TBI

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AMREF INTERNATIONAL UNIVERSITY

DEPARTMENT OF NURSING AND MIDWIFERY

KENYA REGISTERED COMMUNITY HEALTH NURSING

PRE-SERVICE PROGRAM
SEPTEMBER 2022

ASSIGNMENT: HEAD INJURY

PRESENTED BY: PALLASED WANJIRU


REG NO: SHS/DNP/6029-3/2022

PRESENTED TO: WASHIKA MAPESA

DATE: 08 JANUARY 2024


HEAD INJURY(TBI)
This is the disruption of normal brain functions due to trauma related injury resulting in compromised
neurological function.
Its a broad classification that includes injury to the scalp, skull or brain.

TYPES OF TBI
1.CONCUSSION
A cerebral concussion is a minor head injury characterised by temporary loss of neurologic function with no
apparent structural damage.
Its a damage to nerves or blood vessels in the brain often caused by an impact to the head.
May or may not cause unconsciousness.
The jarring of the brain may be so slight as to cause only dizziness and spots before the eyes or it may be severe
enough to cause complete loss of consciousness for a few seconds.

2.CEREBRAL CONTUSION
A severe injury in which the brain is bruised resulting in swollen brain tissue.
The patient is unconscious for more than a few seconds or minutes.
The patient may lie motionless, with a faint pulse, shallow respirations and cool pale skin

3.INTRACRANIAL HEMORRHAGE
Its a collection of blood(hematomas)that develops within the cranial vault.
There are three types of these hematomas;
a)INTRACEREBRAL HEMATOMA
This is collection of blood within the brain
b)EPIDURAL HEMATOMA
This is collection of blood between the skull and the dura mater.
c)SUBDURAL HEMATOMA
This is collection of blood between the dura and the arachnoid mater

4.DIFFUSE AXONAL INJURY


This is severe wide spread injury to axons in the cerebral hemisphere, corpus collosum and brain stem.

MECHANISM OF INJURY AND EFFECT


Diabetes inspidus
Diabetes inspidus is a condition where the body is unable to balance the intake and output of water as it usually
would. This imbalance in water is often due to disruptions in the way antidiuretic hormone (ADH) is produced in
the brain or responded to by the kidneys.
In many cases, diabetes insipidus after a TBI is due to small vessel damage or inflammation rather than neural
damage. In very rare cases, the hypothalamus may be injured in such a way that irregularities in the thirst
receptors occur. This can make you much more thirsty, causing you to drink more water.

SIADH
Brain contusion and brain swelling caused by TBI interfere with and disrupt the normal neuroendocrine function
of the hypothalamus and pituitary system, thus forming the syndrome of inappropriate antidiuretic hormone
secretion and triggering central hyponatremia,

DAI
A diffuse axonal injury is caused by shaking or strong rotation of the head by physical forces, such as with a car
crash. Injury occurs because the unmoving brain lags behind the movement of the skull, causing nerve structures
to tear. The tearing of the nerve tissue disrupts the brain's regular communication and chemical processes.

CLASSIFICATION OF TBI USING GCS


A. SEVERITY OF INJURY
Severity is assessed by the following methods notably using the Glasgow Coma Scale.
-Score below 8 is considered to represent severe head injury
Open head wound from crushing blows or penetrating wounds, unconsciousness exceeding 24 hours and signs of
injury appear on neuroimaging test.
-8 to 12 is assessed as moderate head injury.
Non penetrating blow to the head and violent shaking of the head, unconsciousness up to 24 hours and signs of
injury appear on neuroimaging test

-13 to 15 is mild head injury.


Occurs after falls, crash, explosive blasts and sport injuries. Loss of conscious often does not occur, but brief if it
does and signs of injury do not appear on all neuroimaging tests

SIGNS AND SYMPTOMS OF TBI


a)Confusion
b)Altered level of consciousness
c) Absent corneal reflex
d)Pupillary abnormalities(changes in shape, size and response to light)
e)Altered or absent gag reflex
f)Sudden onset of neurologic deficits
g)Vision and hearing impairment
h)vertigo
i)Headache
j)Movement disorders
k)Seizures
l)Headache
m)Spasticity
n)Sensory dysfunction
o)Changes in vital signs(altered respiratory pattern, hypertension, bradycardia, tachycardia, hypothermia or
hyperthermia)
MANAGEMENT
ABC
Airway and cervical spine;
Maintain cervical spine immobilization in all unconscious or symptomatic(neck pain or tenderness)patients.
Inspect mouth remove debris by sweeping through
Chin lift/jaw thrust (tongue is attached to the jaw) and always airway in tongue falling back
Intubations- keep the neck immobilized in neutral position. Intubate all unconscious patients(GCS <9) to secure
airway
Tracheostomy-is a procedure to help air and oxygen reach the lungs by creating an opening into the
trachea(windpipe) from outside the neck
Cricothyrotomy- its an infrequent procedure that involves placement of a tube through an incision in the
cricothyroid membranes to establish an airway for oxygenation and ventilation

Breathing-oxygenation and ventilation


Circulation and arrest of bleeding-shock is an inadequate organ perfusion and tissue oxygenation.In the trauma
patient,it is most often due to haemorrhage and hypovolemia.The diagnosis of shock is based on clinical findings;
Hypotension, hypothermia, tachycardia, tachypnea, cool extremities, pallor, decreased capillary refill and
decreased urine production

Resuscitation
First priority is to stop any obvious bleeding by Sub fascial gauze pack placement and Manual compression on the
proximal artery. Carefully applied compressive dressing of the entire injured limb can be done.
Fluids: infuse normal saline initially 2L to run as fast as possible through 2 large bore IV lines
Insert urinary catheter and monitor the input and output chart at least 30-50 ml/hour or 0.5/kg/hour of urine flow
Asses by vital signs, pallor, sweating, anxiety ,skin warmth clammy, input and output Blood transfusion must be
considered if the haemoglobin level is less than 7 g/dl and the patient is still bleeding.
Maintain HEAD INJURY OBSERVATION CHART; Monitoring the following in half , hourly or 2 hourly
Continuous monitor of level of consciousness; Best eye opening score, Best verbal response score, Best motor
response
Vital signs-pulse, temperature, blood pressure, respiratory rate
Pupillary reflexes; reaction to light, size of the pupil,
Motor examination of limbs; Spontaneous movement of all the limbs, Paralysis
Monitor danger signs; Severe headache, Vomiting, Convulsions/seizure, Drainage of fluids ear or nose
Give analgesia to relieve pain
Administer tetanus toxoid
Other general care if patient is unconscious; Bladder care , Bowel care, Physiotherapy chest and limbs, Skin care,
Analgesics
Surgical interventions should be carried depending on severity

ICP
Head Position: Raise the head of the bed and maintain the head in midline position at 30 degrees: potential to
improve cerebral blood flow by improving cerebral venous drainage.
Lower cerebral blood volume (CBV) can lower ICP.
Temperature Control: Fever should be avoided as it increases cerebral metabolic demand and affects ICP.
Seizure prophylaxis: Seizures should be avoided as they can also worsen CNS injury by increasing the metabolic
requirement and may potentially increase ICP. Consider administering fosphenytoin at a loading dose of 20mg/kg.
Only use an anticonvulsant when it is necessary, as it may inhibit brain recovery.
Fluid management: The goal is to achieve euvolemia. This will help to maintain adequate cerebral perfusion.
Hypovolemia in head trauma patients is harmful. Isotonic fluid such as normal saline or Ringer Lactate should be
used. Also, avoid hypotonic fluid.
Sedation: Consider sedation as agitation and muscular activity may increase ICP.

NURSING DIAGNOSES AND INTERVENTIONS


a)Ineffective airway clearance related to brain injury
-Administer supplemental oxygen and bronchodilators as prescribed
-Position the client upright to promote lung expansion
-Use chest physiotherapy as needed
b)Deficient fluid volume related to decreased level of consciousness and hormonal dysfunction
-Administer intravenous hydration
-Administer electrolyte replacements as needed
-Monitor intake and output
c)Ineffective cerebral tissue perfusion related to increased inter cranial pressure
-Monitor the patients bilateral motor responses
-Maintain head or neck in midline or neutral position
-Evaluate and monitor pupillary responses
d)Imbalanced nutrition, less than body requirements, related to metabolic changes, fluid restriction and inadequate
intake
-Administering enteral and parenteral nutrition
-Provide nutritional supplements as appropriate
-Provide a pleasant and quiet environment
e)Potential for impaired skin integrity related to bed rest,hemiparesis, hemiplegia and immobility
-Turn and repositioning the patient two hourly
-Use special pressure relieving mattress
-Avoid all pressure, friction and shearing

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