Transcript Chapter 63 Management of Patients with Neurologic Trauma

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Head Injury
 A broad classification that includes injury to the scalp,
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skull, or brain
1.4 million people receive head injuries every year in the
U.S.
The most common cause of death from trauma
Most common cause of brain trauma is MVA
Group at highest risk group for brain trauma is males age
15–24
Those younger than 5 years and the elderly are also at
increased risk
Prevention
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Pathophysiology of Brain Damage
 Primary injury: due to the initial damage
 Contusions, lacerations, damage to blood vessels,
acceleration/deceleration injury, or due to foreign object
penetration
 Secondary injury: damage evolves after the initial
insult
 Due to cerebral edema, ischemia, or chemical changes
associated with the trauma
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Pathophysiology of Traumatic Brain Injury
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Manifestations
 Manifestations depend upon the severity and location of
the injury
 Scalp wounds
 Tend to bleed heavily, and are also portals for infection
 Skull fractures
 Usually have localized, persistent pain
 Fractures of the base of the skull
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Bleeding from nose, pharynx, or ears
Battle’s sign—ecchymosis behind the ear
CSF leak—halo sign—ring of fluid around the blood stain from
drainage
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Basilar Fractures Allow CSF to Leak from the
Nose and Ears
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Manifestations of Brain Injury
 Altered LOC
 Pupillary abnormalities
 Sudden onset of neurologic deficits and neurologic
changes; changes in sense, movement, reflexes
 Changes in vital signs
 Headache
 Seizures
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Brain Injury
 Closed brain injury (blunt trauma): acceleration/deceleration injury occurs
when the head accelerates and then rapidly decelerates, damaging brain
tissue
 Open brain injury: object penetrates the brain or trauma is so severe that
the scalp and skull are opened
 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
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Brain Injury
 Diffuse axonal injury: involves widespread damage to
axons in the cerebral hemispheres, corpus callosum,
and brain stem. It can be seen with mild, moderate, or
severe head trauma. Patient develops immediate
coma.
 Intracranial bleeding
 Epidural hematoma
 Subdural hematoma
 Acute and subacute
 Chronic
 Intracerebral hemorrhage and hematoma
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Concussion
 Patient may be admitted for observation or sent home
 Observation of patients after head trauma; report
immediately
 Observe for any changes in LOC
 Difficulty in awakening, lethargy, dizziness, confusion,
irritability, anxiety
 Difficulty in speaking or movement
 Severe headache
 Vomiting
 Patient should be aroused and assessed frequently
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Location of Subdural, Intracerebral
and Epidural Hemorrhages
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Epidural Hematoma
 Blood collection in the space between the skull and
the dura.
 Patient may have a brief loss of consciousness with
return of lucid state then as hematoma expands
increased ICP will often suddenly reduce LOC.
 An emergency situation!
 Treatment include measures to reduce ICP, remove the
clot and stop bleeding—burr holes or craniotomy.
 Patient will need monitoring and support of vital body
functions; respiratory support.
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Subdural Hematoma
 Collection of blood between the dura and the brain
 Acute/Subacute
 Acute: symptoms develop over 24–48 hours
 Subacute: symptoms develop over 48 hours to 2 weeks
 Requires immediate craniotomy and control of ICP
 Chronic
 Develops over weeks to months
 Causative injury may be minor and forgotten
 Clinical signs and symptoms may fluctuate
 Treatment is evacuation of the clot
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Intracerebral Hemorrhage
 Hemorrhage occurs into the substance of the brain
 May be due to trauma or a nontraumatic cause
 Treatment
 Supportive care
 Control of ICP
 Administration of fluids, electrolytes, and antihypertensive
medications
 Craniotomy or craniectomy to remove clot and control
hemorrhage; this may not be possible due the location or
lack of circumscribed area of hemorrhage
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Diagnostic Evaluation
 Physical and neurologic exam
 Skull and spinal x-rays
 CT scan
 MRI
 PET (Positron emission tomography)
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Management of the Patient with a
Head Injury
 Assume cervical spine injury until this is ruled out
 Therapy to preserve brain homeostasis and prevent
secondary damage
 Treat cerebral edema
 Maintain cerebral perfusion; treat hypotension,
hypovolemia and bleeding, monitor and manage ICP
 Maintain oxygenation; cardiovascular and respiratory
function
 Manage fluid and electrolyte balance
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Supportive Measures
 Respiratory support; intubation and mechanical
ventilation
 Seizure precautions and prevention
 NG to manage reduced gastric motility and prevent
aspiration
 Fluid and electrolyte maintenance
 Pain and anxiety management
 Nutrition
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Nursing Process: The Care of the Patient with
Brain Injury—Assessment
 Health history with focus upon the immediate injury,
time, cause, and the direction and force of the blow
 Baseline assessment
 LOC—Glasgow Coma Scale
 Frequent and ongoing neurologic assessment
 Multisystem assessment
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Nursing Process: The Care of the Patient with
Brain Injury—Diagnoses
 Ineffective airway clearance and impaired gas exchange
 Ineffective cerebral perfusion
 Deficient fluid volume
 Imbalanced nutrition
 Risk for injury
 Risk for imbalanced body temperature
 Risk for impaired skin integrity
 Disturbed thought patterns
 Disturbed sleep pattern
 Interrupted family process
 Deficient knowledge
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Collaborative Problems/Potential
Complications
 Decreased cerebral perfusion
 Cerebral edema and herniation
 Impaired oxygenation and ventilation
 Impaired fluid, electrolyte, and nutritional balance
 Risk of posttraumatic seizures
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Nursing Process: The Care of the Patient with
Brain Injury—Planning
 Major goals may include
 Maintenance of patent airway,
 Adequate cerebral perfusion pressure (CPP),
 Fluid and electrolyte balance,
 Adequate nutritional status,
 Prevention of secondary injury,
 Maintenance of normal temperature,
 Maintenance of skin integrity,
 Improvement of cognitive function,
 Prevention of sleep deprivation,
 Effective family coping,
 Increased knowledge about rehabilitation process, and
 Absence of complications.
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Interventions
 Ongoing assessment and monitoring is vital
 Maintenance of airway
 Positioning to facilitate drainage of oral secretions with
HOB usually elevated 30° to decrease venous pressure
 Suctioning with caution
 Prevention of aspiration and respiratory insufficiency
 Monitor ABGs, ventilation, and mechanical ventilation
 Monitor for pulmonary complications, potential ARDS
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Interventions
 I&O and daily weights
 Monitor blood and urine electrolytes and osmolality and
blood glucose
 Measures to promote adequate nutrition
 Strategies to prevent injury
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Assessment of oxygenation
Assessment of bladder and urinary output
Assessment for constriction due to dressings and casts
Pad side-rails
Mittens to prevent self-injury; avoid restraints
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Interventions
 Strategies to prevent injury
 Reduce environmental stimuli
 Adequate lighting to reduce visual hallucinations
 Measures to minimize disruption of sleep-wake cycles
 Skin care
 Measures to prevent infection
 Maintaining body temperature
 Maintain appropriate environmental temperature
 Use of coverings—sheets, blankets to patient needs
 Administration of acetaminophen for fever
 Cooling blankets or cool baths; avoid shivering
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Interventions
 Support of cognitive function
 Support of family
 Provide and reinforce information
 Measures to promote effective coping
 Setting of realistic, well-defined, short-term goals
 Referral for counseling
 Support groups
 Patient and family teaching
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Spinal Cord Injury (SCI)
Definition:
 Fracture or displacement of one or more vertebrae
causing damae to spinal cord and nerve roots with
resulting neurological deficit and altered sensory
perception or paralysis or both. There will be a total or
partial absence of motor and/or sensory function
below the level of injury. (Ignatavious and Workman,
2006)
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Spinal Cord Injury (SCI)
 A major health problem
 200,000 persons in the U.S. live with disability
from SCI
 Causes include MVAs (35%), violence (24%), falls
(22%), and sports injuries (8%)
 Males account for 82% of SCIs
 Young people ages 16–30 account for more than
half of all new SCIs
 African–Americans are at higher risk
 Risk factors include alcohol and drug use
 Prevention
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Spinal Cord Injury
 The result of concussion, contusion, laceration or
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compression of spinal cord.
Primary injury is the result of the initial trauma.
Secondary injury is usually the result of ischemia,
hypoxia, and hemorrhage that destroys the nerve tissues.
Secondary injuries are thought to be
reversible/preventable during the first 4–6 hours after
injury.
Treatment is needed to prevent partial injury from
developing into more extensive, permanent damage.
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Clinical Manifestations
 Manifestations depend on the type and level of injury
 Incomplete spinal cord lesions (the sensory or motor
fibers, or both, are preserved below the lesion): below the
injury; total sensory and motor paralysis, loss of bladder and
bowel control (usually with urinary retention and bladder
distention), loss of sweating and vasomotor tone, & marked
reduction of blood pressure.
 Complete spinal cord lesion (total loss of sensation and
voluntary muscle control below the lesion): paraplegia or
tetraplegia.
 If conscious, the patient usually complains of acute pain in
the back or neck
 In high cervical cord injury, acute respiratory failure is the
leading cause of death.
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Spinal and Neurogenic Shock
 Spinal shock
 A sudden depression of reflex activity below the level of
spinal injury
 develops due to the loss of autonomic nervous system
function below the level of the lesion
 Muscular flaccidity, lack of sensation and reflexes
 Neurogenic shock
 Due to the loss of function of the autonomic nervous
system
 Blood pressure, heart rate, and cardiac output decrease
 Venous pooling occurs due to peripheral vasodilation
 Paralyzed portions of the body do not perspire
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Medical Management: Acute Phase
 Goals:
 Prevent further SCI and
observe for signs of
neurological deficit
 High dose
corticosteroids
(controversial)
 Research is continuing
Medical management:
 Pharmacologic therapy
 Respiratory therapy
 Skeletal fracture
reduction and traction
 Surgical management
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Nursing Process: The Care of the Patient with
SCI—Assessment
 Monitor respirations and breathing pattern
 Lung sounds and cough
 Monitor for changes in motor or sensory function;
report immediately
 Assess for spinal shock
 Monitor for bladder retention or distention, gastric
dilation, and ilieus
 Temperature; potential hyperthermia
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Nursing Process: The Care of the Patient with
SCI—Diagnoses
 Ineffective breathing pattern
 Ineffective airway clearance
 Impaired physical mobility
 Disturbed sensory perception
 Risk for impaired skin integrity
 Impaired urinary elimination
 Constipation
 Acute pain
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Collaborative Problems/Potential
Complications
 DVT
 Orthostatic hypotension
 Autonomic dysreflexia
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Nursing Process: The Care of the Patient with
SCI—Planning
 Major goals may include improved breathing pattern
and airway clearance, improved mobility, improved
sensory and perceptual awareness, maintenance of
skin integrity, promotion of comfort, and absence of
complications.
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Promotion of Effective Breathing and Airway
Clearance
 Monitor carefully to detect potential respiratory failure
 Pulse oximetry and ABGs
 Lung sounds
 Early and vigorous pulmonary care to prevent and
remove secretions
 Suctioning with caution
 Breathing exercises
 Assisted coughing
 Humidification and hydration
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Improving Mobility
 Maintain proper body alignment
 Turn only if spine is stable and as indicated by
physician
 Monitor blood pressure with position changes
 PROM at least four times a day
 Use neck brace or collar, as prescribed, when patient is
mobilized
 Move gradually to erect position
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