12. Traumatic injuries to the brain
1. Primary trauma:
1. Concussion-transient disorder due to injury in which there is brief loss of consciousness due to paralysis of neuronal function; recovery is usually total.
2. Contusion-structural alteration of brain tissue characterized by extravasation of blood cells (bruising); injury may occur on side of impact or on opposite side (when cranial contents shift forcibly within the skull with impact).
3. Laceration-tearing of brain tissue or blood vessels due to a sharp bone fragment or object or tearing force.
4. Fracture-linear (may result in epidural bleed); comminuted or depressed (may tear dura and result in CSF leak); basilar (most serious). Basilar skull fracture may result in meningitis or brain abscess; bleeding from nose or ears; CSF present in drainage; bruising over mastoid process (Battles sign) and periorbital ecchymosis (raccoon eyes).
2. Secondary trauma (response to primary trauma):
1. Hematomas:
1. Subdural-blood from ruptured or torn vein collects between arachnoid and dura; may be acute, subacute, or chronic.
2. Extradural (epidural)-blood clot located between dura mater and inner surface of skull; most often from tearing of middle meningeal artery; emergency condition.
2. Increased intracranial pressure
3. Mechanisms of injury:
1. Deformation (blow to the head).
2. Acceleration-deceleration (coup-contrecoup)-forward and rebounding motion.
3. Rotation (tension, stretching, shearing force).
4. Pathophysiology of impaired CNS functioning:
1. Depressed neuronal activity in reticular activating system-depressed consciousness
2. Depressed neuronal functioning in lower brain stem and spinal cord-depression of reflex activity-decreased eye movements, unequal pupils-decreased response to light stimuli-widely dilated and fixed pupils.
3. Depression of respiratory center-altered respiratory pattern-decreased rate respiratory arrest.
5. Risk factors: accidents-automobile, industrial and home, motorcycle, military.
6. Assessment:
1. Objective data:
1. Headache.
2. Dizziness, loss of balance.
3. Double vision.
4. Nausea.
2. Objective data:
1. Laceration or abrasion around face or head; profuse bleeding from scalp (highly vascular, poor vasoconstrictive abilities).
2. Drainage from ears or nose (serosanguineous).
3. Projectile vomiting, hematemesis.
4. Vital signs indicating increased intracranial pressure
5. Neurological exam:
1. Altered level of consciousness; a numerical assessment, such as the Glasgow Coma Scale, may be used. The lower the score, the poorer the prognosis, generally.
2. Pupils-equal, round, react to light; or unequal, dilated, unresponsive to light.
3. Extremities-paresis or paralysis.
4. Reflexes-hypotonia or hypertonia; Babinski present (flaring of great toe when sole is stroked).
7. Analysis/nursing diagnosis:
1. Altered thought processes related to brain trauma.
2. Sensory/perceptual alteration related to depressed neuronal activity.
3. Risk for injury related to impaired CNS functioning.
4. Risk for aspiration related to respiratory depression.
5. Self-care deficit related to altered level of consciousness.
6. Ineffective breathing pattern related to CNS trauma.
8. Nursing care plan/implementation:
1. Goal: sustain vital functions and minimize or prevent complications.
1. Patent airway: endotracheal tube or tracheostomy may be ordered.
2. Oxygen: as ordered (hypoxia increases cerebral edema).
3. Be Position: semiprone or prone (coma position) with head level to prevent aspiration (keep off back); turn side to side to prevent stasis in lungs.
4. Vital signs as ordered.
5. Neurological check: pupils, level of consciousness, muscle strength; report changes.
6. Seizure precautions: padded side rails.
7. Medications as ordered:
1. Steroids (dexamethasone [Decadron]).
2. Anticonvulsants (phenytoin [Dilantin], phenobarbital).
3. Analgesics (morphine contraindicated).
8. Cooling measures or hypothermia to reduce elevated temperature.
9. Assist with diagnostic tests:
1. Lumbar puncture (contraindicated with increased intracranial pressure).
2. Electroencephalogram (EEG).
10. Diet: NPO for 24 hours, progressing to clear liquids if awake.
11. Fluids: IVs; nasogastric tube feedings; I&O.
12. Monitor blood chemistries: sodium imbalance common with head injuries.
2. Goal: provide emotional support and use comfort measures.
1. Comfort: skin care, oral hygiene; sheepskins; wrinkle-free linen.
2. Eyes: lubricate q4h with artificial tears if periocular edema present.
3. ROM-passive, active; physical therapy as tolerated.
4. Avoid restraints.
5. Encourage verbalization of concerns about changes in body image, limitations.
6. Encourage family communication.
9. Evaluation/outcome criteria:
1. Alert, oriented-no residual effects (cognitive processes intact).
2. No signs of increased intracranial pressure (decreased respirations, increased systolic pressure with widening pulse pressure, bradycardia).
3. No paralysisregains motor/sensory function.
4. Resumes self-care activities.

Levels of Consciousness

Glasgow Coma Scale