Brain Injury Part II 1. Concept Map: Selected Topics in Neurological Nursing PATHOPHYSIOLOGY...
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Transcript of Brain Injury Part II 1. Concept Map: Selected Topics in Neurological Nursing PATHOPHYSIOLOGY...
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Brain Injury Part IIBrain Injury Part II1
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Concept Map: Selected Topics in Neurological Nursing
PATHOPHYSIOLOGY
Traumatic Brain InjurySpinal Cord Injury
Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntington’s Disease Alzheimer’s Disease Huntington’s Disease Myasthenia Gravis Guillian-Barre’ Syndrome Meningitis Parkinson’s Disease
PHARMACOLOGY
--Decrease ICP--Disease Specific Meds
ASSESSMENTPhysical Assessment Inspection Palpation Percussion Auscultation
ICP Monitoring“Neuro Checks” Lab Monitoring
Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, more…basedOn Nursing Process: A_D_P_I_E
Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary
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ObjectivesObjectives3
Recall anatomy and physiology of the brain & cranial nerves
Explain pathophysiology of various brain (head) injuries
Detail signs, symptoms and prevention of Increased Intracranial Pressure (ICP)
Demonstrate effective use of Glasgow Coma Scale
Discuss medical & nursing management of brain injuries
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Prevent Prevent SecondarySecondary Injury !!!Injury !!!
Meaningful recovery of function after head injury is possible IF IF
secondary injuries are prevented or minimized
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Secondary Secondary Brain InjuryBrain Injury5
Any physiological event that can occur within minutes, hours, or days after the initial injury and leads to further damage of nervous tissue
Secondary Injury is mostly due to Increased Increased ICPICP caused by hypotension, hypoxia, intracranial bleeding, seizures
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Brain Injury Management Brain Injury Management 6
FrequentFrequent
Re-assessmentsRe-assessments
++
Rapid Response Rapid Response
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Be VigilantBe Vigilant for Increased ICP for Increased ICP !!7
To understand intracranial pressure, think of the skull as a rigid box. After brain injury, the skull may become overfilled with swollen brain tissue, blood, or CSF.
The skull will not stretch like
skin to deal with these changes. The skull may become too full and increase the pressure on the brain tissue. This is called increased intracranial pressure.
ICP Peaks ICP Peaks 48 – 72 48 – 72 hours after injuryhours after injury
Foramen Magnum
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Vital Signs Q15 minutes
Glasgow Coma Score Q15 minutes
Monitor: Neuro Checks q 15 minutes
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Expanded Expanded Neuro Neuro
Assessment Assessment ToolTool
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EARLY EARLY Signs of Signs of ↑↑ ICPICP
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1. Slight LOC changes ***MOST IMPORTANT*******MOST IMPORTANT****
2. Pupils sluggish / Impaired eye movement
3. Limb strength changes
4. Headache
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Change in
Level Of Consciousness (LOC)
******MOST IMPORTANTMOST IMPORTANT**** **** +
EARLIESTEARLIEST
Indicator of Indicator of neurological deteriorationneurological deterioration
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Cushing’s Triad: Signs of Cushing’s Triad: Signs of ↑ ↑ ICPICP
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Blood Pressure Systolic BP
Increases Diastolic BP
Decreases Pulse Decreases
WideningPulsePressure
Bradycardia
*** You will also see listed in some resources:--Irregular Respirations (Cheyne-Stokes)--Elevated Temperature (Hyperpyrexia)
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TREND TREND Re-Assessment Data
++
COMPARE COMPARE
to Baseline Assessment Data
Temp
BP
Pulse
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LATE(R) LATE(R) Signs of Signs of ↑↑ ICPICP
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1. Further decreased LOC
2. Cushing’s Triad / Reflex
3. Abnormal respiration patterns
4. Pupils asymmetrical / Dilated
5. Projectile vomiting
6. Hemiplegia / decorticate or decerebrate posturing
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Decerebrate Rigidity15
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Brain Herniation occurs when a part of the brain pushes downward inside the skull through the opening that leads into the neck
(Foramen Magnum)
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Too Late Now!Too Late Now! Tentorial (BrainTentorial (Brain) ) Herniation)Herniation)
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Tentorial (Tentorial (BrainBrain) Herniation) Herniation18
NormalNormal
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ABI Nursing InterventionsABI Nursing Interventions19
1) Continuous monitoring of Vitals, PERL and Glasgow Coma Score
2) Report client condition changes ASAPASAP
3) Maintain airway patency (eg positioning, suctioning, etc)
4) Minimize cerebral edema
5) Maximize cerebral perfusion
6) Implement seizure precautions / Siderails
7) Provide emotional support
8) Address all self-care deficits
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ICP MonitoringIIntraCCranial PPressure
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Neurosurgeon drilling prior to placing an intracranial pressure monitor
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Normal ICP for adults:
22
10 to 15 mm Hg10 to 15 mm Hg
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ABI ABI PriorityPriority Nursing GOALS Nursing GOALS 23
* Minimize cerebral edema
* Maximize cerebral perfusion
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ABI Nursing InterventionsABI Nursing Interventions24
Continuous monitoring of Vitals, PERL and Glasgow Coma Score
Report client condition changes ASAPASAP
Maintain airway patency BUT…
Avoid suctioning or Hyperventilate with 100% O2 FIRST
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ABI Nursing InterventionsABI Nursing Interventions25
Implement seizure precautions / Siderails
Phenytoin (Dilantin) (prevent / treat Sz)
Maintain head midline (neutral position)
HOB > 30 degrees
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ABI Nursing InterventionsABI Nursing Interventions26
Address all self-care deficits…BUT
Avoid clustering activities
Provide emotional support
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ABI Nursing InterventionsABI Nursing Interventions27
High dose barbituates > induced coma *decreases metabolic demands*
Pharmacological paralysis
Avoid overstimulation:
- Dark quiet room- Limit visitors appropriately- Speak softly- Limit dialogue – keep topics
light hearted
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Minimize Cerebral EdemaMinimize Cerebral Edema28
MannitolMannitol (Osmitrol) + Urinary catheter
Fluid restriction (I & O)…?
DexamethasoneDexamethasone / Decadron (Know side effects!)
Prevent / Treat fever
Prevent Infections (closed STERILE monitoring system)
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Burr Holes29
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Minimize Cerebral EdemaMinimize Cerebral Edema30
Maintain
Cerebral perfusion pressure MAP of 50 – 70 mm HgMAP of 50 – 70 mm Hg
Prevents Hypoxia (Hypercarbia)
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If BP too low…then O2 perfusion is poor…and Brain Can’t Function
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Optimize Cerebral Optimize Cerebral PerfusionPerfusion
32
Keep head position midline
HOB elevated ( 30 - 60 degrees )
Oxygen ****
Sedate prior to activity
Minimal ADL movement of client
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Teach Client / FamilyTeach Client / Family33
• Minimal stimulation environment
• No coughing, no straining, no hard laughing
• Head midline + Bedrest + HOB elevated
• S & S to report to nurse ASAP (Headache, drainage, etc)
• Purpose + frequency of neuro checks
• Medication regime (Narcotics, diuretics, stool softeners, etc)
• Medical interventions (Tests, traction, logrolling, surgery, etc)
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Cerebral ConcussionCerebral Concussion34
A ‘concussion’ is a relatively mild form of traumatic brain injury that results in temporarytemporary neurological changes
No apparent structural damage
Usually involves unconsciousnessUsually involves unconsciousness for a few seconds or minutes
Frontal lobe = bizarre irrational behavior
Temporal lobe = amnesia or disorientation
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DischargeDischarge …. ….35
Mild concussion & neurological stability = usually will not require hospital admission
However !!! Must be observed by a reliable companion for at least 12 hours
No alcohol for several days
No pain medications stronger than Tylenol
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Cerebral ContusionCerebral Contusion36
More severe
Brain bruised
Possible surface hemorrhage
Initially appears like shock
Can have B & B incontinence
Can be aroused…briefly
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IntraCerebral IntraCerebral Hemorrhage Hemorrhage
BleedingBleeding within the tissue within the tissue of the brainof the brain
IntraCranial IntraCranial Hemorrhage
BleedingBleeding within within the cranial vaultthe cranial vault
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IntraIntraCranialCranial HemorrhageHemorrhage38
BleedingBleeding within the cranial vault within the cranial vault
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IntracranialIntracranial Epidural / Extradural Hematoma
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- Between skull and dura- Extreme emergency- Mostly arterialarterial
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Epidural / Extradural HematomaEpidural / Extradural Hematoma 40
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Subdural HematomaSubdural Hematoma41
Between dura and brain
Mostly venousvenous
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Subdural HematomaSubdural Hematoma42
3 Types:
AcuteAcute Sx in 24 – 48 hours
SubacuteSubacute Sx in 48 hours – 2 weeks
ChronicChronic Sx in 3 weeks – months Common in elderly after even
minor injury Often misdiagnosed as stroke
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Subdural HematomaSubdural Hematoma43
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Head trauma leading to subdural hematomasubdural hematoma and intracranial hypertension
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Subarachnoid HemorrhageSubarachnoid Hemorrhage45
Subarachnoid space is brain surface where blood vessels that supply the brain are located
Common causes of subarachnoid hemorrhage are trauma to “Circle of Willis” “Circle of Willis” aneurysmsaneurysms and congenital arteriovenous arteriovenous malformationsmalformations (AVM)
Unique S & Ss: - Sudden & unusually severe headache & loss of
consciousness- Neck pain & ridigity (nuchal rigidity) d/t meningeal
irritation
Untreated, the blood supply to a given area of the brain may fall so low that the brain tissue dies resulting in a stroke
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Subarachnoid Hemorrhage46
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IntraIntraCerebral Cerebral HemorrhageHemorrhage
BleedingBleeding within the tissue of the brain within the tissue of the brain
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Intracerebral Intracerebral Hemorrhage / Hematoma
Causes:
- Force is exerted to the head over a small area
(missile injuries, bullet wounds, etc)
- Systemic hypertension causes degeneration and rupture of blood
vessels
- Tumors
- Bleeding disorders
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Gunshot Wounds (GSW)Gunshot Wounds (GSW)
51
Suicides, homicides or accidental shootings
GSWs to the head are the most lethal of all firearm injuries
Estimated that greater than 90% fatality rate and at least two thirds of the victims die before ever reaching a hospital
Because of the high mortality associated with gunshot wounds to the head, they account for only approximately 10% of all traumatic brain injury patients who survive
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Head GSWHead GSW 52
Visualization of a gunshot wound through the cerebellum by showing the bony details using CT. Clearly visible is the typically funnel shaped exit wound.
Comparative visualization of the soft tissue damage along the bullet track within the cerebellum using MRI.
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OutcomeOutcome53
The predictors of poor neurological outcome or death after a gunshot wound to the head include:
- Initial Glasgow Coma Scale score- Older age- Presence of low blood pressure or inadequate oxygenation
early after injury- Dilated non-reactive pupils
Bullet trajectory through the brain has major significance. Bullets that traverse the brainstem, multiple lobes of the brain, or the ventricular system (chambers where cerebrospinal fluid is located) are particularly lethal
Many initial survivors develop uncontrollable intracranial pressure and subsequently succumb
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ALLALL Cranial Injury Tx Cranial Injury Tx 54
ATLSATLS evaluation & intervention (ABCs / Foley / NG / oxygen / Maintain traction)
Constant Monitoring
Diagnosis:
- CT scan (FAST!)- MRI - PET Scan (brain function assessment)
Medical interventions depend on severity:
- Endotracheal intubation / hyperventilation- Sedation- Diuresis- Rapid surgical evacuation - Rapid surgical evacuation
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Surgical OutcomesSurgical Outcomes55
Normal pupil reactivity prior to surgery is associated with a favorable outcome in 84 -100% of patients
When both pupils are dilated a poor outcome or death occurs in the great majority of individuals
Postoperative seizures are relatively common in these patients
In general, a favorable (functional) outcome is more likely in those patients who are treated very soon after injury, those who are younger adults, those with a higher GCS (above GCS of 6 or 7), those with reactive pupils, those without multiple cerebral contusions and those who do not develop difficult to control raised intracranial pressure
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Head Injury RecoveryHead Injury Recovery56
Despite very severe initial injuries, some patients make dramatic recoveries within several months to a year after injury
Despite intensive intervention, long-term disability occurs in a large portion of the survivors
Patients with significant neuro-cognitive impairment are best managed at a comprehensive rehabilitation unit for several weeks or months after they leave the hospital
Recovery of function from the time of discharge to 6 months post-injury can be dramatic, even in some deeply comatose individuals
Improvement generally begins to plateau at 6 months post-injury and is typically maximal by one year to 18 months
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Continued….Continued…. 57
Every brain injury is unique. Severity and types of impairments depend on the area and extent of the damage to the brain
Rehabilitation and support provided to a person who has received an injury has a major impact on the person’s recovery
ABI is known as an Invisible Disability due to the invisible nature of changes that may occur following an injury to the brain, such as memory loss, cognitive impairments, challenging behaviours and personality changes
People with ABI usually retain previous IQ, past memories, skills and interests. Their ability to use this knowledge can be lost to varying degrees
ABI is not an Intellectual or Psychiatric disability and therefore the needs of a person with an ABI are different from the needs of people with an intellectual or psychiatric disability
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Recovery can be a long Recovery can be a long process…process…
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