بــ,،ــنـــــ،،ـــت شـ،،ـيـــوخ
03-26-2009, 03:14 AM
http://www.nursing4all.com/forum/images/smilies/nervous.gifHead injurise
Head injurise include truma to the scaple , skull , or brains .
That caues neurogical impariment thes injurise result from motor vihical , falls , assaults , and sports injurise
Head injuris caues die , intellectuall or behavioral deficit
Amajor risk to the patient with head injuris is damage to the brain from bleeding or swelling that caues increased intracranail pressure (ICP )
1- Scaple injurise
Is calssified a minor head injury . becausei ts many blood vessels constricts poorly treatment local
2- skull fracture
a skull fracture is a breakin the continuity of the skull caused by forceful truma . it may occure with out damage the brain skull fracture callified as linear , comminutied , depressed or basilar .
clinical manifestation
that depend to severityand local of injury
- localised pain
- swlleing site of fracture
- hemorrhage from nose, pharynx , or ears , ecchymosis
- otirrhea , or rhinorrhea
medical management
non deprepressed skull fracture do not require surgical treatment , need close observation
3- Brain injury
• concussion
a cerebral concussion after head injury is atempory loss of nerogical funcationwith no structural damage unconsiousness for few seconds to a few minutes , dizziness and spots from eyes
patients stay at hospital over night for observation or short time and give information if observe signs and symptoms the patient back to ER departement as
- Difficulty in waakening
- Difficulty in speaking
- Confusion
- Sever headache
- Vomiting
- Weakness of one side of the body
• contusion
contusion is more sever injury in which the brain is bruised with possible surface hemorrhage , signs & symptoms depend on the size of the contusions and amount of cerebral edema
- patient may lie motionless
- faint pulse
- shallow respations
- cool , pale skin
- involuntary evacuation of the bowels and the bladder
• diffuse axonal injury
damage to axons in the cerebral hemispheres , corpus callosum , and brain stem
can be see in mild to moderate or sever truma .
• intracranial hemorrage
hematoma ( collection of blood )
hematoma may be
- epidural :- blood may be collecte in the epiduoral , space between the skull and the dura . this result from a skull fraucture .
signs & symptoms
= momentry loss of consciousness at the time of injury
= may be focal neurogic deficient such as dilation and fixation of pupil or paralysis of any extremity
= respiratory arrest
- subdural :- acollection of blood bettwen the dura and the brain that result of truma or rupture small vessels , or aneurysm
signs & symptoms
the clincal symptoms developed over 24 to 48 hours
= Chanage of level of consciousness ( LOC ) .
= pupillary signs
= hemiparesis
= coma
= increasing in blood pressure
= decreased heart rate
= slowing respiratory rate are signs of a rapiduly expanding mass
Nursing Management
The nursing intervention for the patiente with head injury are extensive & diverse ; inculde making nursing assessement , setting prioritese for nursing intervention anticipating needs & complication & initiatiating rehabilitation
Assessment of brain injury
- level of consciousness (LOC) & responsiveness
LOC or responsiveness is regularly assessd because an altaration in LOC chanage in vital and neurogenic signs Glasgow Coma Scale is used to assess LOC on three criteria of eye opening , verbal response , motor response toverbal command or painfull stimuli . and given as score , lowest score 3 . the highest is 15 ascore of 7 or less is generally accepted as coma
Eye opening
Response Spontaneouse
4
To voice 3
To pain 2
None 1
Best verbal response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible
sounds 2
None 1
Best motor response Obeys command 6
Localizes pain 5
Withdraws (pain) 4
Flexion(pain) 3
Extension (pain) 2
None 1
- Vital signs
vital signs is monitoerd to assess intercranial sttracranial status
signs of increasing ( ICP ) .
+ slowing pulse ( bradycardia )
+ increase systolic blood pressure & widing pulse pressure
+ respiration become rapid
+ decrease blood pressure & slow pulse .
arapid raise on body temprature increseas in metabolic demaind of the brain and may indicate brain damage
- Motor function
motor function is assessed frequently by observationg spontaneous movement , asking the patient to rasise and lower the extremities &measuread strength
monitoring & managing potential complications
patient with head injury and risky for sever complication as ICP
impaired oxygen and ventilation
fulid , electrolyte and nutritional imblanaces
undernutrition
systemic infection ( pneumonia , UTI , septicemia )
neurosurgical infection
Discharge Note
If patient discharge from hospital the family instrute observe the fowlling if notify on the patient bring to the ER
• difficiulty in wakening
• difficiulty in speaking
• confusion
• sever headache
• vomiting
• weakness of one side of the body
Level of cognitive
- No response :- completey unresponse to alls stimuli , inculding painfull stimuli
Head injurise include truma to the scaple , skull , or brains .
That caues neurogical impariment thes injurise result from motor vihical , falls , assaults , and sports injurise
Head injuris caues die , intellectuall or behavioral deficit
Amajor risk to the patient with head injuris is damage to the brain from bleeding or swelling that caues increased intracranail pressure (ICP )
1- Scaple injurise
Is calssified a minor head injury . becausei ts many blood vessels constricts poorly treatment local
2- skull fracture
a skull fracture is a breakin the continuity of the skull caused by forceful truma . it may occure with out damage the brain skull fracture callified as linear , comminutied , depressed or basilar .
clinical manifestation
that depend to severityand local of injury
- localised pain
- swlleing site of fracture
- hemorrhage from nose, pharynx , or ears , ecchymosis
- otirrhea , or rhinorrhea
medical management
non deprepressed skull fracture do not require surgical treatment , need close observation
3- Brain injury
• concussion
a cerebral concussion after head injury is atempory loss of nerogical funcationwith no structural damage unconsiousness for few seconds to a few minutes , dizziness and spots from eyes
patients stay at hospital over night for observation or short time and give information if observe signs and symptoms the patient back to ER departement as
- Difficulty in waakening
- Difficulty in speaking
- Confusion
- Sever headache
- Vomiting
- Weakness of one side of the body
• contusion
contusion is more sever injury in which the brain is bruised with possible surface hemorrhage , signs & symptoms depend on the size of the contusions and amount of cerebral edema
- patient may lie motionless
- faint pulse
- shallow respations
- cool , pale skin
- involuntary evacuation of the bowels and the bladder
• diffuse axonal injury
damage to axons in the cerebral hemispheres , corpus callosum , and brain stem
can be see in mild to moderate or sever truma .
• intracranial hemorrage
hematoma ( collection of blood )
hematoma may be
- epidural :- blood may be collecte in the epiduoral , space between the skull and the dura . this result from a skull fraucture .
signs & symptoms
= momentry loss of consciousness at the time of injury
= may be focal neurogic deficient such as dilation and fixation of pupil or paralysis of any extremity
= respiratory arrest
- subdural :- acollection of blood bettwen the dura and the brain that result of truma or rupture small vessels , or aneurysm
signs & symptoms
the clincal symptoms developed over 24 to 48 hours
= Chanage of level of consciousness ( LOC ) .
= pupillary signs
= hemiparesis
= coma
= increasing in blood pressure
= decreased heart rate
= slowing respiratory rate are signs of a rapiduly expanding mass
Nursing Management
The nursing intervention for the patiente with head injury are extensive & diverse ; inculde making nursing assessement , setting prioritese for nursing intervention anticipating needs & complication & initiatiating rehabilitation
Assessment of brain injury
- level of consciousness (LOC) & responsiveness
LOC or responsiveness is regularly assessd because an altaration in LOC chanage in vital and neurogenic signs Glasgow Coma Scale is used to assess LOC on three criteria of eye opening , verbal response , motor response toverbal command or painfull stimuli . and given as score , lowest score 3 . the highest is 15 ascore of 7 or less is generally accepted as coma
Eye opening
Response Spontaneouse
4
To voice 3
To pain 2
None 1
Best verbal response Oriented 5
Confused 4
Inappropriate words 3
Incomprehensible
sounds 2
None 1
Best motor response Obeys command 6
Localizes pain 5
Withdraws (pain) 4
Flexion(pain) 3
Extension (pain) 2
None 1
- Vital signs
vital signs is monitoerd to assess intercranial sttracranial status
signs of increasing ( ICP ) .
+ slowing pulse ( bradycardia )
+ increase systolic blood pressure & widing pulse pressure
+ respiration become rapid
+ decrease blood pressure & slow pulse .
arapid raise on body temprature increseas in metabolic demaind of the brain and may indicate brain damage
- Motor function
motor function is assessed frequently by observationg spontaneous movement , asking the patient to rasise and lower the extremities &measuread strength
monitoring & managing potential complications
patient with head injury and risky for sever complication as ICP
impaired oxygen and ventilation
fulid , electrolyte and nutritional imblanaces
undernutrition
systemic infection ( pneumonia , UTI , septicemia )
neurosurgical infection
Discharge Note
If patient discharge from hospital the family instrute observe the fowlling if notify on the patient bring to the ER
• difficiulty in wakening
• difficiulty in speaking
• confusion
• sever headache
• vomiting
• weakness of one side of the body
Level of cognitive
- No response :- completey unresponse to alls stimuli , inculding painfull stimuli