Subdural Hematoma
A subdural (below the dura) hematoma is typically slow forming (Fig. 78-8C). It is caused by an accumulation of blood, usually from a torn vein on the brain’s surface. Symptoms vary with size and location. The person may feel drowsy or lose consciousness, with seizures, paralysis, and muscle weakness. Speech may be affected; confusion is common. Symptoms may not appear for days or even weeks after the accident.
Penetrating Head Injuries
In a penetrating head injury, the degree of damage depends on the penetrating object’s velocity and location. A highvelocity object, such as a bullet, typically causes more damage than a low-velocity object, such as a stab wound.
Medical and Surgical Treatment
Immediately after any potential or actual injury to the brain, a neurologic evaluation should be done. The Glasgow coma scale (GCS) is commonly used as a broad indicator of the severity of brain injury (Table 78-2). Three areas are given numerical values: eye opening, best verbal response, and best motor response. Each area is evaluated according to standard criteria, and the numbers are totaled. The highest possible number of 15 indicates that the individual has no impairment; the lowest possible number of 3 indicates brain death. The range of 6-8 is associated with a coma state.
Medical treatment consists of methods to limit swelling and damage caused by tlCP. Osmotic diuretics may be given. Immediate neurosurgery may be necessary to prevent death. Surgery involves tying off the bleeding vessel and cleaning the area of debris and any accumulated blood or blood clot. Burr holes may be made in the skull or an intra-ventricular catheter may be inserted to relieve tICP by draining CSF or blood.
Nursing Considerations
Head injury requires sensitive nursing care related to the specific needs resulting from the trauma. Loss of consciousness does not always follow a severe head injury. Every client who suffers a blow to the head, no matter how minor it appears, needs careful observation until it is certain the injury has not damaged the brain. Care providers need to be aware that symptoms of brain damage do not always appear immediately.
The conscious client should remain absolutely quiet, with complete bed rest. Observe for the following signs of ICP: headache, dizziness, visual impairment, hearing loss, nausea, or clear or bloody drainage from the ears, nose, or mouth. Projectile (forceful) vomiting is indicative of brain injury. Also observe the client for changes in blood pressure and pupils. If the client is hospitalized, monitor LOC frequently, and note any personality or behavior changes.
TABLE 78-2. The Glasgow Coma Scale
|
TEST |
SCORE |
|
EYE OPENING (E) |
|
|
Spontaneous |
4 |
|
To voice |
3 |
|
To pain |
2 |
|
None |
1 |
|
MOTOR RESPONSE (M) |
|
|
Obeys commands |
6 |
|
Localizes pain |
5 |
|
Normal flexion (withdrawal) |
4 |
|
Abnormal flexion (decorticate) |
3 |
|
Extension (decerebrate) |
2 |
|
None (flaccid) |
|
|
VERBAL RESPONSE (V) |
|
|
Oriented |
5 |
|
Confused conversation |
4 |
|
Inappropriate words |
3 |
|
Incomprehensible speech |
2 |
|
None |
1 |
GSC score = E + M + V Best possible score = 15; worst possible score = 3.
IN PRACTICE :EDUCATING THE CLIENT 78-4
AFTER A HEAD INJURY
• Know that the client may not be sufficiently coherent to recognize dangerous symptoms.
• Be alert that some symptoms may not appear until several days, weeks, or even months following a head injury.
• Have the client relax for 24 hours so the brain has a chance to recover Check the client’s orientation to time and place every 2 hours for the first 24 hours following any blow to the head.
• Immediately report the following to the physician:
• Unusual or increased drowsiness
• Weakness of arms or legs; muscle twitching
• Nausea and vomiting (especially forceful or projectile vomiting)
• Headaches—localized or generalized, unrelieved by mild analgesic
• Dizziness
• Visual or hearing disturbances, abnormal eye movements
• Difficulty arousing from sleep, particularly during the first 24 hours
• Personality changes, such as forgetfulness, irritability speech difficulties
• Bleeding or clear drainage from the mouth, nose, or ears
• Seizures
• Blood pressure changes
Advise a client who is preparing for release after receiving first aid treatment following a head injury to see a physician immediately if he or she has any recurring symptoms. In addition, teach the family these symptoms because the client may be unable to detect deterioration of functioning. (see In Practice: Educating the Client 78-4).
NCLEX Alert NCLEX clinical scenarios may present client’s symptoms that the nurse must be able to translate into nursing actions. For example, trauma or infection of the brain may result in a headache. As a symptom of this clinical example, a headache could indicate nursing care that includes close monitoring of LOC, elevating the head of the bed, and notifying the physician of projectile vomiting or pupil changes.
NEOPLASMS
Brain tumors occur in all age groups. Only a small percentage of brain tumors are malignant, and they may result from metastasis from another part of the body. Even a benign brain tumor can be fatal, however, because of the pressure that it exerts on the brain. Benign tumors may also later become malignant. Regular follow-up is essential after treatment for any brain tumor.
Signs and Symptoms
The signs and symptoms of brain tumor include headache, sudden projectile vomiting, and visual abnormalities, all caused by ICP. Additional signs and symptoms may develop, depending on the area of the brain that is affected. For example, if the motor area is affected, numbness or twitching in the arm may occur; a tumor on the brain’s frontal lobe may cause personality changes and may affect memory or reasoning abilities.
Often, a seizure is the first symptom of a brain tumor. If tICP near the brain stem is unrelieved, severe respiratory difficulties and possibly death owing to respiratory failure may occur. As brain tumors grow, signs and symptoms progressively worsen.
Diagnostic Tests
Neurologic assessment and history are necessary to make a diagnosis. By questioning the client and family, the physician can determine the progress of any neurologic deficits. Diagnostic tests, such as the CT scan and EEG, are performed to determine the tumor’s location, size, and neurologic effects.
Treatment
Treatment options include surgery, chemotherapy, and radiation therapy, or all three. The specific treatment is determined according to the tumor’s type and location. One type of surgery is a craniotomy.
Craniotomy
Surgical entry into the skull (cranium) is called a craniotomy. This invasive procedure is performed for many reasons; one of the most common being a brain tumor. Any tumor near the brain is removed, when possible, because its growth would put pressure on the brain. A craniectomy is a procedure that removes a portion of skull bone.
Surgerical success for a brain tumor depends on the tumor’s location and whether it can be removed without causing brain damage. Some tumors are inoperable (impossible to remove without causing severe brain damage or death). Even successful brain surgery can result in neurologic deficits.
Nursing Considerations
Providing Preoperative Care
Before a craniotomy, follow routine preoperative preparation. In addition, the client’s head or a portion of it may need to be shaved. If this is the case, inform the client before doing so. Often, hair is not shaved until the client is in the Operating Room. The client (or legal guardian, if the client is a child) must sign an informed consent before hair can be removed or surgery is done. (Shaved hair is put into a paper bag and labeled. This hair can be used later for a wig or hairpiece, if the client desires.)
The physician will inform the client if he or she is to remain awake during a craniotomy. Mild sedatives may be given to relax the client, while allowing him or her to respond to various stimuli applied to parts of the brain during surgery. Advise the client beforehand if the surgeon will ask questions or ask for specific movements during surgery. Midazolam (Versed) may be given so the client does not recall the procedure.
The client and family are almost certain to be apprehensive before such surgery. Provide concerned, competent preoperative care. Reassure the client that little pain is involved in brain surgery because the skin is locally anesthetized. Although the procedure can be noisy because the surgeon will drill out a part of the skull bone, the client will feel no pain because the skull and brain have no sensory nerves. However, warn the client about the possibility of a headache after surgery.
Surgery may take 2-6 hours. Anything the nurse can do to make the waiting period easier for family members will be helpful. Take time to say a few words to them at intervals to let them know that they are not forgotten.
Providing Postoperative Care
During the immediate postoperative period, the client requires expert observation and nursing care, usually provided in the ICU. Monitoring by ICU nurses is done continuously, with comparisons performed between the client’s present condition and the initial neurologic examination (the baseline assessment). Any changes, such as signs of tICP, are noted.
Nursing care focuses on the following activities:
• Monitoring the client’s vital signs and respiratory status regularly.
• Elevating the head of the bed
• Performing nasogastric suction to help prevent aspiration.
• Positioning the client according to physician’s orders
• Checking dressings for blood and cSf, especially at the back and on the side where drainage accumulates by gravity.
• Monitoring the client’s LOC, orientation to time and place, and ability to speak clearly.
• Checking the client’s ability to grasp equally in both hands and to move each foot in any position on command.
These activities are continued even after the client is discharged from the ICU to the nursing unit.
When the client is allowed out of bed, check his or her ability to stand with the eyes closed (Romberg test). The client should be able to stand on each foot without holding on to anything. Immediately report any deviation from normal. If in doubt, notify the surgeon. The client’s neurologic status can change very rapidly.
During convalescence, the client needs encouragement and understanding. For example, the client may find that it takes time to regain control of bodily movements, or that he or she is spilling food, dropping things, and feeling dizzy when walking. Reassure the client and give assistance, as needed.
KEY POINTS
• Because the nervous system controls the body’s movements, disorders in this system may cause unwanted movement or immobility.
• Seizure disorders have different manifestations, ranging from generalized tonic-clonic movements to uncontrolled movements without loss of consciousness.
• Spinal cord injuries can result in a range of physical and mental deficits, including paralysis.
• Degenerative disorders of the nervous system can cause difficulties in movement, sensory deficits, or varying degrees of alteration in mental status.
• Inflammatory disorders of the nervous system can quickly become life-threatening.
• Increased ICP has many causes. It is a significant sign of a brain disorder. One of the first and most important signs of tICP (and other disorders of the brain) is a change in LOC.
• Most brain tumors are nonmalignant. Benign tumors, however, cause pressure on the brain and can be fatal.
