Traumatic Brain Injury – Flashcards
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Primary Brain Injury
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-Severe -GCS 3-8 > 6 hour LOC
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Open Head Injury-Fractures
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-Linear-line -Depressed-bone pieces in brain matter -Open-bone pieces come off -Comminuted-compound-fragments -Basilar -CSF leakage from ears & nose ↑ RF hemorrhage
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Closed Head Injury-Blunt trauma leads to:
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-Concussion-short LOC -Diffuse axonal injury-acc/decel -Contusion-bruising frontal lobe -Laceration-shering forces, cause bleed-(worse than contusion, low BP-hypoxia-ischemia/edema/inflamm) -Countercoup-hits in front/back skull-shaken baby
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Closed Head Injury-Types of Force
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-Check for spinal cord/neck break -Acceleration injury -Deceleration injury
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NURSING FOCUS on the OLDER ADULT: Head Injury
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-5th leadng cause of death/older adults. ▪65-75yo age-group 2nd highest incidence head inj ▪Falls & MVA's most common cause of head injury.
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NURSING FOCUS on the OLDER ADULT: Head Injury
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▪Factors contribute to high mortality: -Falls caus subdural hematomas/clsd hd inj, chronic -Poorly tolerated systemic stress, which is increased by ad-mission to a high-stimuli environment -Medical comps: hypo/hypertension, cardiac probs
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NURSING FOCUS on the Older Adult: Head Injury-(cont)
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-Decreased protective mechanisms, which make clients susceptible to infections (espec pneumonia) -Decreased immunologic competence, which is further diminished by head injury
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Key Features TBI
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-Loss of memory-short term -Seizure-late sign -LOC/drowsiness -Restless/irritable-early -Disorientation
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Key Features TBI-(cont)
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-Scalp bruising/tenderness -Personality changes-erratic behav -Diplopia-doublevision -Gait changes
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Severe head injury-late
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-Pupil changes -Bradycardia -Papilledema-optic edema/ICP-late sign -HTN/wide pulse pressure-worry for brain perfusion -Hypotension & tachycardia -Hypovolemic shock -Nuchal rigidity -CSF leak
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Care of a Patient with Minor Head Injury
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-Wake every 3-4 hour X 2 days, Neuro assess-LOC -Expect C/O H/A, N/V, dizziness-Report if persist or worsen-NO MORE THAN 72HRS -Acetaminophen for headache as needed -Avoid sedatives & alcohol -No strenuous activity X 48 hours-dec ICP risk -No blowing nose or ear cleaning X 48 hours
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Care of a Patient with Minor Head Injury-(cont)
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-Return to ER for symptoms listed in Chart 47-10 -Blurred vision -Weakness inc sleep -Pupils changes- -Slurred speech
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Increased Intracranial Pressure (ICP)
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-ICP leads to: ↓ cerebral perfusion →Tissue hypoxia → ↓ pH and ↑CO2 → Cerebral vasodilation, edema → ↑ ICP →Brain stem herniation → Irreversible brain damage and death
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Types of Edema
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-Vasogenic edema ↑ brain tissue volume -Abnormal permeability of cerebral vessels smaller/rise of ICP-plasma B infil
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Types of Edema
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-Cytotoxic edema -Hypoxic insult -Disturbance in cellular metabolism-dec glucose/glycogen/O2=anaerobic metabolism -Abnormal fluid accumulation-in brain
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Types of Edema
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-Interstitial edema -Acute brain swelling due to HTN or ↑ CSF pressure.
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Brain Hemorrhage
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-Subdural-slower -Venous bleeding beneath dura & above arachnoid -Acute SDH -within 48 hours of injury -Subacute - 48- 2 weeks -Chronic - 2 weeks to several months
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Brain Hemorrhage
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-Epidural hematoma-fast -Arterial bleeding between dura & skull -Lucidity/momentary unconscness w/i mins of injury -Emergent surgical intervention-eval hematoma
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Brain Hemorrhage
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-Intracerebral hemorrhage -Accumulation of blood within the brain tissue in white matter
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Brain Herniation
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-ICP caused brain tissue to shift & herniate downward
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Brain Herniation
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-Uncal herniation -Life threatening -Pressure to 3rd cranial nerve -Late findings - fixed/dialated pupils & rapid ↓ LOC
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Brain Herniation
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-Central herniation -Downward shift of brainstem -Cheyne-Stokes respiration, pinpoint/nonreactive pupils, hemodynamically unstable
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Irreversible Brain Damage
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-Glasgow Coma Scale <3 -Apnea -No pupillary response -No gag or cough reflex -No oculovestibular reflex, corneal reflex -No oculocephalic reflex
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Irreversible Brain Damage
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-Withdrawal or withholding of life support -Flat EEG -Removal of life support -Organ donation
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Nursing Care
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-Airway Management - first priority
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Nursing Care
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-Vital Sign Assessment -Cushing reflex (triad) -Late sign for ICP -Hypertension -Widening pulse pressure -Bradycardia
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Nursing Care
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-Neuro Assessment -Most important to assess LOC ↓or change in LOC 1st sign in deterioration
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Nursing Care
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-Glasgow coma scale (Figure 43-10 pg 941) -Eye opening -Motor response -Verbal response
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Nursing Care
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-Pupillary response -PERRLA -Pinpoint/nonresponsive - brainstem dysfunction -Ovoid pupil - development of ↑ ICP -Fixed/dilated - poor prognosis, marked ↑ ICP
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Nursing Care
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-Motor response -Assess for bilateral motor function
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Nursing Care
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-Posturing (Figure 44-13, pg 939) -Decerebrate-brainstem dysfunction-extension/extremities, pronation/arms, plantar flexion/opisthotonos (tetanic spasm)
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Nursing Care
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-Decorticate-interruption in corticospinal pathways -Arms, wrists, fingers flexed/internally rotated, plantar flexion legs
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KEY FEATURES of Increased Intracranial Pressure
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-Decreased level of consciousness (lethargy/coma) -Behavior chnges: restlessness, irritability, confusion -Headache -Nausea and vomiting -Change in speech pattern -Aphasia -Slurred speech
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KEY FEATURES of Increased Intracranial Pressure (cont)
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-Change in sensorimotor status -Pupil chngs: dilated/nonreactive pupils ("blown pupils") or constricted and nonreactive pupils -Cranial nerve dysfunction -Ataxia -Seizures -Cushing's triad (reflex) -Abnormal posturing (decorticate, decerebrate)
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Goals for Management
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-Preventing or detecting ↑ ICP -Promoting fluid & electrolyte balance -Monitoring treatment & drug therapy effects -Emotional support for patient/family
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ICP Prevention/Detection-Non-surgical management-
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-Vital signs minimally every 1-2 hours -Fever on admission -Defense mechanism to trauma -Indication of inflammatory response -May indicate hypothalamic damage -No sweating -No diurenal (day & night) temperature variation
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ICP Prevention/Detection-Non-surgical management-
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-Respiratory management -Maintain PaCO2 35-38 mm Hg -Prevent hypercarbia → vasodilation → ↑ ICP -Avoid aggress hyperventilation with ENT suctioning -Allow rest b/t suction, minimal suction if possible
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ICP Prevention/Detection-Non-surgical management-
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-Positioning -Avoid extreme flexion or extension of neck -Maintain neutral midline position -Avoid extreme hip flexion -HOB ↑ > 30⁰
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ICP Prevention/Detection-Non-surgical management-
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-Monitor for CSF leakage -Watch at ears & nose -Halo sign, presence of glucose
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Non-surgical management-Drug Therapy
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-Glucocorticoids - no benefit in ICP
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Non-surgical management-Drug Therapy
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-Osmotic diuretic (mannitol) ↓ cerebral edema by pulling fluid out of ECF -Given IV bolus via IVP -Must use filtered needle or tubing -Furosemide/adjunct therapy 2 prev rebound edema -Monitor urine output, serum & urine osmolarity
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Non-surgical management-Drug Therapy
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-Opioids & Sedatives -Morphine or fentanyl ↓ agitation in ventilator patients -Midazolam & lorazepam Anxiety, promote comfort, ↓ agitation -May mask neuro assess & ↓ BP, small doses
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Non-surgical management-Drug Therapy
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-Neuromuscular blocking agents: -Cisatracurium (Nimbix) -No analgesic or sedative effect, must have sedative ↑ RF pneumonia
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Non-surgical management-Drug Therapy
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-Antiepileptic agents -Prevent seizures that occur within 7 days of injury
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Non-surgical management-Drug Therapy
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-Antipyretics if febrile
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Non-surgical management-Drug Therapy
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-Barbiturate Coma ↑ ICP cannot be controlled -Pentobarbital ↓ metabolic demands of brain & blood flow -Hemodynamic & ICP monitoring -Complications - ↓ GI motility, dysrhythmias (↓K+), ↓BP
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Non-surgical management-F & E management
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-Risk for diabetes insipidus (DI) & SIADH -Monitor for fluid overload -Monitor urine specific gravity & osmolarity -Monitor electrolytes
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Non-surgical management-Nutritional Management
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-Changes in smell, swallowing, temp sensation -Decreased LOC -Dysphagia -Nutrition -Tube feedings -Dietician, speech therapist consults -Aspiration precautions -Occupational/Speech therapy
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Non-surgical management-
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-Sensory/Perceptual Alterations -May chng: smell, tste, swall, vision, tmp w/mjr hd inj -Frequent reorientation -Short term memory loss -RF seizures
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Non-surgical management-
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-Behavior/Safety Issues -Keep bed in low position -Hand mittens to prevent pulling out IV -Restraints ↑ agitation -Provide quiet environment
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Non-surgical management-ICP Monitoring Devices (Table 47-3)
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-IVC (intraventricular catheter) -Inserted in anterior horn of lateral ventricle -Monitors and drains CSF to ↓ ICP
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Non-surgical management-ICP Monitoring Devices (Table 47-3)
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-Subarachnoid screw or bolt -Placed in subarachnoid space -Cannot drain CSF -Less invasive, lower RF infection
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Non-surgical management-ICP Monitoring Devices (Table 47-3)
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-Epidural catheter -Placed between skull and dura
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Non-surgical management-ICP Monitoring Devices (Table 47-3)
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-Subdural catheter -Placed under dura matter ↓ RF infection
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Non-surgical management-ICP Pressure Monitoring-Assist w/dev insert
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-Provide information to family/significant others. -Calibrate and level the transducer. Set alarms. -Record ICP pressure readings/analyze waveforms. -Note client's change in response to stimuli. -Monitor cerebral perfusion pressure. -Monitor client's ICP/neuro response 2 care activities.
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Non-surgical management-ICP Pressure Monitoring(Cont)
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-Monitor intake/output/ insertion site for infection. -Monitor temperature and WBC count. -Admin pharma agents/maintain ICP w/i spec range. -Space nursing care to minimize ICP elevation. -Notify HCP/elev ICP/dsnt resp 2 treatmnt protocols
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ICP Prevention/Detection-Surgical Management
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-Craniotomy -ICP cannot be controlled -Removal of non-viable tissue -Allow for further tissue expansion -Hematoma removal
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ICP Prevention/Detection-Surgical Management
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-Rehabilitation -Maximize client's ability 2 return 2 highst lvl function -OT, PT, speech therapy -Adapt home environ/accommodate safety & function -Changes in personality & behavior
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ICP Prevention/Detection-Surgical Management
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-Brain Tumors -Primary tumors- CNS origination -Second tumors-metasts/lungs, brst, kidney, GI tract. -Tumors expand/invade/infiltrate/compress/displace normal brain tissue
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ICP Prevention/Detection-Surgical Management-Complications
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-Cerebral edema-↑ ICP -Neuro deficits-↓ bld flow → ischemia -Seizures -Hydrocephalus-↑ CSF -Pituitary Dysfunction -SIADH or Diabetes Insipidus -Fluid & electrolyte imbalances
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ICP Prevention/Detection-Surgical Management-General Assessment
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-Clinical manifestations vary on location -Headaches usually in AM -N/V -Visual disturbances -Seizures -Personality or mental status changes -Papilledema (swelling of optic disc) -CT, MRI, skull X-ray- Size, locat & extent of tumor -Lumbar puncture - Contraindicated if ↑ ICP present
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ICP Prevention/Detection-Non-surgical Management
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-Chemotherapy -Oral, IV, intra-arterially, intrathecally -Analgesics (codeine & tylenol) -Glucocorticoids- cerebral edema -Antiepileptics - seizures -Histamine block/proton pump inhibs-prev strss ulcrs -Radiation
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ICP Prevention/Detection-Non-surgical Management
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-Sterotactic Radiosurgery -Gamma knife or Cyberknife (no frame) -Destroys lesion w/o damaging surrnd healthy tissue
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ICP Prevention/Detection-Surgical Management
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-Preoperative -Fear neuro deficits post-may req short/lng trm rehab -No alcohol, tobacco, anticoagulants, NSAIDs for 5 days preop -NPO for 8 hours
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Surgical Management
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-Operative -MIS (transnasal with endoscopy) -Craniotomy -Burr holes, bone flap, ICP monitor & drain
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Surgical Management-Postoperative Care
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-ICP monitoring -Neuro chks (15-30 mn/4-6 hr) 2-4 hr/aft 24hr/ if stabl -Monitor for neuro deficits -Decreased LOC -Motor weakness or paralysis -Speech changes -Visual disturbances
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Surgical Management-Postoperative Care
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-May have periorbital edema or ecchymosis -Cardiac and Electrolyte monitoring -Strict I/O -NPO for first 24 hours -Passive gentle ROM every 2-3 hours -Sequential compression stockings
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Surgical Management-Postoperative Care
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-Positioning -HOB ↑ 30 degrees -Avoid extreme hip or neck flexion -Maintain head in midline position
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Surgical Management-Postoperative Care
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-Check dressing every 1-2 hours -Mark area of drainage & time -Surgical drain for 24 hours -Report saturated dressing to MD (>50 mL/8 hrs) -Monitor for hypovolemic shock → lay flat
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Surgical Management-Postoperative Care
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-Labs -CBC, ABG ↓ Na++ may indicate SIADH ↑ Na++ may indicate meningitis, dehydration, DI ↓ K+ may lead to cardiac irritability
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Surgical Management-
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-Respiratory -Mech vent 24-48 hrs post to↓ ICP & imp cerebral O2
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Surgical Management-
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-Drug therapy -Antiepileptics -Histamine blocker, proton pump inhibitor -Corticosteroids -Analgesics - codeine & tylenol -Possible prohylactic antibiotic
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Postop Complications
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-Increased ICP/cerebral edema -Subdural or epidural hematomas -Subarachnoid hemorrhage -Hypovolemic shock -Respiratory complications -Wound infection -Electrolyte imbalances -Seizures -CSF leakage
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Preventing Complications
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-Early recognition of ↑ ICP & hematomas -Hydrocephalus -Ventriculostomy -Frequent turning & deep breathing -Monitor for neurogenic pulmonary edema -Maintain head dressing -Electrolyte monitoring
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Community Based Care
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-Home is the goal. -Neuro deficits - may need assistive devices -Rehab center -Follow up appts and medication compliance -Community Organizations
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