Chp. 63 Head Injury audio

Chapter 6 3 Management of Patients With Neurologic Trauma : 

Chapter 6 3 Management of Patients With Neurologic Trauma Karen Larson MBA/TM, MSN, RN

Head Injury : 

Head Injury A broad classification that includes injury to the scalp, skull, or brain 1.4 million people in the U.S. receive head injuries every year Head injury is the most common cause of death from trauma Most common cause of brain trauma is MVA Group at highest risk group for brain trauma are males age 15 to 24 Those younger than 5 years and the elderly are also at increased risk Prevention: see Chart 63-1

Pathophysiology of Brain Damage : 

Pathophysiology of Brain Damage Primary injury: due to the initial damage Contusions, lacerations, damage to blood vessels, acceleration/deceleration injury, or foreign object penetration Secondary injury: damage evolves after the initial insult Due to cerebral edema, ischemia, or chemical changes associated with the trauma

Manifestations/Types of Brain Injuries : 

Manifestations/Types of Brain Injuries Manifestations depend upon the severity and location of the injury Scalp wounds Tend to bleed heavily; scalp wounds are also portals for infection Skull fractures Usually have localized, persistent pain Fractures of the base of the skull 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

Manifestations/Types of Brain Injury (cont.) : 

Manifestations/Types of Brain Injury (cont.) Closed brain injury (blunt trauma): acceleration/ deceleration injury occurs when the head accelerates 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

Manifestations/Types of Brain Injury (cont.) : 

Manifestations/Types of Brain Injury (cont.) 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

Manifestations of Brain Injury : 

Manifestations of Brain Injury Altered level of consciousness Pupillary abnormalities Sudden onset of neurological deficits and neurological changes; changes in sense, movement, and reflexes Changes in vital signs Headache Seizures See Chart 63-2

Management of the Patient With a Head Injury : 

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 as well as cardiovascular and respiratory function Manage fluid and electrolyte balance Diagnostic Evaluation Physical and neurologic exam, Skull and spinal x-rays, CT scan, MRI, PET scan

Supportive Measures (Brain Injury) : 

Supportive Measures (Brain Injury) 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

Assessment of the Patient With Brain Injury : 

Assessment of the Patient With Brain Injury Health history with focus upon 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 63-1

Interventions : 

Interventions Provide ongoing assessment and monitoring is vital Maintain 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 Monitor I&O and daily weights Monitor blood and urine electrolytes, osmolality and blood glucose

Interventions (cont.) : 

Interventions (cont.) Implement measures to promote adequate nutrition Implement strategies to prevent injury Assess oxygenation Assess bladder and urinary output Assess for constriction due to dressings and casts Pad side rails Use mittens to prevent self-injury; avoid restraints Strategies to prevent injury Reduce environmental stimuli Use adequate lighting to reduce visual hallucinations Implement measures to minimize disruption of sleep–wake cycles Provide skin care Implement measures to prevent infection

Interventions (cont.) : 

Interventions (cont.) 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: see Table 63-2 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 63-6