Trauma

Trauma

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Trauma

- Trauma is a physical injury or wound caused by external force or violence.

- Trauma to the brain is the most common cause of motor & sensory symptoms including brain damage, coma and paralysis.

Trauma

- Normally, the skull’s thick bones, as well as the tough membrane of the meninges (dura), protect the brain, in addition, CSF acts as a shock absorber.

- However, violent blow to the head can cause several kinds of seizures and epilepsy later in life.

Trauma- If one of the normal contents of the

cranial or the spinal cavity (brain, tissue or CSF) increased in size, volume or shape and pressure; this increase in pressure can cause the delicate structure to be moved, damaged or destroyed.

There are 2 types of trauma: 1.Craniocerebral Trauma2.Spinal Cord Trauma

A broad classification that includes injury to the scalp, skull, or brain.

A traumatic insult to the brain capable of causing physical, intellectual, emotional, social, and vocational changes.

- Craniocerebral trauma or head injury is the 2nd most common cause of neurological injuries & the major cause of death between ages 1 to 35.

- Effects of severe head injury include cerebral edema, sensory and motor deficits and increased ICP (intracranial pressure).

- Motor vehicle & motorcycle accidents, falls, industrial accidents, assaults and sports trauma.

Etiology

Etiology/Craniocerebral

Injuries can be direct or indirect

Direct occurs when the head is directly injured. This results in an acceleration-deceleration injury, with rotation of the skull and its content. Bruising/contusion of the occipital and frontal lobes, the brain stem and cerebellum may occur.

Etiology/Craniocerebral

acceleration-deceleration injury is caused when the body at motion abruptly comes to a stop and the body structures are contused from within. (whiplash or brain contusion, rupture of the spleen or hepatic capsules)

Indirect is caused by tension strains and shearing forces transmitted to the head by stretching of the neck.

Concussion – a temporary loss of neurologic function with no apparent structural damage

Contusion – more severe than concussion; brain is bruised, with possible surface hemorrhage

Diffuse Axonal Injury – widespread damage to axons in the cerebral hemispheres, corpus callosum, and brain stem

Intracranial hemorrhage

Brain suffers traumatic injury

Brain swelling or bleeding increases intracranial volume

Rigid cranium allows no room for expansion of contents so ICP increases

Pressure on blood vessels within the brain causes blood flow to the brain to slow

Cerebral hypoxia or ischemia occurs

Intracranial pressure continues to rise. Brain may herniate.

Cerebral blood flow Ceases

1. Concussion – difficulty in awakening or speaking, confusion, severe headache, vomiting, weakness on one side of the body, amnesia, visual disturbances

2. Contusion – altered LOC, nausea, vomiting, ataxia, speech problems, seizures, cool, pale skin, shallow respirations, faint pulses. Full recovery may be delayed for months.

Clinical Manifestations3. Head injuries may be open or closed.

Open injuries may result from a skull fractures or penetrating wound. The amount of injury from this type of wound is determined by the velocity, mass, shape and direction of the impact.

Closed injuries include concussions (a violent jarring of the brain against the skull), contusions (brain tissue is bruised) and lacerations (tearing of the brain tissue).

Clinical Manifestations4. Skull fractures maybe linear,

comminuted, depressed or compound.Linear fracture occur when the impact causes the area of the skull that was stuck to bend inward, making the area around it buckled outward.Depressed fracture is a severe blow to the head. The fracture breaks the bone and forces the broken edges to press against the brain, resulting in significant increase in ICP and meningitis.

Clinical manifestations


Clinical manifestationsCompound/open fracture expose the brain

into external microorganisms which could lead to meningitis and encephalitis. Open fractures are less likely to produce rapid elevations in the ICP because, the fracture allows the brain to swell.

Comminuted/fragmented fracture is when the bone is broken or splintered into pieces which can result in bits of bone being driven into the brain, lacerating it.


Clinical Manifestations

Clinical manifestations5. Hematoma refers to the blood clot within the

skull. Hemorrhage resulting from craniocerebral trauma may occur in the following sites: scalp, epidural, subdural, intracerebral and intraventricular.

Epidural hematomas, resulting from arterial bleeding forms as blood collects rapidly between dura & the skull. If lethargy or unconsciousness develops after the patient develops consciousness, an epidural hematoma may be suspected and needs immediate treatment.

Clinical manifestations Subdural Hematomas form as venous

blood collects below dura. Hematoma formation is slow, because the bleeding is under venous pressure. The clot will cause pressure on the brain surface and will displace brain tissue. Patient who has been conscious for several days after head injury, loses consciousness or develops neurological signs and symptoms, a subdural hematoma should be suspected.


Clinical manifestations Intracranial Hematoma, which form within

the brain due to hemorrhage & edema. The cause may be a fracture of a delicate blood vessels due to HTN or cerebral aneurysm. Rapture blood vessels are one of the causes of CVAs.

Intraventricular hematoma is a bleeding into the brain’s ventricular system, cerebrospinal fluid is produced and circulates through towards the subarachnoid space.



Subjective:

headache, nausea, vomiting, abnormal sensations and history of loss of consciousness and of bleeding from any of the orifice (ears or nose).

Objective: status of respiratory system, level of alertness and consciousness, size and reactivity of the pupils, orientation, motor status, vital signs, presence of bleeding or vomiting and abnormal speech pattern. Presence of “battle’s sign” ( A small hemorrhage spot behind the ear.) usually is indicative of a fracture of a bone of the lower skull.

Raccoon’s eyes & rhinorrhea

Battle’s sign / postauricular ecchymosis

Diagnostic Tests – craniocerebral trauma

CT (computed tomography)CAT (computed axial tomography) MRI (magnetic resonance imaging) PET (positron emission tomography)

- Used to assess the location and extent of the injury.

Medical management – craniocerebral trauma

1. Ensure a patent airway and ensure adequate oxygenation.

2. Suctioning maybe necessary but, never through the nose because of the possibility of skull fracture.

3. Check ABGs 4. Control elevated temperature.

Medical management – craniocerebral trauma

5. Administer medications to reduce cerebral edema and increased ICP. Medications include:- Mannitol & Dexamethasone to treat

cerebral edema - Codeine or analgesics to manage

pain- Anticonvulsants to prevent/treat

siezures

Nursing InterventionsPrevention of infections

1. Patient’s ears and nose are checked carefully for signs of blood or serous drainage.2. No attempt should be made to clean out the orifice.3. If there is evidence of drainage, the patient should not cough, sneeze or blow the nose.

Nursing InterventionsEmotional Support

1. Patients need firm but gentle care, with specific guidelines for what behavior is allowed.2. It’s not helpful to argue with patients.3. Log book or written schedule can be useful in assisting with orientation.

Nursing diagnosis / Interventions Impaired social

interactions related to cognitive and affective deficits from neurophysiological trauma

- Encourage and support verbalization of feelings, medical conditions and current treatment, listen non-judgementally.

- Build trust through consistency & keep your promises.

- Give attention to patient during verbal interactions & recognize qualities to promote self-esteem.

Patient TeachingPatient need to be taught about

observations for complications such as increased drowsiness, nausea, vomiting, worsening headache or stiff neck, seizures, blurred vision, behavioral changes, motor problems, sensory disturbances or decreased heart rate.

PrognosisOutcome is often unpredictableExtent of damage or recovery is not

positively correlated with the amount of damage seen in surgery or on CT scan.

Person with head injury is more prone to injuries and problems related to the brain damage.

Etiology – Spinal Cord Trauma/injury

Injury causes microscopic hemorrhages and gray matter to fill with blood

Edema causes spinal cord compression, and blood supply becomes further decreased

Scarring and meningal thickening occurs, nerves are blocked or tangled, sensory and motor deficits occur


Spinal cord injuries (SCI) involve losses of motor function, sensory function, reflexes and control elimination.

Accidents is a common and increasing cause of serious disability and death.

Automobile, motorcycle, diving, surfing and other athletic accidents and gunshot wounds are the major causes of spinal cord injury.

Etiology – Spinal Cord Trauma/injury The level of cord involved dictates the

consequences of spinal cord injury. (C3 to C5 poses a great risk for impaired spontaneous ventilation because of proximity of the phrenic nerve.

SCIs range from contusions to complete transection of the cord.

Etiology – Spinal Cord Trauma/injury- Complete SCI means that there is no function below the level of the injury (no sensation and no voluntary movement) and both sides of the body are equally affected. - Incomplete SCI means that there is some functioning below the primary level of the injury. One limb may be able to be moved more than the other, the person may be able to feel parts of the body that cannot be moved and there may be more functioning on one side of the body than the other.



Serious Injury Less Serious Injury

•Diving into shallow water•Falls•Gunshot•Motor vehicle accidents•Violence-related accidents

•Poor body mechanism•Minor falls•Sports•osteoporosis

Etiology – Spinal Cord Trauma/injuryCauses of trauma

Hyperflexion forward (head-on collision) Hyperextention backward (rear-end

collision, fall on chin) Axial loading / vertical compression (land

on head or feet) Rotation beyond normal range Penetrating injury (gunshot, knife

wound)

Clinical Manifestations/SCI

Spinal shock or areflexia The loss of systemic vasomotor tone

that may result in vasodilation, increased venous capacity and hypotension.

Spinal shock is temporary, and during this time the patient may need temporary respiratory support.

Clinical Manifestations/SCI Autonomic Dysreflexia

Occurs as a result of abnormal cardiovascular response to stimulation of the sympathetic division of the autonomic nervous system as a result of stimulation of the bladder, large intestine or other visceral organs.

Clinical signs include sever bradycardia, HTN, diaphoresis, “gooseflesh”, flushing (above the lesion), dilated pupils, blurred vision, nause restlessness, severe headache and nasal stuffiness.

Clinical Manifestations/SCI

The most common causes of this condition includes:

▪ Distended bladder▪ Fecal impaction▪ Cold stress▪ Tight clothing

Clinical Manifestations/SCI Emergency care for Autonomic Dysreflexia

or Hyperflexia Unless contraindicated, place patient in

sitting position to decrease blood pressure.

Check patency of catheter for kinking. If catheter is occluded, insert new catheter immediately.

Check rectum for impaction. If it is necessary to remove impaction, an

anesthetic ointment should be used.

Clinical Manifestations/SCI Administer ganglionic blocking agents

such as hexamethonium or a vasodilator such as nitroprusside (Nipride) as ordered if conservative measures are not effective.

Continue monitoring blood pressure. Send urine for culture if no other cause is

found. Urinary infection can lead to symptoms of autonomic dysreflexia.

Box 54-3

Clinical Manifestations/SCISexual Function

In most cases, men experience impotence, decreased sensation and difficulties with ejaculation.

Impairment of fertility is common. The experience of orgasm is described as different than before the injury.

Women with SCI are able to continue to perform sexually, although perception of sexual pleasure is usually altered.

Level of injury and spinal cord damge located by neurologic assessment

Limited movement and activities cause pain

Surface wounds Pain location Loss of sensation below the level of

injury deformity

Subjective Nature of injury Presence of dyspnea Unusual sensations Loss of consciousness Absence of sensation on sensory

examination

Objective Level of alertness & consciousness Orientation Pupil size & reactivity Motor strength Skin integrity Bowel & bladder status Fracture bones or head injury

Spinal X-ray – to detect any cervical fracture / displacement

Myelography – to detect occlusion CT Scan & MRI – to rule out spinal

cord injury Indicates the location of fracture and the

site of compression. Also used to assess the extent of the damage & location of blood or bone fragments.

Medical Management Immobilization Skeletal traction Surgery for spinal decompression Skeletal traction may include:

Crutchfield tongs Halo traction Stryker or foster frame Bracing for thoracic or lumbar injuries

**If the patient is seen within 8 hours of injury, high dose of methylprednisolone is given

Nursing Interventions & Patient Teaching

Mobility Maintain body alignment Monitor skin integrity and provide pin

care as appropriate. Maintain ROM to prevent contractures Use thromboembolism stockings Slowly increase the angle of sitting up.


Urinary function A foley catheter is inserted initially and later

bladder training is started. (Chronic indwelling catheterization increase the risk of infection.)

Intermittent catheterization should begin as early as possible. (Helps maintain bladder tone and decrease the risk for infection.)

Fluid intake more than 2000 ml/d is encourage. Cranberry juice is encouraged to decrease

renal calculi formation.


Bowel Function Patients are usually started on a bowel

program early in their hospital stay. Patients are given bisacodyl (Dulcolax) suppositories at regular intervals, usually every other night.

Followed by digital stimulation to further stimulate peristalsis. The goal is to eliminate the use of suppositories.

Other aids to bowel programs are the use of adequate fluids, stool softener and prune juice.

Nursing Diagnoses / Interventions

Autonomic dysreflexia, related to nuerophysiological trauma to spinal cord above 6th thoracic vertebrae.Box 54-3

Impaired urinary elimination, related to sensory motor impairment.

▪ Check carefully for voiding and for distention of bladder.

▪ Tech patient intermittent self catheterization if indicated.

Nursing Diagnoses / Interventions

Teach patient Crede’s maneuver as indicated. Use foley catheter if indicated, administer

meticulous aseptic technique in changing catheters.

Teach patient signs of infection. Encourage patient to have a genetourinary

check-up at least once a year. Maintain fluid intake of 3 to 4 L daily unless

contraindicated. Use adult perineal protector for incontinency.

Complete SCI - There is almost no chance of return to any

function. Paraplegic or Tetraplegic- Can live a satisfying life with adaptations and

assistance.

***The prognosis for life is generally 5 years less than the people of the same age without SCI.

Nursing Process for patient with a Neurological Disorder Assessment

Complaints about pain, dizziness or vision difficulties.

Ability to speak and reason Vital signs, data about gait, symmetry of body

parts, evidence of pain, or seizure activity. Pupil size, level of alertness, ability to perform

motor tasks, change in level of consciousness, and ability to speak.

Nursing Process for patient with a Neurological Disorder

Nursing Diagnosis Autonomic dysreflexia Impaired verbal communication Compromised family coping Risk for disuse syndrome Risk for falls Grieving Risk for infection Deficient knowledge


Impaired memory Impaired physical mobility Imbalance nutrition, less than body

requirement Acute pain Chronic pain Bathing/hygiene self deficit Feeding self-care deficit


Toileting self-care deficit Impaired swallowing Disturbed thought process Ineffective tissue perfusion (cerebral)


Expected outcome / Planning The plan of care should focus on the

type of deficit the patient has as well as the possible complications.

Considering the patient’s preferences and mental status is important.

The type of care required will determine the supplies and equipment needed.

Schedule timely tests and procedures.


Implementation Nursing interventions for the patient

with neurological disorder include those that maintain cerebral perfusion and other functioning, as well as those that prevent complications such as decubitus, falls, or contractures.

Nursing Process for patient with a Neurological Disorder Implementation

Guidelines in providing neurological care

The neurological system is a complex system that produces a wide variety of neurological signs and symptoms

Identical disorders may result in different sets of signs & symptoms in different patients.

The maintenance of cerebral perfusion is of utmost importance.


Implementation Guidelines in providing neurological

care The patient with neurological illness is

very prone to complications. Disorders of the nervous system produce

not only physical problems, but a wide variety of cognitive difficulties.


Evaluation

The nurse evaluates the success of planned interventions during and after care is given.

The nurse must always be ready to revise the care plan as needed, because patient’s condition often changes.

The evaluation is specific to measure the goals identified.

References

Foundations and Adult Heath Nursing by Christensen & Kockrow 5th edition

Textbook of Basic Nursing by Rosdahl and Kowalski 8th edition

Medical Surgical Nursing by Bruner and Suddarth 11th edition

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Trauma