Traumatic Brain Injury
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trauma to the skull⇒mild or extensive damage to the brain.
immediate cx: cerebral bleeding, hematomas, uncontrolled increased ICP, infections and seizures.
(+)changes in personality or behavior, CN deficits, and any other residual deficits (depending on the area of the brain damage)
TYPES OF HEAD INJURY:
- 1. CONCUSSION- jarring of the brain within the skull with no loss of consciousness.
- 2. CONTUSION- bruising type of injury to the brain tissue; may occur along with other neurological injuries such as with subdural or extradural collection of blood.
- 3. SKULL FRACTURES
- a. Linear -Linear skull fractures are breaks in the bone that transverse the full thickness of the skull from the outer to inner table. They are usually fairly straight with no bone displacement. The common cause of injury is blunt force trauma where the impact energy transferred over a wide area of the skull.
- b. Depressed- A depressed skull fracture is a type of fracture usually resulting from blunt force trauma, such as getting struck with a hammer, rock or getting kicked in the head. Depressed skull fractures present a high risk of increased pressure on the brain, or a hemorrhage to the brain that crushes the delicate tissue.
- c. Compound- A fracture in conjunction with an overlying laceration that tears the epidermis and the meninges—or runs through the paranasal sinuses and themiddle ear structures, putting the outside environment in contact with the cranial cavity—is a compound fracture.
- d. Comminuted- broken into three or more sections.
- 3. EPIDURAL HEMATOMAS- MOST SERIOUS type of hematoma; forms rapidly and results from arterial bleeding; forms between the dura and the skull from a tear in the meningeal artery; assoc with temporary loss of consciousness, followed by a lucid period, that rapidly progresses to coma; SURGICAL EMERGENCY!!!
- 4. INTRACEREBRAL HEMORRHAGE-occurs when a BV in the brain ruptures allowing blood to leak inside the brain.
- 5. SUBARACHNOID HEMORRHAGE-bleeding into the subarachnoid space. It may occur as a result of head trauma or spontaneously, such as from ruptured cerebral aneurysm.
- ↳OPEN- scalp lacerations; fractures in the skull; interruption of the DURA MATER.
- ↳CLOSED- concussions; contusions; fractures
A collection of blood in the tissues and can occur as a result of subarachnoid hemorrhage or an intracerebral hemorrhage
- ☑ clinical manifestation usually result from increased ICP.
- ☑ changing neurological signs in the pt.
- ☑ changes in LOC
- ☑ airway and breathing pattern changes.
- ☑ V/S changes-> increased ICP
- ☑ visual changes, pupillary changes, and papilledema
- ☑ Nuchal rigidity-inability of the neck to flex forward (not tested until SCI is ruled out)
- ☑ CSF drainage from ears and nose
- ☑ weakness and paralysis
- ☑ posturing
- ☑ decreased sensation or absence of feeling
- ☑ reflex act changes
- ☑ seizure act
- ★ MONITOR: RR and maintain a patent airway (↟ CO2 levels ↦ ↟ cerebral edema)
- ★ MONITOR: neurologic status, VS and temp
- ★ WOF: increased ICP
- ★ maintain head elevation to reduce venous pressure
- ★ px neck flexion
- ★ assess CN fxn, reflexes, motor and sensory fxn
- ★ seizure precautions
- ★ !pain and restlessness; MORPHINE-given to decrease agitation and restlessness caused by pain for a pt on a ventilator (WOF: resp depression and increased ICP)
- ★ MONITOR: drainage in the ear and nose bec this may be CSF.
- ★ DO NOT ATTEMPT TO CLEAN THE NOSE OR SUCTION, or allow the pt to blow his or her nose if drainage occurs.
- ★ DO NOT clean the ear if drainage is noted, but apply a loose, dry sterile dressing.
- ★ !HCP if (+) drainage in nose or ears
- ★ pt- avoid coughing bec this may increase ICP
- ★ px cx of immobility
- Surgical procedure that involves an incision through the cranium to remove blood or tumor
- CX: increased ICP, hemorrhage, obstruction of the normal flow of CSF; hematomas, hypovolemic shock. hydrocephalus, resp and neuro cx, pulmonary edema and wound infections
- CX r/t to f&e imbalance: diabetes insipidus and inappropriate secretion of antidiuretic hormone
STEREOTACTIC RADIOSURGERY (SRS)-an alternative to traditional surgery and is usually used to tx tumors and arteriovenous malformations.
- ⇨ secure consent
- ⇨ prepare to shave the pt's head (usually done at the OR)
- ⇨ stabilize pt.
- POSTOP INT:
- ⇨ monitor VS and NS every 30-60mins.
- ⇨ WOF: increased ICP
- ⇨ MONITOR: decreased level of consciousness, motor weakness or paralysis, aphasia, visual changes, and personality changes.
- ⇨ mech vent and slight hyperventilation for the first 24-48 hours, as prescribed to px increased ICP
- ⇨ AVOID: extreme hip or neck flexion, and maintain the head in the midline neutral position.
- ⇨ monitor head dressing frequently for signs of bleeding
- ⇨ mark any area of drainage at least once during shift for baseline comparison
- ⇨ monitor and maintain suction of hemovac; measure drainage every 8 hours and record the amount and color; !HCP if drainage is more than the normal amount of 30-50ml/shift.
- ⇨ !HCP-> (+) excessive amounts of drainage or a saturated head dressing.
- ⇨ fluid restriction (1500 ml/day)
- ⇨ electrolyte levels; imbalanced>dysrhythmias
- ⇨ apply ice packs or cool compression as prescribed
- ⇨ expect periorbital edema or ecchymosis in one or both eyes (NORMAL)
- ⇨ ROM every 8 hours
- ⇨ anti embolism stockings as prescribed
- ⇨ GIVE anticonvulsants, antacids, corticosteroids and antibiotics as prescribed
- ⇨ analgesics-codeine sulfate or acetaminophen as prescribed
- PT POSITIONING FF CRANIOTOMY:
- ⇨ REMOVAL OF A BONE FLAP FOR DECOMPRESSION-turned from the back to the nonoperative side to facilitate brain expansion.
- ⇨ POSTERIOR FOSSA SURGERY- position the client on the side with a pillow under the head for support, and not the back (to protect operative site from pressure and minimize tension).
- ⇨ INFRATENTORIAL SURGERY (surgery below the tentorium of the brain)-flat position without head elevation or with HOB elevated at 30-45 degrees; do not elevate the HOB in the acute phase of care.
- ⇨SUPRATENTORIAL SURGERY (surgery above the tentorium of the brain)- HOB elevated to 30 degrees to promote venous outflow through the jugular veins; do not lower the bed in an acute phase of care ff surgery.
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