1. Neurosensory: Traumatic Brain Injury (TBI) & Brain Tumors
Marnie Quick, RN, MSN, CNRN

2. Normal brain protected by:

3. Normal brain

7. Traumatic Brain Injury (TBI): Etiology/Pathophysiology
Risk factors- MVA; elevated blood alcohol; contact sports; acts of violence- gun, knife
Mechanism of craniocerebral trauma
Acceleration (movement)-deceleration (stationary)
Coup (impact)-contrecoup (opposite) phenomenon
Blunt or penetrating injury
Closed head injury
Scalp lacerations
Skull fractures- Linear; comminuted; depressed; basilar; open/closed

8. Coup-contracoup injury

10. Penetrating injury- Gunshot to brain

11. Penetrating injury: Knife in brain

12. Basilar skull fracture- Base of skull fractured

13. Basilar skull fracture is base of skull if posterior> Battle sign- ecchymosis behind the ear

14. Basilar skull fracture is more anterior Raccoon eyes- periorbital ecchymosis

15. Basilar Skull fractures can cause leakage of CSF from meninges

16. Minor Brain Injury
Concussion- sudden transient disruption of neural activity in the brain with change in LOC
Post Concussion Syndrome- may occur after other brain injuries- severity of symptoms are not related to severity of brain injury. Sym may persist wks-months

17. Major Brain Injury- Focal injury
Brain contusion- bruising; coup-contracoup
Brain laceration- tearing brain tissue, ICH
DAI- diffuse axonal injruy
Widespread disruption of axons
Poor prognosis
Brain bleeds- Note meninges in relation to bleeds on following slides

19. Epidural hematoma

20. Subdural hematoma (SDH)

21. Intracerebral hematoma

22. Secondary brain injury
Cerebral edema
Localized or diffuse
Peaks hrs
Occurs with CHI; open head injury; anoxia
May in itself cause death by pressure> herniation
Increased ICP
Herniation Syndromes

23. Traumatic Brain Injury (TBI): Common Manifestations/Complications
Increased ICP symptoms general and specific
Restlessness- R/O respiratory; waking up
Systemic effects of acute brain injury- hypermetabolism, brainstorming, SIADH
Brainstorming- hypothalamic stimulation-ANS
CSF leak- rhinorrhea/otorrhea- basal skull Fx
Post concussion Syndrome
Associated cervical spinal cord injury

24. Collaborative Care: Traumatic Brain Injury (TBI):
Diagnostic studies (similar to ICP)
Emergency management: assessment and interventions (Lewis 1484 Table 57-9)
Treat IICP- airway; fluid; positioning; temp reg; meds
Prevention of complications
Medications: IICP; seizures; stress ulcer;straining;brainstorming
Diet/calories: hypermetabolic state; ileus; swallow/gag
CSF leak: glucose; halo; HOB 30; no nasal suction
Other: SIADH> hyponatremia
Surgery: bone repair; evacuation clot; craniotomy/ectomy; burr hole; cranioplasty; monitor placement

25. Burr holes craniotomy

26. Place monitors/intraventricular drain:

27. Crainectomy- bone flap out to allow for brain expansion post op

28. Post crani

29. Traumatic Brain Injury (TBI): Nursing assessment specific to TBI
Health history
Description of accident; past medical history
NVS and Glasgow Coma
Brainstem reflexes
VS- Late sign is Cushing reflex
Skull/face; CSF leak; SCI
Consider older adult finding

30. Pertinent Nursing Problems Specific to Traumatic Brain Injury (TBI):
Health promotion
Ineffective tissue perfusion, cerebral (decreased intracranial adaptive capacity)
Ineffective airway clearance/breathing pattern
Hypothermia
Pain
Impaired physical mobility

31. Decreased cerebral perfusion (IICP)
Anxiety
Decreased cerebral perfusion (IICP)
Brain death (ethical dilemmas p.1485)
Home care
Home evaluation/rehab/nursing home
Teach about post concussion syndrome; B&B; spasticity; dysphagia; nutrition; seizure disorder; personality changes; family role changes
6 months typical plateau period
Community agencies/support groups

32. http://library. med. utah

33. Primary brain tumors
Arise from support cells, neurogilia cells; the meninges; or blood vessels
Do not metastasize outside cranium
Cause unknown

34. Grade I and II gilomas (astrocytoma) made up of astrocytes; are benign, slow-growing tumors
Grade III and IV gliomas (glioblastoma Multiforme are invasive and fast-growing
Meningiomas arise from the meninges; slow-growing; benign, encapsulated and compress the brain
Brain tumors may be lethal due to their location

35. Gioblastoma Meningioma

37. Metastatic (secondary) brain tumors
Originate from outside the brain- lung and breast most common sites
Single or multiple
Becoming more common as individual with cancer in other parts of the body are living longer

38. Clinical Manifestations/complications of Brain tumors
General ICP symptoms
Common early symptoms: headache; vomiting; papilledema (visual changes)
Seizures- partial classification in type
Brain tumor symptoms occur due to their ability to compress or destroy brain tissue; edema that forms around the tumor; hemorrhage; & obstruction of CSF flow
Specific symptoms as to the lobe affected>

40. Frontal lobe: personality changes; inappropriate behavior; inability to concentrate; impaired judgment; headache; expressive aphasia if dominant hemisphere; motor weakness or paralysis from motor strip
Parietal lobe: sensory deficits- paresthesia, visual field deficits; contralateral sensory disturbances from sensory strip; loss of interpretation and discrimination for sensing input; perceptual problems

41. Occipital lobe: visual disturbances; visual agnosia
Temporal lobe: complex partial (psychomotor) seizures; auditory hallucinations; memory problems; Wernicke aphasia if dominant hemisphere
Cerebellum: gait distrubances; balance and coordination problems
Brain stem: cranial nerve dysfunction; vital signs

42. Complications of Brain Tumors
Hydrocephalus
Infection
Death is usually caused by IICP/hermiation

43. Collaborative Care for Brain Tumors Diagnostic tests
CT/MRI
EEG
PET
Angiogram
Tissue biopsy

44. Collaborative Care for brain tumors
Surgery
To remove or debulk
Supratentorial- above tentorium
Infratentorial-below
Stereotaxic-localized

45. Rehab- outpatient or in house
Radiation
Used alone or with other therapies
Gamma or Cyber-knife
Complication- increased cerebral edema
Medications
Chemotherapy: IV; intraventricular (ommaya Reservoir) or by wafer implanted
Corticosteroids to treat brain edema
Anticonvulsants to prevent seizures
Rehab- outpatient or in house

46. Health history: progression of symptoms; other cancers, disease
Physical exam
Neuro vital signs
Specific signs of the local functions of different parts of the brain
Similar neuro deficits as the individual with a stroke
Signs of increased intracranial pressure/herniation

47. Pertinent Nursing Problems for Brain Tumor
Impaired tissue perfusion, cerebral
Self-care deficits
Anxiety
Risk for infection-post crani
Acute pain
Disturbed self-esteem
Nutrition
Home care- rehab; home eval; support groups