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Chapter 68: Management of Patients with Neurologic Trauma

Terms in this set (27)

Head Injury
Groups at highest risk for brain trauma include: children 0 to 4 years old, adolescents ages 15 to 19 years, and adults 65 years and older
Pathophysiology of Brain Damage
Primary injury: consequence of direct contact to head/brain during the instant of initial injury
Contusions, lacerations, external hematomas, skull fractures, subdural hematomas, concussion, diffuse axonal
Secondary injury: damage evolves over ensuing days and hours after the initial injury
Caused by cerebral edema, ischemia, or chemical changes associated with the trauma
Scalp Wounds and Skull Fractures
Manifestations depend on the severity and location of the injury
Scalp wounds
Tend to bleed heavily and are portals for infection
Skull fractures
Usually have localized, persistent pain
Fractures of the base of the skull
Bleeding from nose pharynx or ears
Battle sign—ecchymosis behind the ear
CSF leak: halo sign—ring of fluid around the blood stain from drainage
Management of the Patient With a Head Injury
Assume cervical spine injury until it 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
Supportive Measures
Respiratory support; intubation and mechanical ventilation
Seizure precautions and prevention
NG tube to manage reduced gastric motility and prevent aspiration
Fluid and electrolyte maintenance
Pain and anxiety management
Nutrition
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
Brain Injury #1
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 on the amount of damage and associated cerebral edema
Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs
Brain Injury #2
Diffuse axonal injury: widespread axon damage in the brain seen with head trauma. Patient develops immediate coma.
Intracranial bleeding
Epidural hematoma
Subdural hematoma
Acute and subacute
Chronic
Intracerebral hemorrhage and hematoma
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
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 includes 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
Subdural Hematoma
Collection of blood between the dura and the brain
Acute or subacute
Acute: symptoms develop over 24 to 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
Intracerebral Hemorrhage
Hemorrhage occurs into the substance of the brain
May be caused by 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 because of the location or lack of circumscribed area of hemorrhage
Diagnostic Evaluation
Physical and neurologic exam
Skull and spinal radiography
CT scan
MRI
PET
Nursing Process: The Care of the Patient With Brain Injury—Assessment
Health history with focus on the immediate injury, time, cause, and the direction and force of the blow; refer to Figure 68-4 and Table 68-1
Baseline assessment: refer to Chart 68-3
LOC—Glasgow Coma Scale: refer to Chart 68-2
Frequent and ongoing neurologic assessment
Multisystem assessment
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
Collaborative Problems and Potential Complications #1
Decreased cerebral perfusion
Cerebral edema and herniation
Impaired oxygenation and ventilation
Impaired fluid, electrolyte, and nutritional balance
Risk of posttraumatic seizures
Nursing Process: The Care of the Patient With Brain Injury—Planning
Major goals may include:
Maintenance of patent airway and adequate 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
Absence of complications
Interventions #1
Ongoing assessment and monitoring are vital
LOC
Vital signs
Maintenance of airway
Motor function
Interventions #2
I&O and daily weights
Monitor blood and urine electrolytes and osmolality and blood glucose
Measures to promote adequate nutrition
Strategies to prevent injury
Assessment of oxygenation
Assessment of bladder and urinary output
Assessment for constriction caused by dressings and casts
Pad side rails
Mittens to prevent self-injury; avoid restraints
Interventions #3
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
Interventions #4
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
Spinal shock
A sudden depression of reflex activity below the level of spinal injury
Muscular flaccidity, lack of sensation and reflexes
Neurogenic shock
Caused by the loss of function of the autonomic nervous system
Blood pressure, heart rate, and cardiac output decrease
Venous pooling occurs because of peripheral vasodilation
Paralyzed portions of the body do not perspire
Autonomic Dysreflexia
Acute emergency!
Occurs after spinal shock has resolved and may occur years after the injury
Occurs in persons with SC lesions above T6
Autonomic nervous system responses are exaggerated
Symptoms include severe pounding headache, sudden increase in blood pressure, profuse diaphoresis, nausea, nasal congestion, and bradycardia
Triggering stimuli include distended bladder (most common cause), distention or contraction of visceral organs (e.g., constipation), or stimulation of the skin
Nursing Interventions for Autonomic Dysreflexia
Place patient in seated position to lower BP
Rapid assessment to identify and eliminate cause
Empty the bladder using a urinary catheter or irrigate or change indwelling catheter
Examine rectum for fecal mass
Examine skin
Examine for any other stimulus
Administer ganglionic blocking agent such as hydralazine hydrochloride (Apresoline) IV
Label chart or medical record that patient is at risk for autonomic dysreflexia
Instruct patient in prevention and management
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 ileus
Temperature; potential hyperthermia
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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