SILLIMAN UNIVERSITY

Vision
Mission and Vision Statement
A leading Christian institution committed to total human development for the well-being of society and environment.

Mission
Infuse into the academic learning the Christian faith anchored on the gospel of Jesus Christ; provide an environment where Christian fellowship and relationship can be nurtured and promoted. Provide opportunities for growth and excellence in every dimension of the University life in order to strengthen character, competence, and faith. Instil in all members of the University, community an enlightened social consciousness and deep sense of justice and compassion. Promote unity among people and contribute to national development.

Topic: Head Injury

Placement: First Semester, Level III Time allotment: 1 hour Topic description: This topic deals with the overview of the condition, head injury: its classifications, causes and clinical manifestations. This will also include various related medical and nursing management to patients who have experienced head injury. Central objectives: At the end of the presentation, the learner shall develop adequate knowledge, skills and positive attitudes and values in the care of patient with head injury. .

SPECIFIC OBJECTIVE
At the end of the 1-hour discussion, the learners will be able to: >refresh their understanding of the basic anatomy and physiology of the CNS PRAYER INTRODUCTION

CONTENT

T.A
1min. 1min.

T/L ACTIVITIES

REFERENCES
Lewis, S, et al (2004) MedicalSurgical Nursing Management 6th edition, Mosby. Goul, B (2007) Pathophysiology for the Health Professions 3rd edition. Elsevier, Inc.

EVALUATION
Brain puzzle game: -guidelines: 1) find a pair. 2) the pair will pick one puzzle piece. 3) once every pair has already obtained a puzzle piece everyone is asked to form the puzzle. 4)once formed both pair should at least give 3 functions and 2 of the manifestation when that side of the brain is injured.

Almost a quarter of a million people all over the world are hospitalized every year with brain injuries. TBI (traumatic brain injury) can alter an individuals physical ability and even more devastating are the potential personality changes and loss of cognitive abilities.

I. A. Anatomy and Physiology of the Brain The Brain 5mins Video Brain, portion of the central nervous system contained within the skull. The brain is the presentation control center for movement, sleep, hunger, thirst, and virtually every other vital activity necessary to survival. All human emotionsincluding love, hate, fear, anger, elation, and sadnessare controlled by the brain. It also receives and interprets the countless signals that are sent to it from other parts of the body and from the external environment. The brain makes us conscious, emotional, and intelligence. Meninges >The meninges are three layers of protective membranes that surround the brain and spinal cord. The thick dura mater forms the outermost layer, with the arachnoid layer and pia mater being the next two layers. The flax cerebri is a fold of the dura that separates the two cerebral hemispheres and prevent expansion of brain tissue. The arachnoid layer is delicate, impermeable membrane that lies between the thick dura mater and the pia mater. The subarachnoid space lies between the arachnoid layer and the pia mater. This space is filled with CSF. Structures passing to and from the brain and the skull or its foramina must pass through the subarachnoid space.

Smeltzer, et. Al. (2010). Brunner and Suddarths: Textbook of medical-surgical nursing. 12th ed. Philadelphia: Lippincott William and Wilkins. Black, J. M. & Hawks, J.H. (2002). Medical-

Everyone will be highly acknowledged for their participation and prizes will be given after the discussion.

Cerebrum >Most high-level brain functions take place in the cerebrum. Its two large hemispheres make up approximately 85 percent of the brain's weight. The exterior surface of the cerebrum, the cerebral cortex, is a convoluted, or folded, greyish layer of cell bodies known as the gray matter. The gray matter covers an underlying mass of fibers called the white matter. The convolutions are made up of ridge like bulges, known as gyri, separated by small grooves called sulci and larger grooves called fissures. Approximately two-thirds of the cortical surface is hidden in the folds of the sulci. The extensive convolutions enable a very large surface area of brain cortexabout 1.5 m2 (16 ft2) in an adultto fit within the cranium. >The two cerebral hemispheres are partially separated from each other by a deep fold known as the longitudinal fissure. Communication between the two hemispheres is through several concentrated bundles of axons, called commissures, the largest of which is the corpus callosum. > The frontal lobe is the largest of the five and consists of all the cortex in front of the central sulcus. Broca's area, a part of the cortex related to speech, is located in the frontal lobe. The parietal lobe consists of the cortex behind the central sulcus to a sulcus near the back of the cerebrum known as the parieto-occipital sulcus. The parieto-occipital sulcus, in turn, forms the front border of the occipital lobe, which is the rearmost part of the cerebrum. The temporal lobe is to the side of and below the lateral sulcus. Wernicke's area, a part of the cortex related to the understanding of language, is located in the temporal lobe. The insula lies deep within the folds of the lateral sulcus. > The cerebrum receives information from all the sense organs and sends motor commands (signals that result in activity in the muscles or glands) to other parts of the brain and the rest of the body. Motor commands are transmitted by the motor cortex, a strip of cerebral cortex extending from side to side across the top of the cerebrum just in front of the central sulcus. The sensory cortex, a parallel strip of cerebral cortex just in back of the central sulcus, receives input from the sense organs. Many other areas of the cerebral cortex have also been mapped according to their specific functions, such as vision, hearing, speech, emotions, language, and other aspects of perceiving, thinking, and remembering. Cortical regions known as associative cortex are responsible for integrating multiple inputs, processing the information, and carrying out complex responses. Cerebellum >The cerebellum coordinates body movements. Located at the lower back of the brain beneath the occipital lobes, the cerebellum is divided into two lateral (side-by-side) lobes connected by a fingerlike bundle of white fibers called the vermis. The outer layer, or cortex, of the cerebellum consists of fine folds called folia. As in the cerebrum, the outer layer of cortical gray matter surrounds a deeper layer of white matter and nuclei (groups of nerve cells). Three fiber bundles called cerebellar peduncles connect the cerebellum to the three parts of the brain stem

surgical nursing: Clinical management for Positive Outcomes. 6th edition. Philadelphia: W.B. Saunders Co.

the midbrain, the pons, and the medulla oblongata. The cerebellum coordinates voluntary movements by fine-tuning commands from the motor cortex in the cerebrum. The cerebellum also maintains posture and balance by controlling muscle tone and sensing the position of the limbs. All motor activity, from hitting a baseball to fingering a violin, depends on the cerebellum. Thalamus and Hypothalamus >The thalamus and the hypothalamus lie underneath the cerebrum and connect it to the brain stem. The thalamus consists of two rounded masses of gray tissue lying within the middle of the brain, between the two cerebral hemispheres. The thalamus is the main relay station for incoming sensory signals to the cerebral cortex and for outgoing motor signals from it. All sensory input to the brain, except that of the sense of smell, connects to individual nuclei of the thalamus. The hypothalamus lies beneath the thalamus on the midline at the base of the brain. It regulates or is involved directly in the control of many of the body's vital drives and activities, such as eating, drinking, temperature regulation, sleep, emotional behavior, and sexual activity. It also controls the function of internal body organs by means of the autonomic nervous system, interacts closely with the pituitary gland, and helps coordinate activities of the brain stem. Brain Stem >The brain stem is evolutionarily the most primitive part of the brain and is responsible for sustaining the basic functions of life, such as breathing and blood pressure. It includes three main structures lying between and below the two cerebral hemispheresthe midbrain, pons, and medulla oblongata. 1. Midbrain The topmost structure of the brain stem is the midbrain. It contains major relay stations for neurons transmitting signals to the cerebral cortex, as well as many reflex centerspathways carrying sensory (input) information and motor (output) commands. Relay and reflex centers for visual and auditory (hearing) functions are located in the top portion of the midbrain. A pair of nuclei called the superior colliculus control reflex actions of the eye, such as blinking, opening and closing the pupil, and focusing the lens. A second pair of nuclei, called the inferior colliculus, control auditory reflexes, such as adjusting the ear to the volume of sound. At the bottom of the midbrain are reflex and relay centers relating to pain, temperature, and touch, as well as several regions associated with the control of movement, such as the red nucleus and the substantia nigra. 2. Pons Continuous with and below the midbrain and directly in front of the cerebellum is a prominent bulge in the brain stem called the pons. The pons consists of large bundles of nerve fibers that connect the two halves of the cerebellum and also connect each side of the cerebellum with the opposite-side cerebral hemisphere. The pons serves

mainly as a relay station linking the cerebral cortex and the medulla oblongata. 3. Medulla Oblongata The long, stalk like lowermost portion of the brain stem is called the medulla oblongata. At the top, it is continuous with the pons and the midbrain; at the bottom, it makes a gradual transition into the spinal cord at the foramen magnum. Sensory and motor nerve fibers connecting the brain and the rest of the body cross over to the opposite side as they pass through the medulla. Thus, the left half of the brain communicates with the right half of the body and the right half of the brain with the left half of the body. 4. Reticular Formation Running up the brain stem from the medulla oblongata through the pons and the midbrain is a netlike formation of nuclei known as the reticular formation. The reticular formation controls respiration, cardiovascular function (see Heart), digestion, levels of alertness, and patterns of sleep. It also determines which parts of the constant flow of sensory information into the body are received by the cerebrum. Brain Cells >There are two main types of brain cells: neurons and neuroglia. Neurons are responsible for the transmission and analysis of all electrochemical communication within the brain and other parts of the nervous system. Each neuron is composed of a cell body called a soma, a major fiber called an axon, and a system of branches called dendrites. Axons, also called nerve fibers, convey electrical signals away from the soma and can be up to 1 m (3.3 ft) in length. Most axons are covered with a protective sheath of myelin, a substance made of fats and protein, which insulates the axon. Myelinated axons conduct neuronal signals faster than do unmyelinated axons. Dendrites convey electrical signals toward the soma, are shorter than axons, and are usually multiple and branching. Neuroglial cells are twice as numerous as neurons and account for half of the brain's weight. Neuroglia (from glia, Greek for glue) provide structural support to the neurons. Neuroglial cells also form myelin, guide developing neurons, take up chemicals involved in cellto-cell communication, and contribute to the maintenance of the environment around neurons. Neurons >A typical neuron consists of a cell body, and axon, and several dendrites. The cell body containing the nucleus and cytoplasm is the metabolic center of the neuron. Dendrites are short process extending from the cell body. They receive nerve impulse from the axons of other neurons and conducting impulse towards the cell body. The nerve axon projects varying distances from the cell body, ranging from several from several micrometers to more than a meter. Its function is to carry nerve impulses to other neurons or to end organs. The end organs are smooth and striated muscle and glands. Axons may be myelinated or unmyelinated. Many axons present in the CNS and the PNS are covered by a segmentally interrupted myelin sheath composed of a white, lipid

substance that acts as an insulator for the conduction of impulses. Cranial Nerves >Twelve pairs of cranial nerves arise symmetrically from the base of the brain and are numbered, from front to back, in the order in which they arise. They connect mainly with structures of the head and neck, such as the eyes, ears, nose, mouth, tongue, and throat. Some are motor nerves, controlling muscle movement; some are sensory nerves, conveying information from the sense organs; and others contain fibers for both sensory and motor impulses. The first and second pairs of cranial nervesthe olfactory (smell) nerve and the optic (vision) nervecarry sensory information from the nose and eyes, respectively, to the under surface of the cerebral hemispheres. The other ten pairs of cranial nerves originate in or end in the brain stem. B. Cerebral Circulation >The blood supply of the brain arises from internal carotid arteries (anterior circulation) and the vertebral (posterior circulation). Each internal carotid artery supplies the ipsilateral hemisphere, whereas the basilar artery, formed by the junction of the two vertebral arteries, supplies structures within the posterior fossa (cerebellum and brainstem). The circle of Willis arises from the basilar artery and the two internal carotid arteries. It also may function as an anastomotic pathway when occlusion of a major artery on one side of the brain occurs. In general, the two anterior cerebral arteries supply the medial portion of the frontal lobes. The two middle cerebral arteries supply the outer portion of the frontal, parietal, and superior temporal lobe. The two posterior cerebral arteries supply the medial portion of the occipital and inferior temporal lobes. Venous blood drains from the brain through the dural sinuses, which form channels that drain into the two jugular veins. II. Causes of CNS alterations 20 A. Head Injury the term is used primarily to signify craniocerebral trauma, which Mins. includes an alteration in consciousness, no matter how brief. It may be classified as primary or secondary. -primary head injuries are direct injuries, such as lacerations or crushing of the neurons, glial cells, and blood vessels of the brain. -secondary head injuries result from the additional effects of cerebral edema, hemmorrhage, hematoma, cerebral vasospasm, infection, and ischemia related to systemic factors. a. Blunt trauma/closed head injury- occurs when the skull is not fractured in the injury, but the brain tissue may be injured and blood vessels maybe ruptured by the force exerted against the skull. b. Countercoup injury- occurs when an area of the brain contralateral to the

Learners will be able to familiarize and know the cerebral circulation if blood

Identify the different classifications of head injury and effects to the brain

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site of direct damage is injured as the brain bounces off the skull. This injury may be secondary to acceleration or deceleration injuries, in which the skull and brain hit a solid object, which causes the brain to rebound against the opposite side of the skull, usually causing minor damage. c. Penetrating trauma/ open head injuries- are those involving fractures or penetration of the brain by sharp objects or the skull bones itself. d. Skull fracture- frequently occurs with head trauma. -Linear- break in continuity of bone without alteration of relationship of parts -depressed- inward indention of skull -simple- linear or depressed skull fracture without fragmentation or communicating lacerations -comminuated- multiple linear fractures with fragmentation of bone into many pieces - compound- depressed skull fracture and scalp laceration with communicating pathway to intracranial cavity e. Contusion- is the bruising of the brain tissue within a focal area that maintains the integrity of the pia mater and arachnoid layers. e. Concussion- a sudden transient mechanical head injury with disruption of neural activity and a change in the LOC. It is usually considered a minor head injury f. Diffuse axonal injury (DAI) - is widespread axonal damage occurring after a mild, moderate, or sever TBI. The damage occurs primarily around axons in subcortical whit matter of the cerebral hemispheres, basal ganglia, thalamus, and brain stem. g. Intracranial hemorrhage- occurs from bleeding within the parenchyma and occurs within the frontal and temporal lobes, possibly from the rupture of intracerebral vessels t the time of injury. B. Increased ICP- a life threatening situation that results from an increase in any or all of the three components ( brain tissue, blood, CSF) of the skull that would elevate the ICP higher than 15mmhg. Normal ICP is 7-15mmhg. C. Others a. Meningitis- an acute inflammation of the pia matter and the arachnoid membrane surrounding the brain and the spinal cord. Therefore meningitis is

Identify different Neurological assessment to be done with patients suffering from head trauma

always a cerebrospinal infection. Untreated bacterial meningitis has a mortality rate approaching 100%. The organisms usually gain entry to the CNS through the upper respiratory tract or the bloodstream, but they may enter by direct extension from penetrating wounds of the skull or through fractured sinuses in basal skull fractures. b. Brain abscess-a localized infection, frequently occurring in the frontal or temporal lobe. There is usually a necrosis of the brain tissue and a surrounding area of edema. Abscess usually result from the spread of organisms from ear, throat, lung, or sinus infection; multiple septic emboli from acute bacterial endocarditis; or directly from a site of injury or surgery. Common organisms are staphylococci, streptococci, and pneumococci. III-Neurological Assessment 10 a. Glasgow Comma Test- a quick, practical, and standardized system for assessing the Mins. degree of consciousness impairment. The three areas area assessed in the GCS correspond to the definition of coma as the inability of patient to speak, obey commands, or open the eyes when a verbal or painful stimulus is applied. b. Motor activity assessment- motor strength is tested by asking the awake patient to squeeze the nurses hand to compare strength in the hands. The palmar drift test is an excellent measure of strength in the upper extremities. The patient raises the arms in front of the body with the palmar surface facing upward. If there is any weakness in the upper extremity, the palmar surface turns downward and the arm the arm drifts downward. Asking the patient to raise the foot from the bed or to bend the knees up in bed is a good assessment of the lower extremity strength. All four extremities should be tested for strength and evaluated for any asymmetry in strength or movement. >the motor strength of the unconscious or uncooperative patient can be assessed by observation of spontaneous movement. If no spontaneous movement is possible, a pain stimulus should be applied to the patient and a response should be noted. Resistance to movement during passive range of motion exercises is another measure of strength. c. PERRLA-Evaluation of other cranial nerves can be included in the neurologic check. Eye movements controlled by cranial nerves III, IV, and VI can be examined in the patient who Is awake and can be used to assess the function of the brain stem. In unconscious patient, Extraocular eye movements are not specifically tested. Eye movement of the uncooperative and unconscious patient can be elicited by reflex with the use of head movements (oculocephalic) and

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caloric stimulation (oculovestibular). Learners will acquire additional knowledge on different types of management. 20 IV. Management mins 1. Surgical Management a. Craniotomy- surgical procedure that involves opening the skull to gain access to intracranial structures - Is performed to remove a tumor, relieve elevated ICP, evacuate a blood clot, or control hemorrhage. Surgeon cuts the skull to create a bony flap, which can be repositioned after surgery and held in place by periosteal or wire sutures One of two approaches through the skull is used: 1.) Supratentorial craniotomy- Above the tentorium.incision. Incision is made above the area to be operated on. 2.) Infratentorial- Below the tentorium, brain stem (posterior fossa). Incision is made at the nape of the neck, around the occipital lobe. 3.) Transsphenoidal approach- through the mouth and nasal sinuses, often used to gain access to the pituitary gland. Site of surgery is at Sella turcica and pituitary region. Incision is made beneath the upper lip to gain access into the nasal cavity

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b. Craniectomy- surgical procedure that involves removal of a portion of the cranium or skull c. VP (ventriculoperitoneal) shunt- surgically placed to allow drainage if CSF circulation is blocked and decompressive surgery.

2. Pharmacological management a. Mannitol- diuretic and hyperosmotic agent, which is indicated for the reduction of ICP and treatment of cerebral edema b. Corticosteroid- such as dexamethasone (Decadron), prescribed to help reduce the inflammatory cerebral edema if the patient shows evidence of an increasing neurologic deficit c. Furosemide- (lasix) a diuretic, reduces edema - Administered IV immediately before and sometimes during surgery if the patient tends to retain fluid d. Cefuroxime Axetil- an antibiotic e. IV fluids- given by IV pump to help monitor the amount of fluids given, normal saline solutions, insulin administration

Apply nursing interventions appropriate to client condition when exposed to clinical area

3. Management Brain injury: Medical management: Initial: Client must be immobilized at the scene of injury. An IV line is placed and fluids are given to stabilize the blood pressure. Open head wounds should be covered and pressure applied to control bleeding unless there appears to be an underlying depressed or compound skull fracture. Removal of foreign or any penetrating objects from the wound is prohibited. Uncomplicated scalp wounds (not lying over depressed or compound skull fractures) are anesthesized with a local anesthetic agent, cleansed, and sutured. Laboratory studies are performed, as are necessary radiologic studies. Ongoing: Cerebral metabolic rate is reduced with sedatives, paralytic agents, antipyretics, barbiturates, and hypothermia. Morphine is a frequently used narcotic for the head-injured client. Nursing management: Obtaining information from witnesses to the accident can be valuable in determining the extent of the injury. Assess and document the clients vital signs and neurologic status. Notify physician on any findings that indicate possible development of complications. Surgical management: An epidural clot may be surgically evacuated through burr holes or a craniotomy. Simple skull depressions are treated electively by surgically elevating the depressed bone tissue, removing fragments, and repairing lacerated dura. Compound depressed skull fractures are immediately treated surgically. Scalp, skull, and devitalized brain are debrided, and the wound is cleansed thoroughly.

For decreasing ICP: Nursing management: Assess patients level of LOC, responsiveness to stimuli, and identifying any neurologic deficits such as paralysis, visual dysfunction, alterations in personality or speech, and bladder and bowel disorders. Assess frequently spontaneous movements by asking patient to raise and lower extremities, and comparing the strength and equality of the upper and lower extremities.

 Monitor vital signs at frequent intervals to assess the intracranial status. Monitor patients temperature every 2 to 4 hours. Control presence of elevated temperature such as using acetaminophen and cooling blankets. Establish and maintain an adequate airway by: o Maintaining the unconscious patient in a position that facilitates drainage of oral secretions, with the head of the bed elevated about 30 degrees to decrease intracranial venous pressure o Establishing effective suctioning procedures o Closely monitoring ABG values to assess the adequacy of ventilation o Monitoring the patient who is receiving mechanical ventilation for pulmonary complications Strict intake and output measurement is still necessary to assess fluid balance. Administer medications (i.e., osmotic diuretics, anticonvulsants) prescribed by physician and monitor response to these medications. Monitor serum electrolyte levels. Initiation of nutritional therapy. Preventing injury by: Ensuring adequacy of Oxygenation and absence of bladder distention. Using padded side rails or wrapping hands in mitts to protect patient from self-injury and dislodging tubes Opioids are avoided as a means of controlling restlessness Reducing environmental stimuli Turning and repositioning patient every 2 hours. Monitoring potential complications. Keep patients head in a neutral position to facilitate venous drainage.

Medical management: Increasing the ventilator settings to cause hyperventilation, a hypocarbic blood level is created. Prescribing Mannitol to decrease ICP, and prescribing antibiotics. Continuous ICP monitoring is used for clients experiencing conditions associated with potentially elevated ICP. Treating increased ICP with surgical techniques. Preoperative management: Assess LOC and responsiveness to stimuli Assess the patients and familys understanding of and reactions to the anticipated surgical procedure and its possible sequelae.

 Assess for neurologic deficits and their potential impact after surgery. Prepare patient and family by providing information about what to expect during and after surgery. Postoperative: Medical management: Administer medication Mannitol to reduce edema. Dexamethasone (Decadron) may be administered IV every 6 hours for 24 to 72 hours. Acetaminophen is usually prescribed for temperatures exceeding 37.5 0 C and for pain. Codeine is administered IV which is sufficient to relieve headache. Morphine sulfate may also be used in the management. Phenytoin and diazepam are prescribed for antiseizures. Nursing management: Assess vital signs and neurologic status. Reposition patient every 2 hours. Elevate head of bed (if not contraindicated) and applying cold compresses over the eyes will help reduce edema. Monitor closely for indicators of complications. Interventions for Meningitis: Medical management: Early administration of antibiotics such as Vancomycin hydrochloride in combination with one of the cephalosporins (eg, ceftriaxone sodium). Dexamethasone (Decadron) used for the treatment of acute bacterial meningitis and in pneumococcal meningitis. Seizures, which may occur in the course of the disease, are controlled with phenytoin (Dilantin). Nursing management: Neurologic status and vital signs are continually assessed (pulse oximetry and ABG values). Insertion of a cuffed endotracheal tube (or tracheotomy) and mechanical ventilation. Rapid IV fluid replacement may be prescribed, but care is taken to prevent fluid overload. Protecting patient from injury secondary to seizure activity or altered LOC. Monitoring daily body weight; serum electrolytes; and urine volume, specific gravity, and osmolality. Instituting infection control precautions until 24 hours after initiation of antibiotic therapy. Support family and assist them in identifying others who can be supportive to them during the crisis.

Brain Abscess Medical management: Controlling increased ICP, draining the abscess, and providing antimicrobial therapy directed at the abscess and the primary source of infection. Large IV doses of antibiotics are administered. Stereotactic CT-guided aspiration may be used to drain the abscess and identify the causative organism. Prescribing Corticosteroids and antiseizure medications (phenytoin, Phenobarbital). Nursing management: Continuing to assess the neurologic status, administering medications, assessing response to treatment, and providing care. Closely monitoring blood laboratory test results, specifically blood glucose and serum potassium levels especially when corticosteroids are prescribed. Ensure patient safety. Assess familys ability to express distress at patients condition, cope with the patients illness and deficits, and obtain support. V. Evaluation