NUR 4320 Module 5 Brain Injury Paper: Preventing Secondary Injury After Severe TBI Example

Guarding the Brain That Is Left: Nursing a Student With Severe Head Injury in Hackensack

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-4320: Nursing Care of Clients with Complex Health Conditions

Mentor Name

Month Day, Year

Guarding the Brain That Is Left: Nursing a Student With Severe Head Injury in Hackensack

The Patient

Jordan and the hospital are invented. Jordan, 19, a sophomore studying engineering, fell about fifteen feet from a balcony at a party. On arrival his Glasgow Coma Scale score was 6, his right pupil was wider than the left and sluggish, and he had vomited. He was intubated, and a CT scan showed a contusion in the right frontal lobe with swelling and a thin layer of blood over the brain's surface, which did not need surgery. An intracranial pressure monitor was placed, and he was admitted to the neuro ICU. His parents drove in from Pennsylvania overnight.

Two Waves of Injury

The primary injury happens at the moment of impact and cannot be reversed. Secondary injury develops over the following hours and days as swelling, low blood pressure, low oxygen, fever, high or low carbon dioxide, seizures and abnormal blood sugar or sodium further harm brain cells that survived the first blow. Rising pressure inside the skull reduces blood flow to the brain, since cerebral perfusion pressure is found by subtracting intracranial pressure from mean arterial pressure. Nursing care for severe TBI is largely the prevention of secondary injury.

Low Pressure and Low Oxygen

Chesnut et al. (1993) analyzed 717 patients with severe head injury in the Traumatic Coma Data Bank. Hypotension, a systolic pressure below 90, from injury through resuscitation was one of the five strongest predictors of outcome, and a single episode was associated with a marked rise in mortality. Hypoxia also worsened outcomes, and patients with both did worst of all. These findings made preventing even brief drops in blood pressure and oxygen a priority from the scene onward.

Does Monitoring Help

Chesnut et al. (2012) randomly assigned 324 patients with severe TBI in Bolivia and Ecuador to treatment guided by an intracranial pressure monitor or to treatment guided by imaging and clinical examination. A composite measure of survival, consciousness and function at six months did not differ, and six-month mortality was similar. The trial did not show that the monitor itself improves outcome. The authors noted that the result applied to the protocols tested and not to whether pressure should be treated at all.

The Guidelines

Carney et al. (2017) published the fourth edition of the Brain Trauma Foundation guidelines. They recommended treating intracranial pressure above 22 mm Hg, keeping systolic pressure at or above 100 for patients aged 50 to 69 and at or above 110 for patients aged 15 to 49 or over 70, aiming for a cerebral perfusion pressure between 60 and 70, avoiding prolonged hyperventilation to a carbon dioxide level of 25 or less and not using steroids. Monitoring was recommended for patients with severe TBI who could be saved, because it was linked to lower in-hospital and two-week mortality in the studies reviewed.

Nursing Diagnoses

The student identified risk for decreased intracranial adaptive capacity related to brain swelling, risk for ineffective cerebral tissue perfusion from hypotension or hypoxia and interrupted family processes related to sudden critical injury.

Bedside Measures

The nurse raised the bed's head to 30 degrees and kept Jordan's head and neck in line so that venous blood could drain, and the student checked that the cervical collar was not too tight around the neck. Suctioning was kept brief, with extra oxygen before, because coughing and low oxygen raise pressure. His temperature was kept normal with a cooling blanket, since fever increases brain metabolism. The nurse watched carbon dioxide on the ventilator and capnography, keeping it in the normal range as ordered. Sodium levels were checked every six hours during hypertonic saline. The student learned to assess pupils and motor response every hour and to report any change at once.

A Rise in Pressure

On the second night, Jordan's intracranial pressure rose to 27 during turning and stayed there. The nurse checked his position and sedation, gave a dose of hypertonic saline as ordered and called the neurosurgeon. The pressure returned to 18 within twenty minutes. The student learned to cluster care so that his pressure had time to settle between procedures.

His Parents

Jordan's parents were shocked and kept asking whether he would wake up. The student sat with them while the nurse explained the monitor, encouraged them to talk to him and helped them find the social worker and a place to sleep nearby.

Evaluation

Over five days, Jordan's pressure stayed below 22 most of the time, he had no episodes of hypotension or hypoxia and his pupils became equal. By the seventh day he opened his eyes to his mother's voice.

Seizures and Sodium

Seizures after brain injury raise metabolic demand and pressure, and seizures in sedated patients may not be visible. Jordan received a seven-day course of seizure prevention medicine as ordered, which the guidelines support for early seizures. The student learned to watch for subtle signs such as rhythmic eye movements or sudden rises in pressure. Sodium was checked often during hypertonic saline, and the nurse also measured urine output each hour, since a brain injury may upset the hormonal control of water balance and cause sodium to rise or fall quickly.

Limits

The 1993 analysis was observational. BEST-TRIP was conducted where prehospital and rehabilitation care differ from New Jersey. Long-term outcomes after severe TBI vary widely. A student assists and reports but does not give hypertonic saline or adjust the ventilator.

Conclusion

Jordan's severe brain injury could not be undone, but the injury that followed could be limited. The Traumatic Coma Data Bank showed the harm of low pressure and low oxygen, BEST-TRIP placed the monitor in perspective and the guidelines set the targets. Positioning, temperature control, careful suctioning, hourly checks and family support made up the nursing work.

References

Carney, N., Totten, A. M., O'Reilly, C., Ullman, J. S., Hawryluk, G. W. J., Bell, M. J., Bratton, S. L., Chesnut, R., Harris, O. A., Kissoon, N., Rubiano, A. M., Shutter, L., Tasker, R. C., Vavilala, M. S., Wilberger, J., Wright, D. W., & Ghajar, J. (2017). Guidelines for the management of severe traumatic brain injury, fourth edition. Neurosurgery, 80(1), 6-15. https://doi.org/10.1227/NEU.0000000000001432

Chesnut, R. M., Marshall, L. F., Klauber, M. R., Blunt, B. A., Baldwin, N., Eisenberg, H. M., Jane, J. A., Marmarou, A., & Foulkes, M. A. (1993). The role of secondary brain injury in determining outcome from severe head injury. Journal of Trauma, 34(2), 216-222. https://doi.org/10.1097/00005373-199302000-00006

Chesnut, R. M., Temkin, N., Carney, N., Dikmen, S., Rondina, C., Videtta, W., Petroni, G., Lujan, S., Pridgeon, J., Barber, J., Machamer, J., Chaddock, K., Celix, J. M., Cherner, M., & Hendrix, T. (2012). A trial of intracranial-pressure monitoring in traumatic brain injury. New England Journal of Medicine, 367(26), 2471-2481. https://doi.org/10.1056/NEJMoa1207363