In the third post, I will discuss about CARE NURSING PATIENT INJURY TO THE HEAD, and may be useful and do not forget the comments.
DEFINITIONSHead
injury is the deformation in the form of irregularities or deviations
form a line on the skull, the acceleration and deceleration
(acceleration - decelerasi) which is the change in shape is affected by
changes in acceleration factors increase and decrease the speed, and the
notation that the movement of the head was also perceived by the brain
as a result of turnover on preventive measures.
PathophysiologyBrain can function properly when the need for oxygen and glucose can be met. Energy is produced in the nerve cells almost entirely through the process of oxidation. The brain does not have a reserve of oxygen, so the lack of blood flow to the brain even briefly will cause it to malfunction. Similarly, the need for oxygen as fuel for brain metabolism can not be less than 20 mg%, because it will lead to a coma. Needs glucose as much as 25% of the entire body needs glucose, so that when the plasma glucose level fell to 70% will be the beginning symptoms of cerebral dysfunction.At the time of hypoxic brain, the body tries to meet the needs of oxygen through anaerobic metabolic processes that can cause dilation of blood vessels. In severe contusions, hypoxia or brain damage will occur due to the accumulation of lactic acid anaerobic metabolism. This will cause metabolic acidosis.
Under normal circumstances Cerebral blood flow (CBF) was 50-60 ml / min / 100 gr. brain tissue, which is 15% of the cardiac output.Head trauma causes a change of heart function-myocardial sekuncup atypical activity, changes in vascular pressure and pulmonary edema. Autonomous changes in ventricular function is T and P wave changes and dysrhythmias, and vebtrikel atrial fibrillation, tachycardia.Due to brain haemorrhage affects the vascular pressure, which decreased vascular pressure causes blood vessels to the arterioles to contract. Effect of sympathetic and parasympathetic innervation of the arteries and arterioles brain is not so great.
Head injury in the pathophysiology is divided into two:PRIMARY HEAD INJURIESThe direct effect on the dynamic mechanism (acelerasi - decelerasi rotation) that causes disruption to the network.In the primary injury can occur:1. Concussion head light2. Bruising of the brain3. Laceration
SECONDARY HEAD INJURIES1. In the secondary head injury symptoms will arise, such as:2. Systemic hypotension3. Hypoxia4. Hiperkapnea5. Udema brain6. Respiratory complications
Infection / complications in other organsBLEEDING IS OFTEN FOUNDEpidural HematomaThere is a collection of blood between the skull and the dura due to the rupture of blood vessels / branch - the branch of the meningeal artery media contained in the dura mater, the blood vessels can not close on its own because it is very dangerous. Can occur within a few hours to 1-2 days. The most frequent location is in the temporal and parietal lobes.
The symptoms that occur:• Decreased level of consciousness• Headache• Vomiting• hemiparesis• ipsilateral pupillary dilatation• Breathing in the fast later irregular shallow• Decrease the pulse• Increased temperaturesSubdural HematomaAccumulation of blood between the dura and brain tissue, can be acute and chronic. Occurs due to the rupture of veins / vein bridges that are common between the dura mater, and a little slow bleeding. Acute period occurs within 48 hours - 2 days or 2 weeks and chronic can occur within 2 weeks or a few months.The signs and symptoms are:• Headache• Confused• Drowsiness• Withdraw• Thinking is slow• Seizures• Udem pupil
Intracerebral hemorrhage in the form of bleeding in the brain tissue due to arterial rupture; capillaries; vein.Signs and symptoms:• Headache• Impairment of consciousness• Respiratory Complications• contra lateral hemiplegia• dilated pupils• Changes in vital signs
Subarachnoid HemorrhageBleeding in the subarachnoid cavity due to rupture of blood vessels and the brain surface, there is almost always a great pad head injury.Signs and symptoms:• Headache• Impairment of consciousness• Hemiparese• ipsilateral pupillary dilatation• Stiff neck
ASSESSMENT1. Client data collection either subjective or objective on the nervous system disorder in connection with a head injury depends on the shape, location, type of injury and the presence of complications in other vital organs.2. The identity of the client and family (person in charge): name, age, gender, religion, ethnicity, marital status, address, blood type, pengahasilan, client relationship with the person in charge.3. Medical history:• Level of consciousness / GCS (<15)• Convulsi• Vomiting• Dyspnea / tachypnea• Headache• Facial symmetry / no• Weak• Injury to the head• Paralise• The accumulation of secretions in the airway• The liquor from the nose and ears• Seizures
History of the disease should be known well before dealing with the nervous system and other systemic diseases system. as well as a family history of disease, especially who have infectious diseases.
Health history can be studied from the client or the family as a data subjective. These data are very significant because it can affect the prognosis clients.
4. Physical examinationNeurological aspect studied is the level of consciousness, usually GCS <15, disorienting people, places and time. The existence of a positive Babinski reflex, changes in the value of vital signs stiff neck, hemiparese.Cranial nerve can be compromised if a head injury extends to the brain stem due to brain or brain hemorrhage udema also examines nerves I, II, III, V, VII, IX, XII.5. Examination Penujang• CT-Scan (with or without contrast): identify the extent of the lesion, hemorrhage, ventricular determinants, and changes in brain tissue. Note: To determine the presence of infarction / ischemia do dilekukan at 24-72 hours after injury.• MRI: Used the same as CT-Scan with or without contrast radioactive.• Cerebral Angiography: Indicates cerebral circulation anomaly, such as: changes in brain tissue secondary to udema, bleeding and trauma.• Serial EEG: may see the development of a pathological wave• X-Ray: Detecting changes in bone structure (fracture), changes in the structure of the line (hemorrhage / edema), bone fragments.• BAER: Correct limits corteks function and cerebellum• PET: Detecting changes in brain metabolic activity• CSF, lumbar puncture: Can be done if it is suspected subarachnoid hemorrhage.• ABGs: Detecting the presence of ventilation or breathing problems (oxygenation) in the event of increased intracranial pressure• Electrolyte Levels: To correct electrolyte balance as a result of increased pressure intrkranial• Screen Toxicologi: To detect the influence of drugs causing loss of consciousness.
ManagementConservatives:• Bedrest total• Provision of drugs• Observation vital signs (GCS and level of consciousness)
Priority Care:1. Maximize perfusion / brain function2. Preventing complications3. Setting optimal function / returns to normal function4. Supports recovery coping client / family5. Provision of information about the disease process, prognosis, plan treatment, and rehabilitation.
Purpose:1. Improved brain function: neurological deficits were reduced / fixed2. Complications did not occur3. Daily needs can be met alone or assisted others4. Families can accept and participate in care5. The disease process, prognosis, treatment programs can be understood by the family as a source of information.
Nursing Diagnosis can be:1. Ineffective breathing pattern related to respiratory depression in the center of the brain.2. Ineffective airway hygiene in relation to accumulation of sputum.3. Impaired brain tissue perfusion in relation to brain edema4. Limitations of activity in relation to impairment of consciousness (soporos - coma)5. Potential disruption of skin integrity with respect to immobilization, inadequate peripheral circulation.6. Anxiety related families critical condition in patients
REFERENCES
Doenges M.E. (1989) Nursing Care Plan, Planning Guidlines for Patient Care (2 nd ed). Philadelphia, F.A. Davis Company.
Long; BC and Phipps WJ (1985) Essentials of Medical Surgical Nursing: A Nursing Process Approach St. Louis. Cv. Mosby Company.
Asikin Z (1991) Patients with Head Injuries Nursing Symposium.Patients with Aids Panatalaksanaan Breath, Jakarta.
Harsono (1993) Capita Selekta Neurology, Gadjah Mada University Press
PathophysiologyBrain can function properly when the need for oxygen and glucose can be met. Energy is produced in the nerve cells almost entirely through the process of oxidation. The brain does not have a reserve of oxygen, so the lack of blood flow to the brain even briefly will cause it to malfunction. Similarly, the need for oxygen as fuel for brain metabolism can not be less than 20 mg%, because it will lead to a coma. Needs glucose as much as 25% of the entire body needs glucose, so that when the plasma glucose level fell to 70% will be the beginning symptoms of cerebral dysfunction.At the time of hypoxic brain, the body tries to meet the needs of oxygen through anaerobic metabolic processes that can cause dilation of blood vessels. In severe contusions, hypoxia or brain damage will occur due to the accumulation of lactic acid anaerobic metabolism. This will cause metabolic acidosis.
Under normal circumstances Cerebral blood flow (CBF) was 50-60 ml / min / 100 gr. brain tissue, which is 15% of the cardiac output.Head trauma causes a change of heart function-myocardial sekuncup atypical activity, changes in vascular pressure and pulmonary edema. Autonomous changes in ventricular function is T and P wave changes and dysrhythmias, and vebtrikel atrial fibrillation, tachycardia.Due to brain haemorrhage affects the vascular pressure, which decreased vascular pressure causes blood vessels to the arterioles to contract. Effect of sympathetic and parasympathetic innervation of the arteries and arterioles brain is not so great.
Head injury in the pathophysiology is divided into two:PRIMARY HEAD INJURIESThe direct effect on the dynamic mechanism (acelerasi - decelerasi rotation) that causes disruption to the network.In the primary injury can occur:1. Concussion head light2. Bruising of the brain3. Laceration
SECONDARY HEAD INJURIES1. In the secondary head injury symptoms will arise, such as:2. Systemic hypotension3. Hypoxia4. Hiperkapnea5. Udema brain6. Respiratory complications
Infection / complications in other organsBLEEDING IS OFTEN FOUNDEpidural HematomaThere is a collection of blood between the skull and the dura due to the rupture of blood vessels / branch - the branch of the meningeal artery media contained in the dura mater, the blood vessels can not close on its own because it is very dangerous. Can occur within a few hours to 1-2 days. The most frequent location is in the temporal and parietal lobes.
The symptoms that occur:• Decreased level of consciousness• Headache• Vomiting• hemiparesis• ipsilateral pupillary dilatation• Breathing in the fast later irregular shallow• Decrease the pulse• Increased temperaturesSubdural HematomaAccumulation of blood between the dura and brain tissue, can be acute and chronic. Occurs due to the rupture of veins / vein bridges that are common between the dura mater, and a little slow bleeding. Acute period occurs within 48 hours - 2 days or 2 weeks and chronic can occur within 2 weeks or a few months.The signs and symptoms are:• Headache• Confused• Drowsiness• Withdraw• Thinking is slow• Seizures• Udem pupil
Intracerebral hemorrhage in the form of bleeding in the brain tissue due to arterial rupture; capillaries; vein.Signs and symptoms:• Headache• Impairment of consciousness• Respiratory Complications• contra lateral hemiplegia• dilated pupils• Changes in vital signs
Subarachnoid HemorrhageBleeding in the subarachnoid cavity due to rupture of blood vessels and the brain surface, there is almost always a great pad head injury.Signs and symptoms:• Headache• Impairment of consciousness• Hemiparese• ipsilateral pupillary dilatation• Stiff neck
ASSESSMENT1. Client data collection either subjective or objective on the nervous system disorder in connection with a head injury depends on the shape, location, type of injury and the presence of complications in other vital organs.2. The identity of the client and family (person in charge): name, age, gender, religion, ethnicity, marital status, address, blood type, pengahasilan, client relationship with the person in charge.3. Medical history:• Level of consciousness / GCS (<15)• Convulsi• Vomiting• Dyspnea / tachypnea• Headache• Facial symmetry / no• Weak• Injury to the head• Paralise• The accumulation of secretions in the airway• The liquor from the nose and ears• Seizures
History of the disease should be known well before dealing with the nervous system and other systemic diseases system. as well as a family history of disease, especially who have infectious diseases.
Health history can be studied from the client or the family as a data subjective. These data are very significant because it can affect the prognosis clients.
4. Physical examinationNeurological aspect studied is the level of consciousness, usually GCS <15, disorienting people, places and time. The existence of a positive Babinski reflex, changes in the value of vital signs stiff neck, hemiparese.Cranial nerve can be compromised if a head injury extends to the brain stem due to brain or brain hemorrhage udema also examines nerves I, II, III, V, VII, IX, XII.5. Examination Penujang• CT-Scan (with or without contrast): identify the extent of the lesion, hemorrhage, ventricular determinants, and changes in brain tissue. Note: To determine the presence of infarction / ischemia do dilekukan at 24-72 hours after injury.• MRI: Used the same as CT-Scan with or without contrast radioactive.• Cerebral Angiography: Indicates cerebral circulation anomaly, such as: changes in brain tissue secondary to udema, bleeding and trauma.• Serial EEG: may see the development of a pathological wave• X-Ray: Detecting changes in bone structure (fracture), changes in the structure of the line (hemorrhage / edema), bone fragments.• BAER: Correct limits corteks function and cerebellum• PET: Detecting changes in brain metabolic activity• CSF, lumbar puncture: Can be done if it is suspected subarachnoid hemorrhage.• ABGs: Detecting the presence of ventilation or breathing problems (oxygenation) in the event of increased intracranial pressure• Electrolyte Levels: To correct electrolyte balance as a result of increased pressure intrkranial• Screen Toxicologi: To detect the influence of drugs causing loss of consciousness.
ManagementConservatives:• Bedrest total• Provision of drugs• Observation vital signs (GCS and level of consciousness)
Priority Care:1. Maximize perfusion / brain function2. Preventing complications3. Setting optimal function / returns to normal function4. Supports recovery coping client / family5. Provision of information about the disease process, prognosis, plan treatment, and rehabilitation.
Purpose:1. Improved brain function: neurological deficits were reduced / fixed2. Complications did not occur3. Daily needs can be met alone or assisted others4. Families can accept and participate in care5. The disease process, prognosis, treatment programs can be understood by the family as a source of information.
Nursing Diagnosis can be:1. Ineffective breathing pattern related to respiratory depression in the center of the brain.2. Ineffective airway hygiene in relation to accumulation of sputum.3. Impaired brain tissue perfusion in relation to brain edema4. Limitations of activity in relation to impairment of consciousness (soporos - coma)5. Potential disruption of skin integrity with respect to immobilization, inadequate peripheral circulation.6. Anxiety related families critical condition in patients
REFERENCES
Doenges M.E. (1989) Nursing Care Plan, Planning Guidlines for Patient Care (2 nd ed). Philadelphia, F.A. Davis Company.
Long; BC and Phipps WJ (1985) Essentials of Medical Surgical Nursing: A Nursing Process Approach St. Louis. Cv. Mosby Company.
Asikin Z (1991) Patients with Head Injuries Nursing Symposium.Patients with Aids Panatalaksanaan Breath, Jakarta.
Harsono (1993) Capita Selekta Neurology, Gadjah Mada University Press
Thank you hopefully useful...
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