ASUHAN

KEPERAWATAN PASIEN
DENGAN TRAUMATIC
BRAIN INJURY

1
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LOBUS OTAK

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Fungsional otak

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 PENGERTIAN
▪ TRAUMATIC YANG TERJADI PADA OTAK YANG MAMPU
MENGHASILKAN PERUBAHAN PADA PHISIK, INTELEKTUAL,
EMOSIONAL, SOSIAL, DAN VOCATIONAL.
• Trauma atau cedera kepala (Brain Injury) adalah salah satu bentuk
trauma yang dapat mengubah kemampuan otak dalam
menghasilkan keseimbangan fisik, intelektual, emosional, sosial dan
pekerjaan atau dapat dikatakan sebagai bagian dari gangguan
traumatik yang dapat menimbulkan perubahan – perubahan fungsi
otak (Black, 2005)
• Menurut konsensus PERDOSI (2006), cedera kepala yang
sinonimnya adalah trauma kapitis = head injury = trauma
kranioserebral = traumatic brain injury merupakan trauma mekanik
terhadap kepala baik secara langsung ataupun tidak langsung yang
menyebabkan gangguan fungsi neurologis yaitu gangguan fisik,
kognitif, fungsi psikososial baik bersifat temporer maupun
permanen.
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 ETIOLOGI
▪ Dikelompokan berdasarkan mekanisme injury:
1. Trauma tumpul.
2. Trauma tajam (penetrasi)
Dan bagaimana jenis/tipe cedera:
1. Focal.
2. Diffuse.
3. Frakture

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 Epidemiology
Fifty million people suffer from a traumatic brain injury (TBI) worldwide every
year (https://intbir.nih.gov)
The global incidence rate of TBIs is estimated at 200/100,000 people per year.
(www.internationalbrain.org)
In the United States 153 people die each day from injuries related to TBIs
(www.cdc.gov)
In 2013 there were 2.5 million emergency department visits related to TBI
TBI is the leading cause of death related to trauma
◦ It is responsible for 30% of all injury related deaths

Next
Epidemiology
The leading causes of TBI
◦ Falls
◦ Being struck
◦ Motor vehicle crash
Certain groups of individuals are at risk for TBI
◦ Individuals partaking in high risk behavior(s)
◦ Alcohol use, drug use, team sports, not using seat belts
◦ Men > women
◦ Very young (<10 years) and very old (>74 years)

(Hickey, 2014) Next

 TIPE HEAD INJURY
Pattern of Injury Focal Injury Diffuse Injury

Mechanism of Injury Contact Forces Inertial Forces Inertial Forces

(Translational Acceleration) (Rotational Acceleration)

Type of Injury Skull Fracture Counter Coup Contusion Concussion

Epidural Hematoma Intra Cerebral Hematoma Diffuse Axonal Injury
Coup Contusion Subdural Hematoma Intra Ventricular H
Subdural Hematoma Tissue Tear Hemorrhagic
Gliding Contusion
Sub Arachnoids Hemorrhagic

Skema1: Mechanism of particular types of head injury (Marion, 1999:2006)

Skema 2 : Patofisiologi Akibat Cedera kepala

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Contusion
Bruising of brain tissue
Most common area of injury is frontal or temporal lobe
Injury at site of impact is called “Coup” injury
Injury at the opposite site of impact is called “Contracoup” injury

Next
 What’s the Challenge?
Contusion (Luka Memar)
Altered Level of Consciousness
◦ Conscious, stuporous, or comatose
◦ Are they confused or agitated?
◦ Do they need airway management?
Bruising – Peri-contusional Edema – Mass effect
◦ Administer osmotic diuretics and/or hypertonic saline
Bleeding into contusion
◦ Monitor/treat for increased intracranial pressure
Seizures
◦ Clinical or subclinical
Next
◦ Provide continuous electroencephalography (EEG) monitoring
Munro – Kellie Hypothesis

▪ “ The skull is a rigid compartment with non-

compressible components.”

- Brain (80%)
- Blood (10%)
- CSF (10%)

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 Scalp Wound

▪ Highly vascular
▪ Bleeds briskly

▪ Assess for skull fracture

▪ Assess for shock (due to blood loss)
▪ Apply direct pressure
▪ Suture or staple wound
▪ Appropriate dressing Nex
t
(Hickey, 2014)

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 Skull Injury

▪ Different types of skull fractures include:

▪ Linear
 Singular fracture line of the skull
▪ Comminuted
 Splintering or shattering of the skull into pieces
▪ Depressed
 Depressed fragment of the skull
(https://www.slideshare.net/KaleemKhan7/head-
injury-medicolegal-aspect)

Nex
t

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 Basilar Skull Fracture

Linear fracture at the base of the skull

Anterior Fossa

70% of basilar skull fractures

Middle Fossa
CN I injury
Weakest vault
Periorbital hemorrhaging
◦ Raccoon eyes CN VII injury
Posterior Fossa
Rhinorrhea Mastoid (https://www.slideshare.net/0557
935616/head-injury-27020081)
hemorrhaging Uncommon
◦ Battle signs
CN IX, X, XI, XII injury
Nex
Otorrhea
(Hickey, 2014) Clivus or occipital bone t
fracture
 Basilar Skull Fracture
▪ Antibiotic administration is controversial – administer antibiotic for
 Consider antibiotic administration for
Halo
 Cerebral spinal fluid (CSF) leak
Sign
 Penetrating injury (vancomycin + 3rd generation cephalosporin)
▪ Ensure bedrest 7 – 10 days
▪ Assess for CSF leaking by halo sign or Tau protein bands in CSF
▪ Apply nasal drip pad for rhinorrhea http://www.cmaj.ca/content/185/5/416

▪ Maintain lumbar drain, if present

▪ May need surgical dural patch Nex
(Hickey, 2014) t
▪ Consider pneumococcal vaccine

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▪ Kepala dengan bangunan intrakranial dapat
mengalami jejas oleh : tenaga percepatan
(akselerasi), tenaga perlambatan (deselerasi),
rotasi, Penetrasi
▪ Jejas : karena perbedaan gerakan pada tulang
dan otak.
Dasar lobus frontal ---- permukaan kasar fossa
anterior
Lobus temporal ------ pinggiran tulang sfenoid
Korpus kallosum ---- pinggiran falks serebri
Tentorium serebelli ---- permukaan superior
serebellum batang otak.

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▪ Hantaman.
Deselerasi mendadak
deformitas tengkorak
volume kranial
tekanan cairan serebrospinal
Hantaman awal ----------- contercoup, robekan jaringan
Rotasi. Robekan pada otak, akson difus, pembuluh
darah, selaput otak
▪ Hantaman traumatik
Hematoma intrakranial,H. epidural, H. subdural,
perdarahan subarakhnoid, perdarahan intrakranial,
perdarahan intraserebelar, rinore, otorea.

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HEAD INJURY TYPES
• Contusion
• Subdural hematoma
• Extradural hematoma
• Traumatic subarachnoid haemorrhage
• Skull fracture
• Concussion
• Scalp laceration

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CEREBRAL CONTUSION
• Bruising to the brain surface
• Usually caused by trauma of brain being thrown
around inside the skull
• Often accompanied by cerebral oedema
• Contusions size and oedema can increase post injury
• Peak risk for swelling is days 3-5 post injury
• Increase risk of seizure activity

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Pengolongan berdasarkan akibat
Jejas
Jejas kepala.
➢ Lesi primer.
hantaman langsung pada kepala.
akselerasi, deselerasi, rotasi.
fraktur tulang tengkorak, sel neuron rusak, pembuluh
darah robek.
➢ Lesi sekunder.
proses patologik dinamis, komplikasi intrakranial
hematoma intrakranial: epidural, subdural, subarakhnoid,
intraserebral, intraserebelar.
pembengkakan otak, edema otak → TIK meningkat, aliran
darah setempat menurun, spasme pemb. darah, infark.
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Safety Net
Keselamatan

• Clear written discharge advice

• Adult supervision
• Social circumstances
• Concussion advice
• What to do if concerns

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Subdural Haematoma

• Tear in a “Bridging Vein”

• Caution:
• Alcohol dependant patients
• Elderly patients
• Anti-coagulant usage

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Subdural Haematoma

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Extradural Haematoma

• Extradural hematoma is
when bleeding occurs
between the tough outer
membrane covering the
brain and the skull

• Arterial bleed

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Extradural Haematoma

• More common in younger patients

• Usually results from an arterial bleed

• Patients often have a “LUCID PERIOD” with relatively few symptoms

followed by a rapid deterioration

• Carry good prognosis if diagnosed in time

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Concussion
Gegar/goncangan

• A concussion is a mild traumatic brain injury caused by a blunt

jolt or blow to the head

• The sudden movement causes the brain to bounce around or

twist inside the skull

• This leads to stretching and damaging of brain cells and

causes chemical changes in the brain

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Concussion

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Concussion

• Concussion is regarded as a traumatic brain

injury
• Can result from a direct or indirect blow to the
head
• LOC is not required
• Children are more vulnerable
• Symptoms can evolve over minutes or hours
after the event
• Helmets / scrum caps do not protect against
concussion
• Not just sport

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Chemical changes from Concussion

• Concussive symptoms result from neuro hormonal imbalance:

Limited evidence in regards to structural injury

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Klasifikasi cedera kepala
▪ Cedera kepala ringan (GCS : 13 – 15 )
,, ,, sedang (GCS : 9 - 12 )
,, ,, berat (GCS : =< 8 )

▪ Jejas kepala tertutup . Komosio serebri

kontusio serebri
▪ Fraktur depresi tulang tengkorak
▪ Fraktur komplikata tulang tengkorak

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 SECONDARY
BRAIN INJURY

Next

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HYPOXIA

• Any degree of respiratory failure is particularly hazardous for the

TBI patient.
• Loss of consciousness following a TBI may be accompanied by

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decreased respirations and can lead to severe hypoxia.
• Any hypoxia will aggravate cerebral ischemia and increases
cerebral blood flow and cerebral blood volume, thus increasing
intracranial pressure.

Next

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 HYPOTENSION
• The level of systolic blood pressure (SBP) plays a critical role in secondary brain
injury.
• Hypotension has been shown to correlate with diffuse brain swelling.

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• If autoregulation remains intact, a drop in SBP triggers an autoregulatory
vasodilation in an attempt to maintain adequate brain perfusion. This results in
increased cerebral blood volume, which in turn elevates intracranial pressure.
• If autoregulation is not intact, there is dependency on SBP to prevent cerebral
ischemia, which has been ascribed to be the single most important secondary
insult.
Next
• (Carney, et al., 2016)

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 EXCITOTOXICITY
• Increase in excitatory neurotransmitter (glutamate, aspartate) release

• Stimulates receptors (NMDA)

• Widespread depolarization

• Aerobic metabolism and ATP production depleted

• Ionic imbalance with sodium, calcium, and water

Next
• Neuronal damage/death
▪ Damage caused by production of reactive oxygen species

▪ Depolarization and calcium influx

▪ Excessive amounts of reactive oxygen species

Next

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Cerebral Edema

+ Caused by aquaporin dysfunction

Aquaporin are proteins that create water channels
Transports water in and out of cells

+ Cerebral edema can have multiple peaks

First is at 1-2 days Next
Lasts 5-6 days
May have a late peak

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Mitochondrial Dysfunction
Excessive calcium accumulation

Release of cytochrome C

Swelling and cell death

Next
Pemeriksaan
▪ Keadaan umum.
jejas ringan : keadaan sadar-siaga
▪ Jalan nafas, respirasi, tekanan darah,
keadaan jantung.
▪ Kesadaran.
▪ Fungsi mental
▪ Saraf otak
▪ Sistem motorik,
▪ Sistem sensorik, otonom, refleks-
refleks.
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Glascow Coma Scale

▪ Used to document assessment in three areas

 Eyes
 Verbal response
 Motor response
▪ Normal is 15 and less than 8 indicates coma

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From Rehabilitation
Nursing

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GCS

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Klasifikasi Tingkat Kesadaran

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1. Compos Mentis (conscious), yaitu kesadaran normal, sadar sepenuhnya, dapat
menjawab semua pertanyaan tentang keadaan sekelilingnya.
2. Apatis, yaitu keadaan kesadaran yang segan untuk berhubungan dengan sekitarnya,
sikapnya acuh tak acuh.
3. Delirium, yaitu gelisah, disorientasi (orang, tempat, waktu), memberontak,
berteriak-teriak, berhalusinasi, kadang berkhayal.
4. Somnolen (letargi), yaitu kesadaran menurun, respon psikomotor yang lambat,
mudah tertidur, namun kesadaran dapat pulih bila dirangsang (mudah dibangunkan)
tetapi jatuh tertidur lagi, mampu memberi jawaban verbal.
5. Stupor (soporo koma), yaitu keadaan seperti tertidur lelap, tetapi ada respon
terhadap nyeri.
6. Coma (comatose), yaitu tidak bisa dibangunkan, tidak ada respon terhadap
rangsangan apapun (tidak ada respon kornea maupun reflek muntah, mungkin juga
tidak ada respon pupil terhadap cahaya.

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Other Assessment

▪ Assess bodily function including respiratory,

circulatory and elimination
▪ Pupil checks – are pupils equal and how they
react to light
▪ Extremity strength
▪ Corneal reflex test

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Diagnostic Tests
▪ CT
▪ MRI
▪ Cerebral angiography
▪ EEG
▪ PET
▪ No lumbar puncture if there is ICP because
sudden release of pressure can cause brain
to herniate
▪ ABG’s – keep O2 at 100% (Lewis 1615) and
PCO2 as related to ICP (25-35)
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NICE CT Indications (UK)

• These are indications

for head CT scan in UK
EDs

• Patients who do not

meet CT criteria may
still need assessed and
observed in hospital –
be vigilant (eg severe
nausea, headache, “just not right”,
etc ……)

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PENATALAKSANAAN CEDERA KEPALA
▪ Penanganan harus ditangani sejak dari tempat kecelakaan,
selama transportasi, diruang gawat darurat, kamar Ro, sampai
ruang operasi, ruang perawatan/ ICU
▪ Monitor : derajat kesadaran, vital sign,kemunduran motorik,
reflek batang otak, monitor tekanan intrakranial.
▪ Monitor tekanan intrakranial diperlukan pada:
1. Koma dengan perdarahan intrakranial atau kontusio otak
2. Skala Koma Glasgow <6 (motorik < 4)
3. Hilangnya bayangan ventrikel III dan sisterne basalis pada CT
skan otak
4. “Tight brain” setelah evakuasi hematom
5. Trauma multipel sehingga memerlukan ventilasi tekanan positif
intermitten (IPPV)

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 PENATALAKSANAAN CEDERA KEPALA
▪ Indikasi CT san:
1. Skala Koma Glasgow (GCS) ≤ 14
2. GCS 15 dengan:
a. Adanya riwayat penurunan kesadaran
b. Traumatik Amnesia
c. Defisit neurologi fokal
d. Tanda dari fraktur basis kranii atau tulang kepala.

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Tindakan resusitasi ABC (Kegawatan)
a.Jalan nafas (airway)
Jalan nafas dibebaskan dari lidah yang turun
kebelakang dengan posisi kepala ekstensi, kalau perlu
pasang pipa oropharing (OPA )/ endotrakheal,
bersihkan sisa muntah, darah ,lendir, atau gigi palsu. Isi
lambung dikosongkan melalui pipa NGT untuk
menghindari aspirasi muntahan dan kalau ada stress
ulcer
b. Pernafasan (breathing)
_ Ggn sentral : lesi medula oblongata, nafas cheyne
stokes, dan central neurogenik hiperventilasi
_Ggn perifer: aspirasi, trauma dada, edema paru, DIC,
emboli paru, infeksi.
_Tindakan Oksigen, cari dan atasi faktor penyebab,
kalau perlu ventilator
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Kegawatan

3. Sirkulasi (circulation)
_Hipotensi– iskemik—kerusakan sekunder otak.
Hipotensi jarang akibat kelainan intrakranial,
sering ekstrakranial, akibat hipovolemi,
perdarahan luar, ruptur organ dalam, trauma dada
disertai tamponade jantung atau pneumotorak,
shock septik.
_Tindakan: hentikan sumber perdarahan, perbaiki
fungsi jantung ,menggantidarah yang hilang
dengan plasma, darah

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Kegawatan

▪ Tekanan Intra Kranial meninggi

_Terjadi akibat vasodilatasi, udem otak, hematom
_Untuk mengukurnya sebaiknya dipasang
monitor TIK. TIK normal adalah 0-15 mmHg.
Diatas 20 mmHg sudah harus diturunkan dengan:
1. Hiperventilasi
2. Setelah resusitasi ABC lakukan hiperventilasi
terkontrol dengan pCO2 27-30 mmHg.
Dipertahankan selama 48-72 jam lalu dicoba
dilepas, bila TIK naik lagi diteruskan selama 24-48
jam. Bila tidak turun periksa AGD dan CT scan
untuk menyingkirkan hematom

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Lanjutan Penatalaksanaan

▪ Pasien dalam keadaan sadar (GCS 15)

1. Simple head injury
Pasien tanpa diikuti ggn kesadaran,
amnesia, maupun gejala serebral lain
hanya perawatan luka, Ro hanya atas
indikasi, keluarga diminta observasi
kesadaran
2. Kesadaran terganggu sesaat.
Riwayat penurunan kesadaran sesaat
setelah trauma tetapi saat diperiksa sudah
sadar kembali : Ro kepala, penatalaksanaan
selanjutnya seperti simple head injury
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Lanjutan Penatalaksanaan

▪ Pasien dalam keadaan menurun

1. Cedera kepala ringan (GCS 15-13)
Kesadaran disorientasi, atau not obey command,
tanpa defisit neurologi fokal: Peratan luka, Ro
kepala
CT scan: bila dicurigai adanya lucid interval
(hematom intrakranial), follow up kesadaran
semakin menurun, timbul lateralisasi
Observasi: keadaran (GCS), tanda vital, pupil,
gejala fokal serebral

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Lanjutan Penatalaksanaan

2. Cedera kepala sedang GCS 9-12

Biasanya mengalami ggn kardiopulmoner
a. Periksa dan atasi ggn jalan nafas, pernafasan,
sirkulasi
b. Pemeriksaan keadaran, pupil, tanda fokal
serebral, dan cedera organ lain
c. Fiksasi leher dan patah tulang ekstremitas jika
ada.
d. Ro kepala, bila perlu bagian tubuh yang lain
e. CT scan bila dicurigai hematom intrakranial
f. Observasi tanda vital, kesadaran, pupil, defisit
fokal serebral
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Lanjutan Penatalaksanaan

3. Cedera kepala berat GCS 3-8

Biasanya disertai cedera multipel,
disamping kelainan serebral juga ada
kelainan sistemik
a. Resusitasi jantung paru (airway,
breathing, circulation/ABC). Pasien CK
berat sering dalam keadaan hipotensi,
hipoksia, hiperkapnea akibat ggn
pulmoner. Tindakan resusitasi ABC
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Lanjutan penatalaksanaan
▪ Keseimbangan elektrolit
_Pada saat awal masuk dikurangi untuk mencegah udem otak,
1500-2000 ml/hari parenteraldengan cairan koloid , kristaloid
Nacl 0,9%, ringer laktat. Jangan diberikan yang mengandung
glukosa – hiperglikemi, menambah udem otak
_ Pantau keseimbangan cairan, elektrolit darah.
▪ Profilaksis: diberikan pada CK berat dengan fraktur impresi,
hematom intrakranial, PTA yang panjang
▪ Komplikasi sistemik
_Demam, Kelanan gastrointestinal, kelainan hematologis perlu
ditanggulangi segera.
▪ Obat Neuroprotektor
_Manfaat obat pada CK berat masih diteliti manfaatnya seperti
lazaroid, antagonis kalsium, glutamat, citikolin
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Assessment
Next
Subjective
History
◦ Patient identification
◦ Government-issued identification found on the patient
◦ Will be confirmed by family when available
◦ Pertinent past medical history
◦ Include all acute and chronic medical conditions that will affect the
patient’s treatment plan for their trauma
◦ Exclude medical history that has no pertinence, such as childhood
illnesses without chronic sequelae
◦ Include list of patient’s current home medications when available
◦ Include any known allergies that the patient has
◦ Pertinent social history
◦ Include use of tobacco, alcohol, and recreational drug use
◦ Behaviors known to modify injury risk, such as seat belt usage
Next
 Subjective
◦ All known information leading up to the trauma, including the
mechanism of injury and any causative factors
◦ Was the trauma accidental versus intentional?
◦ Intentional can be harm caused by others or self-inflicted harm
◦ Was the patient engaged in high-risk behavior or under the influence of
alcohol or drugs, either prescribed or recreational?
◦ What was the mechanism of injury?
◦ Blunt versus penetrating trauma
◦ Was there peri-trauma loss of consciousness?
◦ Prehospital treatment
◦ How did EMS find the patient upon arrival?
◦ Interventions performs and medications administered?
◦ Changes in patient condition in route to the hospital Next
 Case Study #3 - Subjective Findings
The patient’s outpatient care is provided by physicians associated with the hospital and many aspects
of her medical history can be found in the electronic medical record. The patient’s pertinent medical
history includes the following:
◦ Chronic systolic heart failure with most recent ejection fraction of 35-40%
◦ Chronic kidney disease, stage 3 (GFR 45-59)
◦ Diabetes Mellitus, type II with recent Hgb A1C of 7.8
◦ Chronic atrial fibrillation

The patient has no known drug allergies. Her home medication list includes:
◦ Metoprolol 25 mg BID
◦ Lisinopril 10 mg daily
◦ Warfarin 5 mg daily (think about rapid reversal of anticoagulation)
◦ Furosemide 20 mg daily
◦ Metformin 500 mg BID Next
◦ Glipizide 5 mg daily
 Case Study #3 - Subjective Findings
EMS provides the following report:
“Arrived on scene to 2 vehicle collision. Patient’s car appears to have struck the other car
from behind. The patient was found in the driver’s seat without seat belt engaged. The
patient’s eyes were open and she was responsive to team. She was mumbling
incomprehensible words when questioned and following commands in all four extremities.
Visible contusions on front of forehead where it likely struck the steering wheel. The
patient was removed from the vehicle and placed in the ambulance. Initial vitals HR 114,
BP 134/90, RR 24, SpO2 88% on room air. Patient placed on nasal cannula. Patient became
less responsive en route to hospital and SpO2 continued to fall, so patient placed on non-
rebreather mask and SpO2 stabilized at 94%. Blood glucose 210. Patient only opening eyes
to repeated stimulation and intermittently following commands. Arrived to ED and handoff
of care completed.”
When family arrives, they state she is a former 0.5 pack per day smoker who quit 40 years
ago. She does not drink alcohol or use recreational drugs.
Next
Check Point – Test your Understanding
Based upon the patient’s past medical history, for what potential
complications should the nurse be vigilant in monitoring initially?
(Select all that apply)

A - Acute pulmonary edema

B - Bradycardia
C - Venous thrombosis
D - Acute kidney injury
Next
Check Point – Test your Understanding
What type of injury did this patient experience?

A - Blunt injury with no change in level of consciousness

B - Blunt injury with change in level of consciousness
C - Penetrating injury with no change in level of consciousness
D - Penetrating injury with change in level of consciousness

Next
 Objective
Primary survey - The A, B, C’s (Airway – Breathing – Circulation)
Identify and treat life threatening injuries first (click on each item below)

◦ Airway – “A”

◦ Breathing – “B”

◦ Circulation – “C”
Next
Objective
Vital Signs
◦ Continuous monitoring

Obtain 12-lead Electrocardiogram

◦ Assess for arrhythmia and signs of ischemia
◦ New arrhythmia may be sign of electrolyte abnormality or
hemodynamic compromise

Next
 Objective
Labs
◦ CBC - monitor for bleeding and anemia
◦ Type and screen - patient may require transfusion
◦ Comprehensive metabolic panel
◦ Mg, and PO4 - assess for kidney or liver injury and correct electrolytes
◦ aPTT and PT/INR - ascertain bleeding risk and potentially reverse anticoagulation
◦ ABG - monitor oxygenation and ventilation, can help decide if intubation necessary
◦ Blood glucose - hypoglycemia can cause altered mental status
◦ Toxicology screen – assess use of drugs that can impair level of consciousness
◦ Other labs may be necessary based on patient history, such as BNP or TSH Next
 Objective
Secondary assessment
◦ Head
◦ Assess for ecchymosis, edema, lacerations, and discharge from orifices
◦ Raccoon’s eyes and Battle’s sign are sign of basilar skull fracture
◦ Use gauze to check discharge for halo sign to see if it is cerebral spinal fluid
◦ Send beta2-transferrin for confirmation
◦ Neck
◦ Assess for ecchymosis, tenderness, and impaired range of motion
◦ Cardiac
◦ Assess heart sounds, regularity of rhythm, peripheral pulses
◦ Tachycardia with reduced pulses and cyanosis are signs of potential bleeding and shock
◦ Pulmonary/Thorax
◦ Assess breath sounds, work of breathing, regularity of respirations Next
◦ Check thorax for tenderness, ecchymosis, abnormal chest movement with respiration
Objective
◦ Abdomen/Gastrointestinal
◦ Assess bowel sounds, tenderness, palpable masses
◦ Tenderness or rigidity can be sign of internal hemorrhage or perforation
◦ Nasogastric tube may be needed to drain gastric secretions
◦ May be necessary later for medication administration and nutrition

◦ Genitourinary
◦ Assess for ecchymosis, tenderness, and discharge
◦ Consider placement of indwelling urinary catheter for accurate intake and output

◦ Integumentary/Musculoskeletal
◦ Full body assessment for laceration, ecchymosis, and tenderness
◦ Assess for deformity in extremities Next
◦ Assess range of motion in each extremity
 Objective
Neuro Assessment
◦Mental Status
◦Glasgow Coma Scale (GCS)
◦Scale of 3-15, measures three areas
◦Commonly used and well known
◦Rate motor score on best limb
◦Criticized for use in the intubated patient, unable to
score verbal response Next
Objective
Neuro Assessment
◦ Mental Status
◦ FOUR score
◦ Scale of 0-16, measures 4 areas
◦ Less commonly used
◦ More detailed than GCS
◦ Takes out verbal section, making it better in the
intubated
Next
 Objective
Concussion Assessment
◦Acute Concussion Evaluation(ACE) for the Emergency
Department or the Clinician’s Office
◦Tools available online through the Center of Disease Control
◦Helps define the cause and presentation, as well as lists
symptoms since injury
◦Can be used to plan further care needs of the patient
Next
Acute Concussion Evaluation (ACE)
Select this link to see the Acute Concussion Evaluation form

Next
 Form of Post Concusion Scale

4/17/2021 79
 Objective – Concussion Assessment

Post Concussion Symptom Scale

◦ Initially designed for athletes as a way to see when they could return to sports
◦ Lists 22 concussion symptoms that patient rates on scale of 0-6
◦ Symptoms can be tracked over time to see improvement or worsening

Sports Concussion Assessment Tool, 3rd Edition (SCAT3)

◦ Evaluation tool to assess concussion in athletes
◦ Combination of symptoms, cognitive assessment, and physical exam Next
Post Concussion Symptom Scale
Select this link to view the Post Concussion Symptom Scale

Next
 Objective
◦ Cranial Nerves
◦ Full exam of CN II-XII
◦ CN II - Visual fields and acuity; blink to threat in unconscious patient
◦ CN II & III - Pupillary reaction
◦ Pupillometry is useful to detect subtle changes
◦ CN III, IV, & VI - Extra-ocular movements; vestibulo-ocular reflex (VOR)
◦ CN V - Facial sensation in forehead, cheek, & chin bilaterally; corneal reflex
◦ CN VII - Facial movement (check symmetry)
◦ CN VIII - Whisper test
◦ CN IX & X - Palate elevation; gag reflex
◦ CN XI - Shoulder shrug and turning head Next
◦ CN XII - Tongue protrusion and deviation
Objective
◦ Motor Examination
◦ Strength and range of motion in all extremities
◦ Check for symmetry
◦ Strength is rated on a 0-5 scale
◦ Is movement to command, spontaneous, or to stimuli?
◦ Sensory Examination
◦ Start with light touch and work to noxious stimuli if no initial reaction
◦ Can check sharp versus dull sensation
◦ Cerebellar Examination
◦ Romberg test, finger-to-nose, limb ataxia, proprioception
◦ Reflexes Next
◦ Hyper and hypo reflexia may indicate spinal cord injury
 Case Study #3 - Objective Findings
Vitals upon admission to the ED are as follows:
Heart rate 128, blood pressure 98/50, respiratory rate 32, Temp 97.7°F, SpO2 92% on non-rebreather
Primary survey reveals patent airway with no signs of current obstruction. Breathing is tachypneic and
regular with increased effort displayed by accessory muscle use. Circulation with tachycardia and mild
hypotension. 1+ distal pulses bilaterally and skin is warm and dry.
ECG reveals atrial fibrillation with ventricular rate of 132 and ST depressions in the anterior and lateral leads.
Initial lab work shows:
Na K BUN Cr AST/ALT Glucose Ca Mg PO4 Trop
141 3.1 32 1.4 38/42 224 7.9 1.9 3.1 0.24
WBC Hgb Hct Plt aPTT INR pH pCO2 PaO2 HCO3
12.3 11.9 35.3 199 24.3 3.1 7.31 49 68 24
Next
 Case Study #3 - Objective Findings
Physical Exam is performed with the following pertinent findings:

◦ Head: Hematoma on forehead without laceration; no drainage noted

◦ Neck: Unable to state pain, no grimace to palpation; no overt signs of trauma
◦ Cardiac: Irregular rhythm with no extra heart sounds; 1+ pulses, brisk capillary refill
◦ Pulmonary/Thorax: Fine crackles at bilateral bases; increased work of breathing
◦ GI: soft, non-tender, not distended abdomen; active bowel sounds throughout
◦ GU: no signs of trauma; no discharge or lesion present

Next
Case Study #3 - Objective Findings
Physical Exam is performed with the following pertinent findings:
◦ Integumentary: Scattered ecchymosis on limbs and trunk; no open wounds
◦ Neurologic: Eyes open to noxious stimuli, no verbal response, withdraws to
pain in upper extremities and flexes to pain in lower extremities
◦ CN: Pupils equal and brisk, corneal reflex and VOR intact, grimace to pain
equal bilaterally, gag intact
◦ Motor: withdraws to pain in upper/lower extremities
◦ Sensory: Responds to painful stimuli in all four extremities
◦ Cerebellar: Patient unable to cooperate with exam
◦ Reflexes: normal reflexes in all four extremities
Next
Check Point – Apply your Knowledge

What is the Glasgow Coma Scale Score for this patient?

(Eyes open to noxious stimuli, no verbal response,
withdraws to pain in upper extremities and flexes to pain in
lower extremities)
A. 3
B. 5
C. 7
Next
 Check Point – Apply your Knowledge

Based upon the objective findings, which statement is FALSE regarding this
patient?

A- The patient’s rapid atrial fibrillation could be exacerbated by hypokalemia

B - The patient is showing no signs of heart failure exacerbation
C - The patient is showing signs of cardiac ischemia
D - The patients respiratory status is compromised
Next
Case Study #3 - Continued
After your assessment is completed, that patient develops generalized
convulsive activity concerning for a generalized tonic-clonic seizure. The
provider orders 4 mg of lorazepam and 1000 mg of levetiracetam. The patient’s
airway is at risk during the seizure and the patient is emergently intubated by
the provider. Because the seizure activity is not completely ceased by the initial
medications, a propofol infusion is started. Visible seizure activity ceases after
initiation.

A CT scan is ordered by the provider to assess the type of injury sustained in the
motor vehicle crash and different advanced neurologic monitoring modalities
are being considered. Next
Imaging

◦ CT Scan
◦ Good for overview of structures, very good for identifying hemorrhage
◦ Does not immediately show early ischemia or anoxia
◦ Quick to obtain, but does expose patient to radiation
◦ Good to identify boney injury

◦ CT Angiogram
◦ Can identify thrombosis in major vessels or vascular malformations, like aneurysm
◦ “Spot sign” shows contrast extravasation into hematoma showing active bleed
◦ Iodinated contrast can cause allergic reaction and kidney injury Next
 Advanced Neuromonitoring
Multiple Modalities – select links below to learn more
◦ ICP Monitoring
◦ Intraventricular
◦ Intraparenchymal
◦ Transcranial cerebral oximetry
◦ Brain tissue oxygenation monitoring
◦ Cerebral blood flow monitoring
◦ Cerebral Microdialysis
◦ Continuous EEG https://pbrainmd.wordpress.com/2015/12/13/multim
odality-monitoring-in-neurocritical-care/ Next
(Lee, 2012)
 Case Study #3 - Advanced Monitoring
The CT scan is completed and the patient is accepted by the Neuro ICU team. The patient
is brought up to the ICU and a handoff of care is given at bedside between the ED and ICU
nurses.
The radiology report states a right frontal intraparenchymal hemorrhage (IPH) with
posterior occipital contusion. Vasogenic edema and midline shift is seen. The patient is
started on hypertonic saline for the edema.
The decision is made with the medical team to place a ventriculostomy for ICP monitoring
and CSF drainage. Due to her INR of 3.1 she was reversed prior to placement of
ventriculostomy. After placement of the drain, continuous EEG is placed.
Next
 Check Point – Test your Understanding

What is the best description of the injury described by

the CT report (right frontal intraparenchymal
hemorrhage (IPH) with posterior occipital contusion) ?

A - Right frontal IPH represents coup, and occipital

contusion represents contrecoup

B - Occipital contusion represents coup, and right

frontal IPH represents contrecoup

Next
Check Point – Test your Understanding
What is the purpose of implementing continuous EEG monitoring for
this patient?

A. Monitor for cerebral edema

B. Capture electrical impulses from neuroglial cells
C. Assess for subclinical seizures
D. Monitor vital signs
Next
Check Point – Test your Understanding

The ICP recorded on the monitor for the EVD has been 18. While
suctioning, the ICP increases to 26 while coughing. The ICP returns
to 18 two minutes after coughing completed. What is the best
nursing intervention?

A - Drain extra CSF to prevent further ICP spikes

B - Notify the MD for need for mannitol to rapidly decrease ICP
C - Nothing, these transient increases in ICP are normal
Next
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4/17/2021 97
4/17/2021 98
NURSING MANAGEMENT

99
4/17/2021 100
AIRWAY, OXYGEN, AND
VENTILATION
• Monitor airway protection in non-intubated patients
• Monitor for signs of respiratory failure
• Hypoxia - PaO2 <60 mmHg, hypoxia lasting 10-20 mins occurs in one third of all TBI patients
(Hypoxia may result in cytotoxic edema)
• Hypercarbia
• Anxiety/ restlessness
• Confusion
• Airway obstruction such as the tongue

• Provide airway protection for patient with Glasgow Coma Score (GCS) ≤8
• Insert an oral gastric tube (OG) to help prevent aspiration
Next

4/17/2021 101
AIRWAY, OXYGEN, AND
VENTILATION
• Maintain adequate oxygenation
• Maintain O2 saturation ≥ 90%, PaO2 > 100mmHg
• Control pH & PaCO2
• Keep PaCO2 35 – 45 mmHg
• Avoid hyperventilation unless signs of herniation are present –abnormal posturing with
unilateral or bilateral dilated & non reactive pupils (4th edition of TBI Guidelines)
• Prolonged prophylactic hyperventilation with partial pressure of carbon dioxide in arterial
blood (PaCO2) of 25 mm Hg or less is not recommended (4th edition TBI Guidelines)
• Provide sedation & analgesia as needed

Next

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AIRWAY, OXYGEN, AND
VENTILATION

• Assisted Ventilation
• Positive End Expiratory Pressure (PEEP) – may mildly or slightly increase ICP that may or
may not be a concern

• Suctioning
• ICP often increases but decreases after cessation of stimulus
• If it does not, pre-medicate with a sedative and/or IV push lidocaine
• Hyperoxygenate pre & post suctioning
• Avoid saline instillation
• Limit time to 10 seconds of suctioning at each pass
Next
• Chest Physical Therapy (CPT) is safe

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AIRWAY, OXYGEN, AND
VENTILATION

• Early Tracheostomy
o Reduces mechanical ventilation days when the benefit is felt to outweigh the
complications associated with such a procedure
o No evidence that early tracheostomy reduces mortality or the rate of nosocomial

pneumonia (4th edition TBI Guidelines)

• Ventilator Associated Pneumonia (VAP) Protocol

• Providone-iodine oral care is not recommended to reduce VAP & may cause an
increased risk of acute respiratory distress syndrome (4th edition TBI Guidelines)
Next

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 HEMODYNAMICS

• Maintain Systolic Blood Pressure

• Avoid hypotension - any episode of hypotension doubles mortality
• To decrease mortality & improve outcome consider maintaining SBP at:
• ≥100 mmHg for patients 50 to 69 years old
• ≥110 mmHg or above for patients 15 - 49 or over 70 years old (4th edition TBI Guidelines)
• Maintain euvolemia using isotonic solutions (normal saline)
• Maintain an adequate urine output (0.5 - 1 ml/kg/hr)

Next

4/17/2021 105
 HEMODYNAMICS (CON’T)

• Maintain Cerebral Perfusion Pressure (MAP – ICP = CPP)

• Target in adults is 60 – 70 mmHg but is dependent on autoregulatory status
• Pushing CPP > 70 mmHg with fluid & vasopressors may increase risk of respiratory failure
(4th edition TBI Guidelines)

• Maintain Hematocrit (Hct) > 21% or Hemoglobin (Hgb) 7 mg/dl

• Adjust Hgb/ Hct goal for evidence of ischemia
• Transfuse as appropriate

Next

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Diagnosa Keperawatan
1. Resti tidak efektifnya bersihan jalan nafas b.d akumulasi skret.

2. Perubahan perfusi jaringan cerebral b.d perdarahan dan edema cerebral

3. Resiko peningkatan TIK b.d proses desak ruang akibat edema cerebral

4. Resti gangguan pemenuhan kebutuhan cairan dan elektrolit kurang dari kebutuhan tubuh
b.d intake tidak adequate: penurunan kesadaran (soporokoma)

5. Resti gangguan pemenuhan kebutuhan nutrisi kurang dari kebutuhan tubuh b.d intake tidak
adequate: penurunan kesadaran (soporokoma)

6. Kerusakan integritas kulit b.d adanya luka lacerasi

7. Deficit perawatan diri b.d kelemahan/keterbatasan gerak

8. Resti terbatasnya pengetahuan (kebutuhan belajar) keluarga mengenai proses penyakit,

prognosis dan penatalaksanaannya b.d terbatasnya informasi

107
4/17/2021
 IMPLEMENTASI

1.Resti tidak efektifnya bersihan jalan nafas b.d

akumulasi skret.
Intervensi keperawatan
Mandiri:
▪ Memonitor suara paru tiap 8 jam dan observasi adanya roncki/penumpukan skret
▪ Memberikan posisi semi atau elevasi kepala 30 derajat dan kepala miring 1 sisi
bergantian
▪ Mempertahankan hidrasi cairan 2-3 liter/hari, melalui asupan parenteral yang
diberikan.
▪ Memonitor dan melakukan karakterisitik sekret, warna, jumlah, dan konsistensinya bila
terdapat skret yang keluar melalui hidung/mulut.
Kolaborasi :
▪ Memberikan obat Antibiotik: (Cefriaxon 2 x 2 g (tiap 12 jam) IV)
10
4/17/2021 8
2. Perubahan perfusi jaringan cerebral dan resiko peningkatan TIK b.d
perdarahan dan edema cerebral
Intervensi keperawatan

Mandiri :
▪ Memonitor/obs tanda vital tiap 4 jam dan memonitor/obs kesadaran / GCS setiap 4 jam
▪ Memberikan posisi Elevasi kepala 30 derajat setiap 4 jam
▪ Menentukan faktor2 penyebab penurunan perfusi jaringan otak/resiko TIK meningkat.
▪ Memantau/mencatat status neurologis secara teratur dan membandingkan dg nilai normal
▪ Mempertahankan tirah baring miring kiri/kanan dengan posisi kepala netral
▪ Mengkaji kondisi vaskular (suhu, warna, pulsasi dan capillary refill) tiap 8 jam
▪ mencatat intake dan output.
▪ menurunkan stimulasi eksternal yang dapat meningkatkan TIK dan berikan kenyamanan dengan menciptakan lingkungan tenang dan suhu
ruangan dalam kondisi normal (mengatur suhu ruangan menyalakan AC). Memasang pagar pengaman tempat tidur dan memasang retrain
pada daerah ekstermitas
▪ Penkes pada keluarga dan selalu bicara dan komunikasi dengan pasien.
Kolaborasi :
▪ Memberikan O2 kanul 4 l/mnt
▪ Memberi pertimbangan pemeriksaan AGD, LED, Leukosit setelah 3 hari perawatan
▪ Pemasangan cairan IV NaCl 0,9% /12 jam
▪ Memberikan obat-obatan injeksi :
▪ - Citicolin 2 x 500 mg - Ranitidin 2 x 1 ampl
▪ - Vit C 1 x 400 mg - Kaltropen 3 x 1 ampl
▪ - Dexametason 4 x 1 ampl - Cefriaxon 2 x 2 g
10
4/17/2021 9
3. Resti gangguan pemenuhan kebutuhan cairan dan elektrolit
kurang dari kebutuhan tubuh b.d intake tidak adequate:
penurunan kesadaran (soporokoma).
Intervensi keperawatan
Mandiri:
• Monitor tanda-tanda vital, termasuk Mengukur JVP setiap 8 jam
• Mencatat peningkatan suhu dan durasi demam.
• Memberikan kompres hangat saat temperatur meningkat (Demam), dan
mempertahankan pakaian tetap kering
• Mempertahankan suhu ruangan yang nyaman (mengatur suhu ruangan dengan AC).
• Mengkaji turgor kulit, membran mukosa bibir
• Mengukur intake dan output cairan dan menghitung balance cairan setiap hari selama 24
jam.
• Memberikan cairan minimal 2.5 lt/hari dengan pemberian sedikit-dikit dan melibatkan
keluarga saat pasien sudah dapat minum per oral.
Kolaborasi :
• Memberikan cairan infus NaCl 0,9% /12 jam
• Memberikan manitol 20% (bila kondisi TD sudah normal dan stabil)
11
4/17/2021 0
4. Resti gangguan pemenuhan kebutuhan nutrisi kurang dari kebutuhan tubuh b.d intake tidak adequate:
penurunan kesadaran (soporokoma)
Intervensi keperawatan
Mandiri:
• Mengkaji status nutrisi saat masuk rumah sakit/ruangan dengan menimbang BB/mengukur LL.
• Mengkaji kemampuan menelan ; refleks menelan, gerakan lidah dan bibir dan kesulitan-kesulitan
asupan nutrisi dan mendengarkan bising usus, catat adanya penurunan/hilangnya/suara yang
hiperaktif
• Melatih makan peroral dikit-demi sedikit dengan melibatkan keluarga
• Memberikan makan dalam jumlah kecil dan dalam waktu yang sering dan teratur dalam bentuk
cair
• (Ignatavicius, 1999)
• Menjaga keamanan saat memberikan makan; tinggikan kepala tempat tidur selama makan
peroral.
• Mengkaji pola BAB dan feses, cairan lambung, muntahan darah dan lainnya lalu mencatat hasil.
Kolaborasi :
• Memberikan pertimbangan untuk konsultasi dengan ahli gizi
• Memberikan nutrisi parenteral: Triofusin 500 ml/24 jam
• Memberi pertimbangan dan memantau hasil pemeriksaan laboratorium: albumin, transferin,11
4/17/2021 1
asam
amino, zat besi, ureum/kreatinin, glukosa, elektrolit setelah 3 hari perawatan.
 INCREASED ICP OR HERNIATION
CLINICAL SIGNS AND SYMPTOMS
“EARLY” “LATE”
Headache Changes in level of consciousness or ↓ GCS or FOUR Score ≥ 2
points
Irritability Ipsilesional change in pupillary size, shape and light-
responsiveness
Vomiting Contralesional hemiparesis (new or worsening)
Photophobia, nystagmus, Contralesional change in pupillary size and ipsilesional
diploplia hemiparesis (Kernohan’s phenomenon)

Lethargy Cushing’s triad: ↑ SBP (widened pulse pressure), bradycardia,

irregular respirations
Seizure activity Status epilepticus Next

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ICP MONITORING

• Information from ICP monitoring is recommended to reduce in-hospital &

2-week post-injury mortality
o Greater than 22 mmHg associated with increased mortality

• A combination of ICP values, clinical & brain CT findings may be used

to make management decisions

(Carney, et al., 2016)

Next

4/17/2021 113
 ICP MONITORING

• Nursing Management of ventriculostomy

• Adhere to strict aseptic technique
• Use only normal saline to flush tubing in patient with external ventricular drain (EVD)
system with an external transducer
• Level EVD at tragus of ear, which correlates with foramen of Monroe
• Head of bed should be at 30 degrees
• The system should be leveled during and when:
• Positioning the patient
• Bed transfers
• The height of bed is changed
Next
• Ensure that all connections are tightly closed (Bader, et al., 2016)
• Monitor for CSF leak

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 ICP MONITORING

Waveforms
• P1 - Percussion wave
• Arterial wave
• Sharp peak and a fairly constant amplitude
• Reflects the ejection of blood from the heart
transmitted through the choroid plexus in the
ventricles
• P2 - Tidal wave
• Reflects venous, CSF, & brain bulk
• Reflects compliance
• More variable and ends on the dicrotic notch http://www.derangedphysiology.com/main/requir
ed-reading/neurology-and-
• P3 - Dicrotic wave neurosurgery/Chapter%201.0.5/interpretation-
• Follows the dicrotic notch intracranial-pressure-waveforms
• Venous outflow
• Reflects aortic valve closure Next
(Bader, et al., 2016)

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 ICP MONITORING

Lundberg Waveforms
• A waves
• Plateau
• Elevations of ICP up to 50-100 mmHg lasting for 5-20 minutes
• B waves
• Rhythmic oscillations occurring every one half to two times per minute http://slideplayer.com/slid
• Elevations of ICP up to 20-50 mmHg e/2337467/

• C waves
• Smaller, rhythmic, rapid oscillations occurring at frequency
• 4-8 times per minute
• Elevations of ICP up to 20 mmHg
Next

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ICP MANAGEMENT
IDENTIFY PATIENT FACTORS THAT INCREASE
ICP
• Pain (Bader, et al., 20
• Assess presence of pain & if analgesia is adequate
• Add or titrate analgesia as ordered
• Seizure activity
• Monitor and treat seizure activity
• Hypotension – Ischemia – Cerebral Edema
• Maintain SBP ≥ 100 mmHg (age 50-69) SBP ≥ 110 mmHg (age 15-49)
• Fever
• Maintain normothermia (temp 36.5°C – 37.5°C)
• Use of acetaminophen, body cooling devices
Next
• Prevent shivering, use of acetaminophen, buspirone, magnesium, etc.

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ICP MANAGEMENT
IDENTIFY PATIENT FACTORS THAT
INCREASE ICP (CONTINUED)
• Anemia
• Blood transfusion may be ordered if indicated

• Electrolyte Imbalance
• Hypo/hypernatremia, hypo/hyperosmolarity
• Osmotic diuretic or hypertonic saline may be used

• Fluid Overload
• Monitor fluid status

• Hypocapnia Next
• Assess ventilator settings

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ICP MANAGEMENT
IDENTIFY NURSING FACTORS THAT
INCREASE ICP
• Performing hygiene
• Bathing, oral care, changing diapers has not been generally shown to increase ICP,
it can increase for a moment and returns to baseline within minutes
• Noxious stimuli (i.e. needle sticks)
• Coughing, straining, and valsalva maneuver
• Due to increased intrathoracic pressure and decrease venous drainage
• Consider obtaining laxatives from MD/NP
• Suctioning
• May lead to transiently significant or can have sustained increase in ICP
• Provide oxygenation with 100%
• Adequate sedation to prevent movement and coughing during suctioning Next
• Limit suctioning to < 10 seconds for each insertion

4/17/2021 119
ICP MANAGEMENT
NURSING INTERVENTIONS TO REDUCE
ICP

• Positioning – should be positioned to maintain a good body alignment and avoid

extreme neck flexion, head rotation, and hip flexion
• Cervical collars must fit properly
• Patient turning can result in increases in ICP but the response is variable
• Patients who respond to turning with an increase in ICP should be turned
passively
• Position head of bed to 30° - 45°
• If a cumulative effect of nursing care activities with an increase ICP, the care
should be delayed, if applicable
Next

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ICP MANAGEMENT
NURSING INTERVENTIONS TO REDUCE ICP
(CONTINUED)
• Medications
• Osmotic diuretic: Mannitol
• Can be given 0.25 - 1g/kg body weight
• Infuse rapidly as a bolus (i.e. over 5-10 minutes)
• Apply inline IV filter due to possible crystallization of medication
• Avoid systemic dehydration by targeting serum osmolality <320 mOsm
• Can have rebound effect by passing osmotic particles through the
disrupted blood brain barrier increasing brain edema
Next
• Rebound effect may be seen after multiple doses

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ICP MANAGEMENT
NURSING INTERVENTIONS TO REDUCE ICP
(CONTINUED)
• Medications
• Hypertonic Saline
• Examples: 1.5%, 2%, 3%, 5%, 7%, 23.4%, or 30% saline concentrations
• Central line is necessary for 23.4% saline concentration
• Increases serum osmolality without causing diuresis
• Monitor sodium levels at least every 6 hours
• Caution not to increase by 10 points from baseline within 24 hours
• May have more prolonged effects and less rebound than mannitol
Next
• May be used for fluid resuscitation

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 ICP MANAGEMENT
NURSING INTERVENTIONS TO REDUCE ICP
– MEDICATIONS
Sedation, analgesia, paralysis per MD
Choice and dosing of sedatives, analgesics, & neuromuscular blocking
agents is at the discretion of the prescriber (4th Edition of TBI Guidelines)
• Sedatives • Analgesics
• GABA receptor modulation • NSAIDs
• Benzodiazapines • Should not be used due to effect on
• Propofol (caution risk of propofol infusion platelet function
syndrome) • Opioids
o Goal is to reduce cerebral metabolic demand • Morphine
• Dexmedetomidine • Fentanyl
• 2 agonist • Remifentanil Next
• Hydromorphone

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 ICP MANAGEMENT
NURSING INTERVENTIONS TO REDUCE
ICP - MEDICATIONS
• Sedation
• Titrate sedatives and provide premedication before intervention
Drug Loading Dose Maintenance Peak/Half-Life
Propofol 5-10 mcg/kg/min over 5-10 mins 5-50 mcg/kg/min 3 min/0.5-24 hr
Dexmedetomidine 1 mcg/kg over 10 mins 0.2-1.5 mcg/kg/hr 10-20 min/1-2 hrs
May cause hemodynamic instability, may not be
needed
Pentobarbital 10mg/kg over 30 - 60 mins 5 mg/kg x 3 hrs followed by 1-2mg/kg/hr 5-10 min/35-50 hrs

(Bader et al. 2016)

• Barbiturates
• Indicated for uncontrolled increased ICP and diffuse brain swelling by suppressing neuronal activity, Next
decreasing CBF, metabolic rate and glucose utilization but have severe side effects such as cardiac
depression, hypotension, hypothermia, suppression of immune system

4/17/2021 124
MANAGEMENT OF COMMON
COMPLICATIONS
• Hyperglycemia
• Avoid Hyperglycemia (> 200 mg/dL)
• Keep < 180mg/dL (140 – 180 mg/dL)
• Avoid hypoglycemia

• Nutrition & Timing of Feeding

• Feed patients to meet basal caloric replacement (15% protein) by at least the 5 th
day & no later then 7th day post-injury is recommended to mortality (4th edition
TBI Guidelines)
• Transgastric jejunal feeding is recommended to reduce the incidence of VAP (4th
edition TBI Guidelines) Next

4/17/2021 125
MANAGEMENT OF COMMON
COMPLICATIONS

F ev er
• Fever (pyrexia) - systemic response to a perceived immunologic threat (infection
or injury) that resets temperature at higher level
• Neurogenics or central fever - disruption in the brain’s (hypothalamic) “set point”

• Infectious Causes • Non-infectious Causes

• Pneumonia • Drug or transfusion reaction
• Catheter associated urinary tract infection • Deep vein thrombosis Next
• Central line associated infection
• Neurogenic injury

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 FEVER – PHARMACOLOGIC
MANAGEMENT

• Traditional Antipyretics
• Acetaminophen 2 – 4 gm /day
• Effectiveness of antipyretics depends on intact thermoregulation
• Treating Infection Source
• Source Control
• Remove unnecessary lines
• Start appropriate antibiotics
• Central Fever (Agrawal et al., 2007)
• Bromocriptine
• Amantadine
Next
• Dantrolene
• Propranolol

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FEVER – NORMOTHERMIA COOLING
METHODS
Surface cooling
• Remove blankets
• Tepid sponge bath
• Ice packs over large vessels such as axilla and/or groin
• Cooling blankets/mattresses
• Cooling wraps

Next

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MANAGEMENT OF COMMON
COMPLICATIONS
• Seizure prophylaxis and/or seizures
• Prophylactic use of phenytoin or valproate is not recommended for
preventing late post-traumatic seizures
• Phenytoin is recommended to decrease early post-traumatic seizures (within
7 days of injury)
• Early post-traumatic seizures is not associated with worse outcomes
• May consider using levetiracetam to prevent early post-traumatic seizures
and toxicity, although there is insufficient evidence.
(Carney, et al., 2017)
Next

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 SEIZURES
• Sub-clinical Seizures
• Up to 48% of patient have subclinical seizures on EEG
• May be associated with ICP especially delayed ICP beyond 96 hours
• Look for evidence of sub-clinical seizure
• Changes in vital signs
• Conjugate eye deviation

Herman, 2015 Next

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MANAGEMENT OF COMMON
COMPLICATIONS
• Deep Vein Thrombosis
• Deep vein thrombosis prophylaxis treatment
• Low molecular weight heparin (LMWH) or low-dose unfractionated heparin may be used in
combination with mechanical prophylaxis. However, there is an increased risk for
expansion of intracranial hemorrhage (4th edition TBI Guidelines)
• The use of graduated compression stockings with intermittent pneumatic compression (IPC)
devices is recommended in patients with TBI who have a high risk of bleeding (Geerts, et
al., 2008)
• CLOTS 3 (2013) found the use of IPC devices was an effective tool to reduce DVT
Next

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MONITOR FOR NEURO-ENDOCRINE
DYSFUNCTION

• Incidence of neuro-endocrine dysfunction is 30-50%

• Anterior hypopituitarism
• 27.5% post-trauma (Range 5 – 30%)
• Posterior dysfunction
• 21.6% Diabetes Insipidus (DI)
• Mostly severe TBI
• 6.9% permanent dysfunction
• 12.9% Syndrome of Inappropriate ADH (SIADH)
(Agha et al., 2004) Next

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 NEURO-ENDOCRINE DYSFUNCTION
DI
• Hypernatremia (>145)
• Hyperosmolarity ( > 295)
• Urine osmolarity (< 300)
• Specific gravity (< 1.005)
• Dehydration
SIADH
Symptoms
• Hyponatremia (dilutional)
• extracellular fluid
• Serum hypo-osmolarity (<280)
• plasma volume
• body weight
• Low BUN
• Not necessarily a negative salt
balance
• Urine osmolarity is
inappropriately concentrated
as compared to serum
osmolarity
Cerebral Salt-wasting
• Hyponatremia (primary)
•  extracellular fluid
• Serum hypo-osmolarity
(<280)
•  plasma volume
•  body weight
• High BUN
• Excessive natriuresis
• Negative salt balance
(primary loss of sodium)
Next
4/17/2021 133
 TREATMENTS FOR NEURO-
ENDOCRINE DYSFUNCTION
DI SIADH Cerebral Salt-Wasting

• I & O, daily weight • Treat underlying cause • Correction of hyponatremia with

• Monitor electrolytes Acute management isotonic or hypertonic saline
• Fluid replacement • Fluid restriction (< 1L/day) (match urine output)
• Conscious: oral fluids • Na+ replacement- • Once stable switch to enteral salt
• Comatose: IV cc/ cc replacement hypertonic saline (3%) supplements
hypotonic solution (D5NS with 20mEq • Diuretics, K+ replacement • Fludrocortisone 0.05 – 0.2 mg/d PO
KCL) • Monitor lytes, daily weight, HOB (adult & pediatrics)
• DDAVP 2.5 mcg nasal BID up Chronic management:
to 20 mcg • Long term fluid restriction
• DDAVP 2-4mcg/day IV push/SC (1200-1800 ml/day)
• DDAVP 0.1-1.2 mg/day PO • ADH antagonist –
• Vasopressin 5 units IV/SC Q 4-6 hrs demeclocycline, lithium
• Vasopressin continuous infusion 0.1 • Vasopressin receptor
units/hour uptitrated to max 0.5 antagonist - Conivaptan,
units/hour for adequate urine output blocks both V2 receptors &
V1A receptors Next
(Bader et al., 2016)

4/17/2021 134
Pen-Kes
keluarga diberikan penkes tentang perawatan pasien dengan masalah
cedera kepala, diantara yaitu :
• Penjelasan tentang pengertian, penyebab, pengobatan dan komplikasi
cidera kepala termasuk gangguan fungsi luhur dari pasien, oleh karena
itu perlu control dan berobat secara teratur dan lanjut.
• Mengajarkan bagaimana cara pemenuhan nutrisi dan cairan selama
dirawat dan dirumah nantinya
• Mengajarkan pada keluarga dan melibatkan keluarga dalam pemenuhan
kebutuhan sehari-hari pasien
• Mengajarkan melatih mobilisasi fisik secara bertahap dan terencana agar
tidak terjadi cidera pada neuromuskuler
• Mempersiapkan keluarga untuk perawatan pasien dirumah bila saatnya
pulang, kapan harus istirahat, aktifitas dan kontrol selama kondisi masih
belum optimal terhadap dampak dari cidera kepala pasien dan sering
pasien akan mengalami gangguan memori maka mengajarkan pada
keluarga bagaimana mengorientasikan kembali pada realita pasien.

4/17/2021 135
REHABILITASI

▪ Berbaring lama dan inaktiviti bisa menimbulkan

komplikasi gerakan seperti kontraktur, osteoporosis,
dekubitus, edema, infeksi, trombophlebitis, infeksi
saluran kencing.
▪ Goal jangka pendek
_Meningkatkan spesifik area seperti kekuatan,
koordinasi, ROM, balans, dan posture untuk
mobilitas dan keamanan.
_Pengobatan tergantung kondisi pasien kestabilan
kardiopulmoner, fungsi musculoskletal, defisit
neurologi

4/17/2021 136
REHABILITASI
▪ Rehabilitasi dini pada fase akut terutama untuk menghindari
komplikasi seperti kontraktur dengan terapi fisik pengaturan
posis, melakukan gerakan ROM (pergerakan sendi) dan mobilisasi
dini
▪ Terapi ini kemudian dilanjutkan dengan home program terapi
yang melibatkan lingkungan dirumah
▪ Pada pasien tidak sadar dilakukan dengan strategi terapi coma
management dan program sensory stimulation
▪ Penanganan dilakukan oleh tim secara terpadu dan terorganisis :
dokter ,terapis, ahli gizi, perawat, pasien dan keluarga.
▪ Melakukan mobilisasi dini, rehabilitasi termasuk stimulasi, suport
nutrisi yang adekuat, edukasi keluarga.

4/17/2021 137
Refference

• Expert Sources
• Ns. SUNARDI, M.Kep.,Sp.KMB
• DebOra Argetsinger, MS, AGACNP-BC, CCRN
• Honey Beddingfield, BSN, RN, CCRN, CNRN
• Karen March, MN, RN, CNRN, CCRNalumnus
• Bill Lombardi, DNP, RN, AGACNP-BC
• Yana Serondo, RN, NVRN-BC
• CyntHia Bautista, PhD, Aprn, FNCS
• Olivia Wilson

4/17/2021 138
reffrences
Agha A., Thornton E., O’Kelly P., et al (2004). Posterior pituitary
dysfunction after traumatic brain injury. Journal of Clinical
Endocrinology & Metabolism 89(12), 5987-5992.

Agrawal A., Timothy J., Thapa A. (2007). Neurogenic fever. Singapore Medical Journal, 48(6), 492-494.

Bader, M. K., Littlejohns, L. R., Olson, D. M. (2016). AANN Core Curriculum for Neuroscience Nursing. Chicago, IL: AANN.

Bay, E., McLean, S. A. (2007). Mild traumatic brain injury: An update for advanced practice nurses. Journal of Neuroscience
Nursing, 39(10), 43-57.

Carney, N., Totten, A., O’Reilly, C., et al. (2016). Guidelines for the management of severe traumatic brain injury 4th Edition.
Neurosurgery, 80(1), 6-15.
4/17/2021 139
reffrences
Dennis M. (2013) Effectiveness of intermittent pneumatic compression in reduction of risk of deep vein thrombosis in patients who
have had a stroke (CLOTS 3): a multicenter randomized controlled trial. Lancet, 382, S16-S24.

Geerts W. H., Bergqvist D., Pineo G. F., et al., (2008). Prevention of venous thromboembolism: American College of Chest Physicians
evidence-based clinical practice guidelines (8th edition). Chest, 133(6), 381S–453S.

Herman S., Abend N., Bleck T., Chapman K., Drislane F., Emerson, R., Gerard E., Hahn C., Husain A., Kaplan P., LaRoche S., Nuwer M., Quigg
M., Riviello J., Schmitt S., Simmons L., Tsuchida T., Hirsch L. (2015) Consensus statement of continuous EEG in critically ill adults. Journal
of Clinical Neurophysiology, 32(2), 87-95.

Hickey, J. (2014). The Clinical Practice of Neurological and Neurosurgical Nursing. Philadelphia, PA: Wolters Kluwer.

Lee, K. (2012). The Neuro ICU Book. New York, NY: McGraw Hill.

Van Wyck, D. W., Grant, G. A., Laskowitz, D. (2015). Penetrating traumatic brain injury: A review of current evaluation and management
concepts. Journal of Neurology Neurophysiology, 6(6), 1-7.

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