Disoriented, confused depressed LOC GAS: move eyes, respond verbally, follow a motor command Garbled speech Sluggish or unequal pupil (Epistolary) Respiratory changes, 02 saturation Involuntary, absent movement Skull fractures Linear or depresses Simple or compound Closed or open Location of fracture determines manifestations Basilar (skull base): Facial paralysis, Raccoon eyes (periodontal deem and economist), Battle’s sign (postmenopausal economist), durra tear: Thoreau (SF leakage out of the ear), rhinoceros ( SF leakage out of the nose), halo or ring sign (red blood rounded by cerebration’s fluid).
Head injuries – diffuse or focal Diffuse: Concussion – a sudden transient mechanical head Injury with disruption of neural activity and a change in the LOC – considered a minor head injury. Apt may or may not lose total consciousness. S/s – brief disruption in LOC, amnesia regarding the event (retrograde), and headache. Postcolonial syndrome ” two weeks to two months after injury. Persistent headache, lethargy, personality and behavioral changes, shortened attention span, decreased short-term memory, and changes in Intellectual ability. Focal: Contusion – bruising of the brain tissue within a focal area.
Usually associated with a closed head Injury. May contain areas of hemorrhage, infarction, necrosis and edema at fracture site. Coup-contractor Injury ” damage occurs when the brain moves inside the skull due to high-energy or high-impact injury mechanisms. Contusions or lacerations occur both at the site of direct impact of the brain on the skull (coup) and at a secondary area of damage on the opposite side away from the injury (contractor). Lacerations- actual tearing of the brain tissue and often occur in association with depressed and open fractures and penetrating injuries.
Tissue damage Is severe and surgical repair Is impossible due to nature of brain tissue. Complications of head injuries- Epidural hematite- Bleeding between the durra and inner skull. Classic symptoms: evacuation vs… Herniated. Suburban hematite- Bleeding between the durra and the arachnoids layer Acute immediate deterioration- 24-48 hours, decreased LOC and headache, drowsy to unconscious Subspace- mental status changes- 2-14 days, may enlarge over time as the hematite breaks down. Chronic- progressive LOC changes. Over weeks to months after a minor head injury.
Elders have larger suburban space as the brain atrophies. Treatment surgical evacuation. First hour or “golden hour” Initial assessment: should include primary survey – life threatening problems, Abscess. Initial interventions include: Ensure patent airway Stabilize cervical spine Administer 02 via non-reverberate mask Establish IV access with two large-bore catheters to infuse normal saline or lactated ringers Control external bleeding with sterile pressure dressing Assess for rhinoceros, Thoreau, scalp wounds Remove patients clothing
Secondary survey – focused head to toe assessment of non-life threatening problems, diagnostic testing, medication Ongoing monitoring: Maintain patient warmth using blankets, warm IV fluids, overhead warming lights, warm humidified 02 Monitor VS.., LOC, 02 saturation, cardiac rhythm, Glasgow coma scale score, pupil size and reactivity Anticipate need for intubations if gag reflex is impaired or absent Assume neck injury with head injury Administer fluids cautiously to prevent fluid overload and increasing ICP Priority collaborative care for head injuries -surgical interventions include: Carination – accessory for depressed fractures and fractures with loose fragments to elevate the depressed bone and remove the free fragments. Also performed to visualize bleeding in hemostat and allow control of the bleeding vessels.
Coordinator – if large amounts of bone are destroyed the bone may need to be removed Craniologist – needed at a later time to surgically repair the defect left over from removing the bone. Burr hole openings – may be used in an extreme emergency for a more rapid decompression, followed by a carination. A drain is generally placed postoperatively for several days to prevent recalculation of blood. Nursing diagnoses for Head injury: Risk for ineffective cerebral tissue perfusion r/t interruption of CB associated with hemorrhage, hematite, and edema Hyperthermia Acute headache pain Impaired physical mobility Anxiety Compound family coping (caregiver) Apt and family teaching guide – head injury Notify HCI if…
Increased drowsiness (difficulty arousing, confusion) Seizures Vision difficulties (blurring) Behavioral changes (irritability, anger) Motor problems (clumsiness, difficulty walking, slurred speech, weakness in arms or legs) Sensory disturbances (numbness) Slow HRS Have someone stay with you Abstain from OTOH Check with HCI before taking drugs that may increase drowsiness (muscle relaxants, voids, tranquilizer) Avoid driving, using heavy machinery, playing contact sports and taking hot baths/showers Brain Tumors Lesion that arises from anywhere within the brain structures, e. G. Coverings, cells. Primary or secondary (from areas of metastasis). When tumors grow they… Expand, infiltrate, compress and displace normal tissue within a closed space. Causes: cerebral edema, ICP, focal neurological deficits, SF obstructions, hydrocephalus, seizures and pituitary dysfunction.
Signs and symptoms of primary brain tumors – Headache – dull and constant, worsens at night, awakens from sleep New onset seizures Cognitive loss: Short term memory, mood or personality changes Muscle weakness, sensory loss, aphasia, visual-spatial dysfunction Focal – symptoms which occur depending on the size and location of the tumor Diagnostic tests- Neurological exam MR.. And PET scans CT scan Computerized stereotypic biopsy (surgery) Collaborative care- tumors Surgical complete or partial (debunking) removal Carination Stereotypic biopsy Stereotypic radiographers Ventricular shunts – Placed into the non-dominant lateral ventricle and empty into the Jugular vein or peritoneum. Can malfunction – monitor for ICP Radiation – Follow-up to surgery, may cause cerebral edema Chemotherapy- Route: wafer, intertribal circumstance (V), demolished (Teammate) (POP) Targeted therapy: evacuation (Aviation) Nursing diagnoses – Risk for ineffective cerebral tissue perfusion (local tumor area) Acute pain Self-care deficits (frontal) Impaired memory Personality change Risk for self-harm (frontal)
Imbalanced nutrition less than body requirements (cancer treatment) Risk for complications: seizures, ICP Nursing Interventions associated with brain tumors – Due to loss of emotional control/confusion/disorientation/memory loss/depression – Assisting the family in understanding what is happening to the apt and supporting the family through diagnostic phase Due to confusion and behavioral instability/risk for self harm/rage/aggression- Close supervision of activity, use of side rails, Judicious use of restraints, appropriate sedative medications, padding of the rails and area round the bed and a calm reassuring approach to care Due to perceptual problems- Minimize environmental stimuli, creation of a routine, and use of reality orientation Due to Alterations in mobility – must be managed and apt should be encouraged to provide as much self-care as physically possible Due to language deficits -Attempts to establish a communication system that can be used by both the patient and the staff Nutritional intake may be decreased because of the patient’s inability to eat, loss of appetite, or loss of desire to eat.
Assess nutritional status, ensure adequate nutritional intake. Encouragement of eating, may have to be fed orally or by gastronomy or instigators tube or by parental nutrition Interventions for a cranial surgery patient – Preoperative CICS, frequent VS.., monitor fluid balance Postoperative: standard postoperative care. Frequent neurological and VS.. Assessments HOB at 30 degrees Do not position on operative site if the bone is removed Monitor for pain and nausea, medicate Maintain dressing Observe dressing for bleeding or clear drainage Encourage deep breathing and ambulation – but NOT coughing Monitor for manifestations of ICP (cerebral edema)