neurosensory: traumatic brain injury (tbi) & brain tumors
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Neurosensory: Traumatic Brain Injury (TBI) & Brain Tumors
Marnie Quick, RN, MSN, CNRN
Normal brain protected by:
Normal brain
Traumatic Brain Injury (TBI): Etiology/Pathophysiology Risk factors- MVA; elevated blood alcohol;
contact sports; acts of violence- gun, knife Mechanism of craniocerebral trauma
Acceleration (movement)-deceleration (stationary) Coup (impact)-contrecoup (opposite) phenomenon Blunt or penetrating injury Closed head injury Scalp lacerations Skull fractures- Linear; comminuted; depressed;
basilar; open/closed
Coup-contracoup injury
Penetrating injury- Gunshot to brain
Penetrating injury: Knife in brain
Basilar skull fracture- Base of skull fractured
Basilar skull fracture is base of skull if posterior> Battle sign- ecchymosis behind the ear
Basilar skull fracture is more anterior Raccoon eyes- periorbital ecchymosis
Basilar Skull fractures can cause leakage of CSF from meninges
Minor Brain Injury
Concussion- sudden transient disruption of neural activity in the brain with change in LOC
Post Concussion Syndrome- may occur after other brain injuries- severity of symptoms are not related to severity of brain injury. Sym may persist wks-months
Major Brain Injury- Focal injury
Brain contusion- bruising; coup-contracoup Brain laceration- tearing brain tissue, ICH DAI- diffuse axonal injruy
Widespread disruption of axons Poor prognosis
Brain bleeds- Note meninges in relation to bleeds on following slides
Epidural hematoma
Subdural hematoma (SDH)
Intracerebral hematoma
Secondary brain injury
Cerebral edema Localized or diffuse Peaks 24-72 hrs Occurs with CHI; open head injury; anoxia May in itself cause death by pressure> herniation
Increased ICP Herniation Syndromes
Traumatic Brain Injury (TBI): Common Manifestations/Complications
Increased ICP symptoms general and specific Restlessness- R/O respiratory; waking up Systemic effects of acute brain injury-
hypermetabolism, brainstorming, SIADH Brainstorming- hypothalamic stimulation-ANS CSF leak- rhinorrhea/otorrhea- basal skull Fx Post concussion Syndrome Associated cervical spinal cord injury
Collaborative Care: Traumatic Brain Injury (TBI):
Diagnostic studies (similar to ICP) Emergency management: assessment and interventions
(Lewis 1442 Table 57-9) Treat IICP- airway; fluid; positioning; temp reg; meds Prevention of complications
Medications: IICP; seizures; stress ulcer;straining;brainstorming Diet/calories: hypermetabolic state; ileus; swallow/gag CSF leak: glucose; halo; HOB 30; no nasal suction Other: SIADH> hyponatremia
Surgery: bone repair; evacuation clot; craniotomy/ectomy; burr hole; cranioplasty; monitor placement
Burr holescraniotomy
Place monitors/intraventricular drain:
Crainectomy- bone flap out to allow for brain expansion post op
Post crani
Traumatic Brain Injury (TBI): Nursing assessment specific to TBI
Health history Description of accident; past medical history
NVS and Glasgow Coma
http://www.trauma.org/scores/gcs.html Brainstem reflexes VS- Late sign is Cushing reflex Skull/face; CSF leak; SCI Consider older adult finding
Pertinent Nursing Problems Specific to Traumatic Brain Injury (TBI):
Health promotion Ineffective tissue perfusion, cerebral (decreased
intracranial adaptive capacity) Ineffective airway clearance/breathing pattern Hypothermia Pain Impaired physical mobility
Anxiety Decreased cerebral perfusion (IICP) Brain death (ethical dilemmas p.1450) Home care
Home evaluation/rehab/nursing home Teach about post concussion syndrome; B&B;
spasticity; dysphagia; nutrition; seizure disorder; personality changes; family role changes
6 months typical plateau period Community agencies/support groups
http://library.med.utah.edu/kw/animations/hyperbrain/oculo_reflex/oculocephalic2.html
http://cim.ucdavis.edu/eyes/version15/eyesim.html
http://www.softwarefornurses.com/access/index.asp
Primarybrain tumors Arise from support
cells, neurogilia cells; the meninges; or blood vessels
Do not metastasize outside cranium
Cause unknown
Grade I and II gilomas (astrocytoma) made up of astrocytes; are benign, slow-growing tumors
Grade III and IV gliomas (glioblastoma Multiforme are invasive and fast-growing
Meningiomas arise from the meninges; slow-growing; benign, encapsulated and compress the brain
Brain tumors may be lethal due to their location
Gioblastoma Meningioma
Metastatic (secondary) brain tumors Originate from outside
the brain- lung and breast most common sites
Single or multiple Becoming more common
as individual with cancer in other parts of the body are living longer
Clinical Manifestations/complications of Brain tumors General ICP symptoms Common early symptoms: headache; vomiting;
papilledema (visual changes) Seizures- partial classification in type Brain tumor symptoms occur due to their ability
to compress or destroy brain tissue; edema that forms around the tumor; hemorrhage; & obstruction of CSF flow
Specific symptoms as to the lobe affected>
Frontal lobe: personality changes; inappropriate behavior; inability to concentrate; impaired judgment; headache; expressive aphasia if dominant hemisphere; motor weakness or paralysis from motor strip
Parietal lobe: sensory deficits- paresthesia, visual field deficits; contralateral sensory disturbances from sensory strip; loss of interpretation and discrimination for sensing input; perceptual problems
Occipital lobe: visual disturbances; visual agnosia Temporal lobe: complex partial (psychomotor)
seizures; auditory hallucinations; memory problems; Wernicke aphasia if dominant hemisphere
Cerebellum: gait distrubances; balance and coordination problems
Brain stem: cranial nerve dysfunction; vital signs
Complications of Brain Tumors Hydrocephalus Infection Death is usually caused by IICP/hermiation
Collaborative Care for Brain Tumors Diagnostic tests CT/MRI EEG PET Angiogram Tissue biopsy
Collaborative Care for brain tumors Surgery
To remove or debulk Supratentorial- above
tentorium Infratentorial-below Stereotaxic-localized
Radiation Used alone or with other therapies Gamma or Cyber-knife Complication- increased cerebral edema
Medications Chemotherapy: IV; intraventricular (ommaya
Reservoir) or by wafer implanted Corticosteroids to treat brain edema Anticonvulsants to prevent seizures
Rehab- outpatient or in house
Health history: progression of symptoms; other cancers, disease
Physical exam Neuro vital signs Specific signs of the local functions of different parts
of the brain Similar neuro deficits as the individual with a stroke Signs of increased intracranial pressure/herniation
Pertinent Nursing Problems for Brain Tumor
Impaired tissue perfusion, cerebral Self-care deficits Anxiety Risk for infection-post crani Acute pain Disturbed self-esteem Nutrition Home care- rehab; home eval; support groups
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