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Head InjuryA broad classification that includes injury to the

scalp, skull, or brain1.4 million people receive head injuries every year

in the U.S.The most common cause of death from traumaMost common cause of brain trauma is MVAGroup at highest risk group for brain trauma is

males age 15–24Those younger than 5 years and the elderly are

also at increased riskPrevention

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Pathophysiology of Brain DamagePrimary 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 insultDue to cerebral edema, ischemia, or chemical

changes associated with the trauma

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Pathophysiology of Traumatic Brain Injury

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ManifestationsManifestations depend upon the severity and

location of the injuryScalp wounds

Tend to bleed heavily, and are also portals for infection

Skull fractures Usually have localized, persistent painFractures 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

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Basilar Fractures Allow CSF to Leak from the Nose and Ears

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Manifestations of Brain InjuryAltered LOCPupillary abnormalitiesSudden onset of neurologic deficits and

neurologic changes; changes in sense, movement, reflexes

Changes in vital signsHeadacheSeizures

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Brain InjuryClosed 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 hemorrhageSymptoms and recovery depend upon the amount of

damage and associated cerebral edemaLonger period of unconsciousness with more symptoms of

neurologic deficits and changes in vital signs

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Brain InjuryDiffuse axonal injury: involves widespread

damage to axons in the cerebral hemispheres, corpus callosum, and brain stem. It can be seen with mild, moderate, or severe head trauma. Patient develops immediate coma.

Intracranial bleedingEpidural hematomaSubdural hematoma

Acute and subacute Chronic

Intracerebral hemorrhage and hematoma

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Concussion

Patient may be admitted for observation or sent home

Observation of patients after head trauma; report immediatelyObserve for any changes in LOCDifficulty in awakening, lethargy, dizziness,

confusion, irritability, anxietyDifficulty in speaking or movement Severe headacheVomiting

Patient should be aroused and assessed frequently

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Location of Subdural, Intracerebral and Epidural Hemorrhages

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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.

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Subdural HematomaCollection of blood between the dura and the

brainAcute/Subacute

Acute: symptoms develop over 24–48 hoursSubacute: symptoms develop over 48 hours to 2

weeksRequires immediate craniotomy and control of

ICPChronic

Develops over weeks to monthsCausative injury may be minor and forgottenClinical signs and symptoms may fluctuateTreatment is evacuation of the clot

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Intracerebral HemorrhageHemorrhage occurs into the substance of the

brainMay be due to trauma or a nontraumatic causeTreatment

Supportive care Control of ICP Administration of fluids, electrolytes, and

antihypertensive medicationsCraniotomy or craniectomy to remove clot and

control hemorrhage; this may not be possible due the location or lack of circumscribed area of hemorrhage

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Diagnostic EvaluationPhysical and neurologic examSkull and spinal x-raysCT scanMRIPET (Positron emission tomography)

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Management of the Patient with a Head InjuryAssume cervical spine injury until this is ruled

outTherapy to preserve brain homeostasis and

prevent secondary damageTreat cerebral edema Maintain cerebral perfusion; treat hypotension,

hypovolemia and bleeding, monitor and manage ICP

Maintain oxygenation; cardiovascular and respiratory function

Manage fluid and electrolyte balance16

Supportive Measures

Respiratory support; intubation and mechanical ventilation

Seizure precautions and preventionNG to manage reduced gastric motility and

prevent aspirationFluid and electrolyte maintenancePain and anxiety managementNutrition

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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 assessmentLOC—Glasgow Coma Scale Frequent and ongoing neurologic assessmentMultisystem assessment

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Nursing Process: The Care of the Patient with Brain Injury—DiagnosesIneffective airway clearance and impaired gas

exchangeIneffective cerebral perfusionDeficient fluid volume Imbalanced nutritionRisk for injuryRisk for imbalanced body temperatureRisk for impaired skin integrityDisturbed thought patternsDisturbed sleep patternInterrupted family processDeficient knowledge 19

Collaborative Problems/Potential ComplicationsDecreased cerebral perfusionCerebral edema and herniationImpaired oxygenation and ventilationImpaired fluid, electrolyte, and nutritional

balanceRisk of posttraumatic seizures

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Nursing Process: The Care of the Patient with Brain Injury—PlanningMajor goals may include

Maintenance of patent airway, Adequate cerebral perfusion pressure (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. 21

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 cautionPrevention of aspiration and respiratory insufficiencyMonitor ABGs, ventilation, and mechanical

ventilationMonitor for pulmonary complications, potential

ARDS

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Interventions

I&O and daily weights Monitor blood and urine electrolytes and

osmolality and blood glucoseMeasures to promote adequate nutritionStrategies to prevent injury

Assessment of oxygenation Assessment of bladder and urinary outputAssessment for constriction due to dressings and

castsPad side-railsMittens to prevent self-injury; avoid restraints

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InterventionsStrategies to prevent injury

Reduce environmental stimuliAdequate lighting to reduce visual hallucinationsMeasures to minimize disruption of sleep-wake

cyclesSkin careMeasures to prevent infection

Maintaining body temperatureMaintain appropriate environmental temperatureUse of coverings—sheets, blankets to patient

needs Administration of acetaminophen for feverCooling blankets or cool baths; avoid shivering

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InterventionsSupport of cognitive function

Support of familyProvide and reinforce informationMeasures to promote effective copingSetting of realistic, well-defined, short-term

goalsReferral for counselingSupport groups

Patient and family teaching

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Spinal Cord Injury (SCI)Definition:Fracture or displacement of one or more

vertebrae causing damae to spinal cord and nerve roots with resulting neurological deficit and altered sensory perception or paralysis or both. There will be a total or partial absence of motor and/or sensory function below the level of injury. (Ignatavious and Workman, 2006)

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Spinal Cord Injury (SCI)A major health problem200,000 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 SCIsYoung people ages 16–30 account for

more than half of all new SCIsAfrican–Americans are at higher riskRisk factors include alcohol and drug usePrevention

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Spinal Cord InjuryThe 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.

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Clinical ManifestationsManifestations depend on the type and level of injuryIncomplete spinal cord lesions (the sensory or

motor fibers, or both, are preserved below the lesion): below the injury; total sensory and motor paralysis, loss of bladder and bowel control (usually with urinary retention and bladder distention), loss of sweating and vasomotor tone, & marked reduction of blood pressure.

Complete spinal cord lesion (total loss of sensation and voluntary muscle control below the lesion): paraplegia or tetraplegia.

If conscious, the patient usually complains of acute pain in the back or neck

In high cervical cord injury, acute respiratory failure is the leading cause of death.

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Spinal and Neurogenic ShockSpinal shock

A sudden depression of reflex activity below the level of spinal injury

develops due to the loss of autonomic nervous system function below the level of the lesion

Muscular flaccidity, lack of sensation and reflexesNeurogenic 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 perspire30

Medical Management: Acute Phase

Goals: Prevent further SCI

and observe for signs of neurological deficit

High dose corticosteroids (controversial)

Research is continuing

Medical management:Pharmacologic

therapyRespiratory therapySkeletal fracture

reduction and traction

Surgical management

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Nursing Process: The Care of the Patient with SCI—Assessment

Monitor respirations and breathing patternLung sounds and coughMonitor for changes in motor or sensory

function; report immediatelyAssess for spinal shockMonitor for bladder retention or distention,

gastric dilation, and ilieusTemperature; potential hyperthermia

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Nursing Process: The Care of the Patient with SCI—Diagnoses

Ineffective breathing patternIneffective airway clearanceImpaired physical mobilityDisturbed sensory perceptionRisk for impaired skin integrityImpaired urinary eliminationConstipationAcute pain

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Collaborative Problems/Potential Complications

DVTOrthostatic hypotensionAutonomic dysreflexia

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Nursing Process: The Care of the Patient with SCI—PlanningMajor 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.

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Promotion of Effective Breathing and Airway ClearanceMonitor carefully to detect potential

respiratory failurePulse oximetry and ABGsLung sounds

Early and vigorous pulmonary care to prevent and remove secretions

Suctioning with cautionBreathing exercises Assisted coughingHumidification and hydration

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Improving MobilityMaintain proper body alignmentTurn only if spine is stable and as indicated

by physician Monitor blood pressure with position changesPROM at least four times a dayUse neck brace or collar, as prescribed, when

patient is mobilized Move gradually to erect position

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