ANGELA BRON BSN III A

NCM 116 Care of Clients with Acute and Chronic Problems in Perception
and Coordination

ACTIVITY 2

1. Differentiate the two surgical interventions for brain injuries: a. Craniotomy,

and b. Craniectomy *
Craniotomy
Reasons is a surgery during which a
piece of the skull—called a
bone flap—is removed in
order to allow a surgeon
access to the brain.1
Craniectomy
A procedure that also
includes the removal of a
bone flap, but in this case,
it is not returned to its
location after the
1
procedure is finished.

Benefits  Create access for  The immediate relief

the neurosurgeon to of pressure
reach the area of achieved by
interest, whether it removing a section
be a tumor, blood of bone.
vessel or other  Important in an
structure within the emergency
skull. situation, where
quick action can
prevent further
damage and even
save lives.

Risks Some of the complications There are general risks

linked specifically to a associated with any
craniotomy include: surgical procedure, such
 Cerebrospinal fluid as reactions to the
leakage, requiring anesthesia, infection, and
medication or repair blood clots. Other risks
 Brain swelling specific to craniectomy
 Stroke include:
 Seizures  Inflammation of the
 Brain or nerve brain, called
damage, resulting in meningitis
 difficulty with  Infection of the brain
speech, movement or spinal cord
and other functions  Abscess of the brain
 Brain or nerve
damage, resulting in
difficulty with
speech, movement
and other functions
 Subdural hematoma

2. Identify the assessment data that needs to be collected to patient with

suspected brain injury.
In the initial stages following traumatic brain injury, careful handling is essential
when assessing patients, especially if they are in a minimally conscious state. Close
liaison with the medical team is required before attempting to change the patient's
position, for example, as this may cause blood pressure changes. It may not easy to
obtain baseline data, the immediate health history should include:
 When did the injury occur?
 What caused the injury? A high-velocity missile? An object striking the
head? A fall?
 What was the direction and force of the blow?
Since a history of unconsciousness or amnesia after a head injury indicates a
significant degree of brain damage, and since changes that occur minutes to hours after
the initial injury can reflect recovery or indicate the development of secondary brain
damage, the nurse should try to determine if there was a loss of consciousness, what
the duration of the unconscious period was, and if the patient could be aroused.
In addition to questions that establish the nature of the injury and the patient's
condition immediately after the injury, the nurse should examine the patient thoroughly.
This assessment should include determining the patients LOC, ability to respond to
verbal commands (if conscious), response to tactile stimuli (if unconscious), pupillary
response to light, status of corneal and gag reflexes, motor function, and Glasgow
Coma Scale score. Additional detailed neurologic and systems assessments are made
initially and at frequent intervals throughout the acute phase of care (Dibsie, 1998), The
baseline and ongoing assessment are critical nursing interventions for the patient with
suspected brain injury.
3. Based on the assessment data, what are the patient’s major nursing
diagnoses?
Based on the assessment data, the patient's major nursing diagnoses may
include the following:
 Ineffective airway clearance and impaired gas exchange related to brain
injury as evidenced by hypoxia.
 Ineffective cerebral tissue perfusion related to increased ICP and
decreased CPP as evidenced by changes in vital signs
 Deficient Fluid volume related to decreased LOC and hormonal
dysfunction as evidenced by hyponatremia.
 Deficient knowledge about recovery and the rehabilitation process as
evidenced by patients question
 Disturbed thought processes (deficits in intellectual function,
communication, memory, information processing) related to brain injury
as evidenced by inaccurate interpretation of stimuli.
 Imbalanced nutrition, less than body requirements, related to metabolic
changes, fluid restriction, and inadequate intake as evidenced by weight
loss
 Risk for injury (self-directed and directed at others) related to seizures,
disorientation, restlessness, or brain damage
 Risk for imbalanced (increased) body temperature related to damaged
temperature-regulating mechanism
 Potential for impaired skin integrity related to bed rest, hemiparesis,
hemiplegia, and immobility
 Potential for disturbed sleep pattern related to brain injury and frequent
neurologic checks
 Potential for compromised family coping related to unresponsiveness of
patient, unpredictability of outcome, prolonged recovery period, and the
patient's residual physical and emotional deficit

4. Develop a nursing care plan based from the established nursing diagnoses.

Nursing Planning/outcomes Nursing Rationale

Diagnosis Interventions

Ineffective airway Attains or maintains Keep the To decrease

clearance and effective airway unconscious intracranial
impaired gas clearance, ventilation, patient in a venous
exchange related and brain oxygenation position that pressure.
to brain injury as a. Achieves normal facilitates drainage
evidenced by blood gas values and of oral secretions,
hypoxia. has normal with the head of
breath sounds on the bed elevated
auscultation about 30 degrees

b. Mobilizes and clears Establish effective

secretions suctioning Pulmonary
procedures. secretions
produce
coughing and
straining which
increase ICP.
Guard against
aspiration and
respiratory To avoid
insufficiency. aspiration
respiratory
Closely monitor insufficiency.
arterial blood gas
values to assess
the adequacy of The goal is to
ventilation. keep blood gas
values within the
normal range to
Monitor the patient ensure adequate
who is receiving cerebral blood
mechanical flow.
ventilation
To ensure
Monitor for adequate
pulmonary exchange of air.
complications
such as acute
respiratory Avoid worse
distress syndrome complication.
(ARDS) and
pneumonia.
Ineffective Patient will demonstrate Closely monitor
cerebral tissue stable vital signs and vital signs:
perfusion related absence of signs of a) BP Fluctuations in
to increased ICP increased ICP. pressure may
and decreased occur because
CPP as evidenced Patient will display no of cerebral injury
by changes in further in vasomotor
vital signs deterioration/recurrence area of the
of deficits brain.
b) Heart rate
and rhythm. Changes in rate,
especially
bradycardia, can
occur because
of the brain
damage.
c) Respiration
rate
Irregularities can
suggest location
of cerebral insult
or increasing
ICP and need
for further
intervention.
Position with head
slightly elevated Reduces arterial
and in neutral pressure by
position. promoting
venous drainage
and may
improve cerebral
perfusion.
Maintain bedrest,
provide quiet and Continuous
relaxing stimulation or
environment, activity can
restrict visitors and increase
activities. Cluster intracranial
nursing pressure (ICP).
interventions and Absolute rest
provide rest and quiet may
periods between be needed to
care activities. prevent
Limit duration of rebleeding in the
procedures. case of
hemorrhage.
Prevent straining
at stool, holding Valsalva
breath. maneuver
increases ICP
and potentiates
risk of
rebleeding.
 Administer
supplemental Reduces
oxygen as hypoxemia.
indicated.

Administer
medications as Various
indicated. medication
improve cerebral
blood flow.
Deficient Fluid Achieves satisfactory Monitor serum Especially in
volume related to fluid and electrolyte electrolyte level. patients
decreased LOC balance receiving
and hormonal a. Demonstrates serum osmotic
dysfunction as electrolytes within diuretics,
evidenced by normal range inappropriate
hyponatremia antidiuretics
b. Has no clinical signs hormone
of dehydration or secretions and
overhydration post traumatic
diabetes
insipidus.

Study blood and Head injuries

urine electrolyte may
and osmodiality. accompanied by
sodium
regulation.

Monitor serum To evaluate

electrolyte, blood endocrine
glucose values function.
and intake and
output.

Record daily Especially if

weights. patient has
hypothalamic
involvement and
at risk for
development
diabetes
insipidus.

Deficient Participate in Assess motivation Some patients

knowledge about rehabilitation process and willingness of are ready to
recovery and the as indicated for patient patient and care- learn soon after
rehabilitation and family members givers. they are
process as diagnosed;
evidenced by a. Take active role in others cope
patient's identifying rehabilitation better
question. goals and by denying or
participating in delaying the
recommended patient need for
care activities instruction.
Learning also
b. Prepare for requires energy,
discharge of patient which patients
may not be
ready to use.
Patients
also have a right
to refuse
educational
services.

Allow for and Patients

support self- learn when they
directed, self- feel they are
designed learning. personally
involved in the
learning
process.

Give clear, Provide

thorough information
explanations and using various
demonstrations. mediums.
. Different people
take in
information in
different ways.
Match the
learning style
with the
educational
approach.
Instruct the patient To ensure that
and family about the family and
limitations that can patient are
 be expected and knows what to
complications that expect and need
may occur. immediate
intervention.

Disturbed thought The patient will show Assist with Cognitive

processes improvement in treatment of rehabilitation
(deficits in cognitive function neuropsychologist activities help
intellectual . who plans a the patient to
function, program and devise new
communication, initiates therapy or problem-solving
memory, counseling to help strategies.
information the patient reach
processing) maximal potential.
related to brain
injury as
evidenced by
inaccurate
interpretation of
stimuli.
Imbalanced Attains adequate Give early Head injury
nutrition, less nutritional status initiation of results in
than body nutritional therapy. metabolic
requirements, a. Has less than 50 mL (Parenteral changes that
related to of aspirate in stomach nutrition via a increase calorie
metabolic before each tube central line or consumption
changes, fluid feeding enteral feedings and nitrogen
restriction, and administered via a excretion.
inadequate intake b. Is free of gastric nasogastric or
as evidenced by distention and vomiting nasogastric
weight loss feeding tube may
C. Shows minimal be used/ If there is
weight loss discharge of CSF
from the nose
(CSF rhinorrhea),
an oral feeding
tube should be
inserted in place of
a nasal tube.)

Laboratory values This will help to

should be minimize
monitored closely potential
in patients complications,
receiving and will aid safe,
 parenteral effective and
nutrition. appropriate use
of PN.

Elevating the head Help prevent

of the bed and distention,
aspirating the regurgitation,
enteral tube for and aspiration.
evidence of
residual feeding
before
administering
additional
feedings.

Risk for injury Avoids injury Assess the patient To free from
(self-directed and to ensure that injury.
directed at others) a. Shows lessening oxygenation is
related to agitation and adequate and the
seizures, restlessness bladder is not
disorientation, distended. Check
restlessness, or b. Is oriented to time, dressings and
brain damage place, and person casts for
constriction.

Use padded side To protect the

rails or wrap the patient from self-
patient's hands in injury and
mitts. Avoid dislodging of
restriction. tubes. Restraints
are avoided
because
straining against
them can
increase 1CP or
cause other
injury.

Avoid using These

opioids as a medications
means of depress
controlling respiration,
restlessness. constrict the
pupils, and alter
responsiveness.
 It limits
Minimize unnecessary
environmental stimuli and
stimuli by keeping distraction to
the room quiet, patient.
limiting visitors,
speaking calmly,
and providing
frequent
orientation
information.
To prevent
Provide adequate visual
lighting. hallucinations.

Lubricate the skin To prevent

with oil or irritation due to
emollient lotion. rubbing against
the sheet.

If incontinence
Prolonged use
occurs, consider
of an in-dwelling
use of an external
catheter
sheath catheter on
inevitably
a male patient.produces
infection, the
patient may be
placed on an
intermittent
catheterization
schedule.
Risk for The patient does not Monitor the An increase in
imbalanced have a fever. patient’s body
(increased) body temperature every temperature in
temperature 4 hours. the head-injured
related to patient can be
damaged the result of
temperature- damage to the
regulating hypothalamus,
mechanism cerebral irritation
from
hemorrhage, or
infection.

If the temperature
 rises, efforts are
undertaken. To control it
using
acetaminophen
and cooling
blankets as
prescribed
Cooling blankets
should be used
with caution. Not to induce
shivering, which
increases ICP.

Potential for Demonstrates intact Assess all body Patients with

impaired skin skin integrity surfaces and traumatic head
integrity related to document skin injury often
bed rest, a. Exhibits no redness integrity at least require
hemiparesis, or breaks in skin every 8 hours. assistance in
hemiplegia, and integrity turning and
immobility positioning
b. Exhibits no pressure because of
ulcers Turn and immobility or
reposition the unconscious-
patient every 2 ness. Prolonged
hours. pressure on the
tissues will
decrease
circulation and
Provide skin care lead to tissue
every 4 hours. necrosis.
Potential areas
of breakdown
need to be
Assist patient to identified early
get out of bed to a to avoid the
chair three times a development of
day if physically pressure ulcers
able.

Potential for The patient will be able Group nursing Allow the patient
disturbed sleep to demonstrates normal care activities so longer times of
pattern related to sleep/wake cycle that the patient is uninterrupted
brain injury and disturbed less sleep and rest.
frequent frequently.
neurologic
checks Decrease
Environmental Provide relax
noise and dim the environment to
room lights. sleep.

Provide back rubs

and other To increase
activities. comfort can
assist in
promoting sleep
and rest.

Potential for Demonstrate adaptive Nurse can ask the To promote

compromised coping mechanisms for family how the effective coping.
family coping family patient is different
related to Members at this time: What
unresponsivenes has been lost?
s of patient, a. Join support group What is most
unpredictability of difficult about
outcome, b. Share feelings with coping with this
prolonged appropriate health care situation?
recovery period, personnel
and the patient's Provide family To reduce fear.
residual physical c. Make end-of-life members with
and emotional decisions, if needed accurate and
deficit honest information
and encouraging
them to continue
to set well-defined,
mutual, short-term
goals.

Refer them to Helps address

Family counseling the family
members’
overwhelming
feelings of loss
and
helplessness
and gives them
guidance for the
management of
in-appropriate
behaviors.

Refer them to
 support group with
the same purpose. Help the family
members share
problems,
develop insight,
gain information,
network, and
gain assistance
in maintaining
realistic
expectations
and hope.

1
Johns Hopkins Medicine. Craniotomy.
2
Ambrosio T. (2021). Craniotomy vs. Craniectomy vs. Cranioplasty.
Retrieved from https://www.neurosurgeonsofnewjersey.com/craniotomy-
craniectomy-cranioplasty/
3
Bruner and Suddarth’s Textbook of Medical – Surgical Nursing, 10th
Edition