Nursing management ppt for nursing teachers

1. NURSING MANAGEMENT OF
HEAD INJURY PATIENTS
Preparedby: Mrs. NutanMakasare
College of nursing
GMC, Nagpur

3. GENERAL OBJECTIVE:
At the end of the teaching session,
the group will be able to provide
efficient nursing care to patients
with acute head injury.

4. SPECIFIC OBJECTIVES:
 The Group 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 lobe is 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: It is 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: The cerebellum 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
 Head injury 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
 The incidence 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
 TBI is 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 based on 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 based on 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 AND RISK 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 AND PATHOPHYSIOLOGY
 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 traumatic injury
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.

24. Battle’s sign

25. CSF Otorrhea

26. Halo Sign

27.  Brain injury may 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
 Cerebral edema
 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 AND SURGICAL 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:
 The treatment 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.

34. Seizure care

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 GCS score 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 motor function: 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 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.
 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 for complications (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 Nursing Care:
 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 adequate cerebral 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 fluid and 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 adequate nutrition:
 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 for seizure 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 bladder distention.
 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 body temperature:
 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 cognitive functioning:
 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 sleep patterns 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.

50. THANK YOU