Brain Injury Part II

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Brain Injury Part II
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Concept Map Selected Topics in Neurological
Nursing
PATHOPHYSIOLOGY Traumatic Brain Injury Spinal
Cord Injury Specific Disease Entities
Amyotropic Lateral Sclerosis Multiple
Sclerosis Huntingtons Disease
Alzheimers Disease Huntingtons Disease
Myasthenia Gravis Guillian-Barre Syndrome
Meningitis Parkinsons Disease
PHARMACOLOGY --Decrease ICP --Disease Specific
Meds
ASSESSMENT Physical Assessment Inspection
Palpation Percussion
Auscultation ICP Monitoring Neuro Checks Lab
Monitoring
Care Planning Plan for client adls, Monitoring,
med admin., Patient education, morebased On
Nursing Process A_D_P_I_E
Nursing Interventions Evaluation Execute the
care plan, evaluate for Efficacy, revise as
necessary
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Objectives

• 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 Secondary Injury !!!
• Meaningful recovery of function after head injury
  is possible IF secondary injuries are prevented
  or minimized

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Secondary Brain Injury

• 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 ICP
  caused by hypotension, hypoxia, intracranial
  bleeding, seizures

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Brain Injury Management

• Frequent
• Re-assessments
• Rapid Response

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Be Vigilant for Increased ICP !

• 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.

Foramen Magnum
ICP Peaks 48 72 hours after injury
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Monitor Neuro Checks q 15 minutes

• Vital Signs Q15 minutes
• Glasgow Coma Score Q15 minutes

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Expanded Neuro Assessment Tool
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EARLY Signs of ? ICP

• Slight LOC changes 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 IMPORTANT
• EARLIEST
• Indicator of neurological deterioration

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Cushings Triad Signs of ? ICP

• Blood Pressure
• Systolic BP Increases
• Diastolic BP Decreases
• Pulse Decreases

Widening Pulse Pressure
Bradycardia
You will also see listed in some
resources --Irregular Respirations
(Cheyne-Stokes) --Elevated Temperature
(Hyperpyrexia)
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TREND Re-Assessment Data COMPARE to
Baseline Assessment Data
Temp
Pulse
BP
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LATE(R) Signs of ? ICP

1. Further decreased LOC
2. Cushings Triad / Reflex
3. Abnormal respiration patterns
4. Pupils asymmetrical / Dilated
5. Projectile vomiting
6. Hemiplegia / decorticate or decerebrate posturing

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Decerebrate Rigidity
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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! Tentorial (Brain) Herniation)
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Tentorial (Brain) Herniation
Normal
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ABI Nursing Interventions

1. Continuous monitoring of Vitals, PERL and Glasgow
   Coma Score
2. Report client condition changes ASAP
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 MonitoringIntraCranial Pressure
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Neurosurgeon drilling prior to placing an
intracranial pressure monitor
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Normal ICP for adults

• 10 to 15 mm Hg

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ABI Priority Nursing GOALS

• Minimize cerebral edema
• Maximize cerebral perfusion

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ABI Nursing Interventions

• Continuous monitoring of Vitals, PERL and Glasgow
  Coma Score
• Report client condition changes ASAP
• Maintain airway patency BUT
• Avoid suctioning or Hyperventilate
• with 100 O2 FIRST

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ABI Nursing Interventions

• Implement seizure precautions / Siderails
• Phenytoin (Dilantin) (prevent / treat Sz)
• Maintain head midline (neutral position)
• HOB gt 30 degrees

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ABI Nursing Interventions

• Address all self-care deficitsBUT
• Avoid clustering activities
• Provide emotional support

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ABI Nursing Interventions

• High dose barbituates gt 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 Edema

• Mannitol (Osmitrol) Urinary catheter
• Fluid restriction (I O)?
• Dexamethasone / Decadron (Know side effects!)
• Prevent / Treat fever
• Prevent Infections (closed STERILE monitoring
  system)

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Burr Holes
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Minimize Cerebral Edema

• Maintain
• Cerebral perfusion pressure
• MAP of 50 70 mm Hg
• Prevents Hypoxia (Hypercarbia)

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If BP too lowthen O2 perfusion is poorand Brain
Cant Function
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Optimize Cerebral Perfusion

• 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 / Family

• 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 Concussion

• A concussion is a relatively mild form of
  traumatic brain injury that results in temporary
  neurological changes
• No apparent structural damage
• Usually involves unconsciousness for a few
  seconds or minutes
• Frontal lobe bizarre irrational behavior
• Temporal lobe amnesia or disorientation

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Discharge .

• 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 Contusion

• More severe
• Brain bruised
• Possible surface hemorrhage
• Initially appears like shock
• Can have B B incontinence
• Can be arousedbriefly

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IntraCerebral Hemorrhage
IntraCranial Hemorrhage

• Bleeding within the tissue of the brain

Bleeding within the cranial vault
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IntraCranial Hemorrhage

• Bleeding within the cranial vault

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Intracranial Epidural / Extradural Hematoma

• - Between skull and dura
• - Extreme emergency
• - Mostly arterial

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Epidural / Extradural Hematoma
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Subdural Hematoma
Between dura and brain Mostly venous
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Subdural Hematoma

• 3 Types
• Acute
• Sx in 24 48 hours
• Subacute
• Sx in 48 hours 2 weeks
• Chronic
• Sx in 3 weeks months
• Common in elderly after even minor injury
• Often misdiagnosed as stroke

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Subdural Hematoma
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Head trauma leading to subdural hematoma and
intracranial hypertension
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Subarachnoid Hemorrhage

• 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 aneurysms and
  congenital arteriovenous malformations (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 Hemorrhage
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IntraCerebral Hemorrhage

• Bleeding within the tissue of the brain

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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)

• 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 GSW
Comparative visualization of the soft tissue
damage along the bullet track within the
cerebellum using MRI.

• Visualization of a gunshot wound through the
  cerebellum by showing the bony details using CT.
  Clearly visible is the typically funnel shaped
  exit wound.

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Outcome

• 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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ALL Cranial Injury Tx

• ATLS 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

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Surgical Outcomes

• 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 Recovery

• 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.

• 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 persons 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 process