Managing Patients With Neurologic Trauma PDF

Chapter 63 Management of Patients with Neurologic Trauma Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Head Injuries A broad classification that includes any injury to the head as a result of trauma...

Chapter 63 Management of Patients with Neurologic Trauma Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Head Injuries A broad classification that includes any injury to the head as a result of trauma 2.9 million ER visits in the United States; majority are for a mild TBI About 56,800 people die related to TBI; about 30% of all injury-related deaths Most common cause of TBIs is falls Groups at highest risk for TBI include children 0 to 4 years old, adolescents ages 15 to 19 years, and adults 65 years and older; higher in males Prevention is the best approach Chart 63-1 Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology of Brain Damage Primary injury: consequence of direct contact to head/brain during the instant of initial injury o Contusions, lacerations, external hematomas, skull fractures, subdural hematomas, concussion, diffuse axonal Secondary injury: damage evolves over ensuing days and hours after the initial injury o Caused by cerebral edema, ischemia, or chemical changes associated with the trauma Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology of Traumatic Brain Injury Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #1 Is the following statement true or false? Contusion is a temporary loss of neurologic function with no apparent structural damage to the brain. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #1 False Rationale: Concussion is a temporary loss of neurologic function with no apparent structural damage to the brain. Contusion is a bruising of the brain surface. Copyright © 2022 Wolters Kluwer · All Rights Reserved  Scalp Wounds and Skull Fractures  Manifestations depend on the severity and location of the injury  Certain populations more at risk than others (geriatrics, veterans, pediatrics)  Scalp wounds o Tend to bleed heavily and are portals for infection  Skull fractures o Usually have localized, persistent pain o 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Copyright © 2022 Wolters Kluwer · All Rights Reserved Brain Injury #1  Closed TBI (blunt trauma): acceleration/deceleration injury occurs when the head accelerates and then rapidly decelerates, damaging brain tissue  Open TBI (penetrating): 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 o Symptoms and recovery depend on the amount of damage and associated cerebral edema o Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #2 Is the following statement true or false? Clear rhinorrhea from the nose is a sign of a basilar fracture. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #2 True Rationale: Signs of basilar fracture include CSF drainage from the ears or nose, bleeding from the nose or ears, Battle sign (ecchymosis found on the mastoid), and halo sign (ring of fluid around blood stain from drainage). Copyright © 2022 Wolters Kluwer · All Rights Reserved  Brain Injury #2  Diffuse axonal injury: widespread axon damage in the brain seen with head trauma. Patient develops immediate coma  Intracranial bleeding o Epidural hematoma o Subdural hematoma  Acute and subacute  Chronic o Intracerebral hemorrhage and hematoma Copyright © 2022 Wolters Kluwer · All Rights Reserved  Epidural Hematoma  Blood collection in the space between the skull and the dura  This can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery, the artery that runs between the dura and the skull inferior to a thin portion of temporal bone.  Hemorrhage from this artery causes rapid pressure in the brain.  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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Subdural Hematoma  Collection of blood between the dura and the brain  Common cause is usually trauma  Acute or subacute o S/S include change in LOC, pupillary changes, hemiparesis, coma, VS changes o Acute: symptoms develop over 24 to 48 hours o Subacute: symptoms develop over 48 hours to 2 weeks o Requires immediate craniotomy and control of ICP  Chronic o Develops over weeks to months o Causative injury may be minor and forgotten o Clinical signs and symptoms may fluctuate o Treatment is evacuation of the clot Copyright © 2022 Wolters Kluwer · All Rights Reserved Intracerebral Hemorrhage  Hemorrhage occurs into the substance of the brain  May be caused by trauma or a nontraumatic cause o Such as a ruptured aneurysm, hypertension, tumor, bleeding disorder, complication of anticoagulants  Treatment o Supportive care o Control of ICP o Administration of fluids, electrolytes, and antihypertensive medications o 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Concussion  Patient may be admitted for observation or sent home  Observation of patients after head trauma; report immediately o Observe for any changes in LOC o Difficulty in awakening, lethargy, dizziness, confusion, irritability, anxiety o Difficulty in speaking or movement o Severe headache o Vomiting  Patient should be aroused and assessed frequently Copyright © 2022 Wolters Kluwer · All Rights Reserved Copyright © 2022 Wolters Kluwer · All Rights Reserved  Management of the Patient with a Head Injury #1 Assessment and diagnosis of the extent of injury with initial physical and neurologic examinations CT and MRI scans are the main neuroimaging diagnostic tools Positron emission tomography (PET) for assessing brain function Assume cervical spine injury until it is ruled out Apply cervical collar and maintain until cleared Copyright © 2022 Wolters Kluwer · All Rights Reserved  Management of the Patient with a Head Injury #2 Therapy to preserve brain homeostasis and prevent secondary brain injury o Stabilize cardiovascular and respiratory function to maintain cerebral perfusion/oxygenation o Control of hemorrhage and hypovolemia o Maintain optimal blood gas values o Treat increased ICP and cerebral edema o Surgery if indicated to evacuate clots, debridement, and elevate depressed fractures of skull pieces o Monitor ICP and drain CSF as needed Copyright © 2022 Wolters Kluwer · All Rights Reserved 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient with Traumatic Brain Injury Health history with focus on 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Collaborative Problems and Potential Complications of the Patient with Traumatic Brain Injury Decreased cerebral perfusion Cerebral edema and herniation Impaired oxygenation and ventilation Impaired fluid, electrolyte, and nutritional balance Risk for posttraumatic seizures Copyright © 2022 Wolters Kluwer · All Rights Reserved Planning and Goals for the Patient with Traumatic Brain Injury  Major goals may include: o Maintenance of patent airway and adequate CPP o Fluid and electrolyte balance o Adequate nutritional status o Prevention of secondary injury o Maintenance of body temperature WNL o Maintenance of skin integrity o Improvement in coping o Prevention of sleep deprivation o Increased knowledge about rehabilitation process o Absence of complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Traumatic Brain Injury #1 Ongoing assessment and monitoring are vital Maintain adequate airway Monitor neurologic function o LOC with GCS o Vital signs o Motor function o Other neurologic signs I&O and daily weights Monitor blood and urine electrolytes and osmolality and blood glucose Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Traumatic Brain Injury #2 Early initiation of nutritional therapy and measures to promote adequate nutrition Strategies to prevent injury o Assessment of oxygenation o Assessment of bladder and urinary output o Assessment for constriction caused by dressings and casts o Padded side rails o Mittens to prevent self-injury; avoid restraints Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Traumatic Brain Injury #3  Strategies to prevent injury o Reduce environmental stimuli o Adequate lighting to reduce visual hallucinations o Measures to minimize disruption of sleep–wake cycles o Skin care o Measures to prevent infection  Maintaining body temperature o Maintain appropriate environmental temperature o Use of coverings: sheets, blankets to patient needs o Administration of acetaminophen for fever o Cooling blankets or cool baths; avoid shivering Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Traumatic Brain Injury#4 Improve coping and support of cognitive function Preventing sleep pattern disturbance Support of family o Provide and reinforce information o Measures to promote effective coping o Setting of realistic, well-defined short-term goals o Referral for counseling o Support groups Patient and family teaching Copyright © 2022 Wolters Kluwer · All Rights Reserved  Brain Death  Three cardinal signs of brain death on clinical examination  Coma, absence of brain stem reflexes, and apnea  Organ donation potential based on family or personal direction  Many parameters must be met Copyright © 2022 Wolters Kluwer · All Rights Reserved Spinal Cord Injury 294,000 persons in the United States live with disability from SCI Causes include MVAs, falls, violence (gunshot wounds), and sports-related injuries Males account for 78% of SCIs Average age of injury is 43 Risk factors include young age, male gender, alcohol and drug use Major causes of death are pneumonia, pulmonary embolism (PE), and sepsis Copyright © 2022 Wolters Kluwer · All Rights Reserved Pathophysiology of Spinal Cord Injury The result of concussion, contusion, laceration, or compression of spinal cord Primary injury is the result of the initial trauma and usually permanent Secondary injury resulting from SCI include edema and hemorrhage Major concern for critical care nurses Treatment is needed to prevent partial injury from developing into more extensive, permanent damage Copyright © 2022 Wolters Kluwer · All Rights Reserved Spinal and Neurogenic Shock  Spinal shock o A sudden depression of reflex activity below the level of spinal injury o Muscular flaccidity, lack of sensation and reflexes  Neurogenic shock o Caused by the loss of function of the autonomic nervous system o Blood pressure, heart rate, and cardiac output decrease o Venous pooling occurs because of peripheral vasodilation o Paralyzed portions of the body do not perspire Copyright © 2022 Wolters Kluwer · All Rights Reserved 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for Autonomic Dysreflexia  Place patient in seated position to lower BP  Rapid assessment to identify and eliminate cause o Empty the bladder using a urinary catheter or irrigate or change indwelling catheter o Examine rectum for fecal mass o Examine skin o 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient with Spinal Cord Injury 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 Copyright © 2022 Wolters Kluwer · All Rights Reserved Collaborative Problems and Potential Complications of the Patient with Spinal Cord Injury DVT Orthostatic hypotension Autonomic dysreflexia Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #3 Is the following statement true or false? Never massage the calves or thighs of a patient who is immobile. Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #3 True Rationale: The calves or thighs of a patient who is immobile should never be massaged because of the danger of dislodging an undetected thromboembolus. Copyright © 2022 Wolters Kluwer · All Rights Reserved Planning and Goals for the Patient with Spinal Cord Injury  Major goals may include: o Improved breathing pattern and airway clearance o Improved mobility o Prevention of injury due to sensory impairment o Maintenance of skin integrity o Relief of urinary retention o Improved bowel function o Decreasing pain o Recognition of autonomic dysreflexia and absence of complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Spinal Cord Injury #1  Promoting effective breathing and airway clearance o Monitor carefully to detect potential respiratory failure  Pulse oximetry and ABGs  Lung sounds o Early and vigorous pulmonary care to prevent and remove secretions o Suctioning with caution o Breathing exercises o Assisted coughing o Humidification and hydration Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Spinal Cord Injury #2 Improving mobility o Maintain proper body alignment o If not on a specialized rotating bed, turn only if spine is stable and as indicated by physician o Monitor blood pressure with position changes o PROM at least four times a day o Use neck brace or collar, as prescribed, when patient is mobilized o Move gradually to erect position Copyright © 2022 Wolters Kluwer · All Rights Reserved Nursing Interventions for the Patient with Spinal Cord Injury #3 Strategies to compensate for sensory and perceptual alterations Measures to maintain skin integrity Temporary indwelling catheterization or intermittent catheterization NG tube to alleviate gastric distention High-calorie, high-protein, high-fiber diet Bowel program and use of stool softeners Traction pin care Hygiene and skin care related to traction devices Copyright © 2022 Wolters Kluwer · All Rights Reserved Question #4 A patient with an SCI at T5 begins to complain of a severe headache and is diaphoretic and nauseated. Which nursing intervention would not be appropriate? A. Place the patient immediately in a sitting position B. Lower the patient to a flat, side-lying position C. Assess for bladder distention D. Assess the rectum for a fecal mass Copyright © 2022 Wolters Kluwer · All Rights Reserved Answer to Question #4 B. Lower the patient to a flat, side-lying position Rationale: When a patient with SCI displays symptoms of autonomic dysreflexia, their body is communicating that there is a problem needing immediate intervention. The nurse should complete a rapid assessment to identify and alleviate the cause. The patient is placed immediately in a sitting position to lower blood pressure. The bladder is emptied immediately via a urinary catheter. If an indwelling catheter is not patent, it is irrigated or replaced with another catheter. The rectum is examined for a fecal mass. If one is present, a topical anesthetic agent is inserted 10 to 15 minutes before the mass is removed because visceral distention or contraction can cause autonomic dysreflexia. Other causes may involve skin pressure or positioning abnormalities. Copyright © 2022 Wolters Kluwer · All Rights Reserved Assessment of the Patient with Tetraplegia or Paraplegia Head-to-toe assessment and review of systems Skin for redness or breakdown Bowel and bladder program Emotional and psychological responses Copyright © 2022 Wolters Kluwer · All Rights Reserved Collaborative Problems and Potential Complications Spasticity Infection and sepsis Copyright © 2022 Wolters Kluwer · All Rights Reserved Planning and Goals for the Patient with Tetraplegia or Paraplegia  Major goals may include: o Attainment of some form of mobility o Maintenance of healthy, intact, skin o Achievement of bladder management without infection o Achievement of bowel control o Achievement of sexual expression o Strengthening of coping mechanisms o Knowledge of long-term management o Absence of complications Copyright © 2022 Wolters Kluwer · All Rights Reserved Questions?? Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins