Alterations in the Neurological System

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Alterations in the Neurological System
Head Injuries

• NURSING Level 1 Summer A 2008
• Professor Cynthia Peacock M.S.N., R.N.

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Objectives

• Differentiate types of head injury according to
• mechanism of injury
• clinical signs and symptoms
• diagnostic testing
• treatment options
• Describe the nursing management and collaborative
  care of head injured patients
• Use the nursing process as a framework for care
  of patients with head injury

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Head Injuries

• Can range from a minor injury on the scalp, skull
  or a devastating brain injury
• Leading cause of death and disability in the U.S.
• Traumatic brain injury is the most serious form
  of head injury
• MVC, violence and falls leads the injuries.

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Mechanism of Head Injuries

• Acceleration- the head is struck by a moving
  object
• Deceleration- the head hits a stationary object
• Acceleration-deceleration- injury occurs at point
  of impact as the brain shifts within the skull
• Deformation- results in alteration of the body
  part such as in a skull fracture

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Causes of Head Injuries

• Motor Vehicle Accidents (MVAS)
• Violence (fights)
• Falls
• Sports related-injury
• Missiles (bullets)
• Sharp objects (knives, ice picks, axes,
  screwdrivers)

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Pathophysiology of Head/Brain Injuries

• Brain suffers a traumatic event
• ?
• Brain swelling or bleeding increase IC volume
• ?
• Rigid cranium allows no room for expansion of
  contents so intracranial pressure increases
• ?

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Pathophysiology of Head/Brain Injuries

• Pressure on blood vessels within the brain causes
  blood flow to the brain to slow
• ?
• Cerebral hypoxia and ischemia occur
• ?
• ICP continues to rise. The brain may herniate
• ?
• Cerebral flow ceases

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Pathophysiology

• The brain suffers traumatic injury from three
  mechanisms
• Primary is the initial damage to the brain that
  results from the traumatic event. This includes
• Contusions
• Lacerations
• Torn blood vessels from impact
• Acceleration/deceleration, or foreign object
  penetration

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Pathophysiology

• Secondary Injury includes cerebral edema, brain
  swelling, hemorrhage, infection and ICP
• Tertiary Injury is caused by apnea, hypotension,
  change in pulmonary resistance, and change in
  (ECG, especially ST and T waves)

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Types of Head/Brain Injuries

• Concussion
• Contusion
• Intracranial Hemorrhage
• Epidural Hematoma
• Subdural Hematoma

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Concussion

• Blow to the head, sudden and forceful
• Hard enough to jostle the brain and make it hit
  against the skull, causing temporary neural
  dysfunction
• It can cause temporary unconsciousness from a few
  second to few minutes
• Or only causing dizziness and spots before the
  eyes (seeing stars)

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Contusion

• More severe injury than a concussion
• Brain is bruised with possible surface hemorrhage
• Patient may lie motionless, with a faint pulse,
  shallow resp., and cool and pale skin
• Often incontinence of bladder and bowel
• Maybe aroused but slips back into unconsciousness

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Intracranial Hemorrhage

• Hematomas (collection of blood) that develops
  within the cranial vault
• Most serious brain injury
• Epidural (above the dura)
• Subdural (below the
• dura)
• Intraceberal
• (within the brain)

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Diagnostic Brain Injury

• Complete HP exam
• Skull x-ray
• CT
• MRI
• Cerebral angiogram

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Medical Management of Brain Injuries

• Monitor vital signs
• Close monitoring of patient
• Pupil check every 15 minutes
• Neurological consult

• Management if ICP
• Antibiotics
• Surgery for evaluation of intracranial hematoma,
  repair of CSF leaks

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Medical Management of Brain Injuries Cont

• Surgical debridement of penetrating wound or
  removal of foreign body
• Decompression through drilling of holes (Burr
  Holes)
• Mechanical Ventilation
• Anti-inflammatory agents
• Osmotic diuretics

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Complications

• Bleeding inside the brain (intracerebral
  hematoma)
• IICP
• Infections
• Permanent neurobehavioral alterations
• Permanent neurologic deficits motor, sensory,
  cognitive and speech

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Nursing Assessment

• Monitor vitals and observe closely
• Monitor for signs of IICP
• Loss of consciousness
• Abnormal pump response, vomiting, ?pulse
  pressure, bradycardia, hyperthermia
• Observe for CSF leakage
• Perform neurological checks (cranial nerves,
  motor, and reflex assessment)
• Note contusions of eyes and ears

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Nursing Diagnosis Patient With a Traumatic Brain
Injury

• Ineffective airway clearance and gas exchange r/t
  brain injury
• Ineffective cerebral tissue perfusion r/t IICP or
  brain stem injury
• Deficient fluid volume r/t to decrease LOC and
  hormonal dysfunction

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Nursing Diagnosis Patient With a Traumatic Brain
Injury Cont

• Imbalanced nutrition less than body requirements,
  related to increased metabolic demands, fluids
  restriction and inadequate intake
• Altered thought processes related to physiology
  of injury
• Risk for injury r/t altered thought processes
• Ineffective family coping r/t unpredictable
  outcomes

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Goals/Expected Outcomes

• Goals include
• Maintenance of a patent airway
• Adequate CPP, fluid and electrolyte balance
• Adequate nutritional status
• Prevention of secondary injury
• Maintenance of normal body temperature

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Goals/Expected Outcomes Cont

• Maintenance of skin integrity
• Improvement of cognitive function
• Prevention of sleep deprivation
• Effective family coping
• Increase knowledge about rehabilitation process
• Absence of complications

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Reference/Resources

• Smeltzer, S., Bare, b. (2007). Textbook of
  Medical-Surgical Nursing, 11th ed. Philadelphia
  Lippincott, Williams Wilkins Company
• Miami-Dade College, Nursing Curriculum