NEUROLOGICAL NURSING:

Increased ICP and Head Injury

This unit will assist learners in applying nursing knowledge to the

care of a patient with increased ICP and head injury, in an

acute care setting

OBJECTIVES

By the end of this unit, the learners will be able to:

1. Review anatomy and physiology of brain and its protective structures.

2. Differentiate between primary and secondary head injuries and demonstrate an understanding of the related patho physiology.

3. Anticipate major complications that may result from head injuries.

4. Utilize nursing process in caring for a patient, with head injury.

INTRODUCTION:

Brain is divided into four main parts: • Brain stem (medulla oblongata, midbrain and the Pons, )

controls breathing, heartbeat rates and reactions to auditory and visual stimuli

• Diencephalon controls homeostasis

The diencephalon is a complex of structures within the brain, whose major divisions are the thalamus and hypothalamus. It functions as a relay system between sensory input neurons and other parts of the brain, as an interactive site for the central nervous and endocrine systems, and works in tandem with the limbic system.

• Cerebrum controls intellectual processes and emotions• Cerebellum- maintains body posture and balance

THE PRINCIPAL PARTS OF THE BRAIN• Main parts: brain stem, diencephalon,

cerebrum and cerebellum• Protection(Cranial bones, Meninges, The

meninges are three layers of connective tissue that surround the brain and spinal cord. They are known as: Dura mater, Arachnoid mater and Pia mater and cerebrospinal fluid

• Ventricles: Intraventricular foramen (CSF secretes from it, CSF acts as protection, shock absorber and contain nutrient)

THE PRINCIPAL PARTS OF BRAIN

HEAD INJURIES

• Head injuries are one of the most common causes of disability and death in children

• The Centers of Disease Control and Prevention (CDC) estimates that more than 10,000 children become disabled from a brain injury each year

• Head injuries can be defined as mild as bump to severe in nature

PREVALENCE OF PEDIATRIC TRAUMA

• Trauma is the leading cause of death in infants and children• Trauma is the cause of 50% of deaths in people between 5

and 34 years of age• Motor vehicle related accidents accounts for 50% of pediatric

trauma cases• $ 16 billion is spent annually caring for injuries to children

less than 16 years of age• Other causes include: falls, assaults, sports injuries• Two thirds of patients are under 30 years, most are males.• Head injuries often cause damage to the brain from bleeding

or swelling which results in increased intracranial pressure

INTRACRANIAL PRESSURE

• The cranial skull contains three components: brain, blood, and cerebrospinal fluid (CSF)

• The cranial skull is a closed system, and if one of the three components increases in volume, at least one of the other two must decrease in volume or the pressure increases. Any bleeding or swelling within the skull increases the volume of contents within the skull and therefore causes increases intracranial pressure.

• Normal ICP is 10-20 mm Hg

PATHOPHYSIOLOGY

• Increased ICP- Pathophysiology the pressure increases enough, it can cause displacement of the brain through or against the rigid structures of the skull. This causes restriction of blood flow to the brain, decreasing oxygen delivery and waste removal. Cells in the brain become anoxic and cannot metabolize properly, producing ischemia, infarction, irreversible brain damage and eventually brain death.

CLINICAL MANIFESTATIONS

• Depends on the severity and anatomic location of the underlying brain injury. Localized pain usually suggests that a fracture is present. Fracture of the cranial skull may or may not produce swelling in the region of the fracture. But frequently produce hemorrhage. Therefore, an x-ray is needed for diagnosis.

EARLY SIGNS OF INCREASED ICP

Earliest sign is change in LOC: • Slowing of speech, delay in responding to questions• Restlessness, confusion• Papillary changes• Weakness in one extremity• Headache• Constant, aggravated by movement, increasing in intensity

LATE SIGNS OF INCREASED ICP: • LOC, deteriorates to comatose• Bradycardia, fluctuating to tachycardia• Decreased respiratory rate• Altered respiratory pattern (Cheyne-stokes)• BP and temperature rises• Widening pulse pressure (difference between systolic and

diastolic pressure)• Projectile vomiting• Decorticate or decerebrate posturing, followed by bilateral

flaccidity• Loss of brainstem reflexes(pupils, corneal, gag, swallowing)

are continuous signs

MANAGEMENT OF INCREASED ICP• True emergency requiring prompt treatment• Monitor ICP• Intra ventricular catheter, subarachnoid bolt, epidural catheter• Reduce cerebral edema• Osmotic diuretics (Mannitol)• Corticosteroids (Dexamethasome)• Maintain cerebral perfusion• Maintain cardiac output with fluids and dobutamine• Reduce CSF and blood volume• Drain CSF• Hyperventilation -results in vasoconstriction• Control fever• Fever increases cerebral metabolism and edema• Antipyretics, cooling blanket• Avoid shivering which increases ICP• Reduce metabolic demands• Barbiturates decrease ICP• Muscle relaxants to paralyze patient

HEAD INJURY CLASSIFICATON

• Scalp• Skull• Brain• Scalp- Trauma causes abrasion, contusion, laceration or

hematoma beneath the layers of tissue of the scalp.• Skull fracture- breaks in the continuity of the skull caused

by forceful trauma• Classified as linear, depressed or basilar• Skull fracture may be open or closed• Open- tear in the dura• Closed- dura is intact

BRAIN INJURY• Closed- damage to brain tissue, but no opening through

skull and dura• Open- occurs when object penetrates the skull, enters the

brain-opens the scalp, skull, dura to enter the brain.

COMMON REACTIONS:• Minor Injury- Client rapidly regains mental function• Concussion- temporary loss of neurologic function with brief

loss of consciousness few seconds to few minutes• Contusion- bruising and hemorrhaging at brain surface-

unconsciousness for more than a few seconds to few minutes• Loss of neurologic function- paralysis, speech and visual

disturbances• Increases ICP- Brain compression• Intracranial hemorrhage –hematomas (collection of blood) that

develops within the cranial vault- most serious of brain injuries• Hematoma- epidural (above the dura )• Subdural(below the dura)• Intracerebral (within the dura)

TRAUMATIC BRAIN INJURY:

HEMATOMA: • Most serious brain injury• Collection of blood

Primary brain injury: Results from what has occurred to the brain at the time of injury

Secondary brain injury: physiologic and biochemical events which follow the primary injury

TYPES OF HEMATOMA

• Epidural (between the skull and the dura) this can result from a skull fracture that causes a rupture or laceration in the artery between the skull and the dura

• Subdural (between the dura and the brain) this can cause from the trauma, but can also occur as a result of rupture of an aneurysm.

• Intracerebral (into the substance of the brain) result from: systemic hypertension rupture of aneurysm- intracranial tumors- when force is exerted to the head e.g. bullet wound

EXAMPLES OF PRIMARY BRAIN INJURIES

FACTORS THAT EFFECT SECONDARY BRAIN INJURIES

• Blood Pressure• Oxygenation• Temperature• Control of Blood Glucose• Fluid volume status• Increased Intracranial Pressure

TRAUMATIC BRAIN INJURY

• Complications: several complications can occur immediately or soon after a traumatic brain injury. Severe injuries increase the risk of a greater number of complications and more- severe complications

COMPLICATIONS

• Altered consciousness• Coma• Vegetative state• Minimally conscious state.• Locked-in syndrome• Seizures• Infections• Sensory problems• Degenerative brain diseases• Nerve damage• Cognitive problems• Communication problems• Behavioral changes• Emotional changes

MANAGEMENT

• Based on physical and neurological examination• X-ray• CT scan• MRI• Treatment of increased ICP• supportive measures• Ventilatory support• Fluid and electrolyte maintenance• Nutritional support• Pain and anxiety management

NURSING ASSESSMENT

• History of trauma- time, cause, direction and force of the blow

• Loss of consciousness, duration• Assess LOC, Glasgow coma scale• Response to verbal commands or tactile stimuli• Pupillary response to light• Motor function• Vital signs• Monitor for signs of increased ICP• Motor function• Move extremities, hand grasp, pedal push, speech

NURSING DIAGNOSIS AND INTERVENTIONS

• Ineffective airway clearance related to accumulation of secretions and decresed LOC

• Maintain patient airway• Suction carefully• Discourage coughing(causes increase in ICP)• Elevate HOB 30 degrees.• Guard against aspiration• Monitor ABGs to assess ventilation

• Ineffective breathing pattern related to neurological dysfunction

• Monitor constantly for respiratory irregularities• Cheyne stokes, hyperventilation• Effective suctioning• HOB 30 degrees• Position patient lateral or semi prone

• Altered cerebral tissue perfusion related to increased intracranial pressure• Position patient to reduce ICP• Head in midline position to promote venous drainage• Elevate HOB 30 degree• Avoid extreme rotation or flexion of neck• Avoid extreme hip flexion• Prevent straining• Stool softeners• High fibre diet space nursing activities• Main calm atmosphere, reduce stimuli• Risk for fluid volume deficit related to dehydration procedures and

decreased LOC• Monitor electrolytes• Brain damage can produce metabolic and hormonal dysfunctions• Monitor intake and output• Monitor IV fluids carefully• Record daily weights

• Altered nutrition related to metabolic changes, inadequate intake

• Start enteral feedings when patient stabilized• NG feeding unless CSF rhinorrhea• Elevate HOB 30 degrees• Aspirate for residual before feeding to prevent

distention and aspiration• Use pump to regulate feeds

• Risk for injury related to disorientation, restlessness and brain damage• Assess for cause of restlessness• Often present as patient emerges from coma• May be due to hypoxia, fever, pain, full bladder• Use padded side rails or wrap hands in mitts• Avoid restraints as straining against them increases ICP• Minimize environmental stimuli• Low lights, limit, visitors, speak calmly• Orient patient frequently• Risk for altered body temperature related to temperature regulating mechanism• Monitor temperature every 4 hrs• Can be increased as result of :• Damage of hypothalamus• Cerebral irritation from hemorrhage• Infection• Reduce temperature with acetaminophen and cooling blankets • If infection suspected• Culture potential sites• Start antibiotics• Potential for impaired skin integrity related to bed rest, immobility, unconsciousness• Assess all body surfaces every 8 hours • Turn every 2-4 hours• Provide skin care very 4 hours• Assist patient to chair (if possible)

GLASCOW COMA SCALE