Ms. Bee is a 17-year-old female who experiences seizures and loss of consciousness after suffering head trauma in a sports injury. In the field, emergency medical technicians determine her initial GCS score is 3 (eye opening 1, verbal response 1, motor response 1), which warrants intubation. They transport her to the ED, where an initial head CT shows areas of hemorrhage. Subsequent magnetic resonance imaging confirms diffuse axonal injury.
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Day 1: A parenchymal catheter is placed for ICP monitoring. Ms. Bee’s ICP is 10 mm Hg.
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Day 4: Ms. Bee’s ICP increases intermittently up to 30 mm Hg. The physician orders sedation and intermittent boluses of hypertonic saline solution.
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Day 5: Ms. Bee’s temperature rises to 104° F (40° C). A cooling catheter is placed to keep her temperature at 98.6° F (37° C). When her ICP monitor wire fails, the parenchymal catheter is removed and an EVD is placed for continued ICP monitoring and CSF drainage.
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Day 14: Ms. Bee opens her eyes spontaneously and looks around.
Day 16: Ms. Bee is extubated; she responds purposefully to noxious stimulation.
Day 18: Ms. Bee’s GCS score is 10 (eye opening 4, verbal response 1, motor response 5). Her Rancho Los Amigos Scale score is 2 with emerging 3, as she begins to wake up and respond to her environment. Her ICP drops below 10 mm Hg and her EVD is discontinued.
Day 25: Ms. Bee is able to follow commands, converse, and eat. Her Rancho Los Amigos Scale score is 4.
Day 28: Ms. Bee is discharged to a rehabilitation facility for patients with brain injury.
1. Diffuse axonal injury:
Due to any trauma or injury the damage occurs in the brain especially in the axonal parts of the neuron.The damage is not well defined it is diffuse in form.The injury in axon in diffuse form is known as diffuse axonal injury.It can cause lesion or ischemia in the axons.It is identified by the CT and MRI scan.It cause changes in the GCS score.
2.Early signs of increased ICP:
Early signs are changes in the consciousness level,slow down of speech or slurred speech and unresponsiveness.These are the early signs.This cause alterations in the GCS .The score of GCS is reduced.hence the nurse should assess the Glasgow coma scale.In this scale the assessment includes three , they are eye response,Verbal response and motor response.The minimum score is 3 and the maximum score is 15.By this can find consciousness of the client and the degree of affect due to increased ICP.
3.Cerebral perfusion pressure(CPP):
It is the pressure which defines the blood pressure of the cerebral arteries which provides blood flow into the cerebrum.Within the normal limit of CPP the cerebrum gets enough blood flow.The pressure ranges between 50-70 mm Hg.
CPP= MAP-ICP. So the autoregulation is depends on MAP.When the cerebral blood flow decreases, it makes the arterial resistance decreases so the vascular smooth muscle relaxes and dilate (Vasodilatation), the blood flow is increased.It cause changes in the MAP, it gets reduced.These changes mainly occur in the macrovessels passing blood flow to the brain.This is the autoregulation mechanism of the body.
4.Sedation effect on ICP:
Sedation is usually given to provide relaxation and to calm the client.In relaxing state, the blood pressure is reduced.By the reduced blood pressure the volume inside the brain is reduced it can reduce the ICP level.Sedation lowers the ICP level.
5.Hypertonic saline effect on ICP:
Hypertonic saline contains high concentration of sodium which cause changes in the brain cell.The ICP is increased in Cerebral edema also.Here this saline will cause the fluid shift from intracellular to intercellular.It makes the fluid out of the cells into tissue and if drainage present the fluid gets drained out thus the ICP gets reduced.
6.Cooling catheter:
Placing a cooling catheter is the therapeutic hypothermia.This hypothermia will reduce the brain metabolic and vascular functions this will reduce the ICP.The hypothermic state should be maintained only for some period of time.periodically the warming should be done to avoid brain death.
7.EVD- External ventricular drain.Monroe-kelly doctrines defines that the ICP is maintained only if the three contents of the brain in the normal limit.The three contents are brain tissue,Blood flow within the brain and CSF.The presence of EVD helps to drain the excess fluid within the brain compartment.BY the reduction in the content of the brain the ICP gets reduced.The doctrine clears that increase in Blood flow or CSF cause increased ICP and it is drained EVD hence the ICP level gets reduced.
8.Nursing priorities :
Maintaining normal cerebral blood flow
Maintaining normal ICP level
Reducing the risk of further complications.
Nursing interventions:
1.Elevate the head of the bed .(Aid in EVD)
2.Supplementary oxygen or mechanical ventilation should be provided.(Corrects hypoxia)
3.Monitoring and maintaining normal vital signs.(Temperature and blood pressure cause changs in ICP so by regular monitoring helps to detect changes in ICP)
4.Providing stool softners.(Reduce valsalva pressure which increase the ICP if it is high).
5.Administer medications as per physician order.(To treat and recover from the injury)
Ms. Bee is a 17-year-old female who experiences seizures and loss of consciousness after suffering head...