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Structurally Induced
Structurally Induced Comas
| Question | Answer |
|---|---|
| Structurally Induced Comas | Primary role for nurse is to watch pt’s status, to see if pt is improving or getting worse; look at trends so we can take action if there are any changes in the pt |
| Head has 3 parts | Brain (tissue) fluid (blood and CSF) and skill enclosing these partso Effects if physical stress on one of these parts can induce coma state |
| Monroe Kelly Hypothesis | When there is physical stress to one of these parts (an increase in volume), some other part has to give and it is generally not the skull |
| Vascular System of the Brain | There are a lot of veins and arteries that do surround the brain tissue |
| Circle of Willis | Blood vessels and arteries enter into an area which forms a circle and blood flow is evenly distributed around the brain |
| Head Injury | Trauma can be major to serious (appearance of the pt does not mean more serious trauma) Two types of Head Injury Open-fractured: skull or pierced brain. Closed-fracture: integrity of skull is not violated. |
| Open-fractured | Skull or pierced brain |
| Closed-fracture | Integrity of skull is not violated. |
| In order to know what’s going on, we must look at the mechanism of injury | How the injury occurred, Speed at which the accident occurred, Type of object that hit the head, All determine how serious the injury might be... Also look at: LOC, VS, Pupils, All give an indicator of whats going on with the pt |
| The head is | very rich in blood, very vascular; there may be a lot of blood with a not so serious injury |
| Can have a very bloody accident | and have no skull fx or brain injury*Skull fx in the 2nd most common cause of major neuro deficits |
| Head injury is | the common cause of death in pts 1-35 years of age: generally MVA, falls, violence, and sports related injury |
| Open head injury-Fracture types | Any time there is a violation of the skull it is an open head injury |
| Linear | Occurs 80% of the time, Simple, clean break, No treatment, Monitor pt, Potential that artery can rupture, the it is more serious |
| Open fracture | Fracture of the skull along with scalp laceration, There is a risk for infectiono Probably will be a lot of bloodo Opening from the outside of the head to the inside of the brain |
| Comminuted/Depressed | Bone fragment may press into the tissue, Sometime have to go in and pull back some of the brain tissue away from the skull during a craniotomy, There is a potential for CSF leakage if the meninges are torn |
| Basilar skull fracture | Generally a linear skull fx, Occur across temporal lobe bone, Different, unique, Can damage cranial nerves (acoustic) because of position and ca tear tympanic membranes when they fx, Often not identified on s-ray of CT because of the position of the pt du |
| Basilar skull fracture | CSF leakage means torn meninges & risk 4 inf |
| Rhinorrhea | Blood from nose |
| Otorrhea | Blood from ears |
| Halo sign | Drainage will be + for glucose if it is CSF |
| Raccoons eyes | periorbital ecchymosis (24hrs after) |
| Battle signs | ecchymosis at the mastoid process (24hrs after) |
| Closed head injury | Concussion, Contusion, Laceration, Bleeding |
| Concussion | mild, brief loss of consciousness, minor injury pt is sent home, pt must be monitored at home: wake q2-3h for 2 days, check speech and LOC, no strenuous activity for 24hrs, call if change in mental status, vomiting occurs, expect dizziness |
| Contusion | bruising of brain tissue, usually found at site of impact, means the brain has moved within the skull, common in depressed skull fxo can cause hemorrhage and edema at site, pt may not loose consciousnesso tests depend on cause of contusion |
| Laceration | tearing of cortical surface vessels, may occur in depressed skull fx or penetrating injury, symptoms depend on location of laceration (of brain tissue itself not the scalp), Priorities: Pt is admitted (usually ICU) Monitor ICP Clot size Contro |
| Bleeding | Caused by vascular damage from force of trauma, Brain is very vascular, Laceration and contusion can cause bleeding |
| Hematoma | Caused by localized mass of blood in the brain, Caused increased ICP (body will autoregualte), Very serious when on the brain, Considered mass lesions |
| Epidural | Arterial bleeding into space between dura and skull often caused by a fracture. FastCharacterized by loss of consciousness immediately, period of lucidity (pt will become alert and talkative) and then rapid deterioration and loss of consciousnessHave |
| Subdural | Venous bleeding into space between dura and arachnoid, Slower, generally no loss of consciousness, changes are less acute: Three types 1.Acute: 48hrs 2.Subacute: 3days-2wks 3. Chronic: several mos, Sometimes surgical evacuation is done depending on p |
| Intracerebral Hemorrhage | Accumulation of blood within the brain, ccurs with fragile blood vessels within the brain |
| Subarachnoid bleed | Results from rupture of a cerebral vessel, Most are caused by a rupture of therosclerotic and hypertensive vessels. Blood forced at very high speeds into the space where CSF is, Person is usually asymptomatic until rupture.20-40% die upon rupture, common |
| Tumor | Mass lesion, Tumor may be a primary source or secondary source as a result of etastasis.Invade, infiltrate, compress, Tx: surgery, chemo, and radiation to minimize size |
| Primary Brain Injury | Occurs at the time of injury, Initial infarction, initial disruption of blood supply, initial hematoma.Initial something that does not occur in the brain (mass lesion, xtra fluid, tumor, hematoma); if not treated will develop secondary brain injury |
| Secondary Brain Injury | Progression of initial injury which lead to cellular and toxic changes and causes cerebral edema and increases ICP, Regulate symptoms of primary to prevent secondaryGoal: prevent secondary |
| Primary cause of increased ICP, leading to coma | Space occupying lesion, blood or CSF |
| Other physiologic causes of increased intercranial pressure | Hypercapnia- increased CO2 causes dilation of cerebral blood vessels Hypoxemia – tissue hypoxia causes a decreased pH, increased CO2 Cerebral vasodilation – increased cerebral blood flow All can cause secondary injury |
| Other causes of increased ICP: Body positions | o HOB 30* to encourage venous outflow from the brainHead in line with body greatest venous outflow from jugular vein |
| Other causes of increased ICP: Isometric Muscle | Contractions can increase ICP, Nurse slides pt up in bed don’t let them do it themselveso Nurse turns pt |
| Other causes of increased ICP: Coughing/Sneezing | Causes vagal reaction which increases ICP, Allow pt to cough but if coughing a lot may offer cough med or monitor ICP closely |
| Other causes of increased ICP: Emotional upset/pain | Increases ICP, Use antianxiety drugs, pain relievers, Keep upsetting situations minimal |
| A normal brain | Will compensate for ICP but an injured brain will have trouble |
| Secondary head injury | Cerebral edema, increased fluid content can causes: brain swelling (which is actually tissue enlargement) which causes ICP which causes hypoxia to tissues, Cerebral edema, brain swelling & increased ICP are often used interchangeably.Edema-increases flu |
| Cerebral Edema: Vasogenic | Change or increase in capillary permeability, Blood vessels are more permeable, BBB is disrupted (any med given will go to brain) |
| Cerebral Edema: Cytotoxic | Increased ICF, Swelling of cells can actually occur, With that O2 can be depleted within cells (depressed respirations)and metabolic waste can accumulate, Almost always cytotoxic caused vasogenic |
| Hydrocephalus | CSF is within an enclosed system, Volume increase in CSF caused by increased, duction, obstructed circulation or decreased absorption. Can be removed surgically Another cause of increased ICP |
| Hydrocephalus: Obstruction | Obstruction in circulatory pathway so its not moving around too much and it accumulates Often caused by mass lesion or infection |
| Hydrocephalus: Absorption | CSF is not being absorbed as rapidly as it is being produced, May occur when there is blood within the CSF, See with subarachnoid hemorrhage, May also occur with infection |
| Results of Increased ICP | Skull cannot expand so one of 3 components must decrease, Shift CSF, Decrease cerebral blood flow, Displace brain tissue – Causes Herniation *When there is increased ICP you notice decreased LOC |
| Brain Herniation | Displacement of brain tissue across the tentorium or through the foramen magnum into the spinal canal. Often results in death. Through the spinal column almost always caused death |
| Clinical manifestations of increased ICP | Decrease in Glasgow Coma Scale score (look at changes in #’s) ALOA, restlessness, LOC Speech Pupils Motor/Sensory Cardiac rate/rhythm Respiratory patterns |
| Cushing’s Response may develop with increased ICP | Late response This is an attempt to restore adequate blood flow through cerebral blood vessels Decreased pulse rate Elevated SBP/DBP remains the same Increased pulse pressure Call MD immediately!!!! |
| Emergency Care for those at high risk of developing increased ICP | Maintain airway Improve breathing Promote circulation |
| Intubation | At risk for increased ICP will be intubated By intubating you can increase O2 which will decrease odd resp patterns Hyperventilate (only for a couple of days) by ventilator to get PaCO2 between 27-35mmHg (decreases blood CO2 and helps improve cere |
| Mannitol | o Osmotic diuretico Given thru filter because crystals form in solutiono Decreased ECF volumeo Foley needed for hourly outputs |
| Loop Diuretics | o Lasixo Decreased ECF volumeo Reduce cerebral edema |
| Glucocorticoids | o Decadron (dexymethane)o Commonly used for head injured pto Decreases permeability of cell membraneo Helps to prevent edemao Decreases ICPo Increased risk for infectiono Increases glucoseo Irritating to the stomach so there is and increased |
| Antibiotics | o For skull fx and open head injury pts |
| Antiseizure meds | o Dilantin, Cerovexo To prevent seizures (seizures increase ICP) |
| Nimodipine | o Calcium Channel Blocker used in head ptso Used to tx vasospasmo Used in hemorrhagic stroke to prevent irritation |
| Barbiturates | o Pentobarbital IVo Some times used to tx uncontrolled ICPo Used when all other meds failo Idea is it decreases metabolic rate, decreases cerebral blood flow which reduces cerebral edemao Pt is in “Barbiturate Coma” Cannot do neuro evaluation |
| Ventriculostomy | o A ventricular catheter in placed into the ventricle as a draino A bag will hang from the pts heado Rate of flow 18mls/hro Considered a closed systemo A shunt is placed if the ventriculosomy is still needed Placed in the ventricle There is |
| Craniotomy | o Surgical removal of whatever is causing the problem Can evacuate a hematoma Clip an artery Place an ventriclostomy Place a shunt Decompress a bone fragment Remove tumorso Pre-op care Baseline VS & neuro assessment Discuss fears |
| Supratentorial Craniotomy | o Above the tentoriumo Post-op care In ICU Frequent neuro assessments: assess for changes in LOC, pupil reaction, slurred speech HOB 30 degrees OOB first day |
| Infratentorial Craniotomy | o Lower, the back of the heado Post-op care HOB flat |
| Post-op for Craniotomy | o Body alignmento Prevention of isometric muscle contractiono Manage paino Space activitieso Suction prno Eliminate distress in the room o ICP monitoring |
| ICP Monitoring | Inserted through Burr hole is skull Allows continuous monitoring of ICP Various types: Screw, bolt High risk of infection |
| CPP=MAP-ICP | Norm=70-100mmHg |
| Advantages of ICP monitoring | o Pressure can be recognized and treated before clinical manifestations appear normal ICP: 5-15o Coughing increases ICP to 20-30o Allows drainage of CSF via 3-way stopcocko CPP can be calculated and treatment can be adjustedo Effect of nursing in |
| Nursing care of patient with increased ICP (or risk for inf.) & Craniotomy | P: Risk ineffective family coping E: Risk alter urinary/bowel patterns (Risk for DI/SIADH) R: Risk ineffective airway clearance S: Risk injury or pain r/t surgical procedures O: Risk altered tissue perfusion r/t/ decreased CO, N: Risk inadequate nu |
| Nursing management ALOA | P: Disturbed thought processes E: Bowel incontinence/urinary R: Risk for injury r/t ineffective thermoregulation, corneal reflexS: Ineffective tissue perfusion O: Risk for aspiration, impaired gas exchange.N: Fluid and electrolyte imbalance |
| Nursing care of Pt. with Structurally Induced Coma | Temperature control (thermoregulation may be disturbed Promote venous return-HOB 30-45, avoid flexion/extension of neck, neutral posture Position patient-log roll (prevents isometric muscle contractions) Treat pain/agitation-codeine (drug of ch |
| Diabetes insipidus | often seen with closed head injury. Lesion affecting hypothalamus/post pituitary. Deficiency of ADH causes polyuria/polydipsia. |
| Syndrome of inappropriate antidiuretic hormone- (SIADH) | causes oliguria, high ADH |
| Collaborative Care F/E imbalance | o Monitor I/O (foley)o Urine Specific Gravity ( 1.010-1.025 ), maintain WNLo Serum Osmolality ( 280-300mOsm )o Tx with Vasopressin for DI |
| Goals of care | o Return client to highest level of functioningo Family/client Education These clients respond best to a home environment which is structured and consistent. Changes in personality and behavior are not unusual |
| Nursing care of the patient and family with a head injury | o Health promotiono Long term physical care/rehabo Possibility of residual self care deficitso Other deficits: communication, emotional responses, cognition, and movemento Safety needs, equipment, vocational counseling. |
Created by:
littlemina
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