Head injury Presented by: Remya Gopinath. DEMOGRAPHIC DATA Name: Case No.4 MR No : 185840 Diagnosis...
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Head injury Presented by: Remya Gopinath
Head injury Presented by: Remya Gopinath. DEMOGRAPHIC DATA Name: Case No.4 MR No : 185840 Diagnosis : RTA WITH HEAD INJURY Age: 6 YRS Gender: Male Date
DEMOGRAPHIC DATA Name: Case No.4 MR No : 185840 Diagnosis : RTA
WITH HEAD INJURY Age: 6 YRS Gender: Male Date of admission:
2/10/2012
Slide 3
PHYSICAL ASSESSMENT GENERAL ASSESSMENT: Patient is bedridden,
lying over bed with tracheostomy and NGT in situ. SKIN: Normal in
state, warm To touch. No sores or redness present all over the
body. HEAD AND NECK: Head is slightly extended. No visible injury
noted in the scalp area.Involuntary eye movement present.5mm
tracheostomy tube present over neck region.
Slide 4
RESPIRATORY: Respiration through tracheostomy tube with in
normal rate. Cough with mild to moderate secretion present.spo2
maintaining on room air. Thorax is symmetrical in size.
CARDIOVASCULAR: No deformities noted. GENITOURINARY: self voiding
on diaper GASTROINTESTINAL : Abdomen is soft, not distended.
Feeding via NGT.Bowel sound present.
Slide 5
MUSCULO-SKELETAL : All limbs are spastic with flexed upper
extremities and extended lower extremities. Mild spontaneous limb
movement present. Displaced fracture is seen in middle of left
clavicle. NEUROLOGY : Patient is semi conscious.pupils are
bilaterally reacting to light.Bilatral flexure response to painful
stimuli.GCS E4V T M3.
Slide 6
Patient history Past medical history Patient was in normal
healthy living until the day of accident. Present medical history
Patient received in ER on 2/10/2012 after being involved in RTA
with an unconscious and irritable state. Vomiting and loc at scene
for 5 minutes. On examination vital signs are Pulse-103/mt,
BP-120/70,Temp,36.7 *c,SPO2 -94%,GCS 8/15. Pupils are bilaterally
reacting to light. Limb movements are equal and normal in all 4
limb.NCCT brain shows SAH in right fronto_parietal lobe,diffuse
brain edema,small hemorrhage in the 4 th ventricle and
opacification in all paranasal sinuses. Scalp swelling is seen in
left parital area and no fracture is seen in cranial vault.
Slide 7
After the initial management patient shifted to ICU.On 8 th day
of admission,patient developed tachypnoea,for which he investigated
and found to have collapse of right lung. Intubation done and
relaxant started with Inj.Midazolam and Inj.Fentanyl.Tracheostomy
done on 13/12/2012.The repeat NCCT on 28/10/2012,which shows
subdural haematoma with midline shift 4mm.Right frontal and
parietal burrhole with evacuation of subdural hygroma done. After 2
months of admission clinically patient is opening eyes, bilateral
flexure response to pain. All limbs are spastic,pupils both equal
reacting,afebrile,on NGT feeding with pediasure q 4h.patient
shifted to pedia ward for further management.
Slide 8
DEVELOPMENTAL MILESTONES CHILDS AGE MASTERED SKILLS 1 MONTH
Lifts head when lying on tummy. Respond to sound. Stares at faces.
2 MONTHS Vocalizes: gurgles and coos. Follows objects across field
of vision. Notices his hands. Holds head up for short periods. 3
MONTHS Recognizes your face and scent. Holds head steady. Visually
tracks moving objects. 4 MONTHS Smiles, laughs. Can bear weight on
legs. Coos when you talk to him. 5 MONTHS Distinguishes between
bold colors. Plays with his hands and feet. 6 MONTHSTurns toward
sounds and voices limits sounds roll over in both
Slide 9
CHILDS AGE MASTERED SKILLS 7 MONTHSSits without support. Drags
objects toward herself. 8 MONTHSSays mama or dada to parents.
Passes objects from hand to hand. 9 MONTHSStands while holding onto
something. Jabbers or combines syllables. Understands object
permanence. 10 MONTHSWaves good bye. Picks things up with pincer
grasp. Crawls well, with belly off the ground. 11 MONTHS Says mama
or dada to the correct parent. Plays patty- cake and peek-a-boo.
Stands alone for a couple of seconds. 12 MONTHSImitates others
activities. Indicates wants with gestures.
Slide 10
CHILDS AGE MASTERED SKILLS 13 MONTHS Stands without support 14
MONTHS Pull things out 15 MONTHSPlays with ball, Learns about 5
words, Can walk backward 16 MONTHSCan turn the pages a book, Has
toddler temper 17 MONTHSVocabulary increases, Loves to play
pretended games 18 MONTHSLoves to watch the pictures.
Slide 11
CHILDS AGE MASTERED SKILLS 19 MONTHSLearns to use a spoon and
fork, Runs, Throws ball 20 MONTHSCan take off own clothes with
help, Can imitate actions 21 MONTHSCan walk up stairs, Keeping a
toy in its place 22 MONTHSCan kick a ball forward, Imitates others
behavior 23 MONTHSNames simple pictures in a book, Learns and uses
about 50 words 24 MONTHSCan make short sentences
Slide 12
2-3 YEARS OF AGE SHOWS AFFECTION FOR OTHERS IS ABLE TO PLAY BY
HIMSEF OR HERSELF IMITATES BEHAVIOR RUNS FOEWARD HELP DRESS AND
UNDRESS THEMSELVES HOLDS A PENCIL IN A WRITING POSITION USES 2 OR 3
WORD SENTENCES UNDERSTANDS DIFFERENCES IN MEANING (stop,go,up
&down)
Slide 13
3-6 YEARS OF AGE(PRE SCHOOLERS) Is able to dress and undress
Very active and likes to do things like climb, skip and stunts
Plays co operatively with peers Is developing some independence and
self reliance Learning to distinguish between reality and fantasy
By age of 6 their vocabulary will have increased to between 8000 to
14000 words(of then repeats words without fully understanding their
meaning) They have learned the use of most prepositions and some
basic possessive pronouns( mine, me) Pre school children continue
to be ego centric and concrete in their thinking. They are still
unable to see things from another perspectives and they reason
based on specifics that they can visualize that they have
importance to them. When questioned they can generally express
who,what,where and some times how, but not when or how many. They
are also able to provide a fair amount of details about a
situation
Slide 14
TOPIC PRESENTATION
Slide 15
HEAD INJURY Definition It is an injury to the skull or brain
that is severe enough to interfere with normal functioning.
Slide 16
Anatomy& Physiology The brain is one of the largest and
most complex organs in our body. It controls our body, receives
information, analysis information and stores information. It is
made up of more than 100 billion nerves that communicates in
trillions of connections called synapse. The skull consisting of 22
bones all together.These bones are divided into 8 cranial bones and
14 facial bones. Cranial bones form the cranial cavity and protects
the brain.
Slide 17
There are typically 206 bones in the body. Out of these there
are 22 bones of the Skull, which include: 8 Cranial Bones: 1 x
Ethmoid Bone 1 x Frontal Bone 1 x Occipital Bone 2 x Parietal Bones
1 x Sphenoid Bone 2 x Temporal Bones
Slide 18
14 Facial Bones : 2 x Inferior Nasal Conchae 2 x Lacrimal Bones
1 x Mandible 2 x Maxillae (pl.); Maxilla (sing.) 2 x Nasal Bones 2
x Palatine Bones 1 x Vomer 2 x Zygomatic Bones
Slide 19
Slide 20
CRANIAL NERVES Olfactory I: sense of smell. Optic Nerve II:
sight of retina. Oculomotor Nerve III: eye movement and pupil
constriction. Trochlear Nerve IV: eye movements. Trigeminal Nerve
V: carry somatosensory information to face, head and chewing
muscles of jaws. Abducens Nerve VI: eye movement. Facial VII:
control the muscles used for facial expressions (smiling, frowning
etc). It also stimulates salivary glands to produce saliva.
Slide 21
Vestibulocochlear VIII: hearing and balance. Glossopharyngeal
IX: taste sensation,gag reflexes. Vagus X: It carries somatosensory
information from organs of thoracic, abdominal cavity including
heart and from that of gastrointestinal tract. Spinal Accessory
Nerve XI: leads to muscles of neck, back and larynx. It controls
the head movement. Hypoglossal Nerve XII:controls the muscles of
tongue
Slide 22
Meninges Meninges are the connective tissue membrane enclosing
the brain and the spinal cord. It is divided into 3.outer most
duramater,arachanoid mater and the inner most piamater.
Slide 23
Lobes of brain Frontal lobe : is responsible for problem
solving,judgement and motor function. Parietal lobe: manage
sensation, hand writing and body position. Temporal lobe : is
involved with memory and hearing. Occipital lobe : contain the
brains visual processing system.
Slide 24
Sutures of brain Coronal suture: present between frontal and
parietal bones. Lambdoid suture: present between occipital and
parietal bones. Sagital sutures: present between two parietal
bones. Squamous sutures: present between parietal and temporal
bones.
Slide 25
Major Regions of Brain Brain is divided into 3 major parts 1.
Cerebrum 2. cerebellum 3. Brain stem
Slide 26
Cerebrum: Cerebrum is the most superior part of the brain. It
is made up of by thick gray matter as surface layer and internally
with white matter.It consist of thalamus, hypothalamus and
epithalamus.
Slide 27
Cerebellum: Cerebellum located dorsal to the pons and medulla.
It receives the impulses from cerebral motor cortex, various stem
and sensory receptors in order to control skeletal muscle
contraction.
Slide 28
Brain stem: Brain stem is similarly structured as the spinal
cord. It is divided in to midbrain,pons and medulla oblongata.mid
brain acts as a fibre pathway between higher and lower brain
centres.The pons mainly a conduction region also contribute to the
regulation of respiration and cranial nerves. Medulla oblongata
regulate the respiratory rhythm, heart rate,B P etc...
Slide 29
Blood supply to the brain The major arteries are the vertebral
and internal carotid arteries. This communicating arteries forms
the circle of willis,which equalizes the blood pressure in the
brains anterior and posterior region.
Slide 30
Pathophysiology Damage to the brain from traumatic injury takes
two forms Primary: Initial damage to the brain that result from the
traumatic event. Secondary: It occurs hours and days after the
initial injury and result from inadequate delivery of oxygen and
nutrients.
Slide 31
. Brain suffers traumatic injury Brain swelling or bleeding
increase intracranial volume Increased ICP Pressure on blood
vessels causes blood flow to the brain to slow Cerebral hypoxia or
ischemia Continues increase in ICP Brain herniation Cerebral blood
flow cease Brain death
Slide 32
Types of head injury Concussion: Transient interruption in
brain activity. No structural injury noted on radiographs
Contusion: Bruising of the brain with associated swelling. Intra
cranial haemorrhage: Bleeding in to the brain tissue commonly
associated with edema.
Slide 33
Epidural hematoma: Blood between inner table of skull and
dura.Associated with injury or laceration of the middle meningeal
artery secondary to a temporal bone fracture. Subdural hematoma:
Blood between the dura and arachnoid space caused by venous
bleeding. Commonly associated with ICH or contusion. Diffuse axonal
injury or shear injury: Axonal tear with in the white matter of the
brain. Frequently occurs with the corpus callosum or brain stem and
at the frontal or temporal poles associated with prolonged
coma.
Slide 34
Signs and symptoms Altered level of consciousnessHypothermia or
Hyperthermia ConfusionVision and hearing impairment Pupillary
abnormalitiesSensory dysfunction Altered or absent gag
reflexHeadache Absent corneal reflexSeizure Altered respiratory
patternDecortications, Decerebration Increased pulse pressureCSF
Leakage Bradicardia or TachycardiaVomiting
Slide 35
Patient base Altered level of consciousnessHyperthermia
Confusion Decortications Decerebration Seizure Sensory dysfunction
Vomiting Altered respiratory pattern
Slide 36
Slide 37
CT SCAN
Slide 38
MRI
Slide 39
EEG
Slide 40
NERVE CONDUCTION VELOCITY A nerve conduction study (NCS) is a
medical diagnostic test commonly used to evaluate the function,
especially the ability of electrical conduction, of the motor and
sensory nerves of the human body.
Slide 41
ELECTRONYSTAGMOGRAPHY is a diagnostic test to record
involuntary movements of the eye caused by a condition known as
nystagmus. It can also be used to diagnose the cause of vertigo,
dizziness or balance dysfunction by testing the vestibular
system.
Slide 42
Management All therapy is directs towards preserving brain
homeostasis and preventing secondary brain injury. Treatment to
prevent secondary injury includes stabilization of cardiovascular
and respiratory function to maintain adequate cerebral perfusion,
control of haemorrhage,hypovolemia and maintaining of blood gas
values.
Slide 43
Nursing assessment Assessment 1. Collection of history 2. GCS
score 3. Neurologic status 4. Presence of CSF leakage 5. Pupillary
response to light
Slide 44
Initial management Severe head injury ATLS Evaluation
Intubation with ventilation and sedation Fluid resuscitation CT
Brai n Surgical lesion OT ICU MONITOR ICP YES NO Treat intra
cranial hypertension
Slide 45
Patient side management IntubationInj. manitol Ventilation with
sedationInj.Perfalgan 250mgI V PRN Right frontal and parietal burr
hole with evacuation of subdural hydroma Tab.Gardinal IV fluid
d5%+n/2 +5ml kcl @ 80ml/hrTab.Lyrica 25mg BD Iv antibiotics- Inj.
Ceftriazone 500mg iv bd and inj.amikacin 250mg iv BD Inj.Risek 20
mg IV OD Inj.Phenytoin 60mg iv q8h
Slide 46
Prioritization of nursing problems Ineffective airway clearance
and impaired gas exchange related to artificial airway Ineffective
cerebral tissue perfusion related to increased ICP, decreased CPP
and seizures Fluid volume deficit related to decreased loss of
consciousness and hormonal dysfunction Imbalanced nutrition,
related to increased metabolic demands, fluid restriction and
inadequate intake Risk for injury related to seizures,
disorientation, restlessness or brain damage Risk for imbalanced
body temperature related to damaged temperature regulating
mechanism Risk for impaired skin integrity related to bed rest,
paralysis and immobility Disturbed thought process related to brain
injury Disturbed sleep pattern Interrupted family process
Slide 47
Nursing care plan assessmentNursing diagnosis
planninginterventionrationaleevaluation SUBJECTIVE Not Applicable
Risk for impaired skin integrity related to immobility Skin to be
remain intact and will not develop any bedsore Positioning done
every 2 hourly Positioning reduces pressure Goal met by absence of
bedsores during the stay of facility OBJECTIVE o Unable to move
Maintained personal hygiene of the patient Moistures causes skin
tears o Unable to abduct and adduct extremities Applied cream and
powders as necessary To smoothening the skin Provided air mattress
To reduce pressure
Slide 48
assessmentNursing diagnosis
planninginterventionrationaleevaluation SUBJECTIVE Patients mother
complaints sputum is Ineffective airway clearance related to
tracheo-bronchial secretions Improve the airway patency of the
patient Suctioning done To remove the secretions Goal partially met
by reduced secretion and normal respiratory rate Coming out through
the tracheostomy tube CPT provided Retained secretions interfere
with gas exchange OBJECTIVE Secretions present Provided fowlers
position Helps good air entry RR 26/mt Cough present Administered
nebulization with ventolin and pulmicort Helps to soothening and
expulsion of secretion Administered antibiotics To reduce
infection
Slide 49
Complications Infection-respiratory Hydrocephalus Post
traumatic seizure Permanent neurologic deficit Coma Chronic
headache Death
Slide 50
Health education )Instructed the mother about the calorie needs
of the baby )Involve the family in sensory stimulation programmes
to maximize its effectiveness )Instructed the mother to investigate
for physical sources of restlessness such as uncomfortable
position, signs of UTI or pressure ulcer development. )Provide
necessary education related to tube feeding, positioning, ROM
exercises. ) Instructed to observe for post concussion, syndrome
(headache, decreased concentration, irritability, dizziness,
Insomnia, restlessness)and advised to obtain addition support.
Slide 51
Conclusion Trauma involving the central nervous system can be
life threatening even if it is not life threatening, brain and
spinal cord injury may result in major physical and psychological
dysfunction and can alter the patients life completely.
Slide 52
Bibliography 1.Brunner and suddarths,test book of medical
surgical nursing 12 th edition 2.Lippincott manual of nursing
practice 9 th edition