Traumatic Brain Injury (TBI)

Traumatic Brain Injury (TBI)

• Trauma can lead to hemorrhage, contusion, or laceration
• TBI can cause cerebral edema, hyperemia, hydrocephalus, brain herniation, or death
• Motor vehicle accidents (MVAs) are the most common cause of TBI
• Other causes include falls, assaults, and sports-related injuries
• Diagnosis involves CT scans, MRI, and neuropsychological testing
• Therapeutic interventions include surgical removal of hematoma and controlling increased intracranial pressure (ICP)
• ICP can be controlled via:
  • ICP monitoring
  • Osmotic diuretics like Mannitol (monitor urinary output)
  • Mechanical hyperventilation
• Therapeutic coma can be induced
• Complications of TBI include brain herniation, diabetes insipidus, acute hydrocephalus, labile vital signs, post-traumatic syndrome, and cognitive/personality changes
• Nursing diagnoses include ineffective cerebral tissue perfusion, ineffective airway clearance, and ineffective breathing pattern
• Additional nursing diagnoses are acute confusion, self-care deficit, acute/chronic pain, disturbed sensory perception, impaired physical mobility, and risk for injury
• Open head injury is also called penetrating injury
• Closed head injury is also called non-penetrating injury
• Mechanisms of injury include acceleration, deceleration, acceleration-deceleration, and rotational forces
• Types of injury include concussion, contusion, subdural and epidural hematoma

Brain Tumor

• Pathophysiology involves neoplastic growth of the brain or meninges
• Tumors can be primary or metastatic; they compress or infiltrate brain tissue and can cause increased ICP
• Common signs and symptoms include seizures, motor/sensory deficits, headaches, speech/vision disturbances, personality changes, and hormone disturbances
• Diagnosis uses MRI, angiogram, magnetic resonance angiogram (MRA), and hormone levels
• Therapeutic interventions include surgical removal, radiation therapy, chemotherapy, complimentary/alternative therapy, and symptom control
• Anticonvulsants and steroids (dexamethasone) can be used for symptom control (reduce swelling)
• Complications include seizures, headaches, memory impairment, cognitive changes, ataxia, hemiparesis, aphasia, lethargy, coma, and death
• Nursing diagnoses include risk for acute or chronic confusion, self-care deficit, acute or chronic pain, disturbed sensory perception, impaired physical mobility, and risk for injury

Intracranial Surgery

• Indications include hematoma, tumor, arteriovenous (AV) malformation, trauma, and seizures
• Types- craniotomy, craniectomy, and cranioplasty
• Preoperative care involves patient education, anxiety control, and intensive care unit (ICU) visit
• Postoperative nursing diagnoses include risk for ineffective cerebral tissue perfusion, risk for infection, disturbed body image, and deficient knowledge

Herniated Disk

• Pathophysiology involves herniation of nucleus pulposus, compression of nerve root(s)
• Most commonly occurs in the cervical and lumbar regions
• Etiology can be injury or may be unknown
• Signs and symptoms include pain, muscle spasm, numbness/tingling of extremity, weakness, and atrophy
• Diagnosis uses MRI and myelogram
• Therapeutic interventions include rest, physical therapy, traction, muscle relaxants, NSAIDs/analgesics, epidural anesthetic/steroid injections, and surgery
• Types of surgery include laminectomy, diskectomy, spinal fusion, and artificial disk
• Complications after surgery: hemorrhage, nerve root damage, reherniation, and herniation of another disk
• Preoperative care involves routine teaching, including log-rolling technique
• Postoperative nursing diagnoses include acute pain, impaired urinary elimination, and impaired physical mobility

Spinal Stenosis

• Spinal canal compresses the spinal cord
• Arthritis is a major cause
• Laminectomy is a treatment

Spinal Cord Injury

• Pathophysiology involves damage to nerve fibers and interference with communication between brain and body
• Common causes are MVA and falls
• Other causes include sports injuries and assault
• Cervical injury can result in paralysis, paresthesias, impaired respiration, Loss of bladder and bowel control, quadriplegia/paresis
  • C3 injury or above is fatal
• Thoracic/Lumbar Injury can lead to paraplegia/paresis, altered bowel and bladder control
• Therapeutic measures- cared for in ER and the patient needs to remain immobilized until assessed
• Diagnostic tests- X-Ray, CT Scan, and MRI
• Emergency management includes respiratory, gastrointestinal, genitourinary, and immobilization
• Surgical management- Stabilize spine (halo brace, rods, corset, brace, and body cast)
• Skeletal traction can be achieved via:
  • Crutchfield tongs
  • Gardner-Wells tongs
• Nursing diagnoses include impaired gas exchange, ineffective airway clearance, risk for autonomic dysreflexia, reflex urinary incontinence, constipation, and impaired physical mobility
• Additional nursing diagnoses include self-care deficit, risk for impaired skin integrity, ineffective role performance, risk for sexual dysfunction, and anxiety

Spinal Shock

• Sympathetic Nervous System (SNS) Disruption
• Vasodilation
• Hypotension
• Bradycardia
• Hypothermia
• Urine and Feces Retention

Complications of Spinal Cord Injury

• Infection
• DVT
• Orthostatic Hypotension
• Skin Breakdown
• Renal Complications
• Depression and Substance Abuse
• Autonomic Dysreflexia (involve thoracic nerves of the spine or above (T6 or above)

Parkinson’s Disease

• Involves destruction of substantia nigra, decreased dopamine production, relative excess of acetylcholine, and impairment of semiautomatic movements
• Etiology includes unknown causes, genetic factors, certain drugs, and encephalitis
• Signs and symptoms: muscular rigidity, bradykinesia, changes in posture, pill-rolling tremor, difficulty initiating movement, and shuffling/freezing gait
• Additional signs and symptoms include autonomic nervous system (ANS) dysfunction, such as diaphoresis, constipation, orthostatic hypotension, drooling, dysphagia, seborrhea, and frequent urination
• Diagnostic tests include history, physical examination, and MRI
• Therapeutic interventions include:
  • Dopamine agonists
  • Monoamine oxidase B inhibitors
  • Catechol-O-methyltransferase (COMT) inhibitors
  • Pallidotomy
  • Deep brain stimulation
• Dopamine drugs used include- Amantadine, Apomorphine, Bromocriptine (Parlodel), Carbidopa-levodopa (Sinemet), Entacapone (Comtan), Levodopa (Larodopa), Pramipexole (Mirapex), Ropinirole (Requip), Selegiline (L-Deprenyl, Eldepryl), and Tolcapone (Tasmar)
• Medical management goals- directed toward controlling the symptoms with physical therapy and drug therapy
  • Beneficial PT programs- massage, heat, exercise, and gait training
  • Speech therapy- swallowing and speech issues
• Medical management early in the course-dopamine receptor agonists: Pramipexole (Mirapex) or Ropinirole (Requip) to maximize the intrinsic dopamine
• Nursing diagnoses include impaired physical mobility, self-care deficit, risk for injury, and diagnoses for dementia
• Primary nursing care focus- maintain mobility and prevent injury
• Assessment includes weakness, muscle cramps, sweating, dysphagia, constipation, difficulty voiding, and unusual movements
• Be alert for lack of facial expression, eyes fixed in one direction, drooling, slurred speech, tearing, tremors, muscle stiffness, and poor balance and coordination
• As disease progresses: immobility ensues

Huntington’s Disease

• Autosomal dominant genetic disorder
• Pathophysiology involves degeneration of parts of the brain
• Signs and symptoms include dementia, personality changes, inappropriate behavior, paranoia, violence, choreiform movements, dysphagia, depression, and death
• Diagnosis uses family history, MRI, CT scan, and genetic testing/counseling
• Therapeutic interventions include antipsychotics, antidepressants, and antichorea agents
  • Stem cell transplants are considered experimental
• Provide nursing care on an outpatient basis and address swallowing difficulty
• Encourage to discuss end-of-life care

Comparison of Parkinson’s and Huntington’s Disease

Practice Analysis Tip

• The licensed practical nurse/licensed vocational nurse (LPN/LVN) will:
  • Promote positive self-esteem of client.
  • Promote a therapeutic environment.
  • Assist in the care of the cognitively impaired client.
  • Provide care to immobilized client based on need.
  • Evaluate client oxygen saturation.
  • Participate in staff education (e.g., in-services, continued competency).

Case Study With Concept Map: Mr. Diaz

• Mr. Diaz is a 23-year-old veteran with T4 spinal cord injury from gunfire overseas
• He presents with complaints of being tired all the time and not feeling well
• Has a fever of 100.4°F (38°C) orally and BP 140/82, which is abnormally high for him
• Nurse finds that he has been drinking about 10 beers a day, and states that he doesn't feel like a man anymore because he has to wear this catheter (urinary) and cannot control his bowels or do the things that he used to do before his accident
• BUN = 35 mg/dL with a creatinine of 1.56 mg/dL

SBAR Hand-Off Report: Mr. Gomez Case

• Situation: Mr. Gomez was admitted at 1100
• Background: Mr. Gomez has Parkinson disease
• Assessment: Admitted due to anorexia and he is alert and oriented x3. He has an NG tube in place and is incontinent of stool only
• Recommendation: Keep head of the bed up 30 degrees and Levodopa due at 1600 via NG tube

Review Questions

• A patient is admitted to the surgical unit following removal of a brain tumor- assess speech and swallowing
• Which assessment findings- Bradykinesia, Depression, and Muscle rigidity
• A patient with a cervical spine injury suddenly exhibits a spike in blood pressure- perform a bladder scan