood
flow
Hy&erthermia R( increased meta!olism,
infection, loss of cere!ral integrati"e
function due to hy&othalamic in.ury
Acute &ain
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Nursing Goals for Head 2n.uries
Maintain ade=uate cere!ral oygenation
Remain normothermic
Achie"e &ain control
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Health Promotion to Pre"ent Head
2n.uries
Seat !elts 9!ac$seat, too:
Child safety seats
Helmits for motorcycles and !i$es
Protecti"e headwear for lum!er.ac$s,construction wor$ers, miners, horse!ac$ riders,
snow!oarders
(al$ to grou&s of teenagers
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2ncreased 2ntracranial Pressure
Normal 2CP is K'FK mmHg
2ncreased 2CP is life'threatening and results
from an increase in any of the three
com&onents within the s$ull 9!rain, !lood, CS#: 2ncreased 2CP will decrease cere!ral &erfusion
&ressure and can cause !rain ischemia or
infarction
Edema distorts !rain tissue, further increasing
2CP
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2ncreased 2CP, con+t
Goal> (o maintain cere!ral !lood flow
Sustained increases in 2CP result in !rain
stem com&ression and herniation of the
!rain from the s$ull into the s&inal canal-
(his is fatal
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Clinical Manifestations of 2ncreased 2CP
Change in )*C
Change in "ital signs 9Cushing+s (riad:
Cranial Ner"e 222 com&ression 9i&silateral
&u&il change:
Decreased motor function 9contralateral to
in.ury:
Headache
;omiting
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Monitoring 2CP
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Monitoring 2CP
Gold standard is "entriculostomy- Catheter is &laced into
the lateral "entricle and attached to an eternal
transducer
Measures &ressure inside "entricle and facilitates
remo"al of CS# if the 2CP gets too high 9normally 65'45ml of CS# is &roduced e"ery hour:
(ransducer is le"eled at the (RAGS of the ear- Must
re'%ero transduced any time &atient+s &osition is changed
(hree'way sto&'coc$ o&ens to allow CS# to drain once&ressure reaches a certain le"el
2CP should N*( eceed FK mmHg
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Cere!ral Perfusion Pressure Calculation
(his can only !e done if the &atient has an
2CP monitor
CPP = MAP ICP
Normal CPP is L5'F55- )ess than K5 is
associated with ischemia and tissue death
)ess than 45 is incom&ati!le with life Reminder> MAP 3 9systolic
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Monitoring
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Nursing Management of the Patient
with 2ncreased 2ntracranial Pressure
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2CP Management
Maintain ade=uate cere!ral
&erfusion 9$ee&
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2CP management, con+t
uic$ly treat &ain and
aniety
Oee& room dar$ and =uiet
9noise increases rate of
meta!olism and raises2CP:
Monitor com!inations of
sedati"es, &aralytics,
analgesics PR*P*#*) 9Di&ri"an:
often used due to short
half'life
N*RCR*N 9&aralytic:
allows com&lete res&iratory
control
2I*, electrolytes
(urn slowly, gently
A"oid hi& fleion 9increases
intraa!dominal &ressure
which increases 2CP:
Protect from self'in.ury Pad side rails
(al$, touch e"en if in 7coma8
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Stro$e
*ccurs when there is
ischemia to &art of the
!rain *R hemorrhage
into the !rain Results in death of
!rain cells
A!out 6K of &eo&le
with stro$es areyounger than LK
4rdleading cause of
death !ehind heart
disease and cancer
2schemic stro$es9&artial or com&lete
occlusion of an artery:
account for nearly
?5 of stro$es Pla=ue !uild'u& in
cere!ral !lood "essels
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Hemorrhagic Stro$e
92ntracere!ral Hemorrhage:
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Hemorrhagic Stro$e, cont
Commonly occurs
during acti"itysudden
onset of sym&toms with
ra&id &rogression o"er
minutes
70orst headache 2+"e
e"er had8, then NI;,
decreasing )*C,
wea$ness, de"iation of
eyes, dilated &u&ils,
&osturing
Su!arachnoid
Hemorrhage'''
intracranial !leedinginto the cere!ros&inal
fluid'filled s&ace
!etween the
arachnoid and &iamater mem!ranes
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Su!arachnoid Hemorrhage, con+t
sually caused !y ru&ture of an aneurysm
B5 die immediately with no warning
Can ha&&en at any age
Cocaine causes shar& increases in
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Diagnosis of Cere!ral
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N i C f P ti t ith C ! l
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Nursing Care for Patients with Cere!ral
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Surgical Re&air of Aneurysms
Can surgically cli& the wea$ened area of
the artery
Coiling is most commonly done'''insert a
metal coil into lumen of aneurysm "iainter"entional neuroradiology- Coils
&re"ent !lood &ulsation within the
aneurysm and e"entually a throm!us formswithin the aneurysm and it !ecomes sealed
off
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7Cli&&ing8 and 7Coiling8 Aneurysms
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S&inal Cord 2n.ury 9SC2:
oung adult men FL'45 are at greatest ris$
Causes> M;C 3 B6/ falls 3 6@/
"iolence 3 FK/ s&orts in.uries 3 @
S&inal cord is wra&&ed in tough layers of
dura and is rarely torn or transected !y
direct trauma 9unless GS0 or sta!:-
Most often cord com&ression is made !y
!one dis&lacement
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Mechanisms of 2n.ury
#leion or hy&eretension
#leion'rotation
Etension'rotation
Com&ression
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Post'2n.ury Edema
Edema occurs !y 6B hours after the initial
in.ury
Harmful !ecause of lac$ of s&ace for
tissue e&ansion, so more cordcom&ression occurs
Edema occurs a!o"e and !elow the in.ury
Etent of in.ury and &rognosis for reco"erycannot !e determined for at least @6 hours
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Neurogenic Shoc$
)oss of "asomotor tone caused !y the in.ury
Hy&otension and !radycardia occur
)oss of sym&athetic ner"ous system
inner"ation causes &eri&heral "asodilation,"enous &ooling and decreased cardiac out&ut
Most often occurs with cer"ical or high
thoracic in.ury 9('L or higher: 0arm, dry s$in
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)e"el of 2n.ury
Cer"ical, thoracic, or lum!ar
Cer"ical and lum!ar in.uries are most common
!ecause these le"els of the s&ine ha"e the
greatest flei!ility and mo"ement Cer"ical s&ine in.ury will cause &aralysis of all B
etremities 9tetra&legia:
2f low in the cer"ical s&ine, the arms are rarely
com&letely &araly%ed (horacic or lum!ar in.uries cause &ara&legia 9loss
of sensation and &aralysis of the legs:
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Degree of 2n.ury
Copletecord in"ol"ement results in total loss of
sensory and motor function !elow the le"el of in.ury
Incopletein"ol"ement results in a mied loss of
"oluntary motor acti"ity and sensation 9some tracts
are intact:
!rown"#e$uard #yndroe> damage to of the
cord- )oss of motor function and "asomotor
&aralysis on the i&silateral side- (he contralateralside has loss of &ain and tem& sensation- Most
common with &enetrating trauma
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Nursing CareRes&iratory
Degree of in"ol"ement corres&onds to le"el
of in.ury
C'B or a!o"e causes total loss of res&iratory
muscle function, so mechanical "entilation isreuired
)ower cer"ical and thoracic in.uries &araly%e
a!dominal muscles and intercostal muscles9&oor cough, atelectasis and &neumonia:
Airway always first &riority of care
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Cardio"ascular Care
Any in.ury a!o"e ('L influences
sym&athetic ner"ous system regulation
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rinary Care
Neurogenic !ladder and urinary retention are
common
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G2 System Care
2n.uries ('K or higher cause hy&omotility
Paralytic ileus and gastric distention are common
NG is &laced early to relie"e distention
Reglan may hel& encourage gastric em&tying
Pre"ent stress ulcers 9H6 !loc$ers, &roton &um& inhi!itors
Neurogenic !owel if in.ury is to ('F6 or a!o"e> !owel is
arefleic and anal s&hincter tone is a!sent
high fi!er diet, ade=uate fluids, Dulcola
su&&ository followed 45 minutes later with digital rectalstimulation to cause !owel elimination
Stool softeners e"ery day
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S$in Care
Pre"ent s$in !rea$down with fre=uent
&osition change 9)*GR*)):
0eight gain or weight loss can contri!ute
to !rea$down
;isual and tactile eam of s$in e"ery F6
hours
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(hermoregulation
Poi%ilotheris'''a!ility to maintain
normal !ody tem&erature
2nterru&tion of the sym&athetic ner"ous
system &re"ents &eri&heral tem& sensationsfrom reaching hy&othalamus
2na!ility to shi"er or sweat !elow the le"el of
in.ury Maintain heatJcool with warming or cooling
!lan$ets, a&&ro&riate clothing
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Dee& ;enous (hrom!osis Pre"ention
;ery common in first 4 months to get a D;(
Peo&le will not ha"e &ain or tenderness in
the legs
Pulmonary em!olus is the leading cause ofdeath after initial in.ury
D;( &re"ention with )o"eno, se=uential
com&ression de"ices, &osition changes,R*M
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Seuality
Onowledge of the le"el and com&leteness
of the in.ury is needed to understand male
&atients+ &otential for orgasm, erection,
and fertility 0omen with SC2 remain fertile and can
ha"e successful ®nancies
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High Dose Steroids After 2n.ury1
(his is still &rotocol, !ut has !een
=uestioned lately
0as thought to decrease edema in the
cord and im&ro"e function
Stay tuned to the E
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Autonomic Dysrefleia
Patients with in.uries ('L or higher may
de"elo& Autonomic Dysrefleia
A massi"e uncom&ensated C; reaction
mediated !y the sym&athetic ner"oussystem
*ccurs in res&onse to ;2SCERA)
S(2M)A(2*N
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Autonomic Dysrefleia, con+t
Rece&tors !elow the le"el of in.ury are stimulated
(hey res&ond with refle arterial "asoconstriction
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Sym&toms of Autonomic Dysrefleia
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Nursing Care for Autonomic Dysrefleia
Always measure
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G i f d D i
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Grief and De&ression
G i f d D i
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Grief and De&ression
Peo&le with s&inal cord in.uries may feel o"erwhelmingloss
)oss of control o"er e"eryday life acti"ities and must
de&end on others for daily care
May !elie"e they are useless and !urdens to their families Grief is a difficult, life'long &rocess
Goal is for 7ad.ustment8 to occur-the a!ility to go on with
li"ing with certain limitations
#amilies need grief care as well to a"oid guilt andmis&laced sym&athy
Su&&ort grou&s are "ery im&ortant
< i D th
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