TRAUMATIC BRAIN INJURY
INCREASE ICP OR INTRACRANIAL HYPERTENSION INTERVENTIONS:
Is a form of acquired brain injury caused by the head being hit or hitting an object violently, or when an object pierces the skull and damages brain tissue.
Assess GCS: E4V5M6 = <3 deep coma, <9 severe, 9-12 moderate, >13 minor.
Include Vital signs.
“Monitor patient q1h or more frequently, notify MD if any changes as soon as possible”.
INCREASE ICP: May occur within 72 hours after TBI or (trauma, cerebral tumor, cerebral hemorrhage, meningitis, cerebral ischemia, and encephalopathy).
1. Cushing’s triad. 5. Constant headache.
2. Hiccups – early sign 6. Nausea and vomiting (projectile).
3. Disorientation (LOC changes). 7. Blurred vision (PERRLA changes).
4. Irregular respiration. 8. Agitation.
Note: Infants increase ICP – Increasing head circumference, separation of suture line, and high-pitch cry!
PATIENT AND FAMILY TEACHING:
1. Notify MD if: ●Increase drowsiness. ●Change in behavior. ●Nausea, vomiting or both. ●Motor problems (difficulty walking).●Worsening H/A or stiff neck. ●Sensory disturbance (numbness).●Seizures. ●Decreased heart rate. ●Blurred vision.
2. Have someone stay with the patient.
3. Abstain from alcohol.
4. No OTC drugs without MD advise.
5. Avoid driving, using heavy machinery, playing contact sports, and taking warm baths.
1. Position patient in semi-fowler.
2. Monitor patient every one hour (neurological assessments).
3. Make sure patient is well-oxygenated and monitor patient ABG.
●Pulmonary assessment and suction secretion if any. (Hyperoxygenate patient with 100% O2 20-30 sec. before and after each suction. Aspirate for <10 sec. max 2x).
4. Open a venous access. (Normal saline is preferable because dextrose solution could increase cerebral edema).
5. Administer medication that decreases cerebral edema as ordered. (i.e. diuretics – monitor electrolytes).
6. If not contraindicated, change patient position every two hours and make sure patient is in proper body alignment.
7. Instruct patient to avoid Valsalva maneuver and trendelenburg position.
8. Help patient relieve pain, decrease anxiety and agitation. (Administer analgesic, reassure and provide a quiet and calm environment).
9. Monitor vital signs. (Temperature should be monitor every four hours, administer antipyretics if needed).
10. Assess patient glycemic state.
11. Monitor I and O.
12. Prevent and treat convulsions if any. (Prophylaxis anticonvulsant).
13. Prevent constipation.
14. Provide adequate rest.
LOG-ROLLING AND CERVICAL COLAR must be applied when moving a patient with suspected spinal injury (At least 2 people should move the patient). – The spinal cord could compress between the vertebras which can lead to paralysis.
Sudden excessive discharge from cerebral neurons causing episodes of abnormal motor, sensory or autonomic function, changes in consciousness or sensation.
1. Partial: involved one hemisphere of the brain. ●Simple: Consciousness is intact ●Complex: impaired consciousness.
2. Generalized: widespread, all parts.
CAUSES OF ACQUIRED SEIZURE: CVA, hypoxemia, fever (child), head injury, HPN, infection, brain tumor, drug or alcohol withdrawal.
PHASES:1.Aura. 2. Ictus. 3. Post-ictus.
PATIENT AND FAMILY TEACHING: ●Take all medications as prescribed. ●Reports any medication side-effects. ●Blood test are done as necessary. ●Use nonpharmacologic techniques to prevent attack (diet, biofeedback). ●Encourage the availability of resources. ●Wear medical alert bracelet. ●No alcohol, fatigue or lack of sleep. ●Have a regular meals. ●Teach the care before, during, and after seizure.
Put anything in patient mouth during seizure.
Restrain the patient during seizure activity.
NURSING INTERVENTIONS: Keep room calm and quiet.
DURING: Safety is the top priority. Remain calm. (Call for help).
Provide privacy and protect from onlookers.
Ease the patient to the floor if possible (protect the patient head).
Loosen constrictive clothing or belt.
Push aside any furniture or anything that may injure the patient. (O2 tanks, wheelchair etc.).
If in bed (hosp), raise side-rails, lower the bed, put pads, pillows or cushions on side rails. (Pillows should be removed in the bed-put it on the side rails). Make sure suction and oxygen equipment is available.
Observe and let the seizure subside on its own. If status epilepticus occur, notify MD immediately.
Position the patient on the side.
Reorient the patient and provide reassurance. Be sensitive and supportive to patient and family.
Document the event leading to seizure, length and type of seizure activity, including body parts involved.
Investigate factors that trigger the seizure. i.e. Missed doses of antiepileptic drug, illness, menstruation, or stress
STROKE OR CVA
When a blood vessel is blocked, causing ischemia to a part of the brain or hemorrhage that results to brain cells death. Functions such as movement, sensation, or emotions are loss depending on the part affected.
Modifiable risk factors: ●Smoking. ●Hypertension. ●Diabetes mellitus. ●Alcohol abuse. ●Sedentary lifestyle. ●Obesity. ●Diet etc…
Non-modifiable risk factors: Age. Sex. Race. Family history.
1. Ischemic: Vascular occlusion (thrombus or embolus) and severe hypoperfusion of the brain. (Tx: Thrombolytics).
TIA: Lasting <24h and often resolve within 3hours. Aspirin, Plavix, and anticoagulants.
Sign and symptoms:
●Confusion. ●Transient hemiparesis. ●Vertigo. ●Temporary vision loss to one eye. ●Tinnitus.
2. Hemorrhagic: Bleeding into the brain (tissue or meninges) due to rupture of blood vessel (Tx: Corticosteroids).
5 WARNING SIGNS OF STROKE:
Weakness: Sudden loss of strength or sudden numbness in the face, arm or leg, even if temporary.
Trouble speaking: Sudden difficulty speaking or understanding or sudden confusion.
Vision problems: Hemianopsia.
Headache: Sudden and unusual.
Dizziness: Sudden loss of balance.
OTHER SIGNS: ●Urine incontinence. ●Numbness or tingling. ●Nausea and vomiting. ●Altered taste and sensation. ●Loss of balance and coordination, and tinnitus etc…
F-ace: Can the patient smile? Does one side of the face drops?
A-rms: Ask the patient to raise both arms. Does one arm drift downward? Assess muscle strength.
S-peech: Ask the patient to repeat a simple sentence. “Cincinnati test” are the words slurred? Can the patient repeat the sentence correctly?
T-ime: If any of these symptoms, notify MD or call 911. Brain cells are dying. ●Do a neurological assessment + vital signs.
MEAL PREPARATION: “Position 90˚, 60˚ for tilting patient.”
Give corrective lenses and dentures (after positioning).
Clean mouth and hands (stimulate saliva production promote mastication, increase sense of taste and reduce aspirating pathogenic bacteria – aspiration pneumonia).
Assess swallowing reflex and gag reflex.
Let patient exercise tongue/let ice chips melt in his/her mouth (not during meal time).
Make sure suction device is working – repeated coughing is a sign of swallowing problem.
Place food at the unaffected side.
Address patient at the unaffected side.
Position the table at the epigastric region.
Remove unnecessary items: Prevent spills of food and drinks and sensory overload.
Give only thickened liquid (Check the order what is allowed).
Clear liquid and milk increase salivation: Causing mucous membrane of the mouth to feel sticky can cause coughing and pulmonary aspiration.
Small mouthful should be given at a time (choose proper utensils – don’t give the biggest spoon).
Bending the head slightly forward will reduce the risk of chocking and pulmonary aspiration.
Patient should remain in position for 30-60 mins after meal to prevent gastric reflux and pulmonary aspiration.
Provide oral hygiene after meal: Due to food stuck on the paralyzed side.
Call the patient by name: Attract attention and stimulate senses, reduce environmental stimuli to minimum, give instructions one at a time.
Give positive feedback and encourage autonomy.
HOW TO COMMUNICATE TO PATIENT WITH APHASIA:
Reduce environmental stimuli that may distract the patient.
Position yourself on the unaffected side.
Look at the patient to show your facial expression, maintain eye contact.
Speak in a normal tone and level of voice.
Express one idea or thought at a time.
Use short simple sentences.
Ask simple questions answerable by yes or no. (closed-ended questions)
Let the patient speak, do not interrupt. Allow the patient to complete his/her thought.
Encourage gestures or demonstrations (“show me…, or point to what you want”) Nodding or shaking head.
Allow body contacts (clasp of hand, touching). May be the only way the patient can express his feelings.
Never pretend to understand the patient if you do not. Calmly tell the patient that you do not understand and allow him to WRITE IT or DRAW! Use a thick black marker or big printed letter.
Do not treat the patient like a child. “No baby talk”.
A neurodegenerative disorder characterized by idiopathic degeneration of dopamine-producing neurons in the midbrain area known as the substantia nigra (Symptoms of PD result from dopamine insufficiency).Cause is still unknown.
COMMON FEATURES: “TRAP”
T-remor: Specifically resting tremor. (pill rolling)
R-igidity: Difficulty moving and stiff arms and limbs.
A-kinesia: No or slow movements.
P-ostural instability: Posture problems. (forward tilt posture)
Others: Blank facial expression, slow monotonous, slurred speech, shuffling gait, drooling etc…
1. Dopaminergics: Bradykinesia, tremor, rigidity. ●Levodopa (L-dopa). ●Levodopa-carbidopa (sinemet). 2. Anticholinergic: Tremor. ●Procyclidine (Kemadrin).●Benztropine (Cogentin). 3. Antihistamine: Tremor, rigidity.●Diphenhydramine (Benadryl).
Impaired mobility: ●Assist patient to prevent injury. ●Teach mobility techniques. ●Do ROM exercises. ●Consult PT or OT.
Impaired verbal communication: ●Allow enough time. ●Provide alternative communication methods. ●Encourage DBE before speaking. ●Massage facial and neck muscles. ●Consult speech therapist.
Imbalance nutrition: or during meal: ●Monitor gag and swallowing. ●Consult dietitian. ●Provide soft-solid and thick-liquid. ●Have suction available. ●Position patient upright.
Recreational activities: ●Determine physical or emotional response to activity. ●Provide the patient activities that they like. ●Encourage patient to verbalize feelings d/t decreasing capabilities on activities.
Others: Offer services (on call home care – respite care), CLSC, support groups.
Assess ability to perform Activities of Daily Living (ADL).
Safety is priority due to risk of falling.
Prone to constipation.
is a fatal, progressive and degenerative disease that destroys brain cells. It is the most common form of dementia.
Characterized by disturbance of Judgement, Affect, Memory, Cognition, and Orientation.
Sundowning syndrome: Become noticeable in the afternoon or night time. Confusion, disorientation, anxious, aggressive, agitated, and restless.
Patient behavior associated with sundowning:
Becoming demanding or aggressive.
Experiencing delusions and hallucinations.
Pacing or wandering.
Doing impulsive things.
Attempting to leave home.
Having difficulty understanding others.
Having difficulty doing tasks that were done without difficulty earlier in the day.
What causes sundowning?
Being tired at the end of day (can lead to an inability to cope with stress).
Low lighting and more shadows (can create confusion and hallucinations, especially with common objects that look different when it is darker).
Disruption of the circadian cycle (sleep/wake pattern) because of the dementia (the person cannot distinguish day from night).
Not as much or no activity in the afternoon compared to the morning (can lead to restlessness later in the day).
Some tips in caring for patients with AD: “PLEASE CARE”
Provide basic human needs and safety.
Listen to what the patient is NOT saying (nonverbal cues).
Encourage rest periods.
Assist in ADL.
Sing and dance (make pt. active).
Engage in reminiscing activities.
Call patient by name and ALWAYS introduce yourself at the start.
Activities with simple decision making.
Redirect inappropriate behavior like anger.
Exaggerate facial expression and gesture in communicating face-to-face.
●Delusions: False belief not shared by one’s culture. Incorrect beliefs not based on reality.
●Hallucinations: A sensory experience without any real world stimulus may be visual, auditory, tactile, gustatory or olfactory.
●Illusions: Misperception of real stimuli.
Responding to sundowning:
See if the behaviour is being caused by discomfort (hunger, need to use the toilet, or pain).
Allow for rest and naps between activities.
Avoid making appointments, bathing, or other potentially stressful activities in the late afternoon or evening.
Prevent over-stimulation from the television or radio, which can lead to increased confusion.
Provide adequate lighting to lessen shadows when it begins to get dark.
A rocking chair can provide stimulation while having a calming effect.
Brisk walks or other forms of physical activity throughout the day may reduce restlessness or the need to wander later.
Keep patient active and distracted when sundowning may occur (for example, preparing dinner, setting the table).
Allow quiet time if this helps decrease agitation.
Restrict the amount of caffeine and sugar the patient has in the morning.
Maintain a regular eating and sleep schedule as much as possible.
It may be helpful to keep a daily journal to pinpoint the causes of sundowning symptoms and see which strategies help.
Familiar routines may help patient feel more secure. They can include readying the home for evening (closing curtains, turning on lights) or bedtime routines that include warm milk and soft music.
Change sleeping arrangements, for example, adding a comfortable chair to the room, a night light, or leaving a door open.
Doctors may recommend certain medications to ease the symptoms, for example, antipsychotics, sedatives, or sleep-regulating hormones such as melatonin. These can help some people, but because many have serious side effects such as dizziness, sedation (causing sleepiness), or dependence, it is recommended that other options be tried before relying on drugs.
An acute or sudden or rapid onset of mental confusion as a result of a medical, social, and/or environmental condition.
Duration: Hours to months, depends on the speed of diagnosis.
Thinking: Fluctuates between rational state and disorganized, distorted thinking with incoherent speech.
Memory: Recent and immediate memory impaired.
Prognosis: Treatable and reversible with early diagnosis.
Treatments: Treat underlying cause. Monitor patient response. Be alert for relapse; occurs in 90% of cases
MOST COMMON CAUSE OF DELIRIUM: “DELIRIUM”
L-ung, liver, heart, kidney, brain disorder.
I-nfections (UTI 1st).
R-x drugs (i.e. opioid, anesthetics)
I-njury, pain, stress.
U-nfamiliar environment (2nd).
S-tatus post-operative (3rd).
Progressive loss of brain cells resulting in decline of day-to-day cognition and functioning. A terminal Condition.
Thinking: Gradual loss of cognition and ability to problem solve and function independently.
Memory: Inability to learn new information or to recall information.
Prognosis: Progression can be slowed but not reversed.
Treatments: Cholinesterase inhibitors slow the progression of some dementias. Symptomatic treatment.
MANAGEMENT OF DELIRIUM OR DEMENTIA: 3R’S
Routine: Familiar caregiver (same nurse), familiar environment, and familiar task. Avoid changes.
Repeat: Repeat information, orient to 3 spheres, give one direction at a time and repeat as necessary.
Reinforce: Use environmental cues to stimulate memory (calendar, clock, signs).
Safety: Well lit environment, less stimulating, no frustrating and confusing decision making, speak in clear low pitch voice (never shout at the patient).
Preparation guide for professional examination of the OIIQ, PRN comprendre pour intervenir guide d'evaluation, de surveillance clinique, et d'intervention infermieres, Fundamentals of nursing potter-perry, Ultimate learning guide nursing review, The ABC's of passing philippine nursing exam, Medical-surgical nursing assessment and management of clinical problem, Saunders Comprehensive review for the NCLEX-RN examination, Mosby drug guide for nurses, Critical thinking in nursing Winningham & Pressure
Copyright © Rn101. All rights reserved.