Week 10 - Management of Patients With Neurologic Trauma (2) PDF

# Management of Patients With Neurologic Trauma ## Chapter 65 (4th ed.) NRSG 3013 Adapted by J. Black RN, BScN, MN ## Head Injury - A broad classification that includes injury to the scalp, skull, or brain. - Most common causes of brain injury are falls, motor vehicle accidents, and assault. -...

# Management of Patients With Neurologic Trauma ## Chapter 65 (4th ed.) NRSG 3013 Adapted by J. Black RN, BScN, MN ## Head Injury - A broad classification that includes injury to the scalp, skull, or brain. - Most common causes of brain injury are falls, motor vehicle accidents, and assault. - **Prevention:** see Chart 65-1 ## Other Definitions - **Coma** - **Vegetative state** - **Brain death** ## Pathophysiology of Brain Damage - **Primary Injury:** Result of the initial damage. - Contusions, lacerations, external hematomas, and skull fractures - **Secondary Injury:** Damage evolves after the initial insult. - Caused by intracranial hemorrhage, cerebral edema, intracranial hypertension, hyperemia, seizures, and vasospasm. - **Death:** Can occur at three points in time after a traumatic brain injury. - Immediately after injury. - Within 2 hours after injury. - Approximately 3 weeks after injury. ## Pathophysiology of Traumatic Brain Injury - **Physiology/Pathophysiology Diagram:** - A diagram showing a progression of steps leading to cerebral blood flow ceasing in a patient with a traumatic brain injury. - The steps are: - Traumatic Injury - Brain swelling or bleeding, increasing intracranial volume - Rigid cranium, no room for expansion, intracranial pressure increases - Pressure on blood vessels within the brain, blood flow to the brain slows - Cerebral hypoxia and ischemia - Intracranial pressure continues to rise, brain herniates - Cerebral blood flow ceases - Cerebral blood flow ceases ## Clinical Manifestations - Manifestations depend on the severity and location of the injury. - **Scalp Wounds:** - Tend to bleed heavily; scalp wounds are also portals for infection. - **Skull Fractures:** - **Linear** - **Comminuted** - **Depressed** - **Open** - **Closed** - 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. **Diagram:** An illustration of a basilar skull fracture showing blood flow from the brain to the nose and ears. ## Manifestations of Traumatic Brain Injury - **Altered Level of Consciousness** - **Pupillary Abnormalities** - **Sudden onset of neurologic deficits and neurologic changes: changes in sense, movement, and reflexes.** - **Changes in Vital signs** - **Headache** - **Seizures:** See Chart 65-2 ## Factors That Predict a Poor Outcome - **Intracranial Hematoma** - **Increasing age of patient** - **Abnormal Motor Responses** - **Impaired/absent eye responses** - **Early sustained hypotension, hypoxemia** - **ICP levels higher than 20 mm Hg** ## Types of Traumatic Brain Injury - **Contusion:** Brain is bruised and damaged in specific areas. - Clinical manifestations are dependent on size, location, and the extent of surrounding edema. - Result from acceleration/deceleration force or blunt trauma. - Usually located in the anterior portions of the frontal and temporal lobes, but can occur anywhere. - Characterized by loss of consciousness associated with stupor and confusion. - Managed medically to prevent increased ICP. - **Intracranial Hemorrhage:** - **Epidural Hematoma:** - Results from bleeding between the dura and inner surface of the skull - middle meningeal artery. - Unconsciousness at scene, with a brief lucid interval, followed by a significant decrease in LOC. - Rapid surgical intervention is necessary to prevent cerebral herniation. - **Subdural Hematoma:** - A collection of blood between the dura and the brain - venous in nature. - Commonly caused by trauma, but may also be caused be a rupture of an aneurysm. - Manifestations: changes in LOC, pupillary signs, hemiparesis; signs of increased ICP, coma occur as area of bleeding rapidly enlarges. - Morality rate is high due to associated brain damage. - Can be acute or chronic (see pg. 2060). **Diagram:** A cross-section of the brain showing the location of epidural and subdural hematomas. - **Intracerebral Hemorrhage and Hematoma:** - Bleeding into the parenchyma of the brain. - Commonly seen in head injuries where force is exerted to the head over a small area (bullet wounds, stab injuries). - May also result from: - Systemic hypertension, aneurysm, intracranial tumors, bleeding disorders, complications of anticoagulant therapies. - **Concussion:** A temporary loss of neurologic function with no apparent structural damage. - Mechanism of injury is usually blunt. - Duration of mental status abnormalities indicates the grade of the concussion. - Monitor for decrease in LOC, worsening HA, seizures, abnormal pupil response, irritability, vomiting, slurred speech, numbness/weakness in extremities. - Repeated concussive incidents can lead to chronic traumatic encephalopathy. - **Diffuse Axonal Injury:** Widespread axon damage in the brain seen with head trauma. - Associated with prolonged traumatic coma. - No lucid interval, immediate coma, decorticate and decerebrate posturing, global cerebral edema. - Poor prognosis. - Diagnosis by CT/MRI/clinical signs. **Diagram:** A CT scan showing a brain with diffuse axonal injuries. ## Question - Which of the following types of traumatic brain injury occurs after head injury in which there is a temporary loss of neurologic function with no apparent structural damage? - (a) Contusion - (b) Concussion - (c) Diffuse axonal injury - (d) Intracranial hemorrhage ## Diagnostic Evaluation - **Physical and neurologic examination** - **Skull and spinal x-rays** - **CT scan** - **MRI** - **PET scan - assess function** ## Management of the Patient With a Traumatic 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 as well as cardiovascular and respiratory function. - Manage fluid and electrolyte balance. ## Supportive Measures - **Respiratory Support:** Intubation and mechanical ventilation. - **Seizure precautions and prevention** - **NG:** Manage reduced gastric motility and prevent aspiration. - **Fluid and electrolyte maintenance** - **Pain and anxiety management** - **Nutrition** ## Brain Death - **Three cardinal signs of brain death on clinical examination.** - 1. Coma - 2. Absence of brainstem reflexes - 3. Apnea - **Other tests:** Can be used to confirm brain death. - Cerebral blood flow studies, EEG, transcranial Doppler. - **Client:** Is a potential organ donor. ## Nursing Process - Assessment of the Patient With Traumatic Brain Injury - **Health History:** Focus on the immediate injury, time, cause, and the direction and force of the blow. - **Baseline Assessment** - **LOC:** Use Glasgow Coma Scale. - **Frequent and ongoing neurologic assessment** - **Multisystem Assessment:** See Table 65-1 ## Nursing Process - Diagnosis of the Patient With Traumatic Brain Injury - **Airway clearance** - **Ineffective cerebral tissue perfusion** - **Deficient fluid volume** - **Nutrition** - **Injury Prevention** - **Body Temperature Imbalance** - **Prevention of Pressure Injuries** - **Disturbed thought patterns** - **Disturbed sleep pattern** - **Interrupted Family Process** - **Deficient Knowledge** ## Collaborative Problems and Potential Complications - **Decreased Cerebral Perfusion** - **Cerebral Edema and Herniation** - **Impaired Oxygenation and Ventilation** - **Impaired Fluid, Electrolyte, and Nutritional Balance** - **Risk of Posttraumatic Seizures** ## Nursing Process - Planning the Care of the Patient With Traumatic Brain Injury - **Major Goals:** Include maintenance of patent airway, adequate CPP, fluid and electrolyte balance, adequate nutritional status, prevention of secondary injury, maintenance of normal body temperature, maintenance of skin integrity, improvement of cognitive function, prevention of sleep deprivation, effective family coping, increased knowledge about rehabilitation processes, and the absence of complications. ## Interventions - **Provide ongoing assessment; monitoring is vital** - **Maintain Airway** - Positioning to facilitate drainage of oral secretions with HOB usually elevated 30 degrees to decrease intracranial venous pressure. - Suctioning with caution. - Prevention of aspiration and respiratory insufficiency. - Monitor ABGs, ventilation, and mechanical ventilation. - Monitor for pulmonary complications, potential ARDS. - **Monitor I&O and daily weights** - **Monitor blood and urine electrolytes, osmolality, and blood glucose** - **Implement measures to promote adequate nutrition** - **Implement Strategies to Prevent Injury** - Assess oxygenation. - Assess bladder and urinary output. - Assess for constriction caused by dressings and casts. - Pad side rails. - Use mittens to prevent self-injury; avoid. - Reduce environmental stimuli. - Use adequate lighting to reduce visual hallucinations. - Implement measures to minimize disruption of sleep-wake cycles. - Provide skin care. - Implement measure to prevent infection. - **Maintain body temperature.** - Maintain appropriate environmental temperature. - Use coverings: sheets, blankets as per patient needs. - Administer acetaminophen for fever. - Use cooling blankets or cool baths; prevent shivering. - **Support cognitive function** - **Support Family** - Provide and reinforce information. - Implement measures to promote effective coping. - Set realistic, well-defined, short-term goals. - Refer patient for counseling. - Refer patient to support groups. - **Patient and family teaching:** See Chart 65-6 ## Reference - Prince, R. (2020). Management of patients with neurologic trauma. In M. El Hussein and J. Osuji (Eds.), Brunner & Suddarth's Canadian textbook of medical-surgical nursing (4th ed., pp. 2056-2087). Wolters Kluwer. ## Review Questions - A client with ICP monitoring has a pressure of 12 mm Hg. The nurse understands that this pressure reflects which of the following? - (a) A severe decrease in cerebral perfusion pressure - (b) an alteration in the production of CSF - (c) the loss of autoregulatory control of intracranial pressure - (d) A normal balance between brain tissue, blood, and CSF - A nurse caring for a client with increased ICP knows that the best way to position the client is which of the following? - (a) Keep the head of the bed flat. - (b) Elevate the head of the bed to 30 degrees. - (c) Maintain the client on the left side with head supported on a pillow. - (d) Use a continuous-rotation bed to continuously change the client’s position. - The nurse is alerted to a possible acute subdural hematoma in the client who has which of the following symptoms? - (a) A linear skull fracture crossing a major artery - (b) Focal symptoms of brain damage with no recollection of a head injury - (c) Decreased level of consciousness and a headache within 48 hours - (d) An immediate loss of consciousness with a brief lucid interval followed by decreasing level of consciousness. - During admission of a client with a severe head injury to the emergency department, the nurse places the highest priority on assessment for which of the following? - (a) Presence of a neck injury - (b) Patency of the airway - (c) Neurological status according to the Glasgow Coma Scale - (d) CSF leakage from the ears or nose. - The nurse on the clinical unit is assigned to four clients. Which client should the nurse assess first? - (a) The client with a skull fracture whose nose is bleeding. - (b) The older adult client with a stroke who is confused and whose daughter is present. - (c) The client with meningitis who is suddenly agitated and reporting a headache of 10 on a 0-10 scale. - (d) The client who had a craniotomy for a brain tumour who is now 3 days post-op and has had continued emesis. - Which of the following nursing measures is indicated to reduce the potential for seizures and increased intracranial pressure in the client with an acute head injury? - (a) Administering codeine for relief of head and neck pain. - (b) Controlling fever with prescribed drugs and cooling techniques. - (c) Keeping the room darkened and quiet to minimize environmental stimulation. - (d) Maintaining the client on strict bed rest with the head of the bed slightly elevated. - A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? - (a) Blowing the nose - (b) Isometric exercises - (c) Coughing vigorously - (d) Exhaling during repositioning. - A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse the cerebrospinal fluid is present? - (a) Fluid is clear and tests negative for glucose. - (b) Fluid is grossly bloody in appearance and has a pH of 6. - (c) Fluid clumps together on the dressing and has a pH of 7. - (d) Fluid separates into concentric rings and tests positive for glucose. - The emergency department nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. The client is exhibiting an altered level of consciousness. Following a skill x-ray, the client is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture? - (a) Babinski’s sign - (b) Kernig’s sign - (c) Battle’s sign - (d) Brudzinski’s sign. - Paramedics have brought an intubated client to the emergency department following a head injury due to motor vehicle accident. Increased intracranial pressure (ICP) is suspected. An appropriate nursing intervention would include what? - (a) Keep the head of the bed flat at all times. - (b) Teach the client to perform the Valsalva manoeuvre. - (c) Administer antipyretics on a PRN basis. - (d) Perform endotracheal suctioning every hour. - The nurse is caring for a severely brain-injured client. A family member requests information regarding signs of brain death. The nurse knows that what diagnostic test will be done to confirm neurologic determination of death? - (a) Cerebral blood flow studies - (b) Lumbar puncture - (c) Electromyography - (d) Spiral CT scan. - A client is admitted to the Neuro ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this client to evaluate the brain structure? - (a) MRI - (b) PET scan - (c) X-ray - (d) Ultrasound.