Transcript LWW PPT Slide Template Master

Chapter 45
Nursing Management:
Patients With Neurologic
Trauma
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Head Injuries
• The most common cause of death from trauma in the
United States
• Primary injury is the initial damage to the brain
• Secondary injury is the damage from the sequelae of the
primary injury (eg, increased intracranial pressure)
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Skull Fractures
• A break in the continuity of the skull caused by forceful
trauma
• May occur with or without damage to the brain
• Nondepressed skull fractures generally do not require
surgical treatment
• Depressed skull fractures usually require surgery
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Question
• The nurse has observed that clear fluid is leaking from
the nose of a patient who has just been admitted with a
skull fracture. What conclusion should the nurse draw
from this assessment finding?
A. The patient is diuresing as a result of the injury.
B. The patient is leaking cerebrospinal fluid.
C. The patient is leaking blood plasma.
D. The basement membrane of the patient’s mucous
membranes has been damaged.
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Answer
• B. The patient is leaking cerebrospinal fluid.
• Rationale: Clear fluid that is draining from the nose or
ears should be collected and tested for glucose. If the
drainage is CSF, it will be positive for glucose. It is
unlikely that the patient would be leaking plasma from
his or her nose. Diuresis would not cause this
phenomenon.
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Brain Injury
• Concussion: An alteration in mental status that results
from trauma, and may or may not involve loss of
consciousness:
– Treatment involves observing the patient for
symptoms, including headache, dizziness, lethargy,
irritability, anxiety, photophobia, phonophobia,
difficulty concentrating, and memory difficulties
• Contusion: A more severe injury, involving bruising of
the brain, with possible surface hemorrhage
• Diffuse axonal injury: Involves widespread damage to
axons in the cerebral hemispheres
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Hematomas
• Collections of blood that develop within the cranial vault;
the most serious type of brain injury
• Epidural hematoma: Collection of blood in the space
between the skull and the dura
• Subdural hematoma (SDH): Collection of blood between
the dura and the brain:
– May be acute or chronic
• Intracerebral hemorrhage (ICH): Bleeding into the
parenchyma of the brain
• Treatment of all is directed toward preserving brain
homeostasis and preventing secondary brain injury
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Altered Level of Consciousness
• Exists when a patient is not oriented, does not follow
commands, or needs persistent stimuli to achieve a state
of alertness
• LOC exists on a continuum from a normal state of
alertness to coma
• Altered LOC may have neurologic, metabolic, or
toxicologic causes
• Often results from brain herniation and/or increased
intracranial pressure
• Systematic, thorough assessment is necessary
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Question
• Is the following statement true or false?
• When assessing a patient using the Glasgow Coma Scale,
the nurse will assess the patient’s judgment and insight.
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Answer
• False
• Rationale: The assessment parameters of the GCS are
best verbal response, best motor response, and eye
opening.
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Monitoring Intracranial Pressure
• The earliest sign of increasing ICP is a change in LOC:
– Other early signs include headache, weakness, and
pupillary changes
• ICP can be monitored with the use of an intraventricular
catheter (ventriculostomy) or a subarachnoid bolt or
screw
• The nurse must conduct frequent, focused neurological
assessments
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Management of the Patient With
Increased ICP
• Treating cerebral edema (most often with mannitol)
• Controlling fever
• Maintaining BP and oxygenation
• Reducing metabolic demand
• Preventing seizures
• Preserving the integrity of the skin and corneas
• Promoting nutrition
• Preserving bowel and bladder function
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Question
• Cerebral edema can often be prevented or treated in the
brain-injured patient through which of the following
interventions?
A. Fluid restriction
B. Administration of hypotonic IV solutions
C. Prone positioning
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Answer
• A. Fluid restriction
• Rationale: Limiting overall fluid intake leads to
dehydration and hemoconcentration, which draws fluid
across the osmotic gradient and decreases cerebral
edema. Hypotonic fluids should be avoided in patients
with brain injury as they can cause an increase in
cerebral edema. Similarly, prone positioning may
exacerbate cerebral edema.
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Spinal Cord Injury (SCI)
• An estimated 259,000 people in the United States live
each day with a disability from SCI
• Manifestations of SCI depend on the type and level of
injury (eg, complete or incomplete spinal cord lesions)
• Emergency management at the scene of the injury is
critical
• At the trauma center, treatment may be surgical or
nonsurgical:
– Goals are preservations, stabilization, and
realignment of the spinal cord
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Monitoring and Managing Complications
of SCI
• Spinal and neurogenic shock
• DVT
• Orthostatic hypotension
• Autonomic dysreflexia
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Nursing Management: The Patient With
Acute SCI
• The patient is assessed for:
– Altered breathing
– Changes in motor or sensory function
– Spinal shock
– Urinary retention
– Overdistention of the bladder
– Paralytic ileus
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Nursing Management: The Patient With
Acute SCI (cont’d)
• Goal and interventions address:
– Improved breathing pattern and airway clearance
– Improved mobility
– Improved sensory and perceptual awareness
– Maintenance of skin integrity
– Relief of urinary retention
– Improved bowel function
– Promotion of comfort
– Absence of complications
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Question
• Is the following statement true or false?
• The most common effect on bladder function that is
caused by acute SCI is urinary incontinence.
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Answer
• False
• Rationale: Immediately after SCI, the urinary bladder
may become atonic and is unable to contract by reflex
activity. Urinary retention is typically the result of this.
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