Ch. 56 Head Injury Flashcards
1
Q
Define head injury
A
Any trauma to the skull, scalp, brain
Traumatic brain injury TBI- (serious HI)
High incidence 2% of Americans live with HI
2
Q
What are the causes for head injury? And are male or female more likely to sustain a HI?
A
- Motor vehicle collisions
- Falls
- Firearm-related injuries
- Assaults
- Sports-related injuries
- Recreational accidents
- War-related injuries
Males
3
Q
Head injury outcome
And three points in time after injury
A
High potential for poor outcome.
Death occur at three points in time after injury
1. Immediately after the injury (majority of deaths) either from direct head trauma or from massive hemorrhage and shock.
2. within two hours after the injury (caused by progressive worsening of the head trauma or internal bleeding.
3. 3weeks after the injury (result from multisystem failure)
4
Q
Nursing interventions within a few hours of the trauma
A
That’s occurring within a few hours of the trauma are caused by progressive worsening of the head injury or internal bleeding. Immediately recognizing changes in your logic status in rapid surgical intervention or critical in the prevention of deaths.
5
Q
Nursing interventions 3 weeks after injury
A
Expert nursing care in the weeks following the injury is crucial in decreasing the mortality risk and in optimizing patient outcomes.
6
Q
Case Study: K. D. Is a 33-year-old woman, is brought by paramedics to emergency department following a motor vehicle collision. She has a laceration to her for head and bruises from her seatbelt.
What type of injury did K.D. incur?
A
Closed head injury (traumatic brain injury) secondary to trauma during motor vehicle crash.
7
Q
She is stuporous and does not answer questions. What is the most likely cause of her change in level of consciousness?
A
Closed head injury TBI, secondary trauma during motor vehicle crash.
8
Q
Types of head injuries and major complications of scalp lacerations:
A
Scalp lacerations
1. External head trauma
- Scalp is highly vascular therefore profuse bleeding. Because the scalp contains many blood vessels with poor constructive abilities, most scalp lacerations are associated with profuse bleeding. Even relatively small wounds complete significantly. The major complications associated with scalp lacerations are 
- Major complications—blood loss and infection.
9
Q
Types of head injuries
Hint: SF
A
Skull fractures frequently occur with head trauma
10
Q
Skull fractures—3 types
Linear or depressed
A
Linear fracture occurs when there is a break. It is associated With low velocity injuries. A depressed skull fracture is an inward indentation of school and is associated with a powerful blow.
11
Q
Skull fractures —3 types
Simple, comminuted, or compound
A
A simple linear or depressed skull fracture is without fragmentation or communicating lacerations. It is caused by low to moderate impact.
A comminuted fracture occurs when there are multiple linear fractures with fragmentation of bone into many pieces. It is associated with direct, high momentum impact. An example of a compound fracture is a depressed skull fracture and scalp laceration with communicating pathway to intracranial cavity. This is associated with severe head injury.
12
Q
Skull fractures—3 types
Closed or open
A
Fractures may be closed (skin is not open) or open, depending on the presence of a scalp laceration or extension of the fracture into the air sinuses or dura.
13
Q
Skull Fractures location and nursing interventions
A
Determines manifestations
Apply pressure
14
Q
Skull Fracture Complications hint: 3
A
Infections (intracranial)
Hematoma- collection of blood outside of a blood vessel (major bruising)
Tissue damage- meningeal and brain tissue damage
Brain coming out of skull is possible
15
Q
What else is important to note in cases where a basal skull fracture is suspected?
A
A nasogastric or oral tube should be inserted under flouroscopy.
16
Q
Signs of Basilar Skull Fracture
Manifestations
A
Periorbital Edema and ecchymosis “Racoon Eyes”
Battle signs is bruising around the ear
Leakage of CSF from the nose is called rhinorrhea
Otorrhea- leaking from the ear
When you collect the fluid on a gauze pad you may see a Halo sign, the red blood Accumulate in the middle and there’s a little yellow surrounding ring of CSF
17
Q
What are the risk factors for Head Injury?
A
The most common causes of head injury or falls and motor vehicle accidents. Other causes of head injury include firearms, assault, sports related trauma, recreational injuries, and war related injuries. Men are twice as likely lead to sustain a TBI as women.
18
Q
What are the prevention for head injury?
A
Always wear car seatbelts in motor vehicles.
Do not drive after using drugs or alcohol.
Do not text and drive or drive distracted.
Wear helmets while bicycling skating skateboarding skiing and things contact sports. Athletes should follow safe plan techniques and the rules of the game.
Assess the home safety and implement any corrective measures needed.
Older adults should continue to exercise regularly to improve strength and balance. Follow workplace safety precautions, including wearing helmet and protective gear.
19
Q
During admission of a patient with a severe head injury to the ED, the nurse places the highest priority on assessment for?
A
Patency of airway
20
Q
Assessment of the patient.
So one of the things that important when you’re an emergency room nurse for a head injury is what?
A
Getting a full history from paramedics when bringing patient into ER. Ask Questions like were they wearing a seatbelt?
Was the patient involved in a high velocity collision due to seatbelt injury?
As an ER nurse we want to assess for internal injuries.
21
Q
What else would we want to assess for if a patient is being brought to the emergency room after a vehicle accident?
A
Whether there was a fracture of the windshield. If that was broken during the accident then that means that the patient’s head flew forward and backward In such a force that it actually cracked windshield.
22
Q
Statistically speaking if a patient has a passenger that has died what does this mean?
A
It means that the patient is at a higher risk of a serious injury
23
Q
Check CSF fluid for? (In rhinorrhea)
A
Check the discharge for glucose
If it is sweet then it’s coming from the brain. Pt is leaking CSF
24
Q
What to look out for if patient suffers a basilar skull fracture which means a severe back of the head injury where the brain or CSF can be exposed?
A
Pt. May acquire an infection
25
What are the types of head injuries? (5)
1. Diffuse (generalized) that is where damage cannot be localized to 1 particular area
2. Focal (localized) these are a contusion or hematoma That can be localized to one specific area.
3. Brain injury can be classified as minor of and that would be a Glasgow coma scale of 13 to 15
4. Or moderate and that would be 9 to 12 on the Glasgow coma scale
5. If a patient has a Glasgow coma scale of 3-8 which is severe that means that they’re in pretty serious shape and their chance of overcoming this is very very slim.
26
Diffuse injury is what? And what symptoms would you see?
A concussion
The patient may have a brief description and their level of consciousness
They may have retrograde amnesia (Inability to recall events surrounding the accident)
They will complain of a headache and
most of the time this Is going to be a short duration
May result in post concussion syndrome (Their mentation is affected may take longer to come up with their thoughts, to understand concepts) Possible slight personality changes.
27
Focal injury can occur through (4)
lacerations
contusions
hematomas and
cranial nerve injury’s
28
Post concussion syndrome and symptoms
It occurs 2 from 2 months.
The patient will present with a persistent headache,
lethargy, (tired)
personality and behavior changes,
short attention span, decreased short-term memory, and
changes in intellectual ability and thinking
29
Diffuse axonal injury and symptoms
```
Widespread accidental damage,
decreased level of consciousness,
increased ICP intracranial pressure,
decortication,
decerebration,
global cerebral edema
```
30
This is going to be how you as an RN doing your assessment are going to be able to identify patients who have increasing or severe intercranial pressure (ICP)
CUSHING’s Triad is?
For a decrease in respiratory rate your regular rest area and you’re going to look at a widening pulse pressure mean a large gap between the systolic and the diastolic numbers
For example: 149/68
RR: 12 irregular respirations caused by impaired brain stem fx
HR: 55 bradycardia
31
Many times in the ICU you’re going to be getting a patient in order to calculate that cerebral perfusion pressure CPP. Why do we do this?
To adjust our medications
| In order to provide just the right amount of pressure in the patient’s body To allow perfusion of the brain with blood
32
And unconscious patient with a traumatic head injury has a blood pressure of 170/80 and an intracranial pressure (ICP) piece of 30. The nurse will calculate the cerebral perfusion pressure CPP as what?
First you are going to find a MAP (Mean arterial pressure)
And that is comprised of the diastolic BP x2 + The systolic blood pressure times 1 and divide by 3
80x2= 160+ 170=320/3=110
110-30 (ICP) = 80
33
What measures the patients intercranial brain pressure?
A catheter that is inserted into the brain
34
What is our gold standard study? And other diagnostic tests for HI.
Cat scan
Because that’s gonna tell us right away if there’s bleeding in the brain we’re gonna be able to see automatically white areas on the brain which are going to signify bleeding
```
Other test could be an MRI test NFL potential study which measures the brain activity we can get transcranial Doppler studies cervical spine x-ray why would we want to get those most patients with sustained head entry that severe enough are going to have add an impact on the cervical spine because of how our spine is holding our head upright so many times plus I had entry we always assume and trauma patients in the ER that they have sustained cervical injury so this is why your patients come in cervical spine precautions and we do not allow them to bend their neck until we’ve done sufficient studies that show there’s no fractures there were also going to want to do the Glasgow coma scale
14-13 mild brain injury
12-9 moderate brain injury
8 or less a severe brain injury
You can never get a 2 on GCS
```
35
What is the prognosis for scores eight and under? (Glascow)
This signifies a severe brain injury.
| Not good, Patient is probably not going to make it
36
Contusion
Bruising of brain tissue
Association with closed head injury
Can cause hemorrhage, infarction, necrosis, edema
37
If patient is on Coumadin, warfarin
Give Vit K (have antidote handy)
38
Coup-countrecoup injury
Swing forward, hit steering wheel head flies backward
39
Where are different areas brain can bleed?
Subdural, epidural
40
Complications of epidural hematoma?
Bleeding between the dura and the inner surface of the skull
Neurologic emergency
Venous origin slow
Arterial origin rapid
41
Epidural hematoma complications
Initial period of unconsciousness
Brief lucid
42
Treatment for epidural hematoma?
Evacuation
| Burr hole into the skull to alleviate inner cranial pressure
43
Glasgow coma scale eye opening response
Spontaneously 4
To speech 3
To pain 2
No response 1
44
GC Scale best verbal response
Oriented to time, place, and person
45
GC Scale best motor response
```
Obeys Commands 6
Moves to localized pain 5
Flexion withdrawal from pain 4
Abnormal flexion (decorticate) 3
Abnormal extension (decerebrate) 2
No response 1
```
46
How would you assess a patient using GCS Day 1?
2 Only opens eyes to sternal rub
2 Moans in comprehensible words
5 Pushes your hand out of the way with sternal rub
Total Score = 9
47
Another example of GCS assessment
3 Eyes shut but opens eyes when you say “good morning” as you enter the room
4 Knows she is in the hospital, but cannot recall the date
6 Able to scoot herself up in bed
Score = 13
48
What is a Subdural Hematoma?
What does it result from?
What is the source of most subdural hematomas?
Hematoma venous vs. arterial, which one develops slower/faster?
Subdural hematomas may be?
A subdural hematoma occurs from bleeding between the dura mater and the arachnoid layer of the meninges.
A subdural hematoma usually results from injury to the brain tissue and its blood vessels.
The veins that drain from the surface of the brain into the sagittal sinus are the source of most subdural hematomas.
Because a subdural hematoma is usually venous in origin, the hematoma may be slower to develop.
However, a subdural hematoma may be caused by an arterial hemorrhage, in which case it develops more rapidly.
Subdural hematomas may be acute, subacute, or chronic.
49
Complications of Acute Subdural Hematoma
Acute Subdural Hematoma
Within 24 to 48 hours of the injury
Symptoms related to increased ICP
↓ LOC, headache
*Ipsilateral pupil dilated and fixed if severe
Ipsilateral = same side of body as injury
50
Subacute vs. Chronic
```
Chronic Subdural Hematoma
Weeks or months after injury
More common in older adults
Presents as focal symptoms
↑ Risk for misdiagnosis
ETHOers
```
51
A subacute subdural hematoma usually occurs within 2 to 14 days of the injury.
2 to 14 days of the injury.
After the initial bleeding, a subdural hematoma may appear to enlarge over time, as the breakdown products of the blood draw fluid into the subdural space.
52
A chronic subdural hematoma develops over weeks or months after a seemingly minor head injury.
Chronic subdural hematomas are more common in older adults due to a potentially larger subdural space as a result of brain atrophy. With atrophy, the brain remains attached to the supportive structures, but tension is increased, and it is subject to tearing. The larger size of the subdural space also accounts for the presenting complaint to be focal symptoms, rather than the signs of increased ICP. Chronic alcoholics are also prone to cerebral atrophy and subsequent development of subdural hematoma due to an increased incidence of falls.
53
Delay in diagnosis of a subdural hematoma in the older adult can be attributed to
symptoms that mimic other health problems in persons of this age group, such as somnolence, confusion, lethargy, and memory loss. The manifestations of a subdural hematoma are often misinterpreted as vascular disease (stroke, transient ischemic attack [TIA]) and dementia.
54
Intracerebral Hematoma
Bleeding within the brain tissue
Usually within frontal and temporal lobes
Size and location of hematoma determine patient outcome.
Intracerebral hematoma occurs from bleeding within the brain tissue and occurs in approximately 16% of head injuries.
It usually occurs within the frontal and temporal lobes, possibly from the rupture of intracerebral vessels at the time of injury.
The size and location of the hematoma is a key determinant of the patient’s outcome.
55
ICP (intercranial pressure)
ICP = amount of pressure in the brain and spinal fluid
56
CPP (cerebral perfusion pressure)
```
CPP = amount of pressure required to get a sufficient enough amount of blood to the brain.
Normal = 60 – 100 mg/hg
```
57
Why Care About CCP?
In the past decade more emphasis has been directed towards optimizing cerebral perfusion pressure (CPP) in patients who have suffered TBI. Injured brain may show signs of ischemia if CPP remains below 50 mmHg and raising the CPP above 60 mmHg may avoid cerebral oxygen desaturation.
Though CPP above 70 mmHg is influential in achieving an improved patient outcome, maintenance of CPP higher than 70 mmHg was associated with greater risk of acute respiratory distress syndrome (ARDS). The target CPP has been laid within 50-70 mmHg.
Note: cerebral blood flow will decrease when there is ICP.
58
Cushing’s Triad = Severe ?
| If a patient presents with this, what does this indicate?
Severe ICP ***Cushing's triad is
Irregular, decreased respirations (caused by impaired brainstem function)
Bradycardia
Systolic hypertension (widening pulse pressure)
59
What else will you see with Cushing's triad and when does it usually occur?
Confusion!! Level of consciousness, these are the key signs you’ll see with a head injury.
Cheyne-Stokes type of breathing
Bradycardia- trying to decrease blood flow to the brain
SH w/widening pulse pressure
Older adults lose elasticity of arteries therefore more of a widening pressure, can even be a normal finding minus 2 other signs, as long as no head injury
Occurs during end of life.
60
Calculating CCP An unconscious patient with a traumatic head injury has a blood pressure of 170/80 mm Hg, and an intracranial pressure (ICP) of 30 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.
CPP = mean arterial pressure [MAP] - ICP).
MAP = DBP x 2 + SBP divided by 3 =
170+160 = 320 divided by 3 = 110 minus ICP of 30 = 80 mmHg this is your cerebral perfusion pressure.
Meds MIGHT be ordered to lower the BP
61
Diagnostic Studies for head trauma
| What is the gold standard?
*CT scan
| Best diagnostic test to determine initial extent craniocerebral trauma
62
Other diagnostics for head trauma
MRI, PET
Evoked potential studies (measure brain activity)
Transcranial Doppler studies
Cervical spine x-ray
Glasgow Coma Scale (GCS)
to catch an occult (hidden) type of injury.
MRI, PET, and evoked potential studies may also be used in the diagnosis and differentiation of head injuries.
An MRI scan is more sensitive than the CT scan in detecting small lesions.
Transcranial Doppler studies allow for the measurement of CBF velocity.
A cervical spine x-ray series, CT scan, or MRI of the spine may also be indicated since cervical spine trauma often occurs at the same time as a head injury.
In general, the diagnostic studies are similar to those used for a patient with increased ICP.
63
Anytime there is massive trauma What do you want protect
the cervical spine! Otherwise patient can become paralyzed!
When a patient has massive head injury they can also have other types of injuries.
Goal: is to get patient out of cervical spine device. Assess for skin damage.
It is very important to put your patient in cervical spine precautions. Make sure to DOCUMENT TO SUPPORT EVERYTHING THAT YOU DO!!
Older adults are more susceptible to osteoporosis! Easier to break their bones.
Also, brain shrinks as you get older (just a tad) meaning more room between skull, etc…
64
What is the Glascow Coma Scale?
Can you ever get a 2 on GCS?
What is the prognosis for scores 8 and under?
14-13—mild brain injury
12-9—moderate brain injury
8 or less—a severe brain injury
No
>8 not very good survival prognosis
65
Limitations of GCS (how can these factors influence score)
```
Glucose?
Oxygenation?
ETOH?
Drugs?
Psychological?
Age?
```
Low glucose- lethargic
High glucose- yes, bc can mimic strokes!
Oxygenation- confusion, issues with perfusion
ETOH- cannot comprehend, slurred speech, unresponsive maybe even to the sternal rub, vomiting
Drugs- Affect all CNS function, sedation, hallucinations, altered perception, disorientation, not feeling pain
Psychological- delusion, depressed, inappropriate responses, if they were combative and given meds, may not be able to identify where the pain is
Age – lower immune system, decreased sensation, issues with mobility, slower response time, decreased senses
Ask patient, Tell me about the feeling in your pain?
66
```
NURSING CARE
Admission vital signs for KD were
blood pressure 128/68,
pulse 110,
respirations 26
```
Normal BP
High tachycardic
High RR
67
```
Which shows ICP? Cushing’s Triad?
Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
BP 134/90, pulse 120, resps 20
BP 118/78, pulse 108, resps 27
BP 128/100, pulse 100, resps 18
BP 190/50, pulse 52, resps 12
```
BP 190/50, pulse 52, resps 12
Widened BP
Bradycardia
Lower resp.
68
Case Study
| What would be the initial priority care for K.D. upon admission to the ED?
Airway and cervical spine
69
Collaborative Care Emergency Treatment
***Patent airway (ensure)
***Stabilize cervical spine.
Oxygen via non-rebreather mask
Establish IV access
Intubate if GCS <8.
Control external bleeding with sterile pressure dressing.
Remove patient’s clothing.
70
Collaborative Care
| Emergency Treatment
Maintain patient warmth.
Ongoing monitoring
Anticipate possible intubation.
Assume neck injury.
Administer fluids cautiously.
Ongoing Monitoring of a patient with a head injury during the emergency phase should include the following:
Maintain patient warmth using blankets, warm IV fluids, overhead warming lights, warm humidified O2.
Ongoing monitoring of
vital signs, level of consciousness, O2 saturation, cardiac rhythm, Glasgow Coma Scale score, pupil size and reactivity.
Assess for rhinorrhea, otorrhea, scalp wounds.
Anticipate need for intubation if gag reflex is impaired or absent.
Assume neck injury with head injury.
Administer fluids cautiously to prevent fluid overload and increasing ICP.
Blood bleeds more when it’s cold. So keep your patient warm. Document given patients warm blankets.
71
```
Collaborative CareTreatment principles
Prevent secondary injury
Timely diagnosis
Surgery if necessary (i.e., craniotomy or burr holes).
Concussion and contusion
Observation and management of ICP
```
Principles in caring for patients with a head injury include
measures to prevent secondary injury by treating cerebral edema and managing increased ICP,
timely diagnosis and
surgery (if necessary).
For the patient with concussion and contusion, observation and management of increased ICP are the primary management strategies.
The treatment of skull fractures is usually conservative.
For depressed fractures and fractures with loose fragments, a craniotomy is necessary to elevate the depressed bone and remove the free fragments. If large amounts of bone are destroyed, the bone may be removed (craniectomy), and a cranioplasty will be needed at a later time.
In cases of large acute subdural and epidural hematomas, or those associated with significant neurologic impairment,
primary management strategies. the blood must be removed through surgical evacuation.
A craniotomy is generally performed to visualize and allow control of the bleeding vessels.
Burr-hole openings may be used in an extreme emergency for a more rapid decompression, followed by a craniotomy.
A drain may be placed postoperatively for several days to prevent reaccumulation of blood.
In cases where extreme swelling is expected (e.g., DAI, hemorrhage), a craniectomy may be performed where a piece of the skull is removed to reduce the pressure inside the cranial vault, thus reducing the risk of herniation.
CAT scans put out a lot of radiation!! Cautious how many times you are doing CAT scans.
72
Nursing Assessment Subjective Data
```
Mechanism of Injury
Alcohol/drug use; risk-taking behaviors
Headache
Mentation changes; impaired judgment
Aphasia, dysphasia
Fear, denial, anger, aggression, depression
* Anticoagulants
```
73
Obtain the following important health information related to pertinent functional health patterns:
Health perception–health management: Use of alcohol or recreational drugs; risk-taking behaviors
Cognitive-perceptual: Headache, mood or behavioral change, mentation changes, aphasia, dysphasia, impaired judgment
Coping–stress tolerance: Fear, denial, anger, aggression, depression
74
Case Study
K.D.’s past medical history is negative except for the births of two children.
Her family denies any drug or alcohol use.
She was not taking any anticoagulant medications.
What objective data will you assess K.D. for when she is admitted to the ICU after surgery?
Temperature, (infection)
blood pressure,
mental status
75
Nursing Assessment
| Objective Data
```
Altered mental status
Lacerations, contusions, abrasions
Hematoma
Battle’s sign (basilar)
Periorbital edema and ecchymosis "Racoon's eyes"
Otorrhea
Exposed brain
```
Possible focused assessment findings include
General
Altered mental status
Integumentary
Lacerations, contusions, abrasions, hematoma, Battle’s sign, periorbital edema and ecchymosis, otorrhea, exposed brain matter
76
Nursing Assessment
| Objective Data
```
Rhinorrhea
Impaired gag reflex
Altered/irregular respirations
Cushing’s triad
Vomiting
Bowel and bladder incontinence
```
77
Possible focused assessment findings include
Respiratory
Rhinorrhea, impaired gag reflex, inability to maintain a patent airway. Impending herniation: altered/irregular respiratory rate and pattern
Cardiovascular
Impending herniation: Cushing’s triad (systolic hypertension with widening pulse pressure, bradycardia with full and bounding pulse, irregular respirations)
Gastrointestinal
Vomiting, projectile vomiting, bowel incontinence
Urinary
Bladder incontinence
No Gag reflex Yes intubate patient!
78
Nursing Assessment
| Objective Data
```
Uninhibited sexual expression
Altered LOC
Seizures
Pupil dysfunction
Cranial nerve deficit(s)
```
79
Possible focused assessment findings include
Reproductive
Uninhibited sexual expression
Neurologic
Altered level of consciousness, seizure activity, pupil dysfunction, cranial nerve deficit(s)
Musculoskeletal
Motor deficit/impairment, weakness, palmar drift, paralysis, spasticity, decorticate or decerebrate posturing, muscular rigidity/increased tone, flaccidity, ataxia
Possible Diagnostic Findings
Location and type of hematoma, edema, skull fracture, and/or foreign body on CT scan and/or MRI; abnormal EEG; positive toxicology screen or alcohol level, ↓ or ↑ blood glucose level; ↑ ICP
Dilated pupil is a late sign
80
Nursing Assessment
| Objective Data
```
Motor deficit
Palmar drift
Paralysis
Spasticity
Posturing
Rigidity or flaccidity
Ataxia Possible focused assessment findings include
Musculoskeletal
Motor deficit/impairment, weakness, palmar drift, paralysis, spasticity, decorticate or decerebrate posturing, muscular rigidity/increased tone, flaccidity, ataxia
```
Palmar drift one of the arms lowers
Posturing - decorticate or decerebrate
Ataxia- altered gait
81
```
Nursing Assessment
Objective Data
Abnormal CT scan or MRI
Abnormal EEG
Positive toxicology screen or alcohol level
↑ or ↓Blood glucose level
↑ ICP
```
Possible Diagnostic Findings
Location and type of hematoma, edema, skull fracture, and/or foreign body on CT scan and/or MRI; abnormal EEG; positive toxicology screen or alcohol level, ↓ or ↑ blood glucose level; ↑ ICP
82
Diuretics and Head Trauma***A nurse is evaluating K.D. and she has anisocoria. What medication will the nurse anticipate giving for this patient with ICP? Why?
Anisocoria – one big, one small pupils or different shapes of the pupils
Give Mannitol to pull fluid out of the body, decrease inflammation, along with giving steroids, remember this in an inflammatory
Also given in spinal cord injury to decrease the pressure
83
Nursing Planning
Overall Goals
Cerebral oxygenation & perfusion
```
Cerebral oxygenation & perfusion
Normothermic
Control pain and discomfort
Free of infection
Adequate nutrition
Maximal cognitive, motor, and sensory function
```
84
The overall goals are that the patient with an acute head injury will
The overall goals are that the patient with an acute head injury will
maintain adequate cerebral oxygenation and perfusion;
remain normothermic;
achieve control of pain and discomfort;
be free from infection;
have adequate nutrition; and
attain maximal cognitive, motor, and sensory function.
85
Nursing Implementation
| Health Promotion
Prevent car and motorcycle accidents.
Wear safety helmets.
Use seat belts and child car seats.
Home safety to prevent falls
86
Nursing Implementation
Health Promotion
One of the best ways to prevent head injuries is
One of the best ways to prevent head injuries is to prevent car and motorcycle collisions.
The use of helmets by cyclists has led to fewer TBIs.
The use of car seat belts and the use of child car seats are also associated with reduced TBI mortality rates.
Be active in campaigns that promote driving safety and speak to driver education classes regarding the dangers of unsafe driving and of driving after drinking alcohol and using drugs. The use of seat belts in cars and the use of helmets for riding on motorcycles are the most effective measures for increasing survival after crashes. The wearing of protective helmets by lumberjacks, construction workers, miners, horseback riders, bicycle riders, snowboarders, and skydivers is also recommended.
Additionally, individuals who are at risk for falls (e.g., older adults) should be evaluated for safety in the home, as falls are the second leading cause of head injuries
87
Nursing Planning
| Overall Goals
```
Cerebral oxygenation & perfusion
Normothermic
Control pain and discomfort
Free of infection
Adequate nutrition
Maximal cognitive, motor, and sensory function
```
88
You invite K.D.’s family into her room once you have her settled in.
What would be important to explain to the family at this point?
Prognosis: be realistic! Never lie about patient getting better. Devastating news doctor delivers. This is the doctor’s job to give prognosis.
Use: the patient died.
89
Nursing Implementation
| Acute Intervention
Maintain cerebral perfusion.
Prevent secondary cerebral ischemia.
Monitor for changes in neurologic status.
Patient and family teaching
Management at the injury scene can have a significant impact on the outcome of the head injury.
90
The general goal of nursing management of the head-injured patient is to maintain
cerebral oxygenation and perfusion and prevent secondary cerebral ischemia.
91
Surveillance or monitoring for changes in neurologic status is critically important because
the patient’s condition may deteriorate rapidly, necessitating emergency surgery.
92
Because of the close association between hemodynamic status and cerebral perfusion, be aware of any
coexisting injuries or conditions.
93
Perform neurologic assessments at intervals based on the patient’s condition.
he GCS is useful in assessing the LOC . Indications of a deteriorating neurologic state, no matter how subtle, such as a decreasing LOC or decreasing motor strength, should be reported to the health care provider. Monitor the patient’s condition closely.
94
Explain the need for frequent neurologic assessments to both the patient and caregiver. Behavioral manifestations associated with head injury can result in
a frightened, disoriented patient who is combative and resists help. Your approach should be calm and gentle. A family member may be available to stay with the patient and thus prevent increasing anxiety and fear. One of the most important needs for the caregiver and family members in the acute injury phase is information about the patient’s diagnosis, treatment plan, and rationale for the interventions.
95
Nursing Implementation
```
Acute Intervention
*Major focus of nursing care relates to increased ICP.
Eye problems
Eye drops, compresses, patch
Hyperthermia
Goal 36°to 37° C
Prevent shivering
```
96
The major focus of nursing care for the brain-injured patient relates to
increased ICP. However, there may be problems that require specific nursing intervention.
97
Eye problems may include
loss of the corneal reflex, periorbital ecchymosis and edema, and diplopia. Loss of the corneal reflex may necessitate administering lubricating eye drops or taping the eyes shut to prevent abrasion. Periorbital ecchymosis and edema decrease with time, but cold and, later, warm compresses provide comfort and hasten the process. Diplopia can be relieved by use of an eye patch. A consult with an ophthalmologist should be considered.
98
Hyperthermia may occur from injury to or inflammation of
Remember prevent shivering bc that can cause......
the hypothalamus.
Elevations in body temperature can result in increased CBF, cerebral blood volume, and ICP. Increased metabolism secondary to hyperthermia increases metabolic waste, which in turn produces further cerebral vasodilation. Avoid hyperthermia with a goal of 36°to 37°C as the standard of care. Use interventions to reduce temperature in conjunction with sedation as necessary to prevent shivering.
...can cause ICP
99
Nursing Implementation
***Acute Intervention
If CSF rhinorrhea or otorrhea occurs, inform the physician immediately.
The head of the bed may be raised to decrease the CSF pressure so that a tear can seal.
A loose collection pad may be placed under the nose or over the ear. Do not place a dressing in the nasal or ear cavities.
Instruct the patient not to sneeze or blow the nose. Nasogastric tubes should not be used, and nasotracheal suctioning should not be performed on these patients due to the high risk of meningitis.
100
Nursing Implementation
| ***Acute Intervention
```
Measures for patients leaking CSF
Head of bed elevated
Loose collection pad
No sneezing or blowing nose
***No NG tube
No nasotracheal suctioning
```
101
NGT with basilar skull fracture:Lesson: Recommend
oral gastric tube or NGT under fluoroscopy.
102
Nursing Implementation
```
Acute Intervention
Measures for immobilized patients
Antiemetics
Analgesics
Antibiotics
Diuretics
Pre-op preparation, if needed
```
103
Nursing measures specific to the care of the immobilized patient
such as those related to bladder and bowel function, skin care, and infection, are also indicated.
Nausea and vomiting may be a problem and can be alleviated by antiemetic drugs. Headache can usually be controlled with acetaminophen or small doses of codeine.
If the patient’s condition deteriorates, intracranial surgery may be necessary. A burr-hole opening or craniotomy may be indicated, depending on the underlying injury that is causing the symptoms. The emergency nature of the surgery may hasten the usual preoperative preparation. Consult with the neurosurgeon to determine specific preoperative nursing measures.
The patient is often unconscious before surgery, making it necessary for a family member to sign the consent form for surgery. This is a difficult and frightening time for the patient’s caregiver and family and requires sensitive nursing management. The suddenness of the situation makes it especially difficult for the family to cope.
104
Case Study
KD is hemodynamically stable, extubated, and breathing .
She opens her eyes spontaneously and follow commands.
She needs help with ADLs
She is confused and restless
She has altered gait
The family asks what the next step in her care will be and if she will ever return to her ‘original self.’
How will you respond?
Time will tell. Doctor can give prognosis. But as a nurse do not advise them.
105
Nursing ImplementationAmbulatory and Home Care
| Acute rehabilitation
```
Motor and sensory deficits
Communication issues
Memory and intellectual functioning
Nutrition
Bowel and bladder management
```
106
Seizure disorders are seen in approximately
5% of patients with a nonpenetrating head injury. Seizures are most likely to develop during the first week after the head injury. Some patients may not develop a seizure disorder until years after the initial injury. Antiseizure drugs may be used prophylactically to manage posttraumatic seizure activity.
107
The mental and emotional sequelae of brain trauma are often the most incapacitating problems. One of the consequences of TBI is that
the person may not realize that a brain injury has occurred. Many of the patients with head injuries who have been comatose for more than 6 hours undergo some personality change. They may suffer loss of concentration and memory and defective memory processing. Personal drive may decrease. Apathy may increase. Euphoria and mood swings, along with a seeming lack of awareness of the seriousness of the injury, may occur. The patient’s behavior may indicate a loss of social restraint, judgment, tact, and emotional control.
108
Progressive recovery may continue for
6 months or more before a plateau is reached, and a prognosis for recovery can be made. Specific nursing management in the posttraumatic phase depends on specific residual deficits.
109
In all cases, the family must be given special consideration. They need to understand
what is happening and be taught appropriate interaction patterns. Provide guidance and referrals for financial aid, child care, and other personal needs. Assist the family in involving the patient in family activities whenever possible. Help the patient and family develop and maintain hope. The family often has unrealistic expectations of the patient as the coma begins to recede. The family expects full return to pretrauma status. In reality, the patient usually experiences a reduced awareness and ability to interpret environmental stimuli. Prepare the family for the emergence of the patient from coma and explain that the process of awakening often takes several weeks. Arrange for social work and chaplain consultations for the family in addition to providing open-visitation and frequent status updates.
110
When it is the time for discharge planning,
the caregiver, family, and patient may benefit from specific posthospitalization instructions to avoid family-patient friction. Special “no” policies that may be appropriately suggested by the neurosurgeon, neuropsychologist, and nurse include no drinking of alcoholic beverages, no driving, no use of firearms, no work with hazardous implements and machinery, and no unsupervised smoking. Family members, particularly spouses, go through role transition as the role changes from that of spouse to that of caregiver.
111
Positioning Patients With Head Trauma The nurse is caring for a patient after a head injury. How should the nurse position the patient in bed?
A. Prone with the head turned to the right side
B. High-Fowlers position with the legs elevated
C. Supine position with the head on two pillows
D. Side-lying with the head elevated 30 degrees
Answer: D
Rationale: To prevent increased intracranial pressure, the nurse should maintain the patient in the head-up position (no more than 30 degrees). Head elevation over 30 degrees may decrease cerebral perfusion pressure. Extreme neck flexion (head on two pillows) and hip flexion (high-Fowlers position) should be avoided. Head should remain midline.
Always check the physician orders for head trauma and positioning.
You want to put the patient in a position that will promote drainage.
B. Is not correct bc this will actually cause more ICP!!
112
***What is the first and primary red flag assessment that occurs in head trauma indicative of a problem?
Confusion and altered mental status
113
```
What 3 medicines in the patient’s list are most important to report to the doctor?
Atorvastatin
Furosemide
Aspirin
Diphenhydramine
Metoprolol
Coumadin
Rivaroxaban
```
Aspirin
Coumadin (anticoagulant)
Rivaroxaban (anticoagulant)
114
The nurse is admitting a patient with a basal skull fracture. The nurse notes Battle's sign behind both ears. Which admission order should the nurse question as being potentially unsafe?
A. Keep head of bed elevated
B. Oral care q 2 hours
C. Insert foley catheter
D. Insert Ngt
The NG tube! Because NG tube can accidentally be inserted to the brain.
115
The nurse is admitting a patient with a basal skull fracture. The nurse notes Battle's sign behind both ears. Which admission order should the nurse question as being potentially unsafe?
A. Keep head of bed elevated
B. Oral care q 2 hours
C. Insert foley catheter
D. Insert Ngt
D.
| The NG tube! Because NG tube can accidentally be inserted to the brain.
116
List 5 key assessments for your head injured patient
Vital, BP looking for cushing’s triad, airway, gag reflex, anticoagulants (risk of bleeding), does pt. have hemophilia?
117
List 5 ominous assessments for your head injured patient
How do you know patient is going down hill?
Change in Glasgow, cushing’s triad is key!!, posturing,
decerebr ate worst than decorticate
118
List 5 nursing interventions for your head injured patient
Interventions – follow doctor’s orders, spinal precautions, lay them on the side to promote drainage
119
What med can quickly help to reduce ICP?
Mannitol is a osmotic diuretic
given IV provides reduction of ICP and treatment of cerebral edema.
Do not give to patient if they have hypovolemia
Monitor: CNS for coma
CV: transient volume expansion
