Question

please use complete sentences

M.B is a 23-year-old exchange student from Korea studying electrical engineering at a university. He was driving home after working a night shift when his car crossed the median and struck another car. M.B. was not wearing a seatbelt and was thrown from the car. His injuries included a severe closed head injury with an occipital hematoma and a right hemothorax. He was transported to the local ER.

Upon admission to the ER, M.B was awake but with slurred speech. Vital signs are HR 110, RR 30, B/P 100/50, Pulse Ox 86% on 2L per nasal cannula and GCS 11.

Is M.B. in mild, moderate, or severe brain injury?

Describe the differences between the three.

Identify specific problems you are looking for and immediate actions to take.

After 2 hours, M.B is now unresponsive; Vital Signs are HR 50, RR 12, B/P 140/50, and GCS 5. He is intubated and a ventriculostomy placed. His ICP is 13.

What is a normal ICP and why is an elevated ICP clinically important?

What is M.B.’s cerebral perfusion pressure (CPP)? Why is a low CPP concerning?

What are at least five signs and symptoms of increased ICP?

List five nursing measures that the ICU nurse could use to decrease or control increased ICP?

Answer 1

Mr. M.B has got a moderate brain injury.

The brain consists of the cerebrum, the brainstem and the cerebellum. It controls most of the activities of the body, processing, integrating, and coordinating the information it receives from the sense organs, and making decisions as to the instructions sent to the rest of the body. The human brain regulates various vital functions like breathing, eating, digesting food, and circulating blood. When a person suffers a traumatic brain injury caused by sudden damage to the brain can lead to permanent disability or can have life long health affects ranging from memory issues to paralysis.There are three levels of brain injuries - Mild, Moderate and Severe.

Mild Brain Injury:

• In mild brain injury, the person do not realize that he has sustained a mild traumatic brain injury until much later after the accident.
• These brain injuries result in temporary mental changes, such as confusion and memory loss or unconsciousness for less than 30 minutes.
• Mild brain injuries can also result in symptoms such as headaches, nausea, fatigue, dizziness, memory loss, irritability, and feelings of depression. These symptoms can last one year or longer.

Moderate Brain Injury:

• Moderate brain injury is an injury resulting in unconsciousness for 20 minutes to six hours.
• The Glasgow Coma Scale gives scores between 3 and 15, where 3 is the worst prognosis and 15 is the best prognosis. Scores of 3 to 5 are potentially fatal. A moderate brain injury generally falls between a score of 9 to 12.
• Symptoms of moderate brain injuries include cognitive damages, such as difficulty concentrating, memory loss, confusion, and difficulty processing language. Patients with moderate brain injury may also have problems speaking, reading, and writing, as well as experience loss of vision, hearing, smell, and taste. They may also experience seizures, sleep disorders, and chronic pain. Moderate brain injury can lead to permanent mental and physical disabilities.

Severe Brain Injury

• There are different levels of severe brain injuries depending on the severity of the trauma. Severe brain injury have a range of cognitive, speech, sensory, physical, social, and emotional effects.
• A severe brain injury can lead to a minimally responsive state, vegetative state, coma, or death. If a victim of a severe brain injury is conscious after the accident, symptoms can include amnesia, slurred speech, paralysis, severe headache, blurred vision, and difficulty thinking.
• Severe brain injury typically lead to permanent disability or death. Upon first sustaining a severe brain injury, a patient may be unconscious but respond to outside influences, such as the pressure of a sharp object. However, this type of condition often worsens, and he or she slips into a coma or vegetative state.

Head injury cases is the leading cause of death in the first four decades of life. A head injury also called Traumatic Brain Injury (TBI) is classified by brain injury type; fracture, hemorrhage (epidural, subdural, intracerebral or subarachnoid) and trauma. Acute head injury result from a trauma to the head leading to brain injury or bleeding within the brain, It's can make edema and hypoxia.

The management or nursing care plan (NCP) for patient with an acute head injury are divided on the several levels including prevention, pre-hospital care, immediate hospital care, acute hospital care, and rehabilitation.

In order to give accurate nursing care plan to the patients, The nurses should understand the principles behind medical treatments. It focuses on the evidence based practice that nurses use in assessing, intervening and managing a severe head injury.

A. Assessment Findings on Acute Head Injury

Possible causes of acute head injury are assault, automobile accident, blunt trauma, fall and penetrating trauma. The medical team should be perform serious and critical care to handle this cases, So that they can finding correct assessment may happened to the patients such as:

• Disorientation to time, place or person
• Unequal pupil size, loss of pupillary reaction
• Decreased LOC
• Paresthesia
• Otorrhea, rhinorea, frequent swallowing.

To quickly asses a patient's level of consciousness and to uncover baseline change, use the Glasgow Coma Scale. If the patient has already applied with an endotracheal tube and can't response verbally, use the abbreviation "T" score.

B. Diagnostic Evaluation for Acute Head Injury
The doctors are who responsible to the patient in the emergency department, they will order some examination trough CT scan or MRI (possible for hemorrhage, cerebral edema, or shift of mid line structure), EEG (may reveal seizure activity), ICP monitoring (possible increased of ICP) and skull X-ray (may be fracture).

C. Nursing Diagnose in Acute Head Injury

• Ineffective tissue perfusion (cerebral)
• Risk for Injury
• Decreased intracranial adaptive capacity.

D. Treatment of Acute Head Injury

• Cervical collar (until neck injury is ruled out)
• Craniotomy; surgical incision into te cranium (may be necessary to evacuate a hematoma or evacuate contents to make room for swelling to prevent herniation)
• Oxygen (O2) Therapy; incubation and mechanical ventilation (to provide controlled hyperventilation to decrease elevate ICP)
• Restricted oral intake for 24 to 48 hours
• Ventriculostomy; insertion of a drain into the ventricles (to drain CSF in the presence of hydrocephalus, which may occur as a result of head injury; can also be used to monitor ICP).

E. Drug Therapy Options for Head Injury Cases

• Analgesic; codein phosphate
• Anesthetic; Lidocin (Xylocaine)
• Anticonvulsant; Phenytoin (Dilantin)
• Barbiturate; pentobarbital (Nembutal), if unable to control ICP with diuresis
• Diuretic; mannitol (Osmitrol), furosemide (Lasic) to combat cerebral edema
• Dopamine (Intropin) to maintain cerebral perfusion pressure above 50 mmHg (if blood pressure is low and ICP is elevated)
• Glucocorticoid; dexamethasone (Decadron) to reduce cerebral edema
• Histamin-2 (H2) receptor antagonist such as cimetidine (tagamet), ranitidine (Zantag), famotidine (Pepcid), nizatidine (Axid)
• Mucosal barriel fortifier; sucralfate (Carafate)
• Posterior pituitary : vasopressin (Pitressin) if client develops diabetes insipidus.

F. Planing and Goal on Nursing Care Plan

• The patient will have improved cerebral perfusion
• The patient will have decreased ICP
• The patient will have remain free from injury.

G. Implementation of Nursing Care Plan Procedure

1. Asses neurologic and respiratory status to monitor for sign of increased ICP and respiratory distress
2. Monitor and record vital sign and intake and output, hemodynamic variables, ICP, cerebral perfusion pressure, specific gravity, laboratory studies, and pulse oximetry to detect early sign of compromise.
3. Observe for sign of increasing ICP to avoid treatment delay and prevent neurologic compromise
4. Assess for CSF leak as evidenced by otorhea or rinorrhea. CSF leak could leave the patient at risk for infection
5. Assess for pain. Pain may cause anxiety and increase ICP
6. Check cough and gag reflex to prevent aspiration
7. Check for sign of diabetes insipidus (low urine specific gravity, high urine output) to maintain hydration
8. Administer I.V fluids to maintain hydration
9. Administer Oxygen to maintain position and patency of endotracheal tube if present, to maintain airway and hyperventilate the patient and to lower ICP
10. Provide suctioning; if patient is able, assist with turning, coughing, and deep breating to prevent pooling of secretions
11. Maintain position, patency and low suction of NGT to prevent vomiting
12. Maintain seizure precautions to maintain patient safety
13. Administer medication as prescription to decrease ICP and pain
14. Allow a rest period between nursing activities to avoid increase in ICP
15. Encourage the patient to express feeling about changes in body image ot allay anxiety
16. Provide appropriate sensory input and stimuli with frequent reorientation to foster awareness of the environment
17. Provide means of communication, such as a communication board to prevent anxiety
18. Provide eye, skin, and mouth care to prevent tissue damage
19. Turn the patient every 2 hours or maintain in a rotating bed if condition allows to prevent skin breakdown.

H. Evaluation of Goals in the Nursing Care Plan

• The patient has improved LOC
• The patient doest not exhibit signs of increased ICP
• The patient has remains free from injury

Intracranial pressure (ICP) is the pressure inside the skull and thus in the brain tissue and cerebrospinal fluid (CSF). ICP is measured in millimeters of mercury (mmHg) and, at rest, is normally 7–15 mmHg for a supine adult. The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF. Changes in ICP are attributed to volume changes in one or more of the constituents contained in the cranium. CSF pressure has been shown to be influenced by abrupt changes in intrathoracic pressure during coughing (intra-abdominal pressure), valsalva maneuver, and communication with the vasculature (venous and arterial systems).