Traumatic Brain Injury (TBI) Work Sheet 2024 study guide, Exams of Nursing

Download Traumatic Brain Injury (TBI) Work Sheet 2024 study guide and more Exams Nursing in PDF only on Docsity! Traumatic Brain Injury (TBI) Work Sheet 2024 study guide (Answers can be found within the power point document. Practice question locations may be found on page 4 of the document) Principles to consider when caring for any person with any type of intracranial issues are: • the brain, blood and CSF occupy a determined amount of space within a hard box (the skull). • because these substances are contained inside a closed space, pressure is created. This pressure is known as ICP – intracranial pressure. What would happen to ICP if the brain space was increased? Provide a specific value. ICP would increase. If normal ICP = 5-15 mm/Hg, then an increased ICP would be greater than 15 mm/Hg. Brain cells must have oxygen. What happens if a brain cell is without oxygen? How long (time frame) before this happens? ↓ O2 ⟶ ↓ ATP production ⟶ ↓ ability to work Na/K pump ⟶ Na stays in the cell and water follows ⟶ the cell swells Consider also ⟶ inflammation from trauma/infection/inflammatory disorders ⟶ the cell swells ⟶ when a cell swells there is decreased space for blood to flow ⟶ causing ↓ blood flow to nearby cells ⟶ causes cells nearby to swell ⟶ causes more cells nearby to swell ⟶ causes more cells nearby to swell !!!! I could go on and on. THE POINT - brain swelling causes more brain swelling and the ICP goes UP Brain can survive without O2 4-6 minutes ---short time. The other organs will tolerate low O2 better than the brain!! Identify the mechanisms that can cause brain cells to be without oxygen or to swell (cause edema). The brain has compensatory mechanisms to ensure survival ⟶ known as auto-regulation ⟶ the ability to maintain a constant blood flow by increasing (vasodilation) or decreasing (constriction) vessel diameter ⟶ MAP must be 70-150 for this mechanism to work/function. How does a nurse know if cerebral perfusion is adequate? Nurse calculate the cerebral perfusion pressure (CPP). CPP = 70 – 100 mm/Hg Formula -CPP = MAP – ICP Note: ICP can only be measured if the patient has a ventriculostomy – a hole is drilled through the skull and a tube/bolt is placed in the ventricle of the brain = ICP can then be measured. On the exam if you are given an ICP and a BP you BETTER calculate the CPP!!!!!! Practice. 1. BP = 120/80; ICP = 15, MAP=93.33, CPP= MAP-ICP, 93.33-15= 78.33 2. BP = 90/60; ICP = 15, MAP= 70; CPP=55 • elevATE: HOB 30-45° (NOT >45 - height promotes venous outflow from the brain. Higher than 45° increases intra-abdominal/intrathoracic pressure  ↑ ICP) • strAIGHT: keep neck straight to promote venous outflow • regulATE: keep BP < 150 (in most instances) • separATE: space out stressful activities • intubATE: protect airway • coagulATE: check PT/PTT stat and correct coagulopathy w/Vit K subQ & FFP immediately with bleeds • medicATE: with Mannitol = osmotic diuretic = shifts fluid = ↓ edema (if not hypotensive) • hyperventilATE: keep PaCO2 ~ 25-35 mmHg (↑CO2 = cerebral vasodilation⟶ ↑ ICP BUT ↓ CO2 = cerebral vasoconstriction ⟶ can cause ischemia⟶ need that just right blood vessel balance) • evacuATE: remove CSF via ventriculostomy • operATE: surgical evacuation of clot/tumor/blood What is the consequence of ↑ ICP? One of the main dangers of increased ICP is that it can cause ischemia (tissue death) by decreasing cerebral perfusion pressure. As the ICP increases, cerebral perfusion falls. The body responds to a fall in CPP by increasing systemic blood pressure and dilating cerebral blood vessels. This results in increased cerebral blood volume, which increases ICP, lowering CPP further and causing a vicious cycle. This results in widespread reduction in cerebral flow and perfusion, eventually leading to ischemia and brain infarction. Because of his worsening symptoms and ↓ LOC (GCS now 8), the patient is urgently sent to the x-ray department for a head CT. Because of his worsening symptoms and ↓ LOC (GCS now 8), the patient is urgently sent to the x-ray department for a head CT. A linear skull fracture and epidural hemorrhage are identified. An epidural hemorrhage occurs when a traumatic force causes a skull fracture  this tears a blood vessel  arterial bleeding occurs. Classic symptoms are a brief loss of consciousness followed by alertness followed by ↓ LOC. An epidural hemorrhage is a neurologic emergency. The patient will be taken to the OR for a surgical evacuation of the clot and the prevention of further bleeding. The neurosurgeon also inserts a ventriculostomy to monitor and manage ICP and CPP. The patient returns from the OR on mechanical ventilation. The nurse is managing the ICP by draining the CSF. Mannitol (an osmotic diuretic) has been administered IVP to control cerebral edema and cause diuresis. His blood pressure, heart rate and ABGs (CO2) are within accepted parameters. Neuro checks, done every hour, are unchanged. GCS = 6. Additional HCP orders read: Dilantin-125 Suspension TID per orogastric tube (OGT), OG tube to low suction. Clamp 1 hour after each med admin Provide the indication for the dilantin order. • Dilantin is an anti-seizure medication. Patient’s with any intracranial problems are at risk for seizures. • A seizure (or fever) will also cause an increase in the metabolic rate of the brain cell, increasing the O2 demand of the cell! Why was an OGT inserted instead of an NG tube? • To avoid placing the tube in the intracranial space! • An NG tube should not be inserted if a skull fracture is suspected. The nurse maintains strict aseptic technique while draining CSF from the ventric. HR = 70; B/P = 140/70; ICP = 36. The patient is mechanically ventilated. Volume controlled A/C; TV 600, Rate; 14 (no spont resp); FiO2 40%; PEEP 5; SaO2 100%. Calculate the CPP. Would perfusion to the brain (O2 delivery) be improved by increasing the FiO2 to 50%? CPP = 57.33. The CPP is <60. Perfusion to the brain is decreased. Brain cells are lacking O2 and dying. BUT the SaO2 (measured oxygen saturation) is 100%. There is plenty of O2 in the blood. The O2 cannot be delivered to the brain cells because the ICP is too high causing decreased perfusion. The ICP must be lowered by draining off CSF. Why is it important to use strict aseptic technique when manipulating the ventriculostomy drainage system (hint what vital sign is missing)? This patient has a scalp laceration and a skull fracture. He is at risk for an infection. An infection with a fever would increase his metabolism, increasing metabolic wastes which produce cerebral vasodilatation; this worsens cerebral edema. In addition, infection, and fever (anxiety and pain) increase oxygen demand; this may worsen brain tissue ischemia. I have identified a few practice questions for this topic. The questions that pertain to the course are listed below in- Saunders Comprehensive Review for the NCLEX-RN® Examination, 7e (Saunders Comprehensive Review for Nclex-Rn) by Linda Anne Silvestri Go to Exam review > Study > Content Area > then go to the content area and question number that is listed below Traumatic Brain Injury Study > Content Area > Adult Health > Neurologic > Question # 2, 3, 4, 21, 24, 26, 27, 28, 29, 31, 43, 46, 51, 52, 53, 72, 73, 90, 95, 115, 116, 117, 118, 123, 128, 139, 150, 157, 159, 160, 175, 177, 184 Study > Content Area > Critical Care > Emergency Situations > Question # 118 Additional questions are available in Hughes’ Clues for student success - labeled “Trauma practice questions”. NURSING CONCERNS AND MANAGEMENT OF PATIENTS WITH HEAD INJURIES Cardiovascular Problems • Orthostatic Hypotension • Deep Vein Thrombi Nursing Interventions • Ted Hose • Jobe Hose • Heparin (Usually 5,000 U BID) • Progressive time sitting up • Wheelchair with adjustable back Respiratory Problems • Loss of cough reflex • Immobility • Abnormal breathing patterns due to head injury Nursing Interventions • Hyperventilation for lung expansion • Stimulate cough reflex • Manual cough • Adequate hydration • Turn and mobilize • Aggressive respiratory therapy support Problems with Thermal Control • Loss of thermal control due to medulla trauma Nursing Interventions • Cooling Measures • Environmental control • Light clothing • Hypothermia blanket • Sponge bath • ASA or Tylenol c. Use of egg crates, sheepskin, Clinitron or other special bed. d. Keep linens clean, dry, and unwrinkled. e. Lotion over feet and hands to prevent loss of cutaneous oil. f. Mouth care, including lips every 2-4 hours, PRN g. Keep nails clipped (family). h. Wash hair weekly. 4. Joint Mobility a. ROM every 2-4 hours & PRN (PT consult is important). b. Be alert to foot drop, external rotation, etc. Can use high-top tennis shoes and trochanter rolls. Be sure to remove shoes regularly to check for decubiti. 5. Sensory Functioning a. Eyes may not close or may not blink. 1. May require swiss mask, eye drops, ointment or taping shut PRN with eye shield. 2. Check every 4 hours for signs of corneal ulcers, or inflammation b. Nose 1. Apply ointment to nares. 2. If nasopharyngeal airway is in place, alternate nares every 72 hours c. Hearing 1. Inspect ears every 4-6 hours for signs of dry or fresh drainage. 2. Remember that the last faculty to be lost in unconscious state is hearing, so communicate as if patient can hear. Encourage family to communicate with patient 6. Fluid & Nutritional Status a. IV fluids to high-calorie, high-protein tube feedings, TPN b. After gag reflex returns, will return to oral feedings. c. Oral hygiene important during unconscious period. 7. Bladder & Bowel Function a. Comatose patient is usually incontinent. Retention may also occur. b. Usually will have a foley or condom cath. c. Check for bowel movement daily. 1. If no BM, check for impaction every 2-3 days. 2. May need to initiate bowel program 8. Maintain Safety for Restless Patient a. Side rails up, padded with seizures, or extreme restlessness b. Hand mittens as needed. c. Soft restraints PRN. d. Family member or sitter, if possible. 9. Psychosocial functioning a. May have inappropriate behavior when waking up. b. Provide emotional support for family or significant other. c. Allow family to help with small tasks – combing hair, applying lotion. d. Chaplain The “ATES” of ICP Management • ElevATE - HOB ↑ 30-45° • StrAIGHT - Keep neck straight to promote venous outflow • RegulATE - Keep BP < 150 (in most instances) • SeparATE - Space out stressful activities • IntubATE - Protect the airway • CoagulATE - Check PT/PTT stat and correct coagulopathy with Vit K SQ & FFP immediately with bleeds • MedicATE - With Mannitol (if not hypotensive)  hypertonic diuretic  moves fluid (edema) from brain cell • HyperventilATE - Keep PaCO2 25-35 mmHg • EvacuATE - Remove CSF via a ventriculostomy • OperATE- Surgical evacuation of clot/tumor