head injury presented by: remya gopinath. demographic data name: case no.4 mr no : 185840 diagnosis...

Head injury Presented by: Remya Gopinath

DEMOGRAPHIC DATA Name: Case No.4 MR No : 185840 Diagnosis : RTA WITH HEAD INJURY Age: 6 YRS Gender: Male Date of admission: 2/10/2012

PHYSICAL ASSESSMENT GENERAL ASSESSMENT: Patient is bedridden, lying over bed with tracheostomy and NGT in situ. SKIN: Normal in state, warm To touch. No sores or redness present all over the body. HEAD AND NECK: Head is slightly extended. No visible injury noted in the scalp area.Involuntary eye movement present.5mm tracheostomy tube present over neck region.

RESPIRATORY: Respiration through tracheostomy tube with in normal rate. Cough with mild to moderate secretion present.spo2 maintaining on room air. Thorax is symmetrical in size. CARDIOVASCULAR: No deformities noted. GENITOURINARY: self voiding on diaper GASTROINTESTINAL : Abdomen is soft, not distended. Feeding via NGT.Bowel sound present.

MUSCULO-SKELETAL : All limbs are spastic with flexed upper extremities and extended lower extremities. Mild spontaneous limb movement present. Displaced fracture is seen in middle of left clavicle. NEUROLOGY : Patient is semi conscious.pupils are bilaterally reacting to light.Bilatral flexure response to painful stimuli.GCS E4V T M3.

Patient history Past medical history Patient was in normal healthy living until the day of accident. Present medical history Patient received in ER on 2/10/2012 after being involved in RTA with an unconscious and irritable state. Vomiting and loc at scene for 5 minutes. On examination vital signs are Pulse-103/mt, BP-120/70,Temp,36.7 *c,SPO2 -94%,GCS 8/15. Pupils are bilaterally reacting to light. Limb movements are equal and normal in all 4 limb.NCCT brain shows SAH in right fronto_parietal lobe,diffuse brain edema,small hemorrhage in the 4 th ventricle and opacification in all paranasal sinuses. Scalp swelling is seen in left parital area and no fracture is seen in cranial vault.

After the initial management patient shifted to ICU.On 8 th day of admission,patient developed tachypnoea,for which he investigated and found to have collapse of right lung. Intubation done and relaxant started with Inj.Midazolam and Inj.Fentanyl.Tracheostomy done on 13/12/2012.The repeat NCCT on 28/10/2012,which shows subdural haematoma with midline shift 4mm.Right frontal and parietal burrhole with evacuation of subdural hygroma done. After 2 months of admission clinically patient is opening eyes, bilateral flexure response to pain. All limbs are spastic,pupils both equal reacting,afebrile,on NGT feeding with pediasure q 4h.patient shifted to pedia ward for further management.

DEVELOPMENTAL MILESTONES CHILDS AGE MASTERED SKILLS 1 MONTH Lifts head when lying on tummy. Respond to sound. Stares at faces. 2 MONTHS Vocalizes: gurgles and coos. Follows objects across field of vision. Notices his hands. Holds head up for short periods. 3 MONTHS Recognizes your face and scent. Holds head steady. Visually tracks moving objects. 4 MONTHS Smiles, laughs. Can bear weight on legs. Coos when you talk to him. 5 MONTHS Distinguishes between bold colors. Plays with his hands and feet. 6 MONTHSTurns toward sounds and voices limits sounds roll over in both

CHILDS AGE MASTERED SKILLS 7 MONTHSSits without support. Drags objects toward herself. 8 MONTHSSays mama or dada to parents. Passes objects from hand to hand. 9 MONTHSStands while holding onto something. Jabbers or combines syllables. Understands object permanence. 10 MONTHSWaves good bye. Picks things up with pincer grasp. Crawls well, with belly off the ground. 11 MONTHS Says mama or dada to the correct parent. Plays patty- cake and peek-a-boo. Stands alone for a couple of seconds. 12 MONTHSImitates others activities. Indicates wants with gestures.

CHILDS AGE MASTERED SKILLS 13 MONTHS Stands without support 14 MONTHS Pull things out 15 MONTHSPlays with ball, Learns about 5 words, Can walk backward 16 MONTHSCan turn the pages a book, Has toddler temper 17 MONTHSVocabulary increases, Loves to play pretended games 18 MONTHSLoves to watch the pictures.

CHILDS AGE MASTERED SKILLS 19 MONTHSLearns to use a spoon and fork, Runs, Throws ball 20 MONTHSCan take off own clothes with help, Can imitate actions 21 MONTHSCan walk up stairs, Keeping a toy in its place 22 MONTHSCan kick a ball forward, Imitates others behavior 23 MONTHSNames simple pictures in a book, Learns and uses about 50 words 24 MONTHSCan make short sentences

2-3 YEARS OF AGE SHOWS AFFECTION FOR OTHERS IS ABLE TO PLAY BY HIMSEF OR HERSELF IMITATES BEHAVIOR RUNS FOEWARD HELP DRESS AND UNDRESS THEMSELVES HOLDS A PENCIL IN A WRITING POSITION USES 2 OR 3 WORD SENTENCES UNDERSTANDS DIFFERENCES IN MEANING (stop,go,up &down)

3-6 YEARS OF AGE(PRE SCHOOLERS) Is able to dress and undress Very active and likes to do things like climb, skip and stunts Plays co operatively with peers Is developing some independence and self reliance Learning to distinguish between reality and fantasy By age of 6 their vocabulary will have increased to between 8000 to 14000 words(of then repeats words without fully understanding their meaning) They have learned the use of most prepositions and some basic possessive pronouns( mine, me) Pre school children continue to be ego centric and concrete in their thinking. They are still unable to see things from another perspectives and they reason based on specifics that they can visualize that they have importance to them. When questioned they can generally express who,what,where and some times how, but not when or how many. They are also able to provide a fair amount of details about a situation

TOPIC PRESENTATION

HEAD INJURY Definition It is an injury to the skull or brain that is severe enough to interfere with normal functioning.

Anatomy& Physiology The brain is one of the largest and most complex organs in our body. It controls our body, receives information, analysis information and stores information. It is made up of more than 100 billion nerves that communicates in trillions of connections called synapse. The skull consisting of 22 bones all together.These bones are divided into 8 cranial bones and 14 facial bones. Cranial bones form the cranial cavity and protects the brain.

There are typically 206 bones in the body. Out of these there are 22 bones of the Skull, which include: 8 Cranial Bones: 1 x Ethmoid Bone 1 x Frontal Bone 1 x Occipital Bone 2 x Parietal Bones 1 x Sphenoid Bone 2 x Temporal Bones

14 Facial Bones : 2 x Inferior Nasal Conchae 2 x Lacrimal Bones 1 x Mandible 2 x Maxillae (pl.); Maxilla (sing.) 2 x Nasal Bones 2 x Palatine Bones 1 x Vomer 2 x Zygomatic Bones

CRANIAL NERVES Olfactory I: sense of smell. Optic Nerve II: sight of retina. Oculomotor Nerve III: eye movement and pupil constriction. Trochlear Nerve IV: eye movements. Trigeminal Nerve V: carry somatosensory information to face, head and chewing muscles of jaws. Abducens Nerve VI: eye movement. Facial VII: control the muscles used for facial expressions (smiling, frowning etc). It also stimulates salivary glands to produce saliva.

Vestibulocochlear VIII: hearing and balance. Glossopharyngeal IX: taste sensation,gag reflexes. Vagus X: It carries somatosensory information from organs of thoracic, abdominal cavity including heart and from that of gastrointestinal tract. Spinal Accessory Nerve XI: leads to muscles of neck, back and larynx. It controls the head movement. Hypoglossal Nerve XII:controls the muscles of tongue

Meninges Meninges are the connective tissue membrane enclosing the brain and the spinal cord. It is divided into 3.outer most duramater,arachanoid mater and the inner most piamater.

Lobes of brain Frontal lobe : is responsible for problem solving,judgement and motor function. Parietal lobe: manage sensation, hand writing and body position. Temporal lobe : is involved with memory and hearing. Occipital lobe : contain the brains visual processing system.

Sutures of brain Coronal suture: present between frontal and parietal bones. Lambdoid suture: present between occipital and parietal bones. Sagital sutures: present between two parietal bones. Squamous sutures: present between parietal and temporal bones.

Major Regions of Brain Brain is divided into 3 major parts 1. Cerebrum 2. cerebellum 3. Brain stem

Cerebrum: Cerebrum is the most superior part of the brain. It is made up of by thick gray matter as surface layer and internally with white matter.It consist of thalamus, hypothalamus and epithalamus.

Cerebellum: Cerebellum located dorsal to the pons and medulla. It receives the impulses from cerebral motor cortex, various stem and sensory receptors in order to control skeletal muscle contraction.

Brain stem: Brain stem is similarly structured as the spinal cord. It is divided in to midbrain,pons and medulla oblongata.mid brain acts as a fibre pathway between higher and lower brain centres.The pons mainly a conduction region also contribute to the regulation of respiration and cranial nerves. Medulla oblongata regulate the respiratory rhythm, heart rate,B P etc...

Blood supply to the brain The major arteries are the vertebral and internal carotid arteries. This communicating arteries forms the circle of willis,which equalizes the blood pressure in the brains anterior and posterior region.

Pathophysiology Damage to the brain from traumatic injury takes two forms Primary: Initial damage to the brain that result from the traumatic event. Secondary: It occurs hours and days after the initial injury and result from inadequate delivery of oxygen and nutrients.

. Brain suffers traumatic injury Brain swelling or bleeding increase intracranial volume Increased ICP Pressure on blood vessels causes blood flow to the brain to slow Cerebral hypoxia or ischemia Continues increase in ICP Brain herniation Cerebral blood flow cease Brain death

Types of head injury Concussion: Transient interruption in brain activity. No structural injury noted on radiographs Contusion: Bruising of the brain with associated swelling. Intra cranial haemorrhage: Bleeding in to the brain tissue commonly associated with edema.

Epidural hematoma: Blood between inner table of skull and dura.Associated with injury or laceration of the middle meningeal artery secondary to a temporal bone fracture. Subdural hematoma: Blood between the dura and arachnoid space caused by venous bleeding. Commonly associated with ICH or contusion. Diffuse axonal injury or shear injury: Axonal tear with in the white matter of the brain. Frequently occurs with the corpus callosum or brain stem and at the frontal or temporal poles associated with prolonged coma.

Signs and symptoms Altered level of consciousnessHypothermia or Hyperthermia ConfusionVision and hearing impairment Pupillary abnormalitiesSensory dysfunction Altered or absent gag reflexHeadache Absent corneal reflexSeizure Altered respiratory patternDecortications, Decerebration Increased pulse pressureCSF Leakage Bradicardia or TachycardiaVomiting

Patient base Altered level of consciousnessHyperthermia Confusion Decortications Decerebration Seizure Sensory dysfunction Vomiting Altered respiratory pattern

CT SCAN

NERVE CONDUCTION VELOCITY A nerve conduction study (NCS) is a medical diagnostic test commonly used to evaluate the function, especially the ability of electrical conduction, of the motor and sensory nerves of the human body.

ELECTRONYSTAGMOGRAPHY is a diagnostic test to record involuntary movements of the eye caused by a condition known as nystagmus. It can also be used to diagnose the cause of vertigo, dizziness or balance dysfunction by testing the vestibular system.

Management All therapy is directs towards preserving brain homeostasis and preventing secondary brain injury. Treatment to prevent secondary injury includes stabilization of cardiovascular and respiratory function to maintain adequate cerebral perfusion, control of haemorrhage,hypovolemia and maintaining of blood gas values.

Nursing assessment Assessment 1. Collection of history 2. GCS score 3. Neurologic status 4. Presence of CSF leakage 5. Pupillary response to light

Initial management Severe head injury ATLS Evaluation Intubation with ventilation and sedation Fluid resuscitation CT Brai n Surgical lesion OT ICU MONITOR ICP YES NO Treat intra cranial hypertension

Patient side management IntubationInj. manitol Ventilation with sedationInj.Perfalgan 250mgI V PRN Right frontal and parietal burr hole with evacuation of subdural hydroma Tab.Gardinal IV fluid d5%+n/2 +5ml kcl @ 80ml/hrTab.Lyrica 25mg BD Iv antibiotics- Inj. Ceftriazone 500mg iv bd and inj.amikacin 250mg iv BD Inj.Risek 20 mg IV OD Inj.Phenytoin 60mg iv q8h

Prioritization of nursing problems Ineffective airway clearance and impaired gas exchange related to artificial airway Ineffective cerebral tissue perfusion related to increased ICP, decreased CPP and seizures Fluid volume deficit related to decreased loss of consciousness and hormonal dysfunction Imbalanced nutrition, related to increased metabolic demands, fluid restriction and inadequate intake Risk for injury related to seizures, disorientation, restlessness or brain damage Risk for imbalanced body temperature related to damaged temperature regulating mechanism Risk for impaired skin integrity related to bed rest, paralysis and immobility Disturbed thought process related to brain injury Disturbed sleep pattern Interrupted family process

Nursing care plan assessmentNursing diagnosis planninginterventionrationaleevaluation SUBJECTIVE Not Applicable Risk for impaired skin integrity related to immobility Skin to be remain intact and will not develop any bedsore Positioning done every 2 hourly Positioning reduces pressure Goal met by absence of bedsores during the stay of facility OBJECTIVE o Unable to move Maintained personal hygiene of the patient Moistures causes skin tears o Unable to abduct and adduct extremities Applied cream and powders as necessary To smoothening the skin Provided air mattress To reduce pressure

assessmentNursing diagnosis planninginterventionrationaleevaluation SUBJECTIVE Patients mother complaints sputum is Ineffective airway clearance related to tracheo-bronchial secretions Improve the airway patency of the patient Suctioning done To remove the secretions Goal partially met by reduced secretion and normal respiratory rate Coming out through the tracheostomy tube CPT provided Retained secretions interfere with gas exchange OBJECTIVE Secretions present Provided fowlers position Helps good air entry RR 26/mt Cough present Administered nebulization with ventolin and pulmicort Helps to soothening and expulsion of secretion Administered antibiotics To reduce infection

Complications Infection-respiratory Hydrocephalus Post traumatic seizure Permanent neurologic deficit Coma Chronic headache Death

Health education )Instructed the mother about the calorie needs of the baby )Involve the family in sensory stimulation programmes to maximize its effectiveness )Instructed the mother to investigate for physical sources of restlessness such as uncomfortable position, signs of UTI or pressure ulcer development. )Provide necessary education related to tube feeding, positioning, ROM exercises. ) Instructed to observe for post concussion, syndrome (headache, decreased concentration, irritability, dizziness, Insomnia, restlessness)and advised to obtain addition support.

Conclusion Trauma involving the central nervous system can be life threatening even if it is not life threatening, brain and spinal cord injury may result in major physical and psychological dysfunction and can alter the patients life completely.

Bibliography 1.Brunner and suddarths,test book of medical surgical nursing 12 th edition 2.Lippincott manual of nursing practice 9 th edition

Thank you!!!!!

head injury presented by: remya gopinath. demographic data name: case no.4 mr no : 185840 diagnosis...

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