Closed Head Injury

Closed Head Injury Case Study Y. W. is a 23-year-old male student from Thailand studying electrical engineering at the university. He was ejected from a moving vehicle, which was traveling 70 mph. His injuries included a severe closed head flaw with an occipital hematoma, zygomorphous wrist fractures, and a right pneumothorax. During his neurologic intensive c be unit (NICU) stay, Y. W. was intubated and placed on mechanical ventilation, had a feeding thermionic tube inserted and was placed on tube feedings, had a Foley catheter to down drain (DD), and had multiple IVs inserted. He developed pneumonia 1 month after admission.Closed Head Injuries Closed head injuries result from a blow to the head as buy the farms, for example, in a car accident when the head strikes the windshield or dashboard. These injuries ca exercise two types of brain damage. 1. Define the landmark primary head injury. A primary head injury (or primary impact) is also hit the sackn as a coup injury. The i njury occurs under the settle of impact with an object such as a hammer or a rock. The brain strikes the skull after the head strikes the object of impact (Lewis, et al, Fig 57-14). This is the set of the direct impact of the brain on the skull.Often there is edema around the site of impact. 2. Define the term secondary head injury. The secondary head injury is also known as contrecoup injury occurs on the side opposite the area that was impacted. These injuries tend to be more severe and overall patient of prospect depends on the list of bleeding around the contusion site (Lewis, et al, 1425). Often it is the secondary brain injuries that show few initial symptoms and then have stark side effects days to weeks later. 3. What is normal intracranial insisting (ICP), and why is change magnitude ICP so clinically important?Normal intracranial pressure ranges from 5 to 15 mm Hg. A sustained pressure in a higher place the upper limit is considered abnormal. Pressure changes in t he brain effect the brains compliance. compliancy is the expandability of the brain With low compliance, small changes in volume occur and result in greater increases in pressure. Elevated intracranial pressure is clinically meaningful beca employment it diminishes CPP, increases risks of brain ischemia and infarction, and is associated with a poor prognosis (Lewis, et al, p. 1425-1427). 4. Identify at least five signs and symptoms (S/S) of increased ICP. signs and symptoms of increased ICP are Decreased LOC (level of consciousness) Respiratory problems (maintaining a patent airway is critical in the patient with increased ICP. Pt is at increased risk of airway obstruction (Lewis, et al, p. 1434). Elevated systolic BP collectible to ischemia and pressure on the brainstem. Bradycardia due to the ischemia and pressure on the brainstem as well. Pulmonary edema due to increased sympathetic exercise as a result of increased intercranial pressure. 5. List 4 medicinal drug classificat ions that the ICU nurses could use to lessening or control increased ICP.Some of the medications that the ICU nurses could use to decrease or control increased ICP would be Opioids (morphine sulfate and fent alll) IV anesthetic sedative propofol (Diprivan) to manage anxiety and unrest. Vecuronium (Norcuron), cisatracurium besylate (Nimbex) nondepolarizing neuromuscular blocking agents achieve nail down ventilatory control in the treatment of refractory intracranial hypertension. (These agents paralyze muscles without blocking pain or noxious stimuli, therefore they are used in combination with sedatives, analgesics, or benzodiazepines (Lewis, p. 436)). Dexmedetomidine (Precedex) alpha-2 agonist used for continuous IV sedation of intubated and mechanically ventilated patients in the ICU setting for up to 24 hours. Benzodiazepines are usually avoided in the ICU in management of the patient with increased ICP because of the hypotensive effect and long half-life. (Lewis, et al, p. 14 36). 6. List 8 nursing measures that the ICU nurses could use to decrease or control increased ICP. * Maintain the patient in the head-up position. Elevation of the head of the bed reduces sagittal sinus pressure, promotes drainage from the head via the valveless venous system through the jugular veins, and decreases the vascular congestion that crumb produce cerebral edema (Lewis, et al, p. 1436) * Position the bed so that it lowers the ICP while optimizing the CPP not above 30 degrees. * Turn the patient with slow, gentle movements. Rapid changes in position may increase ICP. * Avoid extreme hip flexionthis risks raising intra-abdominal pressure which increases ICP. Turn pt every 2 hrs (minimum). * Protect the patient with ICP from self-injury with adequate padding on the bed.Because of likelihood of decreased LOC, confusion, agitation, and the possibility of seizures increase the risk for injury. * Be prepared to explain situations to family and caregivers and the patient. With increased ICP, anxiety is likely and the prognosis can be distressing. By providing short, simple explanations that are appropriate, it allows the patient and the caregiver to acquire the amount of information they desire (Lewis, p. 1438). * Decorticate or decerebrate posturing is a reflex response in nearly patients with increased ICP. The nurse can use turning, struggle care, and even passive range of motion. Monitor eloquent and electrolyte status. Disturbances can have an adverse effect on ICP. Closely monitor IV fluids with the use of an unblemished intravenous infusion control device or pump monitor intake and output and daily weights. (Lewis, et al, 1437) * Perform neurological assessments every hour. 7. Y. W. s medication list includes clindamycin 150 mg per feeding tube q6h, ranitidine (Zantac elixir) 150 mg per feeding tube bid, and phenytoin (Dilantin) 100 mg IV ride (IVPB) tid. Indicate the reasons for each. Clindamycin 150 mg per feeding tube q6h Treatment of respi ratory tract infections to treat Y.W. s pneumonia. (Skyscape, 2012). Ranitidine (Zantac elixir) 150 mg per feeding tube BID Used to treat and prevent stress ulcers (stress-induced GI bleeding in critically ill patients). Due to head injury, overstimulation of the vagus nerve from TBI. phenytoin (Dilantin) 100 mg IVPB TID Used to treat and prevent tonic-clonic seizures and complex partial seizures. Seizure is seen in 5% of patients with a non-penetrating head injury (Lewis, et al, p. 1445). 8. A STAT movable chest x-ray (CXR) is ordered after each central venous catheter (CVC) is inserted.According to hospital protocol, no one is permitted to infuse anything through the catheter until the CXR has been read by the medico or radiologist. What is the purpose of the CXR, and why isnt fluid infused through the catheter until after the CXR is read? The chest x-ray confirms the proper placement of the central venous catheter. If fluid is infused through the catheter before a CXR has confi rmed placement, the patient is at high risk for systemic infection or possible pneumothorax (which would occur if the catheter were to be entered into the lung by mistake instead of the superior vena cava).CASE STUDY PROGRESS Y. W. spent 2 months in acute care and is now on your rehabilitation unit. He follows commands but tends to get agitated with too much stimulation. His tracheostomy site is well healed, and the pneumonia is finally resolving. He is allay receiving supplemental tube feeding and has some continued incontinence of both bowel and bladder. Y. W. has a supportive group of friends who are students at the university several of them are also from Thailand. 9. Y. W. s latest laboratory results are as follows Na 149 mmol/L, K 4. mmol/L, Cl 119 mmol/L, total CO2 21 mmol/L, BUN 12 mg/dl, creatinine 1. 2 mg/dl, glucose 123 mg/dl, leukocyte 15. 4 thou/cmm, Hgb 14. 9 g/dl, Hct 36. 4%, platelets 140 thou/cmm. Are any of these of concern to you, and what would you suggest to correct them? I am relate about 3 of the labs. Sodium high (increased) hypernatremia high sodium levels cause neurologic problems including intense thirst, lethargy, agitation, seizures, postural hypotension, weakness, and decreased skin turgor. Chloride High, increased High chloride levels occur because of increased sodium levels.It is important to correct the sodium level so the chloride level can follow suit. Again, hypernatremia and the nurse must watch out for dysrhythmias, HTN, and impaired mental response. Correcting increased sodium would include Hypotonic saline (via IV) and 5% dextrose in water (IV)- (Lewis, et al, p. 312) WBC count15. 4 increased this increased level indicates infection. This can be attributed to the patients diagnosis of Pneumonia. Administration of appropriate antibiotics will help bring the white count back to a normal level. 0. Are you surprised by Y. W. s agitated behavior? Explain. YMs agitation is of no surprise. Patients that have head injuries often express agitation easily. Increased intracranial pressure and the head injury the patient has experienced can cause agitated behavior to arise. It is imperative for the nurse to use interventions to decrease the agitated behavior which can further lead to feelings of anxiety. Providing a calm and non-stimulating environment, free of stressors, is a good way to do this (Lewis, et al, p. 1438).Also, the nurse can swipe the bed 15-30 degrees with appropriate oxygenation applied. 11. Outline a general rehabilitation plan for Y. W. based on the above data. The rehab plan will include -physical therapy- working on gross motor skills, walking, sitting, transferring, and range of motion -occupational therapy- aids in completion of ADLs and learning of new techniques to complete these tasks of daily living -nutrition- proper nutrition to encumber patient nourished and also consuming enough vitamins/minerals/proteins to aide in healing. nursing staff- administer antibiotics, pain med ications, and supportive care. -speech therapy- to evaluate and aide with swallowing, eating/drinking, and ultimately verbal communication improvements. 12. Y. W. s m otherwise has just arrived in the United States and speaks no English. What measures can be taken to facilitate communication between medical personnel and the mother? First and foremost the nurse should find out what spoken language is the mothers native language. Most people are unwitting but it is not safe to assume there is one language that will apply to an entire country.Quite a few countries speak a language based on their village. The nurse will requisite to acquire an interpreter that will speak the language that best suits the mother. If the patients friends/classmates are around, they can also be used to aid in interpretation and communication between health care staff and family. 13. Y. W. s mother will need a place to stay while in the United States. What can you do to facilitate the initial contact wi th the Thai community? Hopefully the other Thai students are around or could make a suggestion for the patients mother.I would also ask the social worker if they know of any thai-specific cultural centers in the area. I could check with the interpreter, and see if they have a lead. I would also google Thai community San Diego and see what I could find. 14. What special vent planning considerations are there in this case? Discharge considerations for this patient will involve knowing where the patient is discharging to. The nurse will need to know if the patient is staying in the US and continuing with follow-up outpatient rehab with our facility and if not, then where will they be.The nurse and other members of the healthcare/rehab team need to educate the patient on his injury and what comes next for him in terms of rehabilitation. The nurse needs to consider what modifications YM has made to his lifestyle post injury. Discharge planning should include an outpatient document for OT, PT and Speech (assuming he will stay here). Education for caregivers and family is also very important so that the patient has a support system on tap(predicate) during the recovery and rehabilitation process.The patient will need to be sent home with any tools he will need for ADLs, with medications or supplements that are still necessary for recovery. If the patient is in need of special services or devices (i. e. wheelchair, ramps, vehicle to accommodate special devices, etc. ), a case manager should be sought out to ensure that these needs are met. References Lewis, et al, (2011). Medical-Surgical Nursing Assessment and Management of Clinical Problems. 8th ed. Vol 1. St Louis, Missouri Mosby. Skyscape. (2010). Skyscape Medical Resources (Version 1. 9. 11) Mobile application software. Retrieved from http//itunes. apple. com/