Head injury

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Head injury
Presented by Remya Gopinath
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DEMOGRAPHIC DATA

• Name Case No.4
• MR No 185840
• Diagnosis RTA WITH HEAD INJURY
• Age 6YRS
• Gender Male
• Date of admission 2/10/2012
•  

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PHYSICAL ASSESSMENT

• GENERAL ASSESSMENT
• Patient is bedridden, lying over bed with
  tracheostomy and NGT in situ.
• SKIN
•  Normal in state, warm To touch. No sores or
  redness present all over the body.
• HEAD AND NECK
  
  
  
  Head is slightly extended. No visible
  injury noted in the scalp area.Involuntary eye
  movement present.5mm tracheostomy tube present
  over neck region.
•  

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• RESPIRATORY
• Respiration through tracheostomy tube with in
  normal rate. Cough with mild to moderate
  secretion present.spo2 maintaining on room air.
  Thorax is symmetrical in size.
• CARDIOVASCULAR
• No deformities noted.
•  
• GENITOURINARY
• self voiding on diaper
• GASTROINTESTINAL
• Abdomen is soft, not distended. Feeding via
  NGT.Bowel sound present.

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• MUSCULO-SKELETAL
• All limbs are spastic with flexed
  upper extremities and extended lower extremities.
  Mild spontaneous limb movement present. Displaced
  fracture is seen in middle of left clavicle.
• NEUROLOGY
• Patient is semi conscious .pupils are bilaterally
  reacting to light.Bilatral flexure response to
  painful stimuli.GCS E4VTM3.

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• Patient history
• Past medical history
• Patient was in normal healthy living until the
  day of accident.
• Present medical history
• Patient received in ER on 2/10/2012 after being
  involved in RTA with an unconscious and irritable
  state. Vomiting and loc at scene for 5 minutes.
  On examination vital signs are Pulse-103/mt,
  BP-120/70,Temp,36.7 c ,SPO2 -94,GCS 8/15.
  Pupils are bilaterally reacting to light. Limb
  movements are equal and normal in all 4 limb.NCCT
  brain shows SAH in right fronto_parietal
  lobe,diffuse brain edema,small hemorrhage in the
  4th ventricle and opacification in all paranasal
  sinuses. Scalp swelling is seen in left parital
  area and no fracture is seen in cranial vault.

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• After the initial management
  patient shifted to ICU .On 8th day of admission
  ,patient developed tachypnoea,for which he
  investigated and found to have collapse of right
  lung. Intubation done and relaxant started with
  Inj.Midazolam and Inj.Fentanyl.Tracheostomy done
  on 13/12/2012.The repeat NCCT on 28/10/2012,which
  shows subdural haematoma with midline shift
  4mm.Right frontal and parietal burrhole with
  evacuation of subdural hygroma done.
• After 2 months of admission
  clinically patient is opening eyes, bilateral
  flexure response to pain. All limbs are
  spastic,pupils both equal reacting ,afebrile,on
  NGT feeding with pediasure q 4h.patient shifted
  to pedia ward for further management.

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• DEVELOPMENTAL MILESTONES

CHILDS AGE MASTERED SKILLS
1 MONTH Lifts head when lying on tummy. Respond to sound. Stares at faces.
2 MONTHS Vocalizes gurgles and coos. Follows objects across field of vision. Notices his hands. Holds head up for short periods.
3 MONTHS Recognizes your face and scent. Holds head steady. Visually tracks moving objects.
4 MONTHS Smiles, laughs. Can bear weight on legs. Coos when you talk to him.
5 MONTHS Distinguishes between bold colors. Plays with his hands and feet.
6 MONTHS Turns toward sounds and voiceslimits sounds roll over in both
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CHILDS AGE MASTERED SKILLS
7 MONTHS Sits without support. Drags objects toward herself.
8 MONTHS Says mama or dada to parents. Passes objects from hand to hand.
9 MONTHS Stands while holding onto something. Jabbers or combines syllables. Understands object permanence.
10 MONTHS Waves good bye. Picks things up with pincer grasp. Crawls well, with belly off the ground.
11 MONTHS Says mama or dada to the correct parent. Plays patty- cake and peek-a-boo. Stands alone for a couple of seconds.
12 MONTHS Imitates others activities. Indicates wants with gestures.
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CHILDS AGE MASTERED SKILLS
13 MONTHS Stands without support
14 MONTHS Pull things out
15 MONTHS Plays with ball, Learns about 5 words, Can walk backward
16 MONTHS Can turn the pages a book, Has toddler temper
17 MONTHS Vocabulary increases, Loves to play pretended games
18 MONTHS Loves to watch the pictures.
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CHILDS AGE MASTERED SKILLS
19 MONTHS Learns to use a spoon and fork, Runs, Throws ball
20 MONTHS Can take off own clothes with help, Can imitate actions
21 MONTHS Can walk up stairs, Keeping a toy in its place
22 MONTHS Can kick a ball forward, Imitates others behavior
23 MONTHS Names simple pictures in a book, Learns and uses about 50 words
24 MONTHS Can make short sentences
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2-3 YEARS OF AGE
SHOWS AFFECTION FOR OTHERS
IS ABLE TO PLAY BY HIMSEF OR HERSELF
IMITATES BEHAVIOR
RUNS FOEWARD
HELP DRESS AND UNDRESS THEMSELVES
HOLDS A PENCIL IN A WRITING POSITION
USES 2 OR 3 WORD SENTENCES
UNDERSTANDS DIFFERENCES IN MEANING (stop,go,up down)
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3-6 YEARS OF AGE(PRE SCHOOLERS)
Is able to dress and undress
Very active and likes to do things like climb, skip and stunts
Plays co operatively with peers
Is developing some independence and self reliance
Learning to distinguish between reality and fantasy
By age of 6 their vocabulary will have increased to between 8000 to 14000 words(of then repeats words without fully understanding their meaning)
They have learned the use of most prepositions and some basic possessive pronouns( mine, me)
Pre school children continue to be ego centric and concrete in their thinking. They are still unable to see things from another perspectives and they reason based on specifics that they can visualize that they have importance to them.
When questioned they can generally express who,what,where and some times how, but not when or how many. They are also able to provide a fair amount of details about a situation
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TOPIC PRESENTATION
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• HEAD INJURY
• Definition
• It is an injury to the skull or brain that is
  severe enough to interfere with normal
  functioning.

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• Anatomy Physiology
• The brain is one of the largest
  and most complex organs in our body. It controls
  our body, receives information, analysis
  information and stores information. It is made up
  of more than 100 billion nerves that communicates
  in trillions of connections called synapse.
• The skull consisting of 22 bones all
  together.These bones are divided into 8 cranial
  bones and 14 facial bones. Cranial bones form the
  cranial cavity and protects the brain.

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• There are typically 206 bones in the body.Out of
  these there are 22 bones of the Skull, which
  include
• 8 Cranial Bones
• 1 x Ethmoid Bone1 x Frontal Bone1 x
  Occipital Bone2 x Parietal Bones1 x Sphenoid
  Bone 2 x Temporal Bones

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• 14 Facial Bones
• 2 x Inferior Nasal Conchae2 x Lacrimal
  Bones1 x Mandible2 x Maxillae (pl.) Maxilla
  (sing.)2 x Nasal Bones 2 x Palatine Bones1 x
  Vomer2 x Zygomatic Bones

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• CRANIAL NERVES
• Olfactory I sense of smell.
• Optic Nerve II sight of retina.
• Oculomotor Nerve III eye movement and pupil
  constriction.
• Trochlear Nerve IV eye movements.
• Trigeminal Nerve V carry somatosensory
  information to face, head and chewing muscles of
  jaws.
• Abducens Nerve VI eye movement.
• Facial VII control the muscles used for facial
  expressions (smiling, frowning etc).  It also
  stimulates salivary glands to produce saliva.

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• Vestibulocochlear VIII hearing and balance.
• Glossopharyngeal IX taste sensation ,gag
  reflexes.
• Vagus X It carries somatosensory information
  from organs of thoracic, abdominal cavity
  including heart and from that of gastrointestinal
  tract.
• Spinal Accessory Nerve XI leads to muscles of
  neck, back and larynx. It controls the head
  movement.
• Hypoglossal Nerve XIIcontrols the muscles of
  tongue

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• Meninges
• Meninges are the connective tissue membrane
  enclosing the brain and the spinal cord. It is
  divided into 3.outer most duramater,arachanoid
  mater and the inner most piamater.

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• Lobes of brain
• Frontal lobe is responsible for problem
  solving,judgement and motor function.
• Parietal lobe manage sensation, hand writing and
  body position.
• Temporal lobe is involved with memory and
  hearing.
• Occipital lobe contain the brains visual
  processing system.

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• Sutures of brain
• Coronal suture present between frontal and
  parietal bones.
• Lambdoid suture present between occipital and
  parietal bones.
• Sagital sutures present between two parietal
  bones.
• Squamous sutures present between parietal and
  temporal bones.

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• Major Regions of Brain
• Brain is divided into 3 major parts
• Cerebrum
• cerebellum
• Brain stem

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• Cerebrum
• Cerebrum is the most superior part of the brain.
  It is made up of by thick gray matter as surface
  layer and internally with white matter.It consist
  of thalamus, hypothalamus and epithalamus.

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• Cerebellum
• Cerebellum located dorsal to the pons and
  medulla. It receives the impulses from cerebral
  motor cortex, various stem and sensory receptors
  in order to control skeletal muscle contraction.

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• Brain stem
• Brain stem is similarly structured as the spinal
  cord. It is divided in to midbrain ,pons and
  medulla oblongata.mid brain acts as a fibre
  pathway between higher and lower brain
  centres.The pons mainly a conduction region also
  contribute to the regulation of respiration and
  cranial nerves. Medulla oblongata regulate the
  respiratory rhythm, heart rate,B P etc...

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• Blood supply to the brain
• The major arteries are the vertebral and internal
  carotid arteries. This communicating arteries
  forms the circle of willis,which equalizes the
  blood pressure in the brains anterior and
  posterior region.

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• Pathophysiology
• Damage to the brain from traumatic injury takes
  two forms
• Primary Initial damage to the brain that result
  from the traumatic event.
• Secondary It occurs hours and days after the
  initial injury and result from inadequate
  delivery of oxygen and nutrients.

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• .

Brain suffers traumatic injury
Brain swelling or bleeding increase intracranial
volume
Increased ICP
Pressure on blood vessels causes blood flow to
the brain to slow
Cerebral hypoxia or ischemia
Continues increase in ICP
Brain herniation
Cerebral blood flow cease
Brain death
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• Types of head injury
• Concussion Transient interruption in brain
  activity. No structural injury noted on
  radiographs
• Contusion Bruising of the brain with associated
  swelling.
• Intra cranial haemorrhage Bleeding in to the
  brain tissue commonly associated with edema.

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• Epidural hematoma Blood between inner table of
  skull and dura.Associated with injury or
  laceration of the middle meningeal artery
  secondary to a temporal bone fracture.
• Subdural hematoma Blood between the dura and
  arachnoid space caused by venous bleeding.
  Commonly associated with ICH or contusion.
• Diffuse axonal injury or shear injury Axonal
  tear with in the white matter of the brain.
  Frequently occurs with the corpus callosum or
  brain stem and at the frontal or temporal poles
  associated with prolonged coma.

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Signs and symptoms Signs and symptoms
Altered level of consciousness Hypothermia or Hyperthermia
Confusion Vision and hearing impairment
Pupillary abnormalities Sensory dysfunction
Altered or absent gag reflex Headache
Absent corneal reflex Seizure
Altered respiratory pattern Decortications, Decerebration
Increased pulse pressure CSF Leakage
Bradicardia or Tachycardia Vomiting
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Patient base Patient base
Altered level of consciousness Hyperthermia
Confusion
Decortications
Decerebration
Seizure
Sensory dysfunction
Vomiting
Altered respiratory pattern
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• Diagnostic procedures

Diagnostic procedures
Diagnostic procedures Diagnostic procedure
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CT SCAN
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MRI
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• EEG

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• NERVE CONDUCTION VELOCITY
• A nerve conduction study (NCS) is a medical
  diagnostic test commonly used to evaluate the
  function, especially the ability of electrical
  conduction, of the motor and sensory nerves of
  the human body.

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• ELECTRONYSTAGMOGRAPHY
• is a diagnostic test to record involuntary
  movements of the eye caused by a condition known
  as nystagmus. It can also be used to diagnose the
  cause of vertigo, dizziness or balance
  dysfunction by testing the vestibular system.

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• Management
• All therapy is directs towards preserving brain
  homeostasis and preventing secondary brain
  injury. Treatment to prevent secondary injury
  includes stabilization of cardiovascular and
  respiratory function to maintain adequate
  cerebral perfusion, control of haemorrhage,hypovol
  emia and maintaining of blood gas values.

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• Nursing assessment
• Assessment
• Collection of history
• GCS score
• Neurologic status
• Presence of CSF leakage
• Pupillary response to light

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• Initial management

Severe head injury
ATLS Evaluation
Intubation with ventilation and sedation
Fluid resuscitation
CT Brain
OT
Surgical lesion
YES
NO
MONITOR ICP
ICU
Treat intra cranial hypertension
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• Patient side management

Intubation Inj. manitol
Ventilation with sedation Inj.Perfalgan 250mgI V PRN
Right frontal and parietal burr hole with evacuation of subdural hydroma Tab.Gardinal
IV fluid d5n/2 5ml kcl _at_ 80ml/hr Tab.Lyrica 25mg BD
Iv antibiotics- Inj. Ceftriazone 500mg iv bd and inj.amikacin 250mg iv BD Inj.Risek 20 mg IV OD
Inj.Phenytoin 60mg iv q8h
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• Prioritization of nursing problems

Ineffective airway clearance and impaired gas exchange related to artificial airway
Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP and seizures
Fluid volume deficit related to decreased loss of consciousness and hormonal dysfunction
Imbalanced nutrition , related to increased metabolic demands , fluid restriction and inadequate intake
Risk for injury related to seizures , disorientation , restlessness or brain damage
Risk for imbalanced body temperature related to damaged temperature regulating mechanism
Risk for impaired skin integrity related to bed rest , paralysis and immobility
Disturbed thought process related to brain injury
Disturbed sleep pattern
Interrupted family process
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• Nursing care plan

assessment Nursing diagnosis planning intervention rationale evaluation
SUBJECTIVE Not Applicable Risk for impaired skin integrity related to immobility Skin to be remain intact and will not develop any bedsore Positioning done every 2 hourly Positioning reduces pressure Goal met by absence of bedsores during the stay of facility
OBJECTIVE Unable to move Maintained personal hygiene of the patient Moistures causes skin tears
Unable to abduct and adduct extremities Applied cream and powders as necessary To smoothening the skin
Provided air mattress To reduce pressure


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assessment Nursing diagnosis planning intervention rationale evaluation
SUBJECTIVE Patients mother complaints sputum is Ineffective airway clearance related to tracheo-bronchial secretions Improve the airway patency of the patient Suctioning done To remove the secretions Goal partially met by reduced secretion and normal respiratory rate
Coming out through the tracheostomy tube CPT provided Retained secretions interfere with gas exchange
OBJECTIVE Secretions present Provided fowlers position Helps good air entry
RR 26/mt Cough present Administered nebulization with ventolin and pulmicort Helps to soothening and expulsion of secretion
Administered antibiotics To reduce infection
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• Complications
• Infection-respiratory
• Hydrocephalus
• Post traumatic seizure
• Permanent neurologic deficit
• Coma
• Chronic headache
• Death

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• Health education

)Instructed the mother about the calorie needs of the baby
)Involve the family in sensory stimulation programmes to maximize its effectiveness
)Instructed the mother to investigate for physical sources of restlessness such as uncomfortable position, signs of UTI or pressure ulcer development.
)Provide necessary education related to tube feeding, positioning, ROM exercises.
) Instructed to observe for post concussion, syndrome (headache, decreased concentration, irritability, dizziness, Insomnia, restlessness)and advised to obtain addition support.
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• Conclusion

Trauma involving the central nervous system can
be life threatening even if it is not life
threatening, brain and spinal cord injury may
result in major physical and psychological
dysfunction and can alter the patients life
completely.
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• Bibliography

1. Brunner and suddarths,test book of medical
   surgical nursing 12th edition
2. Lippincott manual of nursing practice 9th edition

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Thank you!!!!!