TBI are twice as common in males High potential for poor outcome Deaths occur at three points in time after injury

Transcription

1 Head Injury Any trauma to (closed vs. open) Skull Scalp Brain Traumatic brain injury (TBI) High incidence Most common causes Falls Motor vehicle accidents Other causes Firearm- related injuries Assaults Sports- related trauma Recreational injuries War- related injuries 1 Head Injury TBI are twice as common in males High potential for poor outcome Deaths occur at three points in time after injury 1. Immediately after the injury 2. Within 2 hours after the injury 3. 3 weeks after the injury 2 K.D., a 33- year- old woman, is brought by paramedics to ED following a motor vehicle accident. She has a laceration to her forehead and bruises from her seat belt. She is stuporous and does not answer questions. What is the most likely cause of her change in LOC? 3 1

2 Types of Head Injuries Scalp Lacerations External head trauma Scalp is highly vascular Profuse bleeding Major complications blood loss and infection Skull Fractures Linear or depressed Simple, comminuted, or compound Closed or open Location determines manifestations Complications Infections Hematoma Tissue damage 4 Raccoon Eyes and Battle s Sign 5 Types of Head Injuries Diffuse (generalized) Concussion Brief disruption in LOC Retrograde amnesia Headache Short duration May result in postconcussion syndrome Diffuse Axonal Injury Widespread axonal damage Decreased LOC Increased ICP Decortication, decerebration Global cerebral edema Focal (localized) Lacerations Tearing of brain tissue With depressed and open fractures and penetrating injuries Intracerebral hemorrhage Subarachnoid hemorrhage Intraventricular hemorrhage Contusions Bruising of brain tissue Associated with closed head injury Can cause hemorrhage, infarction, necrosis, edema Can rebleed Focal and generalized manifestations Monitor for seizures Potential for increased hemorrhage if on anticoagulants Epidural Hematomas* Bleeding between the dura and the inner surface of the skull Neurologic emergency Venous origin slow Arterial origin rapid Cranial nerve injuries 6 2

3 Coup- Contrecoup Injury 7 An emergent CT scan on K.D. reveals an epidural hematoma. What is an epidural hematoma? What type of emergency treatment would you expect the health care provider to order? 8 Complications Epidural Hematoma Initial period of unconsciousness Brief lucid interval followed by decrease in LOC Headache, nausea, vomiting Focal findings Requires rapid evacuation Subdural Hematoma Bleeding between dura mater and arachnoid Most common source Veins that drain brain surface into sagittal sinus Can also be arterial 9 3

4 Complications Acute Subdural Hematoma Within 24 to 48 hours of injury Symptoms related to increased ICP LOC, headache Ipsilateral pupil dilated and fixed if severe Subacute Subdural Hematoma Within 2 to 14 days of the injury May appear to enlarge over time Chronic Subdural Hematoma Weeks or months after injury More common in older adults Presents as focal symptoms Risk for misdiagnosis 10 Intracerebral Hematoma Bleeding within brain tissue Usually within frontal and temporal lobes Size and location of hematoma determine patient outcome 11 Diagnostic Studies CT scan Best diagnostic test to determine craniocerebral trauma MRI, PET, evoked potential studies Transcranial Doppler studies Cervical spine x- ray Glasgow Coma Scale (GCS) Serum panel BMP, CBC, Coags, T&S, T&C, UA, Drug screen 12 4

5 What would be the initial priority care for K.D. upon admission to the ED? What is the RN focused assessment and plan of care? 13 Interprofessional Care Emergency Treatment Patent airway Stabilize cervical spine Oxygen IV access Intubate if GCS <8 Control external bleeding Remove patient s clothing Maintain patient warmth Ongoing monitoring Anticipate possible intubation Assume neck injury Administer fluids cautiously 14 Interprofessional Care Treatment principles Prevent secondary injury Timely diagnosis Surgery if necessary Concussion and contusion Observation and management of ICP Skull fractures Conservative treatment Surgery if depressed Subdural and epidural hematomas Surgical evacuation Craniotomy, burr- holes Craniectomy if extreme swelling 15 5

6 Nursing Assessment Subjective Data If head trauma severe, subjective data deferred, must utilize astute physical assessment skills, or ask others who are present Past medical history Mechanism of injury Medications Anticoagulants Subjective Data Alcohol/drug use; risk- taking behaviors Headache Mood or behavioral changes Mentation changes; impaired judgment Aphasia, dysphasia Fear, denial, anger, aggression, depression 16 K.D. s past medical history is negative except for the births of two children. Her family denies any drug or alcohol use. She was not taking any an6coagulant medica6ons. What objec6ve data will you assess K.D. for when she is admiaed to the ICU ader surgery? 17 Nursing Assessment Objective Data Altered mental status Lacerations, contusions, abrasions Hematoma Battle s sign Periorbital edema and ecchymosis Otorrhea Exposed brain Rhinorrhea Impaired gag reflex Altered/irregular respirations Cushing s triad Vomiting Bowel and bladder incontinence 18 6

7 Nursing Assessment Uninhibited sexual expression Altered LOC Seizures Pupil dysfunction Cranial nerve deficit(s) Motor deficit Palmar drift Paralysis Spasticity Posturing Rigidity or flaccidity Ataxia 19 Nursing Assessment Objective Data Possible Diagnostic Findings Abnormal CT scan or MRI Abnormal EEG Positive toxicology screen or alcohol level or Blood glucose level ICP 20 K.D. arrives in the ICU with a head dressing and Jackson Pratt drain in place. She responds to painful stimuli by withdrawing but does not follow commands. What nursing diagnoses related to K.D. s neurologic status would be most appropriate when planning her care? 21 7

8 Nursing Diagnoses Risk for ineffective cerebral tissue perfusion Hyperthermia Impaired physical mobility Anxiety Potential complication: increased ICP 22 Planning Overall Goals Cerebral oxygenation and perfusion Normothermic Control pain and discomfort Free of infection Adequate nutrition Maximal cognitive, motor, and sensory function 23 You invite K.D. s family into her room once you have her sealed in. What would be important to explain to the family at this point? How will you therapeu6cally communicate to the family? 24 8

9 Acute Care Maintain cerebral perfusion Prevent secondary cerebral ischemia Monitor for changes in neurologic status Patient and family teaching of diagnosis, treatment plan, rationale for interventions 25 Acute Care Major focus of nursing care relates to increased ICP Eye problems Eye drops, compresses, patch Hyperthermia Goal 36 to 37 C Prevent shivering 26 Acute Care Measures for patients leaking CSF Head of bed elevated Loose collection pad under nose/over ear No sneezing or blowing nose No NG tube No nasotracheal suctioning 27 9

10 Acute Care Measures for immobilized patients Antiemetics Analgesics Preop preparation, if needed most likely for what type of head trauma? 28 K.D. survives the initial traumatic brain injury and surgery. She is hemodynamically stable, extubated, and breathing on her own. She opens her eyes spontaneously and follow commands. K.D. remains confused and restless. She also has some balance and motor deficits. She is dependent on others for activities of daily living. The family asks what the next step in her care will be and if she will ever return to her original self. How will you respond? 29 Ambulatory Care Acute rehabilitation (medically cleared) Motor and sensory deficits Communication issues Memory and intellectual functioning Nutrition Bowel and bladder management 30 10

11 Ambulatory Care Seizure disorders Mental and emotional difficulties Progressive recovery Family participation and education 31 Nursing Evaluation Expected Outcomes Maintain normal cerebral perfusion pressure Achieve maximal cognitive, motor, and sensory function Experience no infection or hyperthermia 32 Audience Response Question The nurse is caring for a patient after a head injury. How should the nurse position the patient in bed? a. Prone with the head turned to the right side b. High- Fowler s position with the legs elevated c. Supine position with the head on two pillows d. Side- lying with the head elevated 30 degrees 33 11

12 Health Promotion Prevent car and motorcycle accidents Wear safety helmets Use seat belts and child car seats Home safety to prevent falls 34 12