Head Injury and Neuro Trauma Flashcards
What is the most important indicator of the patient’s condition?
Level of Consciousness
Coma
Unconsciousness, unarousable unresponsiveness
Akinetic Mutism
Unresponsive to the environment, makes no movement or sound but sometimes opens eyes
Persistent Vegetative State
Devoid of cognitive function but has sleep-wake cycles
Locked-In Syndrome
Inability to move or respond except for eye movements due to a lesion affecting pons
How do you assess LOC?
- Assess verbal response and orientation
- Alertness
- Motor responses
- Respiratory status
- Eye signs (movement, reactivity)
- Reflexes
- Postures
- Glasgow Coma Scale
Decorticate Posturing
Abnormal posturing in which a person is stiff with bent arms, clenched fists, and legs held out straight. The arms are bent in toward the body and the wrists and fingers are bent and held on the chest.
Decerebrate Posturing
** Worse than decorticate
An abnormal body posture that involves the arms and legs being held straight out, the toes being pointed downward, and the head and neck being arched backward. The muscles are tightened and held rigidly.
Potential Complications of Altered LOC
- Respiratory distress or failure
- Aspiration
- Pressure Ulcer
- DVT
Altered LOC Interventions
- Protection
- Maintaining an airway
- Maintaining fluid status
- Maintaining body temperature
- Skin precautions
- Assess bowel/bladder function
- Sensory Stimulation and Communication
Altered LOC Interventions: Protection
A major nursing goal is to compensate for the patient’s loss of protective reflexes and to assume responsibility for total patient care.
** Protection also includes maintaining the patient’s dignity and privacy
Altered LOC Interventions: Maintaining an Airway
- Frequent monitoring of respiratory status including auscultation of lung sounds
- Positioning to prevent accumulation of secretions and prevent obstruction of upper airway – HOB elevated 30 degrees, lateral or semiprone position
- Suctioning, oral hygiene, and CPT
Altered LOC Interventions: Maintaining Fluid Status
- Assess fluid status by examining tissue turgor and mucosa, lab data, and I/O
- Administer IVs, tube feedings, and fluids via feeding tube as required - monitor ordered rate of IV fluids carefully
Altered LOC Interventions: Maintaining Body Temperature
- Adjust environment and cover patient appropriately
- If temperature is elevated, use minimum amount of bedding, administer acetaminophen, use hypothermia blanket, give a cooling sponge bath, and allow fan to blow over patient to increase cooling
- Monitor temperature frequently and use measures to prevent shivering
Altered LOC Interventions: Skin Precautions
- Assess skin frequently, especially areas with high potential for breakdown
- Frequent turning
- Careful positioning in correct body alignment
- Passive ROM
- Use of splint, foam boots, trochanter rolls, and specialty beds as needed
- Clean eyes with cotton balls moistened with saline
- Use artificial tears as prescribed
- Measures to protect eyes; use eye patches cautiously as the cornea may contact patch
- Frequent, scrupulous oral care
Altered LOC Interventions: Bowel/Bladder Function
- Assess for urinary retention and urinary incontinence
- May require indwelling or intermittent catheterization
- Bladder-training program
- Assess for abdominal distention, potential constipation, and bowel incontinence
- Monitor bowel movements
- Promote elimination with stool softeners, glycerin suppositories, or enemas as indicated
- Diarrhea may result from infection, medications, constipation, or hyperosmolar fluids
Altered LOC Interventions: Sensory Stimulation and Communication
- Talk to and touch the patient and encourage family to do the same
- Maintain normal day/night pattern of activity
- Orient the patient frequently
- When arousing from a coma, a patient may experience a period of agitation; minimize stimulation at this time
- Programs for sensory stimulation
- Allow family to vent and provide support
- Reinforce and provide consistent information to family
- Referral to support groups and services for family
Normal ICP
Less than or equal to 15 mm Hg; however, it can fluctuate with position changes
Cerebral Perfusion Pressure (CPP)
Cerebral Perfusion Pressure (CPP) is defined as the difference between the Mean Arterial Pressure (MAP) and the Intracranial Pressure (ICP).
Normal CPP
70-100
Monro-Kelli Hypothesis
The pressure-volume relationship between ICP, volume of CSF, blood, and brain tissue, and cerebral perfusion pressure (CPP)
Causes of Increased ICP
- Head injury/Hematoma
- Cerebral Edema, Stroke
- Abscess, Infection
- Hemorrhage, Impending Aneurysm Rupture
- Brain tumor
- Cranial surgery
- Complication of Dialysis
Factors that Contribute to Increased ICP
- Hypercapnia - causes vasodilation
- Hypoxemia - causes vasodilation
- Valsalva maneuver - impedes blood flow from the head
- Positioning in bed = flexion of neck, hips, head turned to side, Trendelenburg
- Suctioning
Early Symptoms of Increased ICP
- Changes in LOC
- Any change in condition
- Pupillary changes and impaired ocular movements
- Weakness in one extremity or one side
- Headache - constant, increasing in intensity or aggravated by movement or straining
Late Symptoms of Increased ICP
- Respiratory and vasomotor changes
- Change in VS
- Projectile vomiting
- Further deterioration of LOC; stupor to coma
- Hemiplegia, decortication, decerebration, or flaccidity
- Respiratory pattern alterations including Cheyne-Stokes breathing and arrest
- Loss of brainstem reflexes - pupil, gag, corneal, and swallowing
What kind of change in VS can occur with increased ICP?
- Increase in systolic blood pressure
- Widening of pulse pressure
- Slowing of the heart rate
4 Pulse may fluctuate rapidly from tachycardia to bradycardia - Temperature increase
** Cushing’s Triad: bradycardia, hypertension, bradypnea
Nursing Interventions for Increased ICP
- Assess LOC and neuro status frequently
- ICP monitoring
- Hyperventilation with mechanical ventilation
- Lightly sedate or paralyze PRN to decrease coughing, sneezing, thrashing, all of which increase ICP (PATIENT MUST BE ON VENTILATOR)
- Medications to decrease ICP
- Monitor CSF drainage
- Monitor and maintain temperature
- Space out or avoid activity that increases ICP
- Seizure precautions
How does hyperventilation help decrease ICP?
To produce alkalosis, which produces vasocontriction in the brain, thus helping to reduce ICP
Medications that decrease ICP
- Hyperosmotic diuretics - draws fluid out of the brain
- Diuretic - removes excess fluid
- Steroids - decreases swelling
- Barbiturates - decreases metabolism, prevents seizures, and decreased BP
Hyperosmotic Diuretic
Mannitol
Steroid used to lower ICP
Dexamethasone
Medication used to prevent seizures from occurring in an patient with increased ICP
Phenytoin
Medication used to treat acute seizures in a patient with increased ICP
Phenobarbital
Potential Complications of Increased ICP
- Brainstem herniation
- Diabetes insipidus
- SIADH
- Infection
Pre-Op Medical Management for Intracranial Surgery
- CT, MRI, angiography, transcranial Doppler flow studies
- Anti-seizure medications
- Corticosteroids, fluid restriction, Mannitol, and diuretics may be used to reduce cerebral edema
- Prophylactic antibiotics
- Diazepam may be used to alleviate anxiety
Pre-Op Nursing Care for Intracranial Surgery
- Obtain baseline neuro assessment
- Assess patient/family understanding of surgery
- Inform patient his/her head will be shaved
- Inform patient of possible black eyes or eyes that may be swollen shut
- Inform patient about pain medication (No opiates because of the risk of masking changes in neuro status)
Post-Op Nursing Care for Intracranial Surgery
- Position patient as ordered
- Elevate HOB to promote drainage
- Monitor and report respiratory status
- Monitor fluid status (fluid restriction may be ordered)
- Neuro checks as ordered
- Monitor for seizures and other signs of increased ICP
- Monitor dressing (bleeding, CSF)
- Apply ice packs PRN for swollen eyes
- Emotional support
Potential Complications of Intracranial Surgery
- Increased ICP
- Bleeding/Hypovolemic Shock
- Infection
- Seizures
- Diabetes Insipidus
- SIADH
Intracranial Surgery Interventions
- Regulating temperature
- Improving gas exchange
- Sensory deprivation
- Enhance self-image
- Monitor labs
- Preventing infections
Intracranial Surgery Interventions: Regulating Temperature
- Cover patient appropriately
- Treat high temperature elevations vigorously; apply ice bags, use hypothermia blanket, administer prescribed acetaminophen
Intracranial Surgery Interventions: Improving Gas Exchange
- Turn and reposition every 2 hours
- Encourage deep breathing and incentive spirometry
- Suction or encourage coughing cautiously as needed (suctioning and coughing increase ICP)
- Humidification of oxygen may help loosen secretions
Intracranial Surgery Interventions: Sensory Deprivation
- Peri-orbital edema may impair vision
- Announce presence to avoid startling the patient
- Cool compresses over the eyes
- Elevation of HOB may be used to reduce edema if not contraindicated
Intracranial Surgery Interventions: Enhancing Self-Image
- Encourage verbalization
- Encourage social interaction and social support
- Attention to grooming
- Cover head with turban and then later, a wig
Intracranial Surgery Interventions: Monitor Labs
- I/O
- Weight
- Blood glucose
- Serum and urine electrolyte levels
- Osmolality
- Urine specific gravity
Intracranial Surgery Interventions: Preventing Infections
- Assess incision for signs of hematoma or infection
- Assess for potential CSF leak
- Instruct patient to avoid coughing, sneezing, or nose blowing, which may increase the risk of CSF leakage
- Use strict aseptic technique
Classification of Seizures
- Partial seizures - begin in one part of the brain
2. Generalized seizures - involve the whole brain
Types of Partial Seizures
- Simple partial - consciousness remains intact
2. Complex partial - impairment of consciousness
Causes of Seizures
- Cerebrovascular disease
- Hypoxemia
- Fever (childhood)
- Hypertension
- CNS infections
- Metabolic and toxic conditions
- Brain tumor
- Drug and alcohol withdrawal
- Allergies
Status Epilepticus
Is a medical emergency because the constant activity may deplete the brain of oxygen and glucose, which may produce hypoxia and neuronal death
Causes of Status Epilepticus
- Noncompliance with medication treatment
- Concurrent infection
- Alcohol abuse
- Fever
Goals for Caring for a Patient with Status Epilepticus
- Ensure adequate cerebral oxygenation
2. Stop seizure activity
Two types of CVA
- Ischemic
2. Hemorrhagic
Why would a CT or MRI be done for a patient with a suspected CVA?
To distinguish between a thrombotic/hemorrhagic stroke and ischemic (hemorrhagic shows evidence of bleeding)
Why would an angiography be done for a patient with a suspected CVA?
It outlines blood vessels and pinpoints site of occlusion or rupture
Why would a brain scan be done for a patient with a suspected CVA?
Shows the ischemic area
Why would a EEG be done for a patient with a suspected CVA?
Shows brain and/or seizure activity
Why would a lumbar puncture be done for a patient with a suspected CVA?
Analysis of CSF
Medical Management of CVA (not acute)
- Health management measures including a healthy diet, exercise, and the prevention and treatment of periodontal disease
- Carotid endarterectomy
- Anticoagulation therapy
- Antiplatelet therapy: aspirin, dipyridamole, clopidogrel, ticlopidine
- Statins
- Antihypertensive medications
Medical Management of Acute CVA
- Prompt diagnosis and treatment
- Assessment of stroke: NIHSS assessment tool
- Thrombolytic therapy
- Elevate HOB unless contraindicated
- Maintain airway and ventilation
- Continuous hemodynamic monitoring and neurologic assessment
Non-Modifiable Risk Factors for CVA
- Age (over 55)
- Male gender
- African American race
Modifiable Risk Factors for CVA
- HYPERTENSION
- Cardiovascular disease
- Elevated cholesterol or hematocrit
- Obesity
- Diabetes
- Oral contraceptive use
- Smoking and drug and alcohol abuse
S/Sx of TIA
- Diplopia
- Speech deficits
- Unilateral blindness
- Ataxia
- Unilateral weakness or numbness
- Dizziness
S/Sx of Ischemic Stroke
- Symptoms depend upon the location and size of the affected area
- Numbness or weakness of face, arm, or leg, especially on one side
- Confusion or change in mental status
- Trouble speaking or understanding speech
- Difficulty in walking, dizziness, or loss of balance or coordination
- Sudden, severe headache
- Perceptual disturbances
Assessment of the Acute Phase of an Ischemic Stroke
- Ongoing/frequent monitoring of all systems including vital signs and neurologic assessment: LOC, motor symptoms, speech, eye symptoms
- Monitor for potential complications
Potential Complications of Ischemic Stroke
- Musculoskeletal problems
- Swallowing difficulties
- Respiratory problems
- S/sx of increased ICP
- Meningeal irritation
Assessment after the Ischemic Stroke is Complete
Focus of patient function, self-care ability, coping, and teaching needs to facilitate rehabilitation
S/Sx of Hemorrhagic Stroke
- Similar to ischemic stroke
- Severe headache
- Early and sudden changes in LOC or speech
- Vomiting
How to prevent hemorrhagic stroke
Control of hypertension
How to diagnose a hemorrhagic stroke
CT scan, cerebral angiography, lumbar puncture if CT is negative and ICP is not elevated to confirm subarachnoid hemorrhage
Medical Management of Hemorrhagic Stroke
- Care is primarily supportive
- Bed rest with sedation
- Oxygen
- Treatment of vasospasm, increased ICP, hypertension, potential seizures, and prevention of further bleeding
Assessment of Hemorrhagic Stroke
- Complete and ongoing neuro checks/assessments
- Monitor respiratory status and oxygenation
- Monitoring ICP
- Patients with intracerebral or subarachnoid hemorrhage should be monitored in the ICU
- Monitor for potential complications
- Monitor fluid balance and labs
- All changes must be reported IMMEDIATELY!
Types of Head Injury
- Open
2. Closed
Open Head Injury
Open or break in scalp, skull, or dura
Closed Head Injury
No break in skin; however, it is more serious because of the risk of increased ICP
** blunt trauma, coup-countrecoup
S/Sx of Scalp Wounds
Tend to bleed heavily, and are also portals for infection
S/Sx of Skull Fractures
- Usually have localized, persistent pain
- Fractures of base of skull
- Battle’s sign
- Halo sign
- Bleeding from the nose, pharynx, or ears
Linear Fracture
Clean break
Comminuted Fracture
Skull crushed in fragments
Depressed Fracture
Fragments are pushed in towards the brain
Compound Fracture
Depressed skull fracture with scalp laceration
Basilar Fracture
Fracture or crack from the frontal bone to the roof of the orbit of the eye
Primary Brain Injury
Due to the initial damage
- Penetrating or blunt trauma, coup-countrecoup injuries as seen in deceleration injuries
Secondary Brain Injury
Damage evolves after the initial insult
- Due to cerebral edema, ischemia, or chemical changes associated with the trauma
Concussion
A temporary loss of consciousness with no apparent structural damage
Contusion
More severe injury with possible surface hemorrhage
- Symptoms and recovery depend upon the amount of damage and associated cerebral edema
- Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs
Causes of Intracerebral Hemorrhage
- Commonly caused by HTN
2. Trauma
Treatment for Intracerebral Hemorrhage
- Medications for HTN
- Craniotomy
- Evacuation of blood or clot
Where is the bleeding occurring in an intracerebral hemorrhage?
Bleeding into the brain tissue
Where is the bleeding occurring in an subarachnoid hemorrhage?
Bleeding into the subarachnoid space
Causes of Subarachnoid Hemorrhage
- HTN
- Ruptured AVM
- Anticoagulants
- Leukemia
Treatment of Subarachnoid Hemorrhage
- Clipping of aneurysm
2. Evacuation of the clot
Where is the bleeding occurring in an epidural hematoma?
Blood between the skull and dura
Causes of epidural hematoma
Often caused by a skull fracture causing a laceration of the middle meningeal artery
S/Sx of epidural hematoma
Marked neuro deficits/breathing cessation in minutes
Treatment of epidural hematoma
- Burr holes
- Clot removal
- Bleeding control
Where is the bleeding occurring in an subdural hematoma?
Blood between the skull and dura
Causes of Subdural hematoma
- Common cause is trauma
2. Bleeding disorders/aneurysms
S/Sx of subdural hematoma
Patient is usually comatose
Treatment of subdural hematoma
- Emergency craniotomy
2. Clot removal
Medical Management of Head Injury
- Airway management R/O cervical injury
- VS, neuro checks, diagnostic tests
- Monitor for increased ICP, maintaining bodily functions, body temperature
- Ventilate
- Maintain cerebral perfusion
- Antiemetics for nausea
- Mild analgesics for pain
Nursing Interventions for Head Injury
- Elevate HOB
- Neuro assessment and report changes
- Avoid restraints if possible
- If loss of corneal reflex: Methylcellulose drops (artificial tears), eye patches
- Periorbital ecchymoses and edema: alternate cold and warm compresses for comfort
- Monitor respiratory status
- Monitor fluid status
- For rhinorrhea/otorrhea, keep HOB elevated 30 degrees
- Monitor for and report seizure activity
- Care of unconscious/immobilized patient
Potential Complications of Head Injury
- Atelectasis
- Pneumonia
- UTI
- Diabetes Insipidus
- SIADH
