Head & brain injuries - Chap 45, 946-957
interventions
-patient with a severe TBI is admitted to critical care -moderate TBI can go to either general unit or critical, depending on the severity. monitored. -mild TBI may be sent home for ER with instructions
assessment and history
-can be hard with amnesia -amnesia can occur for before or after the event -patient with a serious injury may be unconscious or confused and combative -if the pt cannot provide info, history is obtained by first responders or witnesses -when, where, how injury occurred -did the pt loss consciousness? how long? -change in LOC? -drugs make it difficult to differentiate head trauma from intoxication -fluctuating consciousness or seizures? -history of seizures? -hand dominance -any diseases or injuries to the eyes -allergies to drugs or food -history of alcohol or drug use? -victim of violence?
increased intracranial pressure
ALREADY READ THIS.
risk factors for a TBI
car accidents drugs and drinking assault gunshot falls
signs and symptoms of hematomas
epidural; -LOC, fixed dilated pupil, seizures subdural; -confusion, drowsy, ipsilateral pupil hemorrhage; -varies, headache, herniation
intracranial hemorrhage
epidural; -above the dura subdural; -below the dura -acute, subacute, chronic intracerebral; -within the brain tissue
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incidence and prevalence
-1.4 million people annually -50k die -235k go to the hospital -1.1 million are treated and released
head injury risks
-15 to 24 years old most risk -males twice as likely -very old and very young -likely very under reported -TBI can cause damage but without signs - 'i just bumped my head'
nonsurgical management
-ABC's are priority -prevent or detect secondary brain injury -monitor for ICP -promote electrolyte balance -monitor treatment
surgical management and TBI
-ICP monitoring device -goes through a burr hole (keyhole craniotomy) -strict sterile technique is observed during placement of this device -maintain site the same way, sterile. -be sure to provide on going head to toe assessments even though the ICP monitor is on decompressive craniectomy; -ICP cannot be controlled -removal of a section of the skull -remove ischemic brain tissue or tips of the temporal lobes. -this allows additional space from edema without causing ICP -side lyign restrictions may be placed -patients do not lie on the side from the skull fragment was involved. -must wear head protection when OOB -skull fragment is frozen and re-implanted up to 3 years post removal -a craniotomy without brain tissue removal may be performed for a epidural or subdural clot
maintaining fluid and electro management
-TBI at risk for DI and SIADH -can cause fluctuations in fluids -pituitary is in the brain, edema etc around it
mild, moderate, and severe traumatic brain injury
-TBI is broken down into mild, moderate, or severe scale used is; -glascow coma scale generally is used -presence or absence of brain damage via CT or MRI -estimation of the force of the trauma -symptoms in the injured person
indirect injury
-a force applied to another body part with a rebound effect to the brain is an indirect injury.
hydrocephalus
-abnormal increase in CSF volume -it may be caused by impaired absorption of CSF at the archnoid villi (from a subarchnoid hemorrhage or meningitis). -this is called communicating hydrocephalus -it may also be caused by interference or blockage of CSF outflow from the ventricular system (edema, tumor, debris) -ventricles may dilate from the relative increase in CSF volume -ultimately if not treated, this leads to ICP
intracerebral hemorrhage
-accumulation of blood within the brain tissue caused by tearing of small arteries within the brain tissue and veins -often acts as a space occupying lesion (like a tumor) and may be devastating, depending on its location -ICH may also produce edema and ICP elevations. -traumatic brainstem hemorrhage occurs as a result of a blow to the back of the head, fractures, or torsion injuries to the brainstem. -brainstem injuries have a very poor prognosis
head injury protection
-advances in protective gear have increased the amount of head injuries -body armor -helmets -seat belts -airbags
severe traumatic brain injury
-severe TBI is defined by a GCS of 3 to 8 -loss of consciousness more than 6 hours -focal and diffuse damage to the brain. cerebrovascular vessels or ventricles most common -both open and closed head injuries can cause severe TBI. -injury can be focal or diffuse -when the damage is present in a localized area of the brain, it is usually extensive -CT or MRI can capture tissue damage usually early on. -these people need management big time -monitor hemodynamics, neuro status, ICP changes. -high risk for secondary brain injury from edema, hemorrhage, perfusion, and biomolecular cascade
additional late signs of increased ICP
-severe headache -nausea, vomit ( often projectile) -seizures -papilledema (choked disc, is edema and hyperemia of the optic disc) -headache and seizure are a response to injury and may not always be associated with ICP
CRITICAL RESCUE
-symptoms of neuro impairment from hemorrhage can progress very quickly -monitor ICP elevation it can be deadly. -monitor for epidural bleeding every 5 to 10 min for changes in neuro status -a loss of consciousness from an epidural or subdural hematoma is a neuro emergency. -notify HCP or RRT.
ACTION ALERT
-teach someone with a mild brain injury sometimes called a concussion that symptoms of sleep disturbances, enjoyment of daily activities, work, mood, memory, ability to learn may change personality and require follow up care
mild traumatic brain injury
-the term MTBI and concussion are used synonymously. -MTBI is characterized by a blow to the head, confusion or feeling dazed or disoriented, and one or more of these conditions; 1-loss of consciousness for up to 30 minutes 2-loss of memory for events immediately before or after the accident 3- focal neuro deficit that may oe may not be transient. -loss of consciousness does not have to occur for someone to be diagnosed with MTBI. -with MTBI, there is no evidence of of brain damage on a CT or MRI imaging scan -symptoms can be physical or cognitive. -headache or dizzy to changes in behavior. -symptoms usually resolve in 72 hours. -in some cases can occur for days weeks or months. -for some people severe physical and cognitive problems remain despite relatively mild initial symptoms and normal diagnostic findings. -persistent symptoms following MTBI are known as post concussion syndrome
traumatic brain injury
-this is damage to the brain from an external force and not caused by neuro or congenital issues. -TBI can lead to temporary and permanent impairment of cognitive, physical, physiological functioning -during movement the brain may suffer from diffuse axnonal injury (shearing injuries) -contusion may occur (bruise)
subdural hematoma
-venous bleeding into the space beneath the dura and above the archnoid space -it occurs most often from a tearing of the bridging veins within the cerebral hemispheres -or from laceration of brain tissue -bleeding from this injury occurs more slowly than from an epidural hematoma. SDH are subdivided into; -acute -subacute -chronic ACUTE; -within 48 hours after impact SUBACUTE; -48 hours to 2 weeks CHRONIC; -2 weeks to several months after injury -SDH has the highest mortality rate because they are often unrecognized until the patient presents with severe neuro compromise
health promotion and prevention
-wear protective equipment -bike, motorcycle, skiing, football -wear seat belts -avoid dangerous activities
health promotion and maintenance
-wear your seat belt -don't drink and drive -promote use of helmets for skateboarding or bicycle in young people -motorcycle be careful. helmet -preventative fall measurements for elderly
spinal precautions include
1 - bed rest 2 - no neck flexion with a pillow or role 3 - no thoracic or lumbar flexion with HOB elevation or bed controls. (reverse trendelenburg is acceptable) 4 - manual control of the cervical spine anytime the rigid collar is removed 5 - log roll procedure for re positioning
AN ALERT AN ORIENTED PERSON IS ADMITTED TO THE ER WITH A GCS OF 10, INDICATED MODERATE BRAIN INJURY. WHICH ASSESSMENT FINDING WILL THE NURSE REPORT IMMEDIATELY TO THE PROVIDER?
1. photo phobia with a headache 2. new onset dizzy when lying down 3. a brisk pupillary reaction to light 4. new difficulty in responsiveness or drowsy answer is 4. -they are all somewhat significant but 4 is the worst.
determining brain death
4 prerequisites must be established; -coma of known cause as established by history, labs, neuro images -normal or neat normal core body temp (96.8) -normal systolic BP (higher than 100) -at least one neuro exam (some states want 2) -typically neurologists and critical care specialists establish someone as brain dead -neuro images are not required to confirm brain death but are desirable
types of subdural hematomas
acute; -24 to 48 hours after the trauma -immediate progression of symptoms -similar to epidural hematoma -craniotomy, evacuate and decompress subacute; -48 hours to 3 weeks after the trauma -initial unconsciousness -improve, deteriorate -evacuation and decompress chronic; -3 weeks to months post injury -nonspecific, non localizing -evacuation and decompress
managing nutritional status
brain injury may have changes in these areas; -coma or impaired ability to feed yourself -dysphagia, swallowing issues, pocketing food -sense of smell -sense of taste -for these reasons at risk for nutrition issues -weights daily and assess I and O's -PEG tube if your too unstable -helps meet caloric goals to heal -do not insert anything through the nasal passage in the presence of a cribriform plate fracture since it can allow passage of the tube into the brain -for people who are alert and can eat, make meal time pleasant -raise HOB -semisoft foods and liquids as needed -thickener may be needed
types of brain injury
concussion or mild brain injury; -usually resolves within 72 hours -post concussion syndrome can occur contusion; -brain is bruised diffuse axonal injury; -widespread injury to the brain
different types of injury
head injury; -scalp laceration -skull fracture brain injury; -open or closed -concussion or contusion -diffuse axonal injury -intracranial hemorrhage scalp injury; -minor injury usually -may bleed profusely -high risk for infection -scalp avulsions are a true emergency
The nurse is monitoring a postoperative craniotomy client with increased intracranial pressure (ICP). Which pharmacologic agent does the nurse expect to be requested to maintain the ICP within a specified range?
mannitol Mannitol is an osmotic diuretic used specifically to treat cerebral edema. Glucocorticoids have no demonstrated benefit in reducing ICP. Hydrochlorothiazide is only a mild diuretic; a loop diuretic such as furosemide (Lasix) is commonly used along with mannitol to reduce ICP. Dilantin is used to treat seizure activity caused by increased ICP.
secondary injury
-secondary injury to the brain includes any process that occurs after the initial injury worsening the patients outcome. -most common secondary issues are from -hypotension and hypoxia -intracranial hypertension -cerebral edema
self management education
-seizure safety -personality changes and how to cope -moderate to severe go home with physical or cognitive issues -fatigue, irritability, temper outbursts, depression, memory issues must be dealt with -constant supervision
closed traumatic brain injury
-are caused by blunt force. -blunt force can be direct or blast shock wave. -these injuries lead to contusions and lacerations of the brain. -a contusion is bruising of the brain tissue and is most commonly found with a coup injury or a countrecoup injury -contusions and lacerations are most commonly located at the base of the frontal and temporal lobes. -laceration causes actual tearing of the cortical surface vessels, which may lead to secondary hemorrhage and significant cerebral edema and inflammation. -this is way more serious than a contusion -when damage to the brain is severe but without local injury such as a contusion or laceration, a closed traumatic brain injury may be diagnosed as a diffuse axonal injury or widespread injury to the white matter of the brain.
epidural hematoma
-arterial bleeding into the space between the dura and the inner skull. -it is often caused by a fracture of the temporal bone -this houses the middle meningeal artery -patients with epidural hematomas have "lucid intervals" that lasts minutes during which the patient is awake and communicating. -this is followed by a momentary unconsciousness that occurs within minutes of the injury
vital signs assessment
-auto regulation often impaired with TBI -the more serious the injury, the more severe the impact on auto regulation or the ability of cerebral vasculature to modify systemic pressure such that blood flow to the brain is sufficient -monitor BP and pulse. -hypotension, hypertension, cushing's triad all can occur. -hypotension and tachycardia suggest shock -a decreased blood volume can lead to decreased CPP and secondary brain ischemia
inducing barbiturate coma
-barbiturate coma (coma induced by barbiturates) has been used for intracranial hypertension (increased ICP) that can't other wise be controlled -PENTOBARBITAL sodium or THIOPENTONE are the drugs of choice -they decrease metabolic demands of the brain and cerebral brain flow, stabilize cells, decrease edema, produce a more uniform blood supply -HCP adjusts the dose to maintain complete unresponsiveness -it is difficult to recognize subtle changes with this -mechanical respiration is needed, hemodynamic monitoring, and ICP monitoring complications; -decreased GI motility -cardiac dysrhythmias from hypokalemia -hypotension -fluctuations in body temp
assessment
-battle signs -raccoon eyes
assessing motor responses
-bilateral motor response -motor loss or dysfunction usually appears contralaterally, similar to a stroke -watch for decerebrate or decorticate posturing
factors causing brain injury
-brain can be injured by the internal surfaces of the skull and meninges. -brain tissue in itself is very fragile and prone to injury.
head injury
-broad classification of injuries that affect the scalp, skull, or brain -a head injury is any traumatic event that causes physical, emotional, social, or vocational changes in a persons life
brain injury
-can be open -closed -concussion -contusion (bruise) -diffuse axonal injury is the most severe. involves tissue of the entire brain TBI; -most important aspect is if the brain has been injured
head injury general
-classified as either open or closed. open injury; -integrity of the skull is lost -penetrating or blunt force trauma closed injury; -blunt trauma rating of the injury; -mild, moderate, severe -depends on GCS -time of unconsciousness
brain injury/TBI
-csf leakage -LOC -vision changes -dilated pupil / uneven pupils -headache -ringing in the ears
medical management of head injuries (skull)
-depends on the type of injury -may not need surgery -may be hospitalized -close observation
acceleration injury
-external force contacting the head, suddenly placing the head in motion
airway and breathing pattern assessment
-first priority is airway, breathing, circulation -TBI is occasionally associated with cervical spine cord injuries -older people are especially prone to cervical injuries at c1 or c2, a life threatening issue -injuries to the brainstem causes changes in breathing, cheyne stokes, hyperventilation, and or apnea. -artificial airway may be needed in an unconscious patient to ensure oxygenation
direct injury
-force produced by a blow to the head is a direct injury
deceleration injury
-head is suddenly stopped or hits a stationary object.
hemorrhage
-hemorrhage which causes a brain hematoma (collection of blood) or clot, may occur as a part of the primary injury and begin at the moment of impact. -it may also arise from vessel damage -classically, bleeding is caused by vascular damage from shearing force of the trauma or direct damage from skull fractures or penetrating injury. -all hematomas are potentially life threatening because they act as space occupying lesions and are surrounded by edema -3 major types of hemorrhage after TBI are -epidural -subdural -intracerebral hemorrhage -subarchnoid hemorrhage may also occur
diffuse axonal injury (without contusion or laceration separates this from closed TBI)
-high speed acceleration / deceleration injury -usually seen with a car accident -this causes shearing of large nerve fibers and streching of blood vessels in many areas of the brain. -in addition to bleeding, a DAI may trigger a cascade of toxic substances to the brain during the days following the injury. -DAI occurs throughout the brain, and the frontal and temporal lobes are particulary susceptible. -damage may also occur in the callosum, midbrain, cerebellum, and upper brainstem. -DAI can also occur in a focal but important nerve centers (white matter tracts) -causing visual field loss or weakness on one side of the body. -depending on the severity, small areas of hemorrhage may be seen in the lateral ventricles withn a CT or MRI. -there is no specific diagnosis of DAI -most prominent manifestation of DAI is impaired cognitive function. -disorganization, impaired memory, inattentivness. -severe DAI may result in a coma, and most survivors need long term care
preventing and detecting secondary brain injury cont.
-hyperventilation for an intubated patient may be used for someone with ICP -with ventilation, the goal PACO2 is 35 to 38 -carbon dioxide is very potent vasodilator and can contribute to increased ICP -monitor for hypoxemia -peripheral o2 sats -especially for someone with severe TBI -80 to 100 is the goal pao2 -patients with moderate or severe TBI are at risk for losing airway patency. -absence of gag reflex, pooled secretions, inability to position all facilitate pulmonary secretion removal to manage the airway -pulmonary secretions may be thick due to because of diuretics or fluid intake restrictions to prevent cerebral edema -HOB should be 20 to 45 with TBI -this prevents aspiration -however this may cause lower systemic blood pressure -if hypotension accompanies an elevated bed rest position, pt may be harmed -adjust elevation to sustain CPP of 70 -people with severe TBI often die -organ donor status? -before brain death is declared, contact the local organ procurement organization -did they consent to donate? -typically on a driver's license -physician or organization discusses this with the family -ethical dilemma if family doesn't agree to it
hypotension and hypoxia
-hypotension is defined as MAP below 70 -hypoxemia is defined as PPO2 less than 80 -these things restrict the flow of blood to the brain tissue. -hypotension may be related to shock -could be a clot formation -hypoxia can be due to respiratory failure, asphyxiation, or loss of airway -these things contribute to cerebral edema, creating a cycle of low perfusion and hypoxic damage -patients with hypoxic damage r/t to moderate or severe brain injury face a poor prognosis and typically experience memory impairment and reduced cognitive function
imaging assessment
-immediate CT scan -shows epidural or subdural hematoma -radiography and CT scanning of the cervical spine and skull are done to rule out fractures and dislocations -an MRI is done to detect subtle changes in brain tissue -shows more specific detail of the brain injury -particularly useful for diffuse axonal injury -not recommended for people with ICP monitoring devices
neurological assessment
-many places use the glascow -change of 2 points is bad -most important variable to assess any brain injury is LOC. -decrease LOC is typically first sign of deterioration in neuro status. -decreased arousal or increased sleeping should result in aggressive or frequent checks. early indicators of change in LOC; -behavior changes (restless, irritability) -disorientation -use a bright light to asses PERRLA. -facial trauma makes this difficult
home care management
-maximize patient's ability to return to baseline -smoke and fire alarms that are loud and function -can you smell a fire?
psycho social assessment
-mild brain injury can occur for 1 year or longer -long term effects not common -moderate to severe TBI varying changes occur -personality changes are associated with temper outbursts, depression, risk tasking, denial of disability -talkative or develop an outgoing personality -memory, especially recent or short term is often affected -difficulties concentrating. can't learn new things -changes in language understanding -changes in mobility can occur -changes in sensory perception -work and social issues -angry, can't sleep, can you work? -family may feel burdened -blame themselves for risk taking
moderate traumatic brain injury
-moderate TBI is characterized by a period of loss of consciousness for 30 minutes to 6 hours -GCS of 9 to 12 -often but not always, focal or diffuse brain injury can be seen with CT or MRI -amnesia post trauma for 24 hours -moderate TBI may occur with either closed or open brain injury -a short acute or critical care may be needed for monitoring to prevent secondary injury from edema, bleeding, or perfusion issues. -additional secondary injury can result from complex inflammatory process. this is known as the biomolecular cascade -this occurs in the CNS immediately, hours, or days after a primary injury
nursing interventions
-monitor v/s -monitor neuro status -support the family -pre and post op care -arouse pt every 2 hours (depends on instructions) -discharge teaching -Tylenol for headaches -no alcohol or sedatives
etiology of TBI
-most common cause are falls and car accidents -followed by colliding with stationary or moving objects. -alcohol and drugs are a significant factor -summer, spring, nights, weekends, evenings are the most common times. -young males are more likely than females -men tend to play sports, risks, consume alcohol more than women -falls are the most common cause of TBI in older people
assessment and diagnostics
-neuro assessment -ct scan -MRI -cerebral angiography -rapid assessment for CSF changes
MILD BRAIN INJURY MANAGEMENT
-neuro monitor every hour -Tylenol for a headache every 4 hours as needed -avoid giving sedatives, sleeping pills, or alcohol for at least 24 hours -do not do anything strenuous for 48 hours -watch balance issues for falls go back to ER if this occurs; -severe headache -persistent n/v -blurred vision -drainage from ear or nose -weakness -slurred speech -progressive sleepy -worsening headache -unequal pupil size
laboratory assessment
-no serum test to determine an injury -protein S-100B in serum can show promise to indicate brain injury several tests are used to guide a diagnosis; -arterial blood gases -CBC -serum glucose -osmalarity -electrolyte levels -electrolytes, hypoxia, and hypovolemia can cause secondary injury from reduced BP or infection
physical assessment / clinical manifestations
-no two brain injuries are the same -assess for ICP -hypotension -hypoxemia (decreased o2 to blood) -hypercarbia (PACO2 40-45). this can cause cerebral vasodilation and elevated ICP -determination of hypercarbia in an intubated pt can be done with an end tidal carbon dioxide monitor. -subtle changes in BP, consciousness, and pupillary reaction can be informative.
neuro assessment continued
-observe ears and nose for CSF leakage -this results from a basilar skull fracture -this can be analyzed by laboratory testing for glucose and electrolyte content. -can place the contents on a white absorbent paper or linen and you will see a halo sign. -clear, yellowish ring surrounding a spot of blood -halo sign most reliable when blood is in the center of the absorbent material -palpate the head gently to detect fractures or hematomas -look for areas of ecchymosis -look for tender areas or lacerations -battle sign or mastoid ecchymosis is bruising behind the ears and lower jaw -indicates fracture of the middle cranial fossa of the skull -raccoon's eyes are discoloration around the eyes -often post fracture of skull base -CT scans are used with a head or brain injury, these fractured are often seen before bruising
skull fracture
-occurs when there is a break of the continuity of the skull -caused be trauma -linear -depressed -basilar BRAIN HERNIATION CAN OCCUR. GOES OUTSIDE OF SKULL
managing sensory perception, cognitive, and behavioral changes
-parietal lobe = sensations -loss of sensation to pain, temp, touch, position sense -hazard free environment -coffee is hot and they don't realize it -sensory stimulation program for comatose or stuporus patient's routinely -visual, auditory, tactile stimulation -one at a time -patient's with a mild brain injury may be disoriented and short term memory loss -introduce yourself always -explanations clear and short -maintain a healthy sleep wake cycle -reassure the hospital is appropriate -family can bring in familial things -most people with brain injuries have altered cognition -school, work, personal life -cognitive rehab is an option -become a risk for seizures -bed in a low position -o2 near by and suctioning equipment
spine precautions
-patients with blunt trauma to the head or neck are transported with a rigid cervical collar and a long spine board -goal is to prevent new and secondary spine injury during transport. -supine position and aligning spinal column in a neutral position -no rotation, flexion, or extension -long spine board is removed ASAP once at the ER -some facilities require it to be off within 20 minutes -rigid collar is maintained until diagnostic studies to rule out a cervical injury are completed. -once spinal board is removed, spinal precautions are maintained until HCP indicates it is safe to bend or rotate the cervical, thoracic, or lumbar spine -preplanning and the assistance of 3 or more people to move a person on precautions. -one person is assigned to maintain manual control of the cervical spine -another 2 positioned on each side of the torso to turn the pt while preventing rotation, flexion, or extension, or lateral bending of the chest or abdomen during transfer -a fourth may be needed to check skin integrity or change linens and position padding
eye changes and neuro status
-pinpoint and nonresponsive pupils indicate brainstem dysfunction at the level of pons -ovoid pupil which is regarded as midstage between a normal size pupil and dilated pupil -asymmetric pupils, loss of light reaction, or unilateral or bilateral dilated pupils are treated as herniation of the brain from ICP increase -pupils that are fixed (nonreactive) and dilated are a poor prognostic sign -"blown pupils" -can you read this? -how many fingers do i have up? -loss of vision is usually caused by either direct injury to the eye or occipital lobe -test 3,4,6, by following an H -damage to optic chiasm or optic tract may cause visual field deficits or diplopia
CRITICAL RESCUE;
-position the TBI patient to avoid flexion or extension of the neck and maintain mid line neutral position -log roll the patient to avoid hip flexion -keep HOB at least 30 degrees or as ordered
expecting findings after an injury
-presence of alcohol or drugs -amnesia -loss of consciousness -CSF leakage with a basilar skull fracture -halo sign: yellow stain surrounded by blood on a paper towel
brain herniation
-presence of increased ICP the brain tissue may shift and herniate downward. -uncal herniation is one of the most clinically significant because it is life threatening -this is a shift of one or both areas of the temporal lobe, known as the uncus. -this shift causes pressure on the third cranial nerve -late findings include dilated and nonreactive pupils, ptosis, and rapidly decrease LOC. -central herniation is caused by a downward shift of the brainstem and diencephalon from a supratentorial lesion -it presents with cheyne stokes respirations, pinpoint or nonreactive eyes, and potential hemodynamic instability -all herniation syndromes are potentially life threatening, and physician must be notified right away when they are suspected.
medical management
-preserve brain function -prevent secondary injury -treat ICP -ICU monitoring -surgery -supportive measures
primary brain injury
-primary brain damage occurs at the time of injury and results from physical stress (force) within the tissue caused by blunt force. -can be categorized into two things; -focal -diffuse focal brain injury; -confined to a specific area of the brain and causes localized damage that can often be detected with a CT scan or MRI. diffuse brain injury; -characterized by damage throughout many areas of the brain. -initially may not be detected by CT scan. -MRI has greater ability to detect microscopic damage, but these areas may not be imaged until necrosis occurs. -primary brain injuries are also classed to either open or closed type injury; open traumatic brain injury; -skull is fractured or when it is pierced by a penetrating object. -integrity of the brain and dura is violated. -exposure to the environment. closed traumatic brain injury; -integrity of the skull is not violated
preventing and detecting secondary brain injury
-record v/s every 1 to 2 hours or more -IV fluids r drug therapy to monitor hypo or hyper tension -dysrhythmias and cardiac changes can occur -possible response from autonomic nervous system -can be from epinephrine in the blood -document and report any cardiac dysrhythmias, hypotension, hypertension -target BP will be given by provider -pt with brain injury may report a fever -result of systemic trauma, blood in the cranium, or general inflammatory response to brain injury -fever as a response to an infection usually occurs later in the course of the disease -central fever caused by hypothalamic damage -manifested by absence of sweating and no diurnal (night and day) variation -high and lasts several days to weeks -responds better to cooling than it does to antipyretics like Tylenol -fever of any cause is associated with higher morbidity and mortality rates
A client has an intraventricular catheter. Besides monitoring the client's intracranial pressure, what is another advantage of this catheter?
Allows sampling of cerebrospinal fluid An advantage of using an intraventricular catheter is that it allows cerebrospinal fluid sampling. A subarachnoid bolt does not penetrate the brain parenchyma. An advantage of subdural or epidural catheters is that they are the least invasive. A fiberoptic transducer-tipped catheter has less waveform artifact.
drug therapy
MANNITOL; -osmotic diuretic -cerebral edema -pulls water out of the extracellular space -given in boluses rather than continuous -given with IV filter or filtered needle to eliminate microscopic crystals. -serum osmalarity should be 310 to 320 FUROSEMIDE; -loop diuretic -adjunctive to reduce incidence of rebound from MANNITOL -enhances therapeutic action of mannitol -reduces edema and blood volume GLUCOCORTICOIDS; dexamethasone, methylprednisolone -have no benefit in management of increased ICP caused by brain injury or infarction DEXMEDETOMIDINE or PROPOFOL -used continuous IV for agitation -also used for ventilatory asynchrony -short duration of action -can be stopped for a faily neuro exam -when a pt requires sedation for management of ICP hypertension, stopping these drugs is not advised until periods of ICP elevation are infrequent and not sustained MORPHINE SULFATE, FENTANYL; -opiods for pain -decrease agitation and control restless -FENTANYL has fewer effects on BP and HR than with morphine and is considered safer -narcan to reverse effects PHENYTOIN; -prevent seizures -not recommened routinely -may be an option to prevent early onset seizure -tylenol and aspirin are given for febrile patients greater than 101 to reduce fever
medications
MANNITOL; -used to treat cerebral edema -given IV -watch I and O -catheter with it usually BARBITURATES; -this is an induced coma -helps with uncontrollable ICP -decreases demands of the body
A client has had a traumatic brain injury and is mechanically ventilated. Which technique does the nurse use to prevent increasing intracranial pressure (ICP)?
Maintaining Paco2 levels at 35 mm Hg After the first 24 hours when a client is mechanically ventilated, keeping the Paco2 levels at 35 mm Hg prevents vasodilation, which could increase ICP. CO2 is a powerful vasodilator. Turner's sign is a bluish gray discoloration in the flank region caused by acute pancreatitis. The head of the bed should be at 30 degrees; the Trendelenburg position will cause the client's ICP to increase. Although some suctioning is necessary, frequent suctioning should be avoided because it increases ICP.
A client who sustained a head injury in a motor vehicle crash several days ago has been active and talkative, and headaches have been well-controlled with acetaminophen. When performing the daily assessment, the nurse observes increased dilation of the client's pupils and notes a sluggish response to light. Which action is correct?
Notify the provider immediately. Changes in pupil size or reactivity can indicate increased intracranial pressure, even several days after the trauma event. The nurse should notify the provider immediately. Performing more assessments only delays immediate action.
MILD TRAUMATIC BRAIN INJURY KEY FEATURES
PHYSICAL; -appear dazed or stunned -loss of consciousness for 30 minutes -ha, n/v, dizzy, fatigue -balance or gait issues -vision issues -sensitivity to light and noise COGNITIVE; -mentally foggy -slowed down feeling -difficulty concentrating -difficulty remembering -amnesia of events before or after the injury SLEEP; -drowsy -sleep less than usual -sleep more than usual -trouble falling asleep EMOTIONAL; -irritability -sadness -nervous -more "emotional"
community based care
mild brain injury; -recover at home severe brain injury; -long term case management -ongoing rehab
head injury cont.
most common causes of death; -4.2 million people each year die -500k hospitalized -100k permanent disability -50k will die mechanisms of injury; -acceleration / deceleration -deformation types of injury; -blunt trauma -penetrating injury -coup/contra coup -open and closed head injuries most serious form of head injury; -traumatic brain injury (TBI) -usually from motor accidents
primary and secondary injury
primary; -damage from the traumatic incident secondary; -occurs after the initial injury -usually due to bleeding
open traumatic brain injury
the type of skull fractures associated with open traumatic brain injury are; -linear (simple, clean break. most common) -depressed (bone presses inward) -open (scalp and dura are lacerated. directly open) -comminuted (fragmented bone with depression) -a unique skull fracture is a basilar fracture. -occurs at the base of the skull -can result in CSF leakage from nose or ears -CSF leaks increase the risk for CNS infection -also associated with a high risk for hemorrhage caused by damage to internal carotid artery. -CN 1,2,7,8 can also be damaged -most penetrating injuries to the brain are caused by a gunshot wound or knife injury. -degree of injury depends on the speed, mass, shape, and direction of impact. -high velocity produces the most damage