Closed Head Injury

unlikable Head Injury Case Study Y. W. is a 23-year-old male savant from Thailand studying electrical engineering at the university. He was ejected from a abject vehicle, which was traveling 70 mph. His injuries included a irritationful closed wit injury with an occipital hematoma, bilateral wrist fractures, and a right pneumothorax. During his neurological intensive c be unit (Nintensive care unit) stay, Y. W. was intubated and placed on mechanical ventilation, had a provide resistance inserted and was placed on tube feedings, had a Foley catheter to beat drain (DD), and had multiple IVs inserted. He developed pneumonia 1 month afterward(prenominal) admission.Closed Head Injuries Closed top dog injuries result from a blow to the head as en awaiters, for example, in a car accident when the head strikes the windscreen or dashboard. These injuries ca wasting disease two types of disposition damage. 1. Define the term capital head injury. A primary head injury (or primar y impact) is similarly k this instantn as a coup injury. The injury occurs under the rank of impact with an object such as a hammer or a rock. The brain strikes the skull after the head strikes the object of impact (Lewis, et al, anatomy 57-14). This is the site of the direct impact of the brain on the skull.Often in that location is dropsy rough the site of impact. 2. Define the term substitute(prenominal) head injury. The secondary head injury is also known as contrecoup injury occurs on the side opposite the area that was impacted. These injuries tend to be more severe and overall forbearing prognosis depends on the amount of bleeding around the contusion site (Lewis, et al, 1425). Often it is the secondary brain injuries that show fewer initial symptoms and then use up serious side effects age to weeks later. 3. What is normal intracranial pressure (ICP), and why is change magnitude ICP so clinically important?Normal intracranial pressure ranges from 5 to 15 mm Hg. A sustained pressure above the upper limit is consumeed abnormal. bosom changes in the brain effect the brains compliance. Compliance is the expandability of the brain With low compliance, small changes in volume occur and result in greater increases in pressure. depute intracranial pressure is clinically probatory be agent it diminishes CPP, increases risks of brain ischemia and infarction, and is associated with a poor prognosis (Lewis, et al, p. 1425-1427). 4. Identify at least five signs and symptoms (S/S) of increase ICP. signs and symptoms of increase ICP are Decreased LOC ( train of consciousness) respiratory problems (maintaining a patent airway is critical in the long-suffering with increased ICP. Pt is at increased risk of airway obstruction (Lewis, et al, p. 1434). Elevated systolic BP referable to ischemia and pressure on the brainstem. Bradycardia due to the ischemia and pressure on the brainstem as well. Pulmonary edema due to increased sympathetic activity as a result of increased intercranial pressure. 5. List 4 medication classifications that the ICU applys could use to decrease or affirm increased ICP.Some of the medications that the ICU nurses could use to decrease or go increased ICP would be Opioids (morphine sulfate and fentanyl) IV anesthetic sedative propofol (Diprivan) to repugn anxiety and agitation. Vecuronium (Norcuron), cisatracurium besylate (Nimbex) nondepolarizing neuromuscular blocking agents achieve complete ventilatory control in the get byment of refractory intracranial hypertension. (These agents paralyze muscles without blocking pain or noxious stimuli, therefore they are used in combine with sedatives, analgesics, or benzodiazepines (Lewis, p. 436)). Dexmedetomidine (Precedex) alpha-2 agonist used for continuous IV sedation of intubated and mechanically ventilated patients in the ICU setting for up to 24 hours. Benzodiazepines are usually avoided in the ICU in management of the patient with increased ICP be evidence of the hypotensive effect and long half-life. (Lewis, et al, p. 1436). 6. List 8 nursing measures that the ICU nurses could use to decrease or control increased ICP. * Maintain the patient in the head-up position. Elevation of the head of the bed reduces sagittal sinus pressure, promotes waste pipe from the head via the valveless venous dust through the jugular veins, and decreases the vascular over-crowding that foot produce cerebral edema (Lewis, et al, p. 1436) * Position the bed so that it lowers the ICP while optimizing the CPP non above 30 degrees. * Turn the patient with slow, settle movements. Rapid changes in position may increase ICP. * Avoid peak hip flexionthis risks raising intra-abdominal pressure which increases ICP. Turn pt each 2 hrs (minimum). * Protect the patient with ICP from self-injury with adequate padding on the bed.Because of likelihood of decreased LOC, confusion, agitation, and the possibility of seizures increase the risk for injury. * B e prepared to beg off situations to family and caregivers and the patient. With increased ICP, anxiety is likely and the prognosis can be distressing. By providing short, simple ex endations that are appropriate, it allows the patient and the caregiver to acquire the amount of randomness they desire (Lewis, p. 1438). * Decorticate or decerebrate posturing is a reflex solvent in some patients with increased ICP. The nurse can use turning, flake care, and even passive range of motion. Monitor fluid and electrolyte status. Disturbances can have an adverse effect on ICP. Closely monitor IV fluids with the use of an accurate intravenous infusion control device or tenderness monitor intake and output and daily weights. (Lewis, et al, 1437) * Perform neurological assessments both hour. 7. Y. W. s medication list includes clindamycin 150 mg per feeding tube q6h, ranitidine (Zantac elixir) 150 mg per feeding tube bid, and phenytoin (Dilantin) one C mg IV piggyback (IVPB) tid. Indicate the reasons for each. Clindamycin 150 mg per feeding tube q6h Treatment of respiratory tract infections to treat Y.W. s pneumonia. (Skyscape, 2012). ranitidine (Zantac elixir) 150 mg per feeding tube BID Used to treat and prevent stress ulcers (stress-induced GI bleeding in critically trouble patients). Due to head injury, overstimulation of the vagus nerve from TBI. Phenytoin (Dilantin) 100 mg IVPB TID Used to treat and prevent tonic-clonic seizures and complex partial seizures. Seizure is seen in 5% of patients with a non-penetrating head injury (Lewis, et al, p. 1445). 8. A STAT portable bosom x-ray (CXR) is ordered after each central venous catheter (CVC) is inserted.According to hospital protocol, no one is permitted to infuse anything through the catheter until the CXR has been read by the mendelevium or radiologist. What is the purpose of the CXR, and why isnt fluid infused through the catheter until after the CXR is read? The chest x-ray confirms the fit placement of t he central venous catheter. If fluid is infused through the catheter before a CXR has confirmed placement, the patient is at high risk for systemic infection or possible pneumothorax (which would occur if the catheter were to be entered into the lung by mistake instead of the superior vena cava).CASE say PROGRESS Y. W. spent 2 months in acute care and is now on your rehabilitation unit. He follows commands but tends to get stimulate with in addition much stimulation. His tracheostomy site is well healed, and the pneumonia is finally resolving. He is thus far receiving supplemental tube feeding and has some continued incontinence of both bowel and bladder. Y. W. has a supportive group of friends who are students at the university some(prenominal) of them are also from Thailand. 9. Y. W. s latest lab results are as follows Na 149 mmol/L, K 4. mmol/L, Cl 119 mmol/L, total CO2 21 mmol/L, curl 12 mg/dl, creatinine 1. 2 mg/dl, glucose 123 mg/dl, WBC 15. 4 thou/cmm, Hgb 14. 9 g/dl, H ct 36. 4%, platelets 140 thou/cmm. ar any of these of concern to you, and what would you suggest to correct them? I am bear on about 3 of the labs. Sodium high (increased) hypernatremia high sodium levels cause neurologic problems including intense thirst, lethargy, agitation, seizures, postural hypotension, weakness, and decreased skin turgor. Chloride higher(prenominal), increased High chloride levels occur because of increased sodium levels.It is important to correct the sodium level so the chloride level can follow suit. Again, hypernatremia and the nurse must observation post out for dysrhythmias, HTN, and impaired mental response. > Correcting increased sodium would include hypotonic saline (via IV) and 5% dextrose in water (IV)- (Lewis, et al, p. 312) WBC count15. 4 increased this increased level indicates infection. This can be attributed to the patients diagnosis of Pneumonia. Administration of appropriate antibiotics go out help wager the white count back to a norm al level. 0. Are you affect by Y. W. s agitated behavior? Explain. YMs agitation is of no surprise. Patients that have head injuries often express agitation easily. Increased intracranial pressure and the head injury the patient has experienced can cause agitated behavior to arise. It is imperative for the nurse to use interventions to decrease the agitated behavior which can further lead to feelings of anxiety. Providing a calm and non-stimulating environment, big of stressors, is a good way to do this (Lewis, et al, p. 1438).Also, the nurse can elevate the bed 15-30 degrees with appropriate oxygenation applied. 11. Outline a general rehabilitation plan for Y. W. ground on the above data. The rehab plan pass on include -physical therapy- running(a) on gross motor skills, walking, sitting, transferring, and range of motion -occupational therapy- aids in completion of ADLs and learning of new techniques to complete these tasks of daily living -nutrition- proper nutrition to keep patient nourished and also consuming seemly vitamins/minerals/proteins to aide in healing. nursing staff- administer antibiotics, pain medications, and supportive care. -speech therapy- to esteem and aide with swallowing, eating/drinking, and eventually verbal conversation improvements. 12. Y. W. s receive has just arrived in the unify States and speaks no English. What measures can be taken to facilitate communication between medical personnel and the mother? early and foremost the nurse should find out what language is the mothers native language. Most people are unaware but it is not safe to assume there is one language that will keep to an entire country.Quite a few countries speak a language based on their village. The nurse will need to acquire an interpreter that will speak the language that best suits the mother. If the patients friends/classmates are around, they can also be used to aid in interpretation and communication between health care staff and family. 13. Y . W. s mother will need a place to stay while in the United States. What can you do to facilitate the initial contact with the Thai company? Hopefully the other Thai students are around or could repair a suggestion for the patients mother.I would also ask the loving worker if they know of any thai-specific cultural centers in the area. I could equalise with the interpreter, and see if they have a lead. I would also google Thai partnership San Diego and see what I could find. 14. What especial(a) discharge planning considerations are there in this case? Discharge considerations for this patient will involve well-educated where the patient is discharging to. The nurse will need to know if the patient is staying in the US and continuing with follow-up outpatient rehab with our facility and if not, then where will they be.The nurse and other members of the healthcare/rehab team need to educate the patient on his injury and what comes next for him in terms of rehabilitation. The nur se take to consider what modifications YM has made to his lifestyle post injury. Discharge planning should include an outpatient memorial for OT, PT and Speech (assuming he will stay here). Education for caregivers and family is also very important so that the patient has a support system available during the recovery and rehabilitation process.The patient will need to be sent home with any tools he will need for ADLs, with medications or supplements that are still necessary for recovery. If the patient is in need of special services or devices (i. e. wheelchair, ramps, vehicle to accommodate special devices, etc. ), a case manager should be sought out to ensure that these needs are met. References Lewis, et al, (2011). Medical-Surgical Nursing Assessment and Management of Clinical Problems. 8th ed. Vol 1. St Louis, bit Mosby. Skyscape. (2010). Skyscape Medical Resources (Version 1. 9. 11) Mobile application software. Retrieved from http//itunes. apple. com/