1. Chapter 63 Management of Patients With Neurologic Trauma

2. Question
Is the following statement True or False? Contusion is a temporary loss of neurologic function with no apparent structural damage to the brain.

3. Answer
False Concussion is a temporary loss of neurologic function with no apparent structural damage to the brain. Contusion is a bruising of the brain surface.

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

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

6. Pathophysiology of Traumatic Brain Injury

7. Manifestations
Manifestations depend upon the severity and location of the injury
Scalp wounds
Tend to bleed heavily, and 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

8. Basilar Fractures Allow CSF to Leak from the Nose and Ears

9. Manifestations of Brain Injury
Altered LOC
Pupillary abnormalities
Sudden onset of neurologic deficits and neurologic changes; changes in sense, movement, reflexes
Changes in vital signs
Headache
Seizures

10. Refer to fig. 63-4

11. Brain Injury
Closed brain injury (blunt trauma): acceleration/deceleration injury occurs when the head accelerates and 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

12. Brain Injury
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

13. 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
Vomiting
Patient should be aroused and assessed frequently

14. Location of Subdural, Intracerebral and Epidural Hemorrhages

15. 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 include 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.

16. Subdural Hematoma Collection of blood between the dura and the brain
Acute/Subacute
Acute: symptoms develop over 24–48 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

17. Intracerebral Hemorrhage
Hemorrhage occurs into the substance of the brain
May be due to 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 due the location or lack of circumscribed area of hemorrhage

18. Diagnostic Evaluation
Physical and neurologic exam
Skull and spinal x-rays
CT scan
MRI
PET

19. 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; cardiovascular and respiratory function
Manage fluid and electrolyte balance

20. Supportive Measures
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

21. Nursing Process: The Care of the Patient with Brain Injury—Assessment
Health history with focus upon 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

22. Nursing Process: The Care of the Patient with Brain Injury—Diagnoses
Ineffective airway clearance and impaired gas exchange
Ineffective cerebral perfusion
Deficient fluid volume
Imbalanced nutrition
Risk for injury
Risk for imbalanced body temperature
Risk for impaired skin integrity
Disturbed thought patterns
Disturbed sleep pattern
Interrupted family process
Deficient knowledge

23. Collaborative Problems/Potential Complications
Decreased cerebral perfusion
Cerebral edema and herniation
Impaired oxygenation and ventilation
Impaired fluid, electrolyte, and nutritional balance
Risk of posttraumatic seizures

24. Nursing Process: The Care of the Patient with Brain Injury—Planning
Major goals may include maintenance of patent airway, adequate CPP, fluid and electrolyte balance, adequate nutritional status, prevention of secondary injury, maintenance of normal temperature, maintenance of skin integrity, improvement of cognitive function, prevention of sleep deprivation, effective family coping, increased knowledge about rehabilitation process, and absence of complications.

25. Interventions Ongoing assessment and monitoring is vital
Maintenance of 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

26. Interventions I&O and daily weights
Monitor blood and urine electrolytes and osmolality and blood glucose
Measures to promote adequate nutrition
Strategies to prevent injury
Assessment of oxygenation
Assessment of bladder and urinary output
Assessment for constriction due to dressings and casts
Pad side-rails
Mittens to prevent self-injury; avoid restraints

27. Interventions 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

28. Interventions Support of cognitive function 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

29. Spinal Cord Injury (SCI)
A major health problem
200,000 persons in the U.S. live with disability from SCI
Causes include MVAs (35%), violence (24%), falls (22%), and sports injuries (8%)
Males account for 82% of SCIs
Young people ages 16–30 account for more than half of all new SCIs
African–Americans are at higher risk
Risk factors include alcohol and drug use
Prevention

30. Spinal Cord Injury
The result of concussion, contusion, laceration or compression of spinal cord.
Primary injury is the result of the initial trauma.
Secondary injury is usually the result of ischemia, hypoxia, and hemorrhage that destroys the nerve tissues.
Secondary injuries are thought to be reversible/preventable during the first 4–6 hours after injury.
Treatment is needed to prevent partial injury from developing into more extensive, permanent damage.

31. 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
Due to the loss of function of the autonomic nervous system
Blood pressure, heart rate, and cardiac output decrease
Venous pooling occurs due to peripheral vasodilation
Paralyzed portions of the body do not perspire

32. Autonomic Dysreflexia***
Acute emergency!
Occurs after spinal shock has resolved and may occur years after the injury.
Occurs in persons with a SC lesion 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 (such as constipation), or stimulation of the skin.

33. Nursing Interventions
Place patient in seated position to lower BP
Rapid assessment to identify and eliminate cause
Empty the bladder using a urinary catheter or irrigate/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

34. Nursing Process: The Care of the Patient with SCI—Assessment
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 ilieus
Temperature; potential hyperthermia

35. Nursing Process: The Care of the Patient with SCI—Diagnoses
Ineffective breathing pattern
Ineffective airway clearance
Impaired physical mobility
Disturbed sensory perception
Risk for impaired skin integrity
Impaired urinary elimination
Constipation
Acute pain

36. Collaborative Problems/Potential Complications
DVT
Orthostatic hypotension
Autonomic dysreflexia

37. Question
Is the following statement True or False? Never massage the claves or thighs, because of the danger of dislodging an undetected DVT.

38. Answer
True Never massage the claves or thighs, because of the danger of dislodging an undetected DVT.

39. Nursing Process: The Care of the Patient with SCI—Planning
Major goals may include improved breathing pattern and airway clearance, improved mobility, improved sensory and perceptual awareness, maintenance of skin integrity, promotion of comfort, and absence of complications.

40. Promotion of 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

41. Improving Mobility Maintain proper body alignment
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

42. Roto Rest Bed
Refer to fig. 63-6

43. Cervical Collar
Refer to fig. 63-7

44. Halo Systems for Cervical and Thoracic Injuries
Refer to fig A and B

45. Interventions
Strategies to compensate for sensory and perceptual alterations
Measures to maintain skin integrity
Temporary indwelling catherization or intermittent catherization
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