Herzing UniversityNF 216WEEK 3./ complete solution

WEEK 3 TRAUMATIC BRAIN INJURY • Description o Head injury is trauma to the skull, resulting in mild to extensive damage to the brain o Immediate complications include cerebral bleeding, hematomas, uncontrolled incr ...

WEEK 3 TRAUMATIC BRAIN INJURY • Description o Head injury is trauma to the skull, resulting in mild to extensive damage to the brain o Immediate complications include cerebral bleeding, hematomas, uncontrolled increased ICP, infections and seizures o Changed in personality or behavior, cranial nerve deficits and any other residual deficits depend on the area of the brain damage and the extent of the damage • Types o Concussion ▪ A jarring of the brain within the skull ▪ There may or may not be a loss of consciousness o Contusion ▪ Bruising type of injury to the brain tissue ▪ May occur along with other neurological injuries such as with subdural or extradural collections of blood o Skull fractures ▪ Linear-a break in a cranial bone resembling a thin line, without splintering, depression, or distortion of bone ▪ Depressed -a break in a cranial bone (or "crushed" portion of skull) with depression of the bone in toward the brain ▪ Compound-involves a break in, or loss of, skin and splintering of the bone ▪ Comminuted-splinter of the bone in 2 or more places pointing inward o Epidural hematoma ▪ The most serious type of hematoma, epidural hematoma forms rapidly and results from arterial bleeding ▪ The hematoma forms between the dura and skull from a tear in the meningeal artery ▪ It is often associated with temporary loss of consciousness, followed by a lucid period that than rapidly progresses to coma ▪ Epidural hematoma is a surgical emergency o Subdural hematoma ▪ Subdural hematoma forms slowly and results from a venous bleed ▪ It occurs under the dura as a result of tears in the veins crossing the subdural space o Intracerebral hemorrhage ▪ Occurs when a blood vessel within the brain ruptures, allowing blood to leak inside the brain o Subarachnoid hemorrhage ▪ Bleeding into the subarachnoid space. It may occur as a result of head trauma or spontaneously such as from a rupture cerebral aneurysm o Open ▪ Scalp lacerations ▪ Fractures in the skull ▪ Interruption of the dura matter o Closed ▪ Concussion ▪ Contusions ▪ Fractures • Hematoma o Description ▪ A collection of blood in the tissues that can occur as a result of subarachnoid hemorrhage or intracerebral hemorrhage o Assessment ▪ Assessment findings depend on the injury ▪ Clinical manifestations usually result from ICP ▪ Changing neurological signs in the client ▪ Changes in LOC ▪ Airway and breathing pattern changes ▪ Vital signs change, reflecting increased ICP ▪ Headache, nausea and vomiting ▪ Visual disturbances, pupillary changes and papilledema ▪ Nuchal rigidity, not test until spinal cord injury is ruled out ▪ CSF drainage from the ears or nose • CSF can be distinguished from other fluids by the presence of concentric rings, bloody fluid surrounded by yellowish stain; halo sign) when the fluid is placed on a white sterile background, such as a gauze pad. CSF also tests positive for glucose when tested using a glucose strip ▪ Weakness and paralysis ▪ Posturing ▪ Decreased sensation or absence of feeling ▪ Reflex activity changes ▪ Seizure activity • Interventions o Monitor respiratory status and maintain a patent airway, because increased carbon dioxide levels increase cerebral edema o Monitor neurological status and vital signs, including temp o Maintain head elevation to reduce venous pressure o Prevent neck flexion o Initiate normothermia measures for increased temperature o Assess cranial nerve function, reflexes and motor and sensory function o Initiate seizure precautions o Monitor for pain and restlessness o Morphine sulfate or opioid medication may be prescribed to decrease agitation and control restlessness caused by pain for the head injured client on a ventilator. Administer with caution because it is a respiratory depressant and may increase ICP o Monitor for drainage from the nose, or ears because this may be CSF o Do not attempt to clean the nose, suction or allow the client to blow her nose if drainage occurs o Do not clean the ear if drainage is noted but apply a close sterile dressing o Check drainage for the presence of CSF o Notify the PCP if drainage from the ears or nose is noted and the drainage test positive for CSF o Instruct the client to avoid coughing because this may increase ICP o Monitor for signs of infection o Prevent complications of immobility o Inform the client and family about the possible behavior changes that may occur including those that are expected and those that need to be reported • Craniotomy o Description ▪ Surgical procedure that involves an incision through the cranium to remove accumulated blood or a tumor ▪ Complications of the procedure include increased ICP from cerebral edema, hemorrhage, or obstruction of the normal flow of CSF ▪ Additional complications include hematomas, hypovolemic shock, hydrocephalus, respiratory and neurogenic complications, pulmonary edema and wound infections ▪ Complications related to fluid and electrolyte imbalances include diabetes insipidus and inappropriate secretion of antidiuretic hormone ▪ Stereotactic radiosurgery (SRS) may be an alternative to traditional surgery and is usually used to treat tumors and arteriovenous malfunctions o Preoperative interventions ▪ Explain the procedure to the client and family ▪ Prepare to shave the clients head as prescribed and cover the head with and appropriate covering ▪ Stabilize the client before surgery o Post op ▪ Monitor vital signs and neurological status every 30 to 60 mins ▪ Monitor for increased ICP ▪ Monitor for decreased level of consciousness, motor weakness or paralysis, aphasia, visual changes and personality changes ▪ Maintain mechanical ventilation and slight hyperventilation for the first 24 to 48 hours as prescribed to prevent increase ICP ▪ Assess the primary health care providers prescription regarding client positioning ▪ Avoid extreme hip or neck flexion, and maintain the head in a midline neutral position ▪ Provide a quiet environment ▪ Monitor the head dressing frequently for signs of drainage