1 Nursing Care & Priorities for Those with Traumatic Brain Injury & Brain Tumors Keith Rischer, RN, MA, CEN

2 Todays Objectives  Differentiate the causes of traumatic brain injury.  Review pathophysiology and clinical manifestations of TBI & brain tumors.  Identify nursing priorities and client education with TBI & brain tumors.  Identify manifestations of ICP and purpose of ICP monitoring.  Prioritize nursing care with craniotomy-postop.

3 Traumatic Brain Injury  Patho Open head injury Halo sign C-spine precautions Closed head injury Concussion Mild-mod-severe  Glasgow coma scale

4 Traumatic Brain Injury  Types of force Acceleration Deceleration Coup-contrecoup  Hemorrhage Intracerebral Epidural Subdural  Diagnosis CT MRI

5 Increased Intracranial Pressure  Normal pressure  Patho  Clinical Manifestations (chart 48-5 p.1037) Decreased LOC Restlessness/irritability Headache N&V Slurred speech Pupillary changes Seizures  Brain herniation Pupil changes LOC Cheyne-stokes resp VS changes…Cushings triad

6 Nursing Interventions: I-ICP  Maintain airway and optimal ventilation  HOB elevated 15 – 30 degrees  All ADL’s increase ICP – spacing  Limit suctioning  Calm environment  Prevent hyperthermia

7 Nursing Priorities with TBI  Establish baseline  Early detection of subtle changes  Airway/breathing ABG’s  Vital signs Maintain adequate cerebral perfusion pressure (CPP) Cushings triad  Positioning  Neuro Assessment Glascow Coma Scale LOC Eye/pupils Motor Decerebrate/decorticate posturing Response to pain

8 Medical-Nursing Priorities w/Critical TBI  Drug therapy Steroids Mannitol Filter needle/tubing Furosemide Nursing priorities…  Neuromuscular blocking agents Nursing considerations…  Anti-convulsant agents  Respiratory management Managing CO2 w/vent

9 Medical-Nursing Priorities w/Critical TBI  Fluid & lyte management Diabetes Insipidus SIADH  Nutritional management Enteral tube feedings if LT  Surgical management Craniotomy ICP monitoring Intraventricular catheter

10 Brain Tumors  Patho  Complications Cerebral edema-inflammation I-ICP Focal neuro deficits Obstruction of CSF Pituatary dysfunction SIADH DI

11 Brain Tumors  Types Gliomas astrocytomas Metastatic  Clinical Manifestations Headaches N&V Visual changes Seizures Change in mentation/personality  Diagnosis  Interventions

12 Craniotomy:Post-op Priorities (p )  Nursing priorities… Detect early changes in status Prevent/minimize complications ICP  Neuro assessment  I&O  Pain control  Cardiac monitoring VS  Position  Dressing assessment  Monitoring lab values Sodium CBC ABG’s

13 Craniotomy Post-op Complications (p )  ICP Hydrocephalus  Hematomas  Hypovolemic shock  Respiratory Atelectasis Pnuemonia  Wound infection  Meningitis  Seizures  CSF leak  Fluid/lyte imbalances DI-SIADH

14 Neuro Case Study  72 yr. male w/PMH AAA  Slipped and fell in BR 2 weeks ago w/no LOC  Chief c/o headache that has continued all day and gotten worse  While in ED dramatic change in LOC Lethargic…obtunded Decerebrate posturing Intubated and paralyzed  CT rt. Occipital SDH w/midline shift

15 Neuro Case Study  To OR for immediate evacuation  CT: shows small residual hematomas  POD 1 Extubated-Is alert, MAE, follows commands lt. facial weakness, lt. hemiplegia, speech garbled  ICP 14-20…BP 176/67 Mannitol q3h for ICP >10 CPP???  Labs Na: 131/was 144 preop u/o 200cc last 8 hours. Was averaging 400cc/hr last 24 hours Creatinine 0.9

16 Neuro Case Study: POD 2  Nursing priorities…  Developed focal seizures eyes deviate to right and twitch for <1”  Cerebryx IV load & Ativan IV prn  MRI No change in SDH  Labs Na: 138 Creatinine: 1.3  Meds Ancef IV Labetolol IV prn to keep CPP 50-60

17 Neuro Case Study: POD 7  Transferred to neuro floor  Continues to have significant lt. hemiplegia w/garbled speech  PEG placed  Plan for NHP