NURSING PROCESS: THE PATIENT WITH A BRAIN INJURY
Depending on the patient’s neurologic status, the nurse may elicit information from the patient, family, or witnesses or from emer-gency rescue personnel (Munro, 2000). Although it may not be possible to obtain all usual baseline data initially, the immediate health history should include the following questions:
· When did the injury occur?
· What caused the injury? A high-velocity missile? An object striking the head? A fall?
· What was the direction and force of the blow?
Since a history of unconsciousness or amnesia after a head in-jury indicates a significant degree of brain damage, and since changes that occur minutes to hours after the initial injury can re-flect recovery or indicate the development of secondary brain damage, the nurse should try to determine if there was a loss of consciousness, what the duration of the unconscious period was, and if the patient could be aroused.
In addition to questions that establish the nature of the injury and the patient’s condition immediately after the injury, the nurse should examine the patient thoroughly. This assessment should include determining the patient’s LOC, ability to respond to verbal commands (if conscious), response to tactile stimuli (if unconscious), pupillary response to light, status of corneal and gag reflexes, motor function, and Glasgow Coma Scale score (Chart 63-4).
Additional detailed neurologic and systems assessments are made initially and at frequent intervals throughout the acute phase of care (Dibsie, 1998). The baseline and ongoing assess-ments are critical nursing interventions for the brain-injured patient, whose condition can worsen dramatically and irrevocably if subtle signs are overlooked. More information on assessment is provided below and in Figure 63-5 and Table 63-1.
Based on the assessment data, the patient’s major nursing diag-noses may include the following:
· Ineffective airway clearance and impaired gas exchange re-lated to brain injury
· Ineffective cerebral tissue perfusion related to increased ICP and decreased CPP
· Deficient fluid volume related to decreased LOC and hor-monal dysfunction
· Imbalanced nutrition, less than body requirements, related to metabolic changes, fluid restriction, and inadequate intake
· Risk for injury (self-directed and directed at others) related to seizures, disorientation, restlessness, or brain damage
· Risk for imbalanced (increased) body temperature related to damaged temperature-regulating mechanism
· Potential for impaired skin integrity related to bed rest, hemiparesis, hemiplegia, and immobility
· Disturbed thought processes (deficits in intellectual function, communication, memory, information processing) related to brain injury
· Potential for disturbed sleep pattern related to brain injury and frequent neurologic checks
· Potential for compromised family coping related to un-responsiveness of patient, unpredictability of outcome, pro-longed recovery period, and the patient’s residual physical and emotional deficit
· Deficient knowledge about recovery and the rehabilitation process
The nursing diagnoses for the unconscious patient and the patient with increased ICP also apply.
Based on all the assessment data, the major complications include the following:
· Decreased cerebral perfusion
· Cerebral edema and herniation
· Impaired oxygenation and ventilation
· Impaired fluid, electrolyte, and nutritional balance
· Risk of post-traumatic seizures
The goals for the patient may include maintenance of a patent airway, adequate CPP, fluid and electrolyte balance, adequate nutritional status, prevention of secondary injury, maintenance of normal body temperature, maintenance of skin integrity, im-provement of cognitive function, prevention of sleep deprivation, effective family coping, increased knowledge about the rehabili-tation process, and absence of complications.
The nursing interventions for the patient with a head injury are extensive and diverse; they include making nursing assessments, setting priorities for nursing interventions, anticipating needs and complications, and initiating rehabilitation.
The importance of ongoing assessment and monitoring of the brain-injured patient cannot be overstated. The following para-meters are assessed initially and as frequently as the patient’s condition requires. As soon as the initial assessment is made, the use of a neurologic flow chart is started and maintained.
The LOC is regularly assessed because changes in it precede all other changes in vital and neurologic signs. The Glasgow Coma Scale, which is used to assess LOC, is based on the three criteria of eye opening, verbal responses, and motor responses to verbal commands or painful stimuli. It is particularly useful for monitoring changes during the acute phase, the first few days after a head injury. It does not take the place of an in-depth neurologic assessment; rather, it is used to monitor the patient’s motor, verbal, and eye-opening responses. The pa-tient’s best responses to predetermined stimuli are recorded (see Chart 63-4). Each response is scored (the greater the num-ber the better the functioning), and the sum of these scores gives an indication of the severity of coma and a prediction of possible outcome. The lowest score is 3 (least responsive); the highest is 15 (most responsive). A score of 8 or less is generally accepted as indicating a severe head injury (Teasdale & Jennett, 1974).
Although a change in LOC is the most sensitive neurologic indi-cation of deterioration of the patient’s condition, vital signs are monitored at frequent intervals also to assess the intracranial sta-tus. Table 63-1 depicts the general assessment parameters for the patient with a head injury.
Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure. As brain compression increases, respirations be-come rapid, the blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs (March, 2000). A rapid rise in body temperature is regarded as unfavorable because hyperthermia increases the meta-bolic demands of the brain and may indicate brain stem damage, a poor prognostic sign. The temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.
Motor function is assessed frequently by observing spontaneous movements, asking the patient to raise and lower the extremities, and comparing the strength and equality of the hand grasp and pedal push at periodic intervals. To assess the hand grasp, the nurse instructs the patient to squeeze the examiner’s fingers tightly. The nurse assesses lower extremity motor strength (pedal push) by placing the hands on the soles of the patient’s feet and asking the patient to push down against the examiner’s hands. The presence or absence of spontaneous movement of each extremity is also noted, and speech and eye signs are assessed.
If the patient does not demonstrate spontaneous movement, responses to painful stimuli are assessed. Motor response to pain is assessed by applying a central stimulus, such as pinching the pectoralis major muscle, to determine the patient’s best response. Peripheral stimulation may provide inaccurate assessment data because it may result in a reflex movement rather than a voluntary motor response. Abnormal responses (lack of motor response; extension responses) are associated with a poorer prognosis.
In addition to the patient’s spontaneous eye opening evaluated with the Glasgow Coma Scale, the size and equality of the pupils and their reaction to light are assessed. A unilaterally dilated and poorly responding pupil may indicate a developing hematoma, with subsequent pressure on the third cranial nerve due to shift-ing of the brain. If both pupils become fixed and dilated, this in-dicates overwhelming injury and intrinsic damage to the upper brain stem and is a poor prognostic sign.
The patient with a head injury may develop focal nerve palsies such as anosmia (lack of sense of smell) or eye movement abnor-malities and focal neurologic deficits such as aphasia, memory deficits, and post-traumatic seizures or epilepsy. Patients may be left with residual organic psychological deficits (impulsiveness, emotional lability, or uninhibited, aggressive behaviors) and, as a consequence of the impairment, lack insight into their emotional responses (Davis, 2000).
One of the most important nursing goals in the management of the patient with a head injury is to establish and maintain an ad-equate airway. The brain is extremely sensitive to hypoxia, and a neurologic deficit can worsen if the patient is hypoxic. Therapy is directed toward maintaining optimal oxygenation to preserve cerebral function. An obstructed airway causes CO2 retention and hypoventilation, which can produce cerebral vessel dilation and increased ICP.
Interventions to ensure an adequate exchange of air and include the following:
· Keep the unconscious patient in a position that facilitates drainage of oral secretions, with the head of the bed elevated about 30 degrees to decrease intracranial venous pressure (Bader & Palmer, 2000).
· Establish effective suctioning procedures (pulmonary secre-tions produce coughing and straining, which increase ICP).
· Guard against aspiration and respiratory insufficiency.
· Closely monitor arterial blood gas values to assess the ade-quacy of ventilation. The goal is to keep blood gas values within the normal range to ensure adequate cerebral blood flow.
· Monitor the patient who is receiving mechanical ventilation.
· Monitor for pulmonary complications such as acute respi-ratory distress syndrome (ARDS) and pneumonia (Munro, 2000).
Brain damage can produce metabolic and hormonal dysfunctions. The monitoring of serum electrolyte levels is important, especially in patients receiving osmotic diuretics, those with inappropriate antidiuretic hormone secretion, and those with post-traumatic diabetes insipidus.
Serial studies of blood and urine electrolytes and osmolality are carried out because head injuries may be accompanied by dis-orders of sodium regulation. Hyponatremia is common follow-ing head injury due to shifts in extracellular fluid, electrolytes, and volume. Hyperglycemia, for example, may cause an increase in extracellular fluid that lowers sodium (Hickey, 2003). Hyper-natremia may also occur due to sodium retention that may last several days, followed by sodium diuresis. Increasing lethargy, confusion, and seizures may be due to electrolyte imbalance.
Endocrine function is evaluated by monitoring serum elec-trolytes, blood glucose values, and intake and output. Urine is tested regularly for acetone. A record of daily weights is main-tained, especially if the patient has hypothalamic involvement and is at risk for the development of diabetes insipidus.
Head injury results in metabolic changes that increase calorie consumption and nitrogen excretion (Donaldson et al., 2000). There is an increased demand for protein. As soon as possible, nu-trition should be provided. Early initiation of nutritional therapy has been shown to improve outcomes in head-injured patients (Bader & Palmer, 2000). Parenteral nutrition via a central line or enteral feedings administered via a nasogastric or nasojejunal feeding tube may be used. If there is discharge of CSF from the nose (CSF rhinorrhea), an oral feeding tube should be inserted in place of a nasal tube.
Laboratory values should be monitored closely in patients re-ceiving parenteral nutrition. Elevating the head of the bed and as-pirating the enteral tube for evidence of residual feeding before administering additional feedings can help prevent distention, re-gurgitation, and aspiration. A continuous-drip infusion or pump may be used to regulate the feeding. Enteral or par-enteral feedings are usually continued until the swallowing reflex returns and the patient can meet caloric requirements orally.
As the patient emerges from coma, there is often a period of lethargy and stupor followed by a period of agitation. Each phase is variable and depends on the individual, the location of the in-jury, the depth and duration of coma, and the patient’s age. The patient emerging from a coma may become increasingly agitated toward the end of the day. Restlessness may be due to hypoxia, fever, pain, or a full bladder. It may indicate injury to the brain but may also be a sign that the patient is regaining consciousness. (Some restlessness may be beneficial because the lungs and extremities are exercised.) Agitation may also be due to discomfort from catheters, intravenous lines, restraints, and repeated neurologic checks. Alter-natives to restraints must be used whenever possible.
Strategies to prevent injury include the following:
· Assess the patient to ensure that oxygenation is adequate and the bladder is not distended. Check dressings and casts for constriction.
· To protect the patient from self-injury and dislodging of tubes, use padded side rails or wrap the patient’s hands in mitts (Fig. 63-6). Restraints are avoided because straining against them can increase ICP or cause other injury. En-closed or floor-level specialty beds may be indicated.
· Avoid using opioids as a means of controlling restlessness because these medications depress respiration, constrict the pupils, and alter responsiveness.
· Minimize environmental stimuli by keeping the room quiet, limiting visitors, speaking calmly, and providing fre-quent orientation information (eg, explaining where the pa-tient is and what is being done).
· Provide adequate lighting to prevent visual hallucinations.
· Minimize disruption of the patient’s sleep/wake cycles.
· Lubricate the skin with oil or emollient lotion to prevent irritation due to rubbing against the sheet.
· If incontinence occurs, consider use of an external sheath catheter on a male patient. Because prolonged use of an in-dwelling catheter inevitably produces infection, the patient may be placed on an intermittent catheterization schedule.
An increase in body temperature in the head-injured patient can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the patient’s temperature every 4 hours. If the temperature rises, efforts are undertaken to identify the cause and to control it using acetamin-ophen and cooling blankets as prescribed (Bader & Palmer, 2000). Cooling blankets should be used with caution so as not to induce shivering, which increases ICP. If infection is suspected, potential sites of infection are cultured and antibiotics are pre-scribed and administered.
Patients with traumatic head injury often require assistance in turning and positioning because of immobility or unconscious-ness. Prolonged pressure on the tissues will decrease circulation and lead to tissue necrosis. Potential areas of breakdown need to be identified early to avoid the development of pressure ulcers. Specific nursing measures include the following:
· Assess all body surfaces and document skin integrity at least every 8 hours.
· Turn and reposition the patient every 2 hours.
· Provide skin care every 4 hours.
· Assist patient to get out of bed to a chair three times a day if physically able.
Although many patients with head injury survive because of re-suscitative and supportive technology, they frequently have sig-nificant cognitive sequelae that may not be detected during the acute phase of injury. Cognitive impairment includes memory deficits, decreased ability to focus and sustain attention to a task (distractibility), reduced ability to process information, and slow-ness in thinking, perceiving, communicating, reading, and writ-ing. Psychiatric or emotional problems develop in as many as 44% of patients with head injury (van Reekum et al., 2000). Re-sulting psychosocial, behavioral, emotional, and cognitive im-pairments are devastating to the family as well as to the patient (Davis, 2000; Perlesz, Kinsella, & Crowe, 1999).
These problems require collaboration among many disciplines (Bader & Palmer, 2000). A neuropsychologist (specialist in eval-uating and treating cognitive problems) plans a program and ini-tiates therapy or counseling to help the patient reach maximal potential. Cognitive rehabilitation activities help the patient to devise new problem-solving strategies. The retraining is carried out over an extended period and may include the use of sensory stimulation and reinforcement, behavior modification, reality orientation, computer-training programs, and video games. As-sistance from many disciplines is necessary during this phase of recovery. Even if intellectual ability does not improve, social and behavioral abilities may.
The patient recovering from a brain injury may experience fluctuations in the level of cognitive function, with orientation, attention, and memory frequently affected. When pushed to a level greater than the impaired cortical functioning allows, the patientmay show symptoms of fatigue, anger, and stress (headache, dizziness). The Rancho Los Amigos Level of Cognitive Function is a scale frequently used to assess cognitive function and evalu-ate ongoing recovery from head injury. Nursing management and a description of each level are included in Table 63-2.
Patients who require frequent monitoring of neurologic status may experience sleep deprivation. They are awakened hourly to assess LOC and as a result are deprived of long periods of sleep and rest. In an effort to allow the patient longer times of uninter-rupted sleep and rest, the nurse can group nursing care activities so that the patient is disturbed less frequently. Environmental noise is decreased and the room lights are dimmed. Back rubs and other activities to increase comfort can assist in promoting sleep and rest.
Having a loved one sustain a serious head injury can produce a great deal of prolonged stress in the family. This stress can result from the patient’s physical and emotional deficits, the unpre-dictable outcome, and altered family relationships. Families report difficulties in coping with changes in the patient’s temperament, behavior, and personality. Such changes are associated with dis-ruption in family cohesion, loss of leisure pursuits, and loss of work capacity, as well as social isolation of the caretaker. The family may experience anger, grief, guilt, and denial in recurring cycles (Perlesz et al., 1999).
To promote effective coping, the nurse can ask the family how the patient is different at this time: What has been lost? What is most difficult about coping with this situation? Helpful inter-ventions include providing family members with accurate and honest information and encouraging them to continue to set well-defined, mutual, short-term goals. Family counseling helps address the family members’ overwhelming feelings of loss and helplessness and gives them guidance for the management of in-appropriate behaviors. Support groups help the family members share problems, develop insight, gain information, network, and gain assistance in maintaining realistic expectations and hope.
The National Head Injury Foundation serves as a clearing-house for information and resources for patients with head in-juries and their families, including specific information on coma, rehabilitation, behavioral consequences of head injury, and fam-ily issues. This organization can provide names of facilities and professionals who work with patients with head injuries and can assist families in organizing local support groups.
Many patients with severe head injury die of their injuries, and many of those who survive experience long-term problems that prevent them from resuming their previous roles and functions. During the most acute phase of injury, family members need sup-port and facts from the health care team.
Many individuals with severe head injuries that result in brain death are young and otherwise healthy and are therefore consid-ered for organ donation. Family members of patients with such injuries need support during this extremely stressful time and as-sistance in making decisions to end life support and permit do-nation of organs. They need to know that the brain-dead patient whose respiratory and cardiovascular systems are maintained through life support is not going to survive and that the severe head injury, not the removal of the patient’s organs or the re-moval of life support, is the cause of patient’s death. Bereavement counselors and members of the organ procurement team areoften very helpful to family members in making decisions about organ donation and in helping them cope with stress.
Maintenance of adequate CPP is important to prevent serious complications of head injury due to decreased cerebral perfusion (Bader & Palmer, 2000; March, 2000). Adequate CPP is greater than 70 mm Hg. Any decrease in this pressure can impair cerebral perfusion and cause brain hypoxia and ischemia, leading to per-manent damage. Therapy (eg, elevation of the head of the bed and increased intravenous fluids) is directed toward decreasing cerebral edema and increasing venous outflow from the brain. Systemic hypotension, which causes vasoconstriction and a signif-icant decrease in CPP, is treated with increased intravenous fluids.
The patient with a head injury is at risk for additional complica-tions such as increased ICP and brain stem herniation. Cerebral edema is the most common cause of increased ICP in the patient with a head injury, with the swelling peaking approximately 48 to 72 hours after injury. Bleeding also may increase the volume of contents within the rigid closed compartment of the skull, causing increased ICP and herniation of the brain stem and re-sulting in irreversible brain anoxia and brain death.
Impaired oxygen and ventilation may necessitate mechanical ven-tilatory support. The patient must be monitored for a patent air-way, altered breathing patterns, and hypoxemia and pneumonia. Interventions may include endotracheal intubation, mechanical ventilation, and positive end-expiratory pressure.
Fluid, electrolyte, and nutritional imbalances are common in the patient with a head injury. Common imbalances may include hyponatremia, which is often associated with the syndrome of in-appropriate secretion of antidiuretic hormone (see Chaps. 14 and 42), hypokalemia, and hyperglycemia (Hickey, 2003). Modifica-tions in fluid intake with tube feedings or intravenous fluids may be necessary to treat these imbalances. Insulin administra-tion may be prescribed to treat hyperglycemia.
Undernutrition is also a common problem in response to the increased metabolic needs associated with severe head injury. If the patient cannot eat, enteral feedings or parenteral nutrition may be initiated within 24 hours of injury to provide adequate calories and nutrients.
Patients with head injury are at an increased risk for post-traumatic seizures. Post-traumatic seizures are classified as im-mediate (within 24 hours of injury), early (within 1 to 7 days of injury), or late (more than 7 days following injury) (Kado & Patel, 1999). Seizure prophylaxis refers to the practice of administering antiseizure medications to patients following head injury to pre-vent seizures. It is important to prevent post-traumatic seizures, especially in the immediate and early phase of recovery, as seizures may increase ICP and decrease oxygenation.
Many antiseizure medications impair cognitive performance, prolonging the dura-tion of rehabilitation. Therefore, it is important to weigh the overall benefit of these medications against their side effects. Currently, there is no conclusive evidence that long-term antiseizure prophylaxis improves outcomes in patients with head in-jury. Research evidence supports the use of prophylactic antiseizure agents to prevent immediate and early seizure after head injury, but not for prevention of late seizures (Brain Trauma Foundation, American Association of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, 2000).
Nurses must assess patients carefully for the development of post-traumatic seizures. Risk factors that increase the likelihood of seizures are brain contusion with subdural hematoma, skull fracture, loss of consciousness or amnesia of 1 day or more, and age over 65 years (Annegers & Coan, 2000).
Other complications after traumatic head injury include sys-temic infections (pneumonia, urinary tract infection [UTI], sep-ticemia), neurosurgical infections (wound infection, osteomyelitis, meningitis, ventriculitis, brain abscess), and heterotrophic ossifi-cation (painful bone overgrowth in weight-bearing joints).
Teaching early in the course of head injury often focuses on re-inforcing information given to the family about the patient’s con-dition and prognosis. As the patient’s status and expected outcome change over time, family teaching may focus on interpretation and explanation of changes in the patient’s physical and psycho-logical responses.
If the patient’s physical status allows him or her to be dis-charged home, the patient and family are instructed about limi-tations that can be expected and complications that may occur. Monitoring for complications that merit contacting the neuro-surgeon is explained to the patient and family verbally and in writing. Depending on the patient’s prognosis and physical and cognitive status, the patient may be included in teaching about self-care management strategies.
Because of the risk for post-traumatic seizures, antiseizure med-ications may be prescribed for 1 to 2 years after injury. The patient and family require instruction about the side effects of these med-ications and about the importance of continuing to take them as prescribed.
Rehabilitation of the patient with a head injury begins at the time of injury and extends into the home and community. Depending on the degree of brain damage, the patient may be referred to a rehabilitation setting that specializes in cognitive restructuring of the brain-injured patient. The patient is encouraged to continue the rehabilitation program after discharge because improvement in status may continue 3 or more years after injury. Changes in the head-injured patient and the effects of long-term rehabilitation on the family and their coping abilities need frequent assessment. Teaching and continued support of the patient and family are es-sential as their needs and the patient’s status change. Teaching points to address with the family of the head-injured patient who is about to return home are described in Chart 63-6.
Depending on his or her status, the patient is encouraged to return to normal activities gradually. Referral to support groups and the National Head Injury Foundation may be warranted.
During the acute and rehabilitation phase of care, the focus of teaching is on obvious needs, issues, and deficits. The nurse needs to remind patients and family members of the need for continuing health promotion and screening practices following these initial phases. Patients who have not been involved in these practices in the past are educated about their importance and are referred to appropriate health care providers.
Expected patient outcomes may include:
1) Attains or maintains effective airway clearance, ventilation, and brain oxygenation
a) Achieves normal blood gas values and has normal breath sounds on auscultation
b) Mobilizes and clears secretions
2) Achieves satisfactory fluid and electrolyte balance
a) Demonstrates serum electrolytes within normal range
b) Has no clinical signs of dehydration or overhydration
3) Attains adequate nutritional status
a) Has less than 50 mL of aspirate in stomach before each tube feeding
b) Is free of gastric distention and vomiting
c) Shows minimal weight loss
4) Avoids injury
a) Shows lessening agitation and restlessness
b) Is oriented to time, place, and person
5) Does not have a fever
6) Demonstrates intact skin integrity
a) Exhibits no redness or breaks in skin integrity
b) Exhibits no pressure ulcers
7) Shows improvement in cognitive function and improved memory
8) Demonstrates normal sleep/wake cycle
9) Demonstrates absence of complications
a) Exhibits normal ICP, normal vital signs and body temperature, and increasing orientation to time, place, and person
b) Demonstrates reduced ICP
10) Patient experiences no post-traumatic seizures
a) Takes antiseizure medications as prescribed
b) Identifies side effects/adverse effects of antiseizure medications
11) Demonstrate adaptive coping mechanisms for family members
a) Join support group
b) Share feelings with appropriate health care personnel
c) Make end-of-life decisions, if needed
12) Participate in rehabilitation process as indicated for pa-tient and family members
a) Take active role in identifying rehabilitation goals and participating in recommended patient care activities
b) Prepare for discharge of patient