Nursing Care & Priorities for Those with Traumatic

Nursing Care & Priorities for Those with Traumatic

Nursing Care & Priorities for Those with Traumatic Brain Injury & Brain Tumors Keith Rischer, RN, MA, CEN 1 Todays Objectives Differentiate the causes of traumatic brain injury. Review pathophysiology and clinical manifestations of TBI & brain tumors. Identify nursing priorities and client education with TBI & brain tumors. Identify manifestations of ICP and purpose of ICP monitoring. Prioritize nursing care with craniotomy-postop. 2

Traumatic Brain Injury Patho Open head injury Halo sign C-spine precautions Closed head injury Concussion Mild-mod-severe Glasgow coma scale 3 Traumatic Brain Injury Types of force

Hemorrhage Acceleration Deceleration Coup-contrecoup Intracerebral Epidural Subdural Diagnosis CT MRI 4 Increased Intracranial Pressure

Normal pressure Patho Clinical Manifestations (chart 48-5 p.1037) Decreased LOC Restlessness/irritability Headache N&V Slurred speech Pupillary changes Seizures Brain herniation

Pupil changes LOC Cheyne-stokes resp VS changesCushings triad 5 Nursing Interventions: I-ICP Maintain airway and optimal ventilation HOB elevated 15 30 degrees All ADLs increase ICP spacing Limit suctioning Calm environment Prevent hyperthermia 6 Nursing Priorities with TBI Establish baseline Early detection of subtle changes Airway/breathing

Vital signs ABGs Maintain adequate cerebral perfusion pressure (CPP) Cushings triad Positioning Neuro Assessment Glascow Coma Scale LOC Eye/pupils Motor Decerebrate/decorticate posturing Response to pain 7

Medical-Nursing Priorities w/Critical TBI Drug therapy Steroids Mannitol Filter needle/tubing Furosemide Nursing priorities Neuromuscular blocking agents Nursing considerations Anti-convulsant agents

Respiratory management Managing CO2 w/vent 8 Medical-Nursing Priorities w/Critical TBI Fluid & lyte management Nutritional management Diabetes Insipidus SIADH Enteral tube feedings if LT Surgical management

Craniotomy ICP monitoring Intraventricular catheter 9 Brain Tumors Patho Complications Cerebral edema-inflammation I-ICP Focal neuro deficits Obstruction of CSF Pituatary dysfunction SIADH DI 10

Brain Tumors Types Gliomas astrocytomas Metastatic Clinical Manifestations Headaches N&V Visual changes Seizures Change in mentation/personality

Diagnosis Interventions 11 Craniotomy:Post-op Priorities (p.1059-1062) Nursing priorities Detect early changes in status Prevent/minimize complications Neuro assessment I&O Pain control Cardiac monitoring

ICP VS Position Dressing assessment Monitoring lab values Sodium CBC ABGs 12 Craniotomy Post-op Complications (p.1064-5) ICP

Hematomas Hypovolemic shock Respiratory Hydrocephalus Atelectasis Pnuemonia Wound infection Meningitis Seizures CSF leak Fluid/lyte imbalances DI-SIADH 13

Neuro Case Study 72 yr. male w/PMH AAA Slipped and fell in BR 2 weeks ago w/no LOC Chief c/o While in ED dramatic change in LOC headache that has continued all day and gotten worse Lethargicobtunded Decerebrate posturing Intubated and paralyzed CT rt. Occipital SDH w/midline shift 14

Neuro Case Study To OR for immediate evacuation CT: shows small residual hematomas POD 1 ICP 14-20BP 176/67 Extubated-Is alert, MAE, follows commands lt. facial weakness, lt. hemiplegia, speech garbled Mannitol q3h for ICP >10 CPP??? Labs Na: 131/was 144 preop

u/o 200cc last 8 hours. Was averaging 400cc/hr last 24 hours Creatinine 0.9 15 Neuro Case Study: POD 2 Nursing priorities Developed focal seizures eyes deviate to right and twitch for <1 Cerebryx IV load & Ativan IV prn MRI No change in SDH Labs Na: 138 Creatinine: 1.3 Meds

Ancef IV Labetolol IV prn to keep CPP 50-60 16 Neuro Case Study: POD 7 Transferred to neuro floor Continues to have significant lt. hemiplegia w/garbled speech PEG placed Plan for NHP 17

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