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Head injury
- 1. NURSING MANAGEMENT OF HEADINJURY PATIENTS Preparedby: Mrs. NutanMakasare College of nursing GMC, Nagpur
- 3. GENERAL OBJECTIVE: At theend of the teaching session, the group will be able to provide efficient nursing care to patients with acute head injury.
- 4. SPECIFIC OBJECTIVES: TheGroup will be able to; Review the Anatomy and Physiology of the brain or structures within the cranium. Define the term ‘Head Injury’. Classify the head injury. Enlist the causes (etiology) and risk factors. Explain the mechanism and pathophysiology of patient with head injury. Recognize the signs and symptoms of different type of head injury. Enlist the diagnostic test which is carried out in patients with head injury. Enumerate the complications of head injury. Describe the medical and surgical management of patients with head injury. Describe the Nursing management of patients with head injury. Make general, neurological assessment of patients with head injury. Assess the G C S and interpret it. Applies acute nursing care in managing the patients with head injury.
- 5. INTRODUCTION Every year,millions of people sustain a head injury. Most of these injuries are minor because the skull provides the brain with considerable protection. More than half a million head injuries a year, however, are severe enough to require hospitalization. Brain injury is a common cause of morbidity and mortality in all age groups and represents a major public health problem with high annual cost.
- 6. ANATOMY AND PHYSIOLOGY The brain is part of the CNS, housed within the cranial vault. The major parts of the brain are: cerebrum, diencephalons, brainstem and the cerebellum. Cerebrum: This is the largest part of the brain and it occupies the anterior and middle cranial fossae. It is divided into right and left cerebral hemispheres; each containing one of the lateral ventricles. Transverse fissure separates the cerebrum from the cerebellum. Each hemisphere receives sensory and motor impulses from the opposite side of the body. Left hemisphere is responsible for the control of language while right for the nonverbal perceptual functions. Each cerebral hemisphere is divided into frontal, parietal, temporal and occipital lobes.
- 8. Frontal lobeis the largest lobe which is responsible for concentration, abstract thought, information storage or memory and motor function. Parietal lobe is concerned with sensation. Temporal lobe incorporates the auditory centre. Occipital lobe is devoted to all aspects of visual perception. Basal ganglia: These are areas of gray matter, lying deep within the cerebral hemispheres, with connections to the cerebral cortex and thalamus. It involved in initiating muscle tone in slow and coordinated activities.
- 11. Diencephalon: Itis embedded in the cerebrum superior to the brainstem. It consists of the thalamus, hypothalamus and epithalamus. Diencephalon conducts sensory and motor impulses, regulates autonomic nervous system, regulates and produces hormones and mediates emotional responses. Brainstem: The brainstem consists of the midbrain, pons, and medulla oblongata. The midbrain is a center for auditory and visual reflexes. In addition, it functions as a nerve pathway between the cerebral hemispheres and lower brain. The pons is located just below the midbrain. It consists mostly of tracts, but it also contains nuclei that control respiration. The medulla oblongata, located at the base of the brainstem, is continuous with the superior portion of the spinal cord. Medulla oblongata contains motor fibers from the brain to the spinal cord and sensory fibers from the spinal cord to brain. Nuclei of the Medulla oblongata play an important role in controlling cardiac rate, blood pressure, respiration and swallowing.
- 12. Cerebellum: Thecerebellum is connected to the midbrain, pons and medulla. Its function includes co-coordinating skeletal muscle activity, maintaining balance, and controlling fine movements. Ventricles: The brain contains four Ventricles (right and left lateral ventricles, third and fourth ventricles), which are chambers filled with CSF. CSF forms a cushion for the brain tissue, protects the brain and spinal cord from trauma, helps provide nourishment for the brain, and removes waste product of cerebrospinal cellular metabolism. Meninges: The brain and spinal cord are covered and protected by three connective tissue membranes called meninges. The meninges have three layers. The outermost layer covers the brain and the spinal cord is dura mater. The middle layer is the arachnoid mater, which encloses the entire CNS. It forms the subarachnoid space that contains CSF. The innermost layer, the pia mater, clings to the brain, spinal cord and segmental nerves and is filled with small blood vessles. Cerebral circulation: The brain receives about 750ml of blood per minute, approximately 15% of the cardiac output. The anterior part of the brain is supplied with blood by the two internal carotid arteries and the posterior part of the brain is supplied with blood by the vertebral arteries.
- 15. DEFINITION Headinjury is a broad term that includes injury to the scalp, skull, or brain. The National Head Injury Foundation defines Traumatic Brain Injury (TBI) as a traumatic insult to the brain capable of causing physical, intellectual, emotional, social and vocational changes.
- 16. INCIDENCE Theincidence of TBI varies by age, gender, region and other factors. Approximately 1 million people receive treatment for head injuries every year. Of these, 230,000are hospitalized, 80,000 have permanent disabilities, and 50,000 people die. The annual incidence of mild TBI is difficult to determine but may be100-600 people per 100,000. In India, it is the seventh-leading cause of mortality contributing to 11% of total deaths; 78% of cases are due to road traffic injuries alone.
- 17. CLASSIFICATION TBIis usually classified based on mechanism (the causative forces), severity and pathological features of the injury. Classification based on Mechanism (causative forces): Closed or nonpenetrating (blunt) injury occurs when the brain is not exposed. Open or penetrating injury occurs when an object pierces the skull and breaches the dura mater.
- 18. Classification basedon severity: severity GCS PTA LOC Mild 13-15 <1 day 0 – 30 minutes Moderate 9-12 >1 to <7 days >30 min to <24 hours Severe 3-8 >7 days >24 hours N.B. GCS- Glasgow coma scale PTA- Post traumatic amnesia LOC- Loss of consciousness
- 19. Classification basedon pathological features of the injury: Extra-axial – Lesions can be extra-axial i.e. occurring within the skull but outside of the brain. Intra-axial – Lesion occurring within the brain tissue. OR Concussions: A concussion is head trauma that may result in loss of consciousness for 5 minutes or less and retrograde amnesia. There is no break in the skull or dura, and no visible damage on a CT or MRI scan. Contusions: Contusions damage the brain itself, causing multiple areas of petechial and punctate hemorrhage and bruised areas. Diffuse Axonal Injury: This is the most severe form of head injury. It begins with immediate loss of consciousness, prolonged coma, abnormal flexion or extension posturing, increased ICP, hypertension and fever.
- 20. ETIOLOGY ANDRISK FACTORS Males aged 15 to 24 years are three times more likely to succumb to a Traumatic head injury than are females. Peak occurrence is during evenings, nights, and weekends. Motor vehicle accidents are the foremost cause of head injuries. Other causes are assaults, falls, sport injury, domestic violence, abuse, industrial accidents, firearms and blast injuries from explosions. Risk factors: Alcohol abuse, drug abuse, careless driving, using cell phones while driving, not wearing helmets, failure to wear seat belt and protective gear, and improper use of weapons.
- 21. MECHANISM ANDPATHOPHYSIOLOGY Head injuries are caused by a sudden force to the head. The results are complex. Three mechanisms contribute to head trauma: Acceleration: An acceleration injury occurs when the immobile head is struck by a moving object. Deceleration: If the head is moving and hits an immobile object, a deceleration injury occurs. Deformation: It refers to injuries in which the force results in deformation and disruption of the integrity of the impacted body part (e.g. skull fracture). In an acceleration-deceleration injury, a moving object hits the immobile head, and then the head hits an immobile object. These injuries are also associated with rotation injury, where the brain is twisted within the skull.
- 22. Brain suffers traumaticinjury Brain swelling or bleeding Increases intracranial volume Pressure on blood vessels within the brain causes blood flow to the brain to slow Cerebral hypoxia and ischemia occur ICP continues to rise, Brain may herniate Cerebral blood flow ceases
- 23. CLINICAL MANIFESTATIONS The symptoms, apart from those of the local injury, depend on the severity and the distribution of brain injury. Following concussion, observers report a loss of consciousness for 5 minutes or less and retrograde amnesia, PTA or both. Signs of post concussion syndrome may include headache, dizziness, anxiety, irritability, and lethargy. Contusions are often associated with other serious injuries, including cervical fractures. The common complication of contusions of the brain, leading to increased ICP, hypoxia and further brain damage is cerebral edema. Persistent localized pain usually suggests that a fracture is present. The most common, accounting for 80% of all skull fractures are linear fractures. Fractures of the Base of the skull frequently produce hemorrhage from the nose, pharynx or ears and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle’s sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF Otorrhea) and the nose (CSF Rhinorrhea). A halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or the head dressing and is highly suggestive of a CSF leak. Bloody CSF suggests a brain laceration or contusion.
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- 27. Brain injurymay have various signs including altered LOC, confusion, Pupillary abnormalities, altered or absent gag reflex, absent corneal reflex, sudden onset of neurologic deficits, Changes in vital signs (altered respiratory pattern, hypertension, bradycardia), hypothermia or hyperthermia, vision and hearing impairment and sensory dysfunction In acute or subacute subdural hematoma, changes in level of consciousness, papillary signs, hemiparesis, coma, hypertension, bradycardia, and slowing respiratory rate are signs of expanding mass. Chronic subdural hematoma may result in severe headache, alternating focal neurologic signs, personality changes, mental deterioration, and focal seizures.
- 30. DIAGNOSTIC ASSESSMENTS Diagnostic assessments, such as x-rays, CT or MRI scan, may reveal fractures and areas of bleeding or brain shift. Functional imaging (PET scan) can measure cerebral blood flow or metabolism, inferring neuronal activity in specific regions and potentially helping to predict outcome. Electroencephalography and transcranial Doppler may also be used. Lumber puncture can also be used to assess for bleeding within the subarachnoid space. Cerebral angiography may also be used to identify and intracerebral hematomas and cerebral contusions.
- 31. COMPLICATIONS Cerebraledema Infection (e.g. meningitis, brain abscess) Acute hydrocephalus Diabetes insipidus Syndrome of inappropriate secretion of antidiuretic hormone (SIADH) Dysrhythmias Neurogenic pulmonary edema Arteriovenous aneurysms Altered behavior Post trauma response
- 32. MEDICAL ANDSURGICAL MANAGEMENT All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury. Management involves supportive care, control of ICP, maintenance of fluid and electrolyte balance, administration of antihypertensive, antipyretic, analgesics, diuretics, anticonvulsants, sedatives, paralytic agents, muscle relaxants, antacids, stool softeners, antibiotics etc. Increased ICP is managed by adequate oxygenation, mannitol administration, ventilator support, hyperventilation, elevation of the head of the bed, maintenance of fluid and electrolyte balance, nutritional support, pain and anxiety management, or neurosurgery.
- 33. SURGERY: Thetreatment of choice for epidural hematomas and large acute subdural hematomas is surgical evacuation of the clot. This can often be performed through burr holes made into the skull. Surgical procedure that involves an incision through the cranium to remove accumulated blood or tumor is craniotomy. Complications of this procedure include increased ICP from cerebral edema, hemorrhage, or obstruction of the normal flow of CSF.
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- 35. NURSING MANAGEMENT Assessment: Obtain health history, including time of injury, cause of injury, direction and force of the blow, loss of consciousness, and condition following injury. Detailed neurologic information (level of consciousness, ability to respond to verbal commands if patient is conscious), response to tactile stimuli (if patient is unconscious), pupillary response to light, corneal and gag reflexes, motor function, and system assessments provide baseline data. Glasgow Coma Scale (GCS) serves as a guide for assessing level of consciousness (LOC) based on three criteria: Eye opening, Verbal responses, and Motor responses to a verbal command or painful stimulus.
- 36. A GCSscore 8 or less is generally accepted as indicating a severe head injury. Inspects the patient’s scalp for any laceration, hemorrhage, contusion, abrasion, concussion, compression. Palpate the patient’s head to detect or assess fractures, hematomas and ecchymosis. Inspects ears, nose for CSF leak, hemorrhage. Inspects other body parts for bone fracture, laceration, dislocation, hemorrhage, abrasion. Avoid flexion, hyper extension, rotation of the neck. Application of cervical collar, placing sand bag on either side of the head, use of spine board till cervical injury if ruled out. Monitoring vital signs: Monitor patient at frequent intervals to assess intracranial status. Assess for increasing ICP, including slowing of pulse, increasing systolic pressure and widening pulse pressure. Monitor for rapid rise in body temperature; keep temperature below 38oC (100.4oF) to avoid increased metabolic demands on brain. Keep in mind that tachycardia and hypotension may indicate bleeding elsewhere in the body.
- 37. Assessing motorfunction: Observe spontaneous movements; ask patients to raise and lower extremities; compare strength of hand grasp at periodic intervals. Note presence or absence of spontaneous movement of each extremity. Assess responses to painful stimuli in absence of spontaneous movement. Determine patient’s ability to speak; note quality of speech. Evaluating eye signs: Evaluate spontaneous eye opening. Evaluate size of pupils and reaction to light (unilaterally dilated and poorly responding pupils may indicate developing hematoma). If both pupils are fixed and dilated, it usually indicates overwhelming injury and poor prognosis.
- 38. Evaluating eyesigns: Evaluate spontaneous eye opening. Evaluate size of pupils and reaction to light (unilaterally dilated and poorly responding pupils may indicate developing hematoma). If both pupils are fixed and dilated, it usually indicates overwhelming injury and poor prognosis. Assess cranial nerve functioning and respiratory rate and rhythm of a client with a brain stem injury along with GCS. Oxygen needs are also monitored by assessing tissue perfusion, oximetry readings, and ABG analysis results. Assess fluid status with the help of B.P; CVP; fluid balance and hourly output.
- 39. Monitoring forcomplications (cerebral edema and herniation): Deterioration in condition may be due to expanding intracranial hematoma, progressive brain edema, and herniation of the brain. Peak swelling occurs about 72 hours after injury, with resulting elevation of ICP. Monitoring for other complications: Assess for complications, including systemic infections or neurosurgical infections, wound infection, osteomyelitis, or meningitis. After injury, some patients develop focal nerve palsies, such as anosmia (lack of sense of smell) or eye movement abnormalities and focal neurologic defects such as aphasia, memory defects, and post traumatic seizures or epilepsy. Patients may be left with organic psychosocial deficits and may lack insight into their emotional responses.
- 40. Acute NursingCare: Maintaining the airway and breathing pattern: First determine patient’s respiratory rate, rhythm and depth. Guard against aspiration and respiratory insufficiency. The head injury patient with airway obstruction requires immediate endotracheal intubation. Patency of airway is indicated by equal bilateral chest movement, normal air entry on auscultation and oxygen saturation above 95 %. Position the unconscious client to facilitate drainage of secretions, elevate head of bed 30 to 45 degrees to decrease intracranial venous pressure. Establish effective suctioning procedures. Visible mucus bubbling in the ET tube indicates the need for suctioning. Monitor ABGs to assess adequacy of ventilation. Monitor patient on mechanical ventilation. Humidified oxygen, endotracheal intubation, a tracheostomy, or a mechanical ventilator may be required to maintain Pao2 at 80 mmHg or above. Monitor for pulmonary complications (ARDS and pneumonia).
- 41. Maintaining adequatecerebral tissue perfusion: Administer the medications that are ordered to reduce cerebral edema (e.g. osmotic diuretics, corticosteroids). Maintain normothermia. Elevating the head of the bed to at least 30degrees, keeping the head in neutral position, and avoiding extreme hip flexion can facilitate venous jugular drainage and decrease cerebral edema. Early treatment of dysrhythmias and blood replacement as indicated may be necessary for maintenance of an adequate cardiac output. Control active bleeding by compression when possible, unless a skull fracture is present. Control of increased ICP: Elevate the head of the bed to 300. Hyperventilate the patient. Prevent the Valsalva maneuver. Maintain the patient’s head and neck in a neutral position. Maintain normothermia. Maintain fluid restriction.
- 42. Maintaining fluidand electrolyte balance: Fluid and electrolyte balance is particularly important in patients receiving osmotic diuretics, those with inappropriate antidiuretic hormone secretion, and those with posttraumatic diabetes insipidus. Monitor serum and urine electrolyte levels (including blood glucose and urine acetone), osmolality, and intake and output to evaluate disorders of sodium regulation and endocrine function. Record daily weights if possible (which may indicate fluid loss from diabetes insipidus).
- 43. Providing adequatenutrition: Parenteral nutrition via a central line or enteral feedings administered via a nasogastric tube. Start nasogastric feedings as soon as condition stabilizes unless there is discharge of CSF from the nose; oral feeding tubes may be used. Food intake may resume when swallowing reflex returns and patient can meet caloric requirements orally. Give small, frequent feedings to lessen the possibility of vomiting and diarrhea; elevate head of bed, and check residual feeding before feedings.
- 44. Monitoring forseizure development and preventing injury: Protect the client at risk, prophylactically, by placing padding on side rails, keeping the bed in a low position, giving the anticonvulsant medication (e.g. diazepam) on time. If a seizure does occur, call for help as you are protecting the client’s head and turning the client to a lateral position to displace the tongue and to promote an open airway. Stay with the client; protect the client from harm; and observe the onset, progression, and duration of the seizure. Suction as necessary and monitor vital signs. Notify the physician, give oxygen and prepare for administration of an IV anticonvulsant. Observe for restlessness, which may be due to hypoxia, fever, pain, or a full bladder.
- 45. Avoid bladderdistention. Avoid restraints when possible because straining can increase ICP. Avoid using narcotics for restlessness because they depress respiration, constrict pupils, and alter LOC. Keep environmental stimuli to a minimum. Provide adequate lighting to prevent visual hallucinations. Do not disrupt sleep/wake cycles.
- 46. Preventing infection: Prevent risk for infection by not suctioning a client nasally if an anterior fossa or basilar fracture or CSF leakage from the ears (Otorrhea) or nose (Rhinorrhea) is present. If drainage is present test it for the presence of glucose. Use sterile dressings to absorb the fluid. Change them whenever they become wet to decrease the entry of microorganisms. If the client is conscious, discourage nose blowing, coughing, and inhibition of sneezing. Instruct the client to sneeze through an open mouth; suppressing a sneeze forces the bacteria backward. Administer prescribed antibiotics on time. Report any signs of meningitis. Use an external sheath catheter for incontinence because an indwelling catheter may produce infection. Use strict aseptic technique.
- 47. Maintaining bodytemperature: Monitor temperature every 2 to 4 hours. If temperature rises, administer acetaminophen and cooling blankets as prescribed to achieve normothermia. Monitor for infection related to fever. Maintaining skin integrity: Assess all body surfaces, and document skin integrity every 8 hours. Head injury patient’s position is changed every 2 hourly to prevent complications of prolonged bed rest. Provide skin care every 4 hours; Use skin lubricant to prevent irritation due to rubbing against the sheet. Assist patient to get out of bed three times a day (when appropriate).
- 48. Maintaining cognitivefunctioning: Develop patient’s ability to devise problem-solving strategies through cognitive rehabilitation overtime; use a multidisciplinary approach. Be aware that there are fluctuations in orientation and memory and that these patients are easily distracted. Do not push to a level greater than patient’s impaired cortical functioning allows because fatigue, headache, and stress (headache, dizziness) may occur.
- 49. Preventing sleeppatterns disturbance: Group nursing activities so that patient is disturbed less frequently. Decrease environmental noise, and dim room lights. Provide strategies (e.g. back rubs) to increase comfort. Monitoring and managing potential complications: Monitor for a patent airway, altered breathing pattern, and hypoxemia and pneumonia. Assist with intubation and mechanical ventilation. Provide enteral feedings, IV fluids and electrolytes, or insulin as prescribed. Initiate PN as ordered if patient is unable to eat. Monitor for systemic or neurosurgical infection. Take measures to control cerebral perfusion pressure: elevate head of bed 30 degrees, maintain head and neck in alignment (no twisting), prevent Vulsalva maneuver, use medications to decrease ICP, Maintain normal body temperature, hyperventilate on mechanical ventilation, maintain fluid restriction, avoid noxious stimuli (suctioning), administer sedation to reduce metabolic demands. Monitor for major post operative complications like increased ICP, Hemorrhage, and obstruction of the normal flow of CSF after craniotomy. Assess carefully for development of posttraumatic seizures. Providing psychological support to patient and family.
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