brain injury 1. concept map: selected topics in neurological nursing pathophysiology traumatic brain...
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Brain InjuryBrain Injury1
Concept Map: Selected Topics in Neurological Nursing
PATHOPHYSIOLOGY
Traumatic Brain InjurySpinal Cord Injury
Specific Disease Entities: Amyotropic Lateral Sclerosis Multiple Sclerosis Huntington’s Disease Alzheimer’s Disease Huntington’s Disease Myasthenia Gravis Guillian-Barre’ Syndrome Meningitis Parkinson’s Disease
PHARMACOLOGY
--Decrease ICP--Disease Specific Meds
ASSESSMENTPhysical Assessment Inspection Palpation Percussion Auscultation
ICP Monitoring“Neuro Checks” Lab Monitoring
Care PlanningPlan for client adl’s, Monitoring, med admin.,Patient education, more…basedOn Nursing Process: A_D_P_I_E
Nursing Interventions & EvaluationExecute the care plan, evaluate for Efficacy, revise as necessary
ObjectivesObjectives3
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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Sometimes:The Lights are on…. But nobody’s home….
Anatomy & Physiology ReviewAnatomy & Physiology Review 5
OOOTTAFAGVSH
IIIIIIIVVVIViiVIIIIXXXIXII
lfactorypticculomotorrochlearrigeminalbducensacialcousticlossopharyngealaguspinal accessoryypoglossal
Cranial Nerve Function Structures Innervated
I Olfactory Smell Olfactory Bulb
II Optic Vision Retina
III Oculomotor Eyeball movementLens AccomodationPupil Constriction
4 eyeball muscles1 eyelid muscle
IV Trochlear Eyeball Movement Superior Oblique Muscles
V Trigeminal 1. Sensation2. General Sensory From Tongue3. Proprioception
1. Face, scalp, teeth, lips, eyeballs, nose, throat lining2. Anterior 2/3 of tongue3. Muscles of mastication
VI Abducens Eyeball movement Lateral Rectus muscle
VII Facial 1. Taste2. Proprioception3. Facial Expressions4. Salivation & Lacrimation
1. Face & Scalp2. Face & Scalp3. Muscles of face4. Salivary & Lacrimal Glands
VIII Acoustic 1. Balance2. Hearing
1. Vestibular apparatus2. Cochlea
IX Glossopharyngeal
1. Taste2. Proprioception for swallowing3. Blood pressure receptors4. Swallowing & gag reflex5. Tear production6. Saliva production
1. Posterior 2/3 of tongue2. Throat muscles3. Carotid sinuses4. Throat muscles5. Lacrimal glands6. Parotid glands
X Vagus 1. Chemoreceptors2. Pain receptors3. Sensations4. Taste5. Heart Rate & Stroke Volume6. Peristalsis7. Air Flow8. Speech & Swallowing
1. Blood O2 Concentration, Aortic bodies2. Respiratory & Digestive Tracts3. External ear, larynx, pharynx4. Tongue5. Pacemaker & Ventricular Muscles6. Smooth muscles of digestive tract7. Smooth muscles of bronchioles8. Muscles of larynx & pharynx
XI Spinal Accessory
1. Head rotation, upright position2. Shrugging shoulders
1. Trapezius & sternocleidomastoid muscles
XII Hypoglossal Speech & Swallowing Tongue & Throat muscles
Brain TraumaBrain Trauma7
Brain injury results in more trauma deaths than do injuries to any other body region!
Primary InjuryPrimary Injury
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Mechanical trauma that occurs at the moment of impactmoment of impact and may lead to irreversible cell damage from physical disruption of neurons or axons
93 Top Causes3 Top Causes
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Risk FactorsRisk Factors11
Highest in young people and the elderly
*Age 65 – 75 has highest incidence of HI of ALL age groups*
Occurs twice as often among males compared with females
Motor vehicle crashes account for the major proportion of head and brain injuries….and involve a disproportionately large number of young persons
Alcohol intoxication is a compounding factor in at least 30% to 50% of head injuries and is a contributing factor in almost ½ of all fatal motor vehicle crashes in the United States
Did you Know ?Did you Know ?12
Laws that require helmet use have been shown to
reduce deaths
in motorcyclists
by about 30%
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Boxing:
Coup-
Contre Coup
Injury :
“The second collision”
““Rear-EndedRear-Ended” – ” – ““WhiplashWhiplash”” EffectEffect
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At the Scene: - EMS- EMS- First Responders- First Responders
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1. Maintain ability to breathe
2. Prevent shock
3. Immobilization to prevent further spinal cord damage
(Backboard + C-Collar)
EMS type C- CollarEMS type C- Collar17
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Spinal Injury Spinal Injury
Assumed Assumed
WithWith
AnyAny
Head InjuryHead Injury
EMS Back BoardsEMS Back Boards19
Upon Arrival to ER…Upon Arrival to ER…20
Baseline Assessment21
Vital Signs
Glasgow Coma Score (GCS)
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The GCSGCS is the most widely used method of defining a patient's Level of Consciousness (LOC)
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Everybody Check
Hand Grasps for Motor Strength by
CROSSINGCROSSING
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Oculocephalic Reflex Oculocephalic Reflex (Doll’s (Doll’s Eye)Eye)
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OCR27
C – Spine C – Spine X-Ray“Cross-Table Lat”
BeforeBefore removal of ANY immobilization devices
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As Much as Possible In ER29
Instruct client to avoid sneezing or coughing
Provide calm environment
Maintain immobilization
Avoid meds the decrease LOC such as analgesics
Severity of Head InjurySeverity of Head Injury30
GCS 3 – 8 : SevereSevere Head
InjuryGCS 9 – 12: ModerateModerate Head
InjuryGCS 13 -15: MildMild Head
Injury
GCSSCORE< 8 =COMA
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The best guide to the severity of head
injury is the level of consciousness
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History of InjuryHistory of Injury33
Loss of Consciousness?
Other victims seriously hurt?
Mechanism of injury?
Driver / passenger / seatbelt ?Fall height / what caused fall?Hit where and with what?Gunshot / impaled object ?
Open or Closed Injury ?34
DiagnosticsDiagnostics35
Damaged areas of the brain have a reduced or no blood flow or glucoseglucose metabolism. This can be seen in the images below where there has been a blow to the head by a rock
Skull FracturesSkull Fractures36
Present on CT scans in about two thirds of patients after head injury
Skull fractures can be linear, depressed, or diastatic and may involve the cranial vault or skull base
Depressed Skull FracturesDepressed Skull Fractures37
A portion of the skull is extending into the intracranial space
Often results in pressure on the brain or direct injury to the brain
In addition, the bone fragment may cause a laceration of the dura mater resulting in a cerebrospinal fluid leak
Outcome is based upon the underlying brain injury. If no brain injury is present the surgery represents a cosmetic procedure and the outcome is generally quite good
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Frontal Lobe- associated with reasoning, planning, parts of speech, movement, emotions, and problem solving
Parietal Lobe- associated with movement, orientation, recognition, perception of stimuli
Occipital Lobe- associated with visual processing
Temporal Lobe- associated with perception and recognition of auditory stimuli, memory, and speech
Basal Skull FracturesBasal Skull Fractures39
Clinical Clues may includeClinical Clues may include: :
CSF leakage through the ear or nose (otorrhea or rhinorrhea)
Hemotympanum (blood behind the eardrum)
Bruising behind the ears (postauricular ecchymoses) “Battle Sign”
Bruising around the eyes (periorbital ecchymoses) “Raccoon Eyes” “Panda Eyes”
Injury to cranial nerves:Injury to cranial nerves:
VII Facial nerve - weakness of the face VIII Acoustic nerve - loss of hearing I Olfactory nerve - loss of smell II Optic nerve - vision loss VI Abducens nerve - double vision
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Basal Skull FracturesBasal Skull Fractures41
1 frontal2 ethmoid3 sphenoid4 temporal5 parietal6 occipital
Involve the floor of the skull and include fractures of the cribriform plate, frontal bones, sphenoid bones, temporal bone and occipital bones
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1. Frontal sinus
2. Crista galli
3. Cribriform plate3. Cribriform plate
4. Lesser wing of sphenoid
5. Superior orbital fissure
6. Superior border of petrous part of temporal bone
7. Dense shadow of petrous part of temporal bone
8. Perpendicular plate of the ethmoid
9. Vomer
10. Maxillary sinus
11. Inferior concha
12. Ramus of mandible
13. Body of mandible
CSF LeakageCSF Leakage43
Rhinorrhea and otorrhea are clinical signs of cerebrospinal fluid (CSF) leakage in patients with skull fracture
Presence ofPresence of glucoseglucose (CSF) in otorrhea and rhinorrhea detected by Beta-2 transferrinBeta-2 transferrin. Nasal/ear discharge (glucostix) was traditionally used to diagnose CSF leak at the bedside, but has fallen into disuse as it has poor positive predictive value
CSF leakage opens the brain & spinal canal to infectioninfection
CSF is needed to cushion the brain, maintain pressure within the eye and cleanse the CNS (like the lymphatic system serves the same function in the rest of the body)
44Halo
Effect of CSF
Prevent Infection !45
Cover any suspected source of CSF leakage with a
Sterile Dressing STAT !
CSF Infection Infection 46
Nuchal Rigidity
CSF has WBCs
Increased Temperature
Basal Skull FracturesBasal Skull Fractures47
•Most basal skull fractures do not require treatment and heal themselves
•Persistent CSF leakage may warrant operative repair of the leakage, particularly CSF leaks related to frontal bone and cribiform plate fractures
Associated with Brain InjuryAssociated with Brain Injury48
Blood on Ocular Surface
Blood in the anterior chamber of the eye (hyphaema) as a complication of blunt trauma. Eyes with hyphaema may show other signs of damage
Another Clue….Another Clue….49
Avulsed eye and lacerations to the forehead
Penetrating Brain InjuryPenetrating Brain Injury50
Head Injury AssessmentHead Injury Assessment51
Obvious Skull Fractures?
Lacerations?
Deformities? (bumps / indentations)
Facial Injuries?
Blood and/or CSF drainage from nostrils? (rhinorrhea)
Blood and/or CSF drainage from ear canals? (otorrhea)
Blood and/or CSF drainage from mouth?
Blood and/or CSF drainage from eyes?
Pain?
Headache?
Collaborative Treatment Collaborative Treatment Goals Goals
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Maintain AirwayBreathingCirculation
Maintain cerebral perfusionMaintain electrolyte balanceMaintain fluid balanceMaintain cognitive function
HOW ????HOW ????
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Prevent Prevent SecondarySecondary Injury !!!Injury !!!
Meaningful recovery of function after head injury is possible IF IF
secondary injuries are prevented or minimized