Neuro Chapter 63:
Head Injury
- 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
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
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
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
- 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
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
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
- Patient should be aroused and assessed frequently
Vomiting
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
Management of the Patient with a Head Injury #2
Therapy to preserve brain homeostasis and prevent secondary brain injury
-Stabilize cardiovascular and respiratory function to maintain cerebral perfusion/oxygenation
-Control of hemorrhage and hypovolemia
-Maintain optimal blood gas values
-Treat increased ICP and cerebral edema
-Surgery if indicated
-Monitor ICP and drain CSF as needed
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
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
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
Planning and Goals for the Patient with Traumatic Brain Injury
Major goals may include:
Maintenance of patent airway and adequate CPP
Fluid and electrolyte balance
Adequate nutritional status
Prevention of secondary injury
Maintenance of body temperature WNL
Maintenance of skin integrity
Improvement in coping
Prevention of sleep deprivation
Increased knowledge about rehabilitation process
Absence of complications
Nursing Interventions for the Patient with Traumatic Brain Injury #1
-Ongoing assessment and monitoring are vital
-Maintain adequate airway
-Monitor neurologic function
LOC with GCS
Vital signs
Motor function
Other neurologic signs
-I&O and daily weights
-Monitor blood and urine electrolytes and osmolality
and blood glucose
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
。 Assessment of oxygenation
。 Assessment of bladder and urinary output
。 Assessment for constriction caused by dressings and casts
* Padded side rails
。 Mittens to prevent self-injury; avoid restraints
Nursing Interventions for the Patient with Traumatic Brain Injury #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
Nursing Interventions for the Patient with Traumatic Brain Injury#4
Improve coping and support of cognitive function.
Preventing sleep pattern disturbance.
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 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
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
Spinal and Neurogenic Shock
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
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
Collaborative Problems and Potential Complications of the Patient with Spinal
Cord Injury
- DVT
- Orthostatic hypotension
- Autonomic dysreflexia
Planning and Goals for the Patient with Spinal Cord Injury
Major goals may include:
- Improved breathing pattern and airway clearance
-Improved mobility
-Prevention of injury due to sensory impairment
-Maintenance of skin integrity
-Relief of urinary retention
-Improved bowel function
-Decreasing pain
-Recognition of autonomic dysreflexia and absence of complications
Nursing Interventions for the Patient with Spinal Cord Injury #1
❖ Promoting effective breathing and airway clearance
* Monitor carefully to detect potential respiratory failure
- Pulse oximetry and ABGs
-Lung sounds
Early and vigorous pulmonary care to prevent and remove secretions
Suctioning with caution
Breathing exercises
Assisted coughing
Humidification and hydration
Nursing Interventions for the Patient with Spinal Cord Injury #2
Improving mobility
- Maintain proper body alignment
-If not on a specialized rotating bed, turn only if spine is stable and as indicated by physician
-Monitor blood pressure with position changes
-PROM at least four times a day
-Use neck brace or collar, as prescribed, when patient is mobilized
-Move gradually to erect position
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
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
Collaborative Problems and Potential Complications
- Spasticity
- Infection and sepsis
-
Planning and Goals for the Patient with Tetraplegia or Paraplegia
◆ Major goals may include:
Attainment of some form of mobility
Maintenance of healthy, intact, skin
Achievement of bladder management without infection
Achievement of bowel control
Achievement of sexual expression
Strengthening of coping mechanisms
Knowledge of long-term management
Absence of complications
