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 injury with an occipital hematoma, bilateral wrist fractures, and a right pneumothorax. During his neurologic intensive care unit (NICU) stay, Y. W. was intubated and placed on mechanical ventilation, had a feeding 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 occurs, for example, in a car accident when the head strikes the windshield or dashboard. These injuries cause two types of brain damage. 1. Define the term primary head injury. A primary head injury (or primary impact) is also known as a “coup injury. ” The injury occurs under the site 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 site 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 prognosis depends on the amount 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 serious side effects days to weeks later. 3. What is normal intracranial pressure (ICP), and why is increased ICP so clinically important?
Normal intracranial pressure ranges from 5 to 15 mm Hg. A sustained pressure above the upper limit is considered abnormal. Pressure changes in the brain effect the brain’s compliance. Compliance 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 significant because “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 due 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 activity as a result of increased intercranial pressure. 5. List 4 medication classifications that the ICU nurses could use to decrease 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 fentanyl) •IV anesthetic sedative propofol (Diprivan) to manage anxiety and agitation. •Vecuronium (Norcuron), cisatracurium besylate (Nimbex): nondepolarizing neuromuscular blocking agents: achieve complete 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. 1436). 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 can 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 flexion—this 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 some patients with increased ICP. The nurse can use turning, skin care, and even passive range of motion. Monitor fluid and electrolyte status. Disturbances can have an adverse effect on ICP. Closely monitor IV fluids with the use of an accurate 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 piggyback (IVPB) tid. Indicate the reasons for each. •Clindamycin 150 mg per feeding tube q6h: Treatment of respiratory 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 portable 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 physician or radiologist. What is the purpose of the CXR, and why isn’t 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 confirmed 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 still 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 lab 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, WBC 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 concerned 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 count:15. 4 increased; this increased level indicates infection. This can be attributed to the patient’s 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. YM’s 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 elevate 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 keep patient nourished and also consuming enough vitamins/minerals/proteins to aide in healing. nursing staff- administer antibiotics, pain medications, and supportive care. -speech therapy- to evaluate and aide with swallowing, eating/drinking, and eventually verbal communication improvements. 12. Y. W. ’s mother 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 language is the mother’s native language. Most people are unaware 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 need to acquire an interpreter that will speak the language that best suits the mother. If the patient’s 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 with the Thai community? Hopefully the other Thai students are around or could make a suggestion for the patient’s 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 discharge 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 schedule 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 available 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/
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