Nursing Case Study of a Patient with Severe Traumatic Brain Injury

A Case Study Presentation byElisa Rubio

Brigham Young University-Idaho

Slide Show

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After reviewing this slide show, the nurse should be able to:

•Explain how secondary brain injury results from primary

injury.

•Explain how the concept of brain compliance relates to ICP

levels.

•Calculate cerebral perfusion pressure and identify the

relationship between CPP and ICP and between CPP and

blood pressure.

•Identify equipment used in caring for patients with STBI.

•Identify abnormal neurologic findings in a patient with STBI.

•Describe how abnormal lab values including sodium, hct,

hgb, potassium, and abnormal ABG’s are affected by and

how they affect a patient with an STBI.

•State expected ranges for ICP, CPP, and PbtO2 for a patient

with STBI.

•Critically analyze rationales for interventions listed in

Critical Care Protocol and Critical Care Algorithms provided.

•List medications commonly used in cases of STBI with their

indications.

•Determine which medication drip is associated with which

assessment variable.

•Discuss the complex role of the critical care nurse in caring

for a patient with STBI

(George, 2002, p. 126, emphasis added)

“The condition that validates the existence of a requirement for nursing in

an adult is the health-associated absence of the ability to maintain

continuously that amount and quality of self-care that is therapeutic in

sustaining life and health, in recovering from disease or injury, or in coping with their effects…” –Dorothea Orem, 2001

Also called “activities of daily living” (ADLs)

these self-care requisites are interrelated

and usually a lower need must be fulfilled

before an upper need can attended to.

This pyramid can help nurses make decisions

about priorities for nursing diagnoses.

(George, 2002, p. 128)

Each of these healthcare requisites has associated needs and abilities.

(George, 2002, p. 128)

Patient abilities

Patient needs

In a healthy individual, a balance exists between the patient’s self-care needs and the patient’s abilities to fulfill his own self-care needs.

Health (balance)

When the patient’s needs increase, as in the case of illness, and/or his abilities decrease…

Each of these healthcare requisites has associated needs and abilities.

Patient needs

Patient abilities

Self-care deficit

A self-care deficit exists, creating the need for NURSING.

(George, 2002, p. 128)

Patient needs

Patient abilities

During the assessment phase, the nurse examines the patient’s abilities.

During the diagnosis phase, the nurse must examine the patient’s needs and evaluate the degree self-care deficit.

During the planning phase, the nurse takes this information and decides what support and how much support to give the patient in order to restore balance.

Nursing support

Nursing support

Implementation involves putting the plan into play (or actually supporting the patient)

(George, 2002, p. 128)

Patient needs Patient abilities

Nursing support

The evaluation phase involves verifying that the self-care deficit is resolved, or ensuring that a balance exists with nursing assist.

(George, 2002, p. 128)

Severe Traumatic Brain Injury

◦ Primary brain injury-actual insult to the brain. Focal—hematomas

Epidural, subdural, intracerebral Diffuse brain injury

Concussion Diffuse axonal injury (DAI)

Shearing or stretching of axons within brain, may remain comatose. Diagnosis based on presentation.

Subarachnoid hemorrhage (SAH)◦ Secondary brain injury-occurs seconds to days

after initial primary brain injury. Involves inflammation and apoptosis.

(Hills, 2006)

Secondary brain injury

“Secondary brain injury is the leading cause of hospital deaths following traumatic brain injury, resulting from brain swelling and an increase in intracranial pressure with the subsequent decrease in cerebral perfusion leading to brain ischemia” (Krell, 2004).

This is what we have to prevent in our case study patient.

Brain compliance◦ Brain tissue (80% intracranial volume)◦ Blood (10% intracranial volume)◦ Cerebrospinal fluid (CSF) (10% intracranial

volume) If there is an increase in one of these

components, the other two will try to compensate.

Intracranial pressure (ICP) elevation occurs if at any time the brain is unable to effectively use its own compensatory mechanisms. (Hills, 2006)

Injury Inability to compensate Increased ICP↓

CPP

↓ brain tissue oxygenationBrain tissue cell death

The medical team must break the chain by managing ICP

Injury Inability to compensate Increased ICP↓

CPP

↓ brain tissue oxygenationBrain tissue cell death

Intracranial pressure (ICP)-measured with ventriculostomy in healthy brain tissue.Ideally 0-15 mm Hg. Must keep below 20 mm Hg to avoid secondary brain injury (Hill, 2006) As described before, is increased in any case that the brain is unable to compensate for increases in one of the components of the intracranial vault.

Cerebral perfusion pressure (CPP)- the difference between the MAP and the ICP. May be managed by increasing BP or decreasing ICP. “Autoregulation of cerebral blood flow is impaired in the injured brain, resulting in further ischemic damage if the cerebral perfusion is not maintained above a critical threshold” (Krell, 2004). Should be maintained at about 60 mm Hg. Avoid too high or too low levels.

CPP=MAP - ICP

Partial pressure of brain tissue oxygen (PbtO2)-A recent advancement in monitoring, this is an objective and direct measurement of oxygenation to brain tissue since ICP is not always directly related to oxygenation. Measured with LICOX monitor inserted into injured brain tissue. Must be above 20 mm Hg.

“…the measurement of ICP and CPP alone does not accurately reflect the tissue oxygenation in injured brain” (Littlejohns, Bader & March, 2003)

Bispectral Index (BIS) monitoring gives a numeric value to reflect electrical activity in the brain. This correlates to the level of sedation. By monitoring this on patients, particularly neuro patients, the level of sedation can be objectively measured to ensure neither under nor oversedation (Franges, 2006).

Another useful tool for measuring level of sedation is to monitor the burst/ suppression ratio on a simple EEG reading. Medications can be titrated to maintain a desired ratio depending on the patient’s needs. A decreased sedation goal can help maintain a stable ICP.

BURST BURST

suppression

While the BIS and the EEG are used to monitor level of sedation, the Train of Four (TOF) test is used to monitor the degree of neuromuscular block. A series of four electrical impulses are delivered to a small muscle in succession. The nurse observes the muscle for twitching. If the patient is blocked adequately, a typical ratio is 2 twitches to 4 signals.

1 twitch2 twitches

To view illustration again, click

←, then →

Nursing: The Juggling Act

Particularly in the case of a patient with STBI, the critical care nurse is constantly evaluating and re-evaluating as she/he intervenes, making adjustments to interventions as required.

Implementation

Evaluation

To view illustration again, click

←, then →

Interventions to reduce ICP are aimed at either decreasing blood flow,

decreasing brain tissue or decreasing CSF. The annotations on the

following protocol help to encourage critical

thinking through each rationale for the given

intervention

If PbtO2 >20 mm Hg and ICP > 20 mm Hg:

•Drain CSF if ventriculostomy is inserted

•Assess level of sedation/analgesia

•Decrease PCO2 by slowly increasing respiratory rate

2breaths/min until ICP <20. Stop if PbtO2 < 20.

•Keep PCO2 at 35-40 mm Hg (some sources say lower is ok)

•Use IVF crystalloids to increase CVP to 10

•IVF NS bolus

•3% hypertonic saline (watch sodium level)

•Administer PRN mannitol as ordered

•Call MD if none of the above is effective to reduce ICP

Protocol from Hills, 2006This helps reduce the CSF component. For a desired ICP of “x” mm Hg, the drainage chamber is leveled at “x” cm below the midline of the head, that way drainage is limited to “excess” CSF.

If the patient’s ICP remains high and the BIS is high or the EEG B/S ratio is high (indicating high brain activity), the nurse may titrate propofol, or thiopental up to reduce brain activity. Reduced brain activity reduces the need for blood flow. Reducing the blood flow component reduces ICP. The oxygen demands also decrease, therefore increasing sedation should not harm the PbtO2 levels.

Changing PCO2 levels affects vasoactivity. I think of it as the PCO2 is directly related to the diameter of the blood vessel. Decreased PCO2 means smaller diameter or vasoconstriction. This is in an effort to reduce the blood flow component. Watch the PbtO2 levels, as reduced blood flow may reduce this level as well!

Crystalloids and hypertonic solutions use osmotic gradients to help pull fluids from the interstitial spaces of the brain. This is in an effort to reduce the volume of the brain tissue component.

Mannitol is given for the same reason as the crystalloid and hypertonic solutions: to reduce interstitial fluid of the brain matter component. However, it is a much stronger agent and acts as a diuretic as well.








•IVF NS bolus




Interventions to increase PbtO2 are

aimed at either increasing oxygen supply, increasing

oxygen delivery, or decreasing oxygen

demand. The annotations on the

following protocol help to encourage critical

thinking through each rationale for the given

intervention








•IVF NS bolus




If PbtO2 is <20 mm Hg and ICP is > 20 mm Hg

•Drain CSF

•Place patient on 100% FiO2 x 15 minutes. Titrate FiO2 per O2

needs.

•Assess sedation/analgesia

•If PbtO2 remains <20 mm Hg after above interventions, transfuse

2 units PRBC if hemoglobin <10gm/dL

•Increase PCO2 (not to exceed 45 mm Hg) by adjusting respiratory

rate by 2 breaths/min. Stop if ICP raises more than 5 mm Hg over

current reading

•Use IVF/pressors as indicated


•MD if none of the above measures is effective

Protocol from Hills, 2006

This helps reduce the CSF component. For a desired ICP of “x” mm Hg, the drainage chamber is leveled at “x” cm below the midline of the head, that way drainage is limited to “excess” CSF.

Clearly this intervention is designed to increase oxygen supply. FiO2 of 100% makes that much more oxygen available to bind to hemoglobin in order to be deivered to tissues.

Changing PCO2 levels affects vasoactivity. Since the PCO2 is directly related to the diameter of the blood vessel. Decreased PCO2 means smaller diameter or vasoconstriction. This is in an effort to reduce the blood flow component. Watch the PbtO2 levels, as reduced blood flow may reduce this level as well!

If the patient’s ICP remains high and the BIS is high or the EEG B/S ratio is high (indicating high brain activity), the nurse may titrate propofol, or thiopental up to reduce brain activity. Reduced brain activity reduces the need for blood flow. Reducing the blood flow component reduces ICP. The oxygen demands also decrease, therefore increasing sedation should not harm the PbtO2levels.

Mannitol is given for the same reason as the crystalloid and hypertonic solutions: to reduce interstitial fluid of the brain matter component. However, it is a much stronger agent and acts as a diuretic as well.

A low hemoglobin reduces the oxygen-carrying capacity of the blood. By increasing the hemoglobin, more oxygen can be delivered to the tissues.

Increasing the blood pressure makes the difference between the MAP and the ICP greater (Increases the cerebral perfusion pressure). With more perfusion to the brain, more oxygen is delivered.


•Drain CSF


needs.


•If PbtO2 remains <20 mm Hg after aboveinterventions, transfuse 2

units PRBC if hemoglobin <10gm/dL



current reading











•IVF NS bolus




If PbtO2 is <20 mm Hg and ICP is <20 mm Hg

•Increase FiO2 to 100% x 15 minutes. Titrate FiO2 per O2 needs

•If PCO2 < 35 mm Hg, decrease respiratory rate by 2 breaths/min to increase PCO2

(not to exceed 45 mm Hg) Goal PbtO2 >20, stop if ICP >20.


•Consider PRBC


•Call MD if none of the above is effective


Clearly this intervention is designed to increase oxygen supply. FiO2 of 100% makes that much more oxygen available to bind to hemoglobin in order to be deivered to tissues.

Changing PCO2 levels affects vasoactivity. Since the PCO2 is directly related to the diameter of the blood vessel. Increased PCO2 means larger diameter or vasodilation. This is in an effort to increase perfusion to brain tissue and delivery of oxygen. Watch the ICP levels, as increased blood flow may increase this level as well!

If the patient’s PbtO2 remains low and the BIS is high or the EEG B/S ratio is high (indicating high brain activity), the nurse may titrate propofol, or thiopental up to reduce brain activity. Reduced brain activity reduces the demand for oxygen. Reducing the blood flow component also reduces ICP, increasing the CPP.

A low hemoglobin reduces the oxygen-carrying capacity of the blood. By increasing the hemoglobin, more oxygen can be delivered to the tissues.

Increasing the blood pressure makes the difference between the MAP and the ICP greater (Increases the cerebral perfusion pressure). With more perfusion to the brain, more oxygen is delivered.

The following insert, taken from an article in the Journal of Neuroscience Nursing, is also intended to help the nurse critically think through interventions.

The categories describe two reasons for decreased PbtO2 :Increased demand and decreased delivery of oxygen. Associated possible etiologies are listed. Under the arrows are suggestions for reversing the etiologies.

Disclaimer: This photograph is not of the actual patient from the case study.

Mr. L

Mr. L. was a victim of a single car rollover MVA. He had

sustained some pulmonary contusions and lacerations, as

well as a C6 fracture and head injury. Mr. L. was

unconscious and decorticate posturing upon EMS arrival.

The patient had undergone placement of a ventriculostomy

and LICOX monitor to monitor and manage ICP and PbtO2.

Due to the difficulty of controlling these values initially, the

patient was placed in a drug-induced coma. Consequently,

the patient was being monitored with a simple EEG and

bispectral index monitor (BIS) in order to assess his degree

of coma, to avoid over or undersedation.

Patient needs

Patient abilities

Obtain data in the following areas:

1.The person’s health status

2.The physician’s perspective of the patient’s health

5.The person’s requirements for self-care

6.The person’s capacity to perform self-care

3. *The person’s perspective of his health

4. *The health goals within the context of the

life history, life style, and health status

*Since the patient is unconscious with no family available, we will not focus on these areas of assessment.

(George, 2002, p. 137)

1. The person’s health status

Neurological Findings•Pupils 2 mm bilaterally, round and sluggishly reactive.•GCS V3, drug-induced coma with Propofol, thiopental, and fentanyl drips.•BIS 10 •EEG burst/suppression ratio (BSR) 3/5 seconds. •Medically paralyzed with atracurium besylate. Train of Four (TOF) 2/4 at 60 mA. •ICP - 18•MAP - 82 •CPP - 66•Ventriculostomy, (right side of the brain) open an leveled to 15 cm below midline and draining 15 ml of clear CSF in 2 hours. •LICOX (left side of brain) measured PbtO2 of 23.•Intracranial temperature reading of 96.3 O F. •Neck X-ray showed cervical spine subluxation at C6. C-collar in place

Cardiac NSR. S1 and S2, distant. BP 135/73 with MAP of 82 per right radial arterial line. Generalized 2+ pitting edema. CVP was 18.

Respiratory AC mode ventilation. Settings: PEEP - 11, FiO2 - 60% set rate - 33. Lung sounds clear. SaO2

99%. The patient was on a roto rest bed to keep spine in alignment while also turning pt for optimal pulmonary mobilization. Sputum culture was positive for stapholococcus aureus infection.

Gastrointestinal no BM since accident, several days ago. Abdomen distended, firm. BS audible x4. Crucial to dobhoff at 65 ml/hr. NG to low/int suction draining moderate amounts bile-colored liquid.

Endocrine insulin drip titrated to keep blood sugar less than 130 mg/dL. Blood sugar was presently 94 mg/dL.

Genitourinary swollen genitals, extremely edematous scrotum. Foley catheter draining sufficient amounts of amber clear urine. BUN and serum creatinine within normal limits.

Integumentary The patient had a diffuse “heat” rash to right side of body where skin came in contact with vinyl bed covering. Also had multiple lacerations to face. No pressure ulcers, but pt is at risk.

2. The physician’s perspective of the person’s healthA good way to get this information is to speak with the physician or read the progress

notes.

Orem’s Step 1: Orem’s Step 1: AssessmentAssessment

(From the progress notes: ) “This has been a

difficult day [for the patient… and] I have

had several conferences with the family that

he is probably approaching the peak of his

cerebral edema and that his prognosis

remains guarded, but there is little else to

change here.”

Laboratory tests and analysis of results

Date/time Test Value Normal Interpretation

10/14 0348 ABG

pH 7.41 7.36-7.44 Normal

PCO2 36 38-52 mm Hg sl low

PO2 112 65-80 mm Hg High, supp O2

HCO3 22 23-30 mEq/L Slightly low

BE -2.1 -3.0-3.0 Normal

We are keeping close tabs on the CO 2 level. It is important in ICP because it is related to vasoconstriction. When the CO 2 level is low, the blood vessels constrict, reducing blood flow and thus pressure to the brain (Urden et al., 2006). We are managing this value by the set mechanical ventilatory respiratory rate and we want the CO 2 low--as low as 25-30 n a patient with intracranial hypertension as long as PbtO 2 is adequate. (Urden et al., 2006).

The HCO 3 is attempting to compensate for the alkalotic CO 2 by going acidotic (decreasing). This is a good thing because, although we want the CO 2 low, we want the pH to remain within normal limits, so compensation is to our advantage.

Due to the decreased CO 2 that we are desiring and the compensation of the HCO 3, the patient has a …

Mild Compensated Respiratory Alkalosis

(Urden et al., 2006, p. 776-777)604-607)

The base deficit of -2.1 also indicates that the metabolic system is attempting to correct by creating an acidotic state.

PaO 2 is “high” due to supplemental oxygen administration.


10/14/08 0345 Na 166 136-145 mEq/L Sig high

K 3.3 3.5-5.1 mEq/L Sl low

Cl 133 100-110 mEq/L High

10/14/08 0345 Serum osmolality 342 275-295 mmol/kg High

10/14/08 1001 335 improved

Up until today, we were using a 7% normal saline (highly hypertonic) solution on this patient in an effort to draw fluid from the cerebral interstitial space by osmotic pressure. This has a tendency to increase the serum sodium.

After these values was viewed by the physician, the 7% NS was discontinued.

Increases in serum chloride level are usually associated with increases in other electrolytes (in this case, sodium). With sodium, plays a major role in serum osmolality.

(Urden et al., 2006, p. 797-798)

As they are both cations, sodium and potassium are in constant competition in the body. To preserve electrical neutrality, when serum sodium is elevated, serum potassium is decreased and vice versa. This potassium level is likely decreased secondary to hypernatremia.

Both sodium and chloride contribute to this high osmolality. To a degree, high osmolality is desired to draw fluid from the interstitial brain tissue in order to reduce ICP.

As we can see, the value has decreased since the 7% NS was discontinued early this morning.


Total Protein 5.5 6.4-8.2 g/dL Low

Albumin 1.4 3.4-5.0 g/dL Low

AST 35 8-28 units/L Sl high

Increased AST might be due to alcohol consumption or possibly to trauma to the liver during the accident. It may or may not be related to the present illness.

Remember that protein and albumin increase oncotic pressures in the blood vessels. When these values are low, fluid leaks into the interstitial spaces, including brain tissue, increasing the brain tissue component of the intracranial vault, resulting in increased ICP.

Continued attention to nutrition with possible protein supplements and albumin infusions might be helpful to increase these values and reduce third spacing.

(Kee, 1999, p. 69)

A great deal of ICU patients have low protein and albumin levels secondary to their increased protein consumption for healing and decreased protein intake.


WBC 15.3 4-10.5 K/mm3 High

WBC diff

Segs 82 47-76 % High

Bands 5 0-4% High

The patient’s sputum was positive for staph aureus. A respiratory infection is definitely enough to increase the white blood count. This patient has been placed on Vancomycin.

The differential shift indicates that the infection is not new, since the immature neutrophils (bands) are not actively multiplying.

(Cook, 1999; Glauser, 2005)


RBC 3.38 4.4-5.9 m/mm3 Low

Hgb 10 13.5-17.5 g/dL Low

Hct 29.8 39.8-52.2 % Low

RDW 15.9 11.5-14.5 % High

Despite major trauma, this patient has not had a blood transfusion since his admission six days ago. These values are low but stable since admit. The patient is not actively bleeding, but likely had some bleeding at the time of the accident, which caused these numbers to be low.

Keep in mind that these values are important to us because changes in Hct will affect oxygen carrying capacity, and, in turn, will effect oxygenation to tissue such as to the brain. A blood transfusion may not be a bad idea.

This value indicates the size of the RBC’s. It is slightly high. In the presence of a normal MCV, usually indicates iron deficiency, which may also have contributed to our low hct/hgb/RBC.

(Kee, 1999)

We’re interested in keeping the patient supplied with iron, since it plays significant role in hemoglobin formation, and therefore the oxygen-carrying capacity of the blood. Perhaps iron supplementation would be appropriate.

Orem’s Step 1: DiagnosisOrem’s Step 1: Diagnosis

What needsdoes this

patienthave?Patient needs

5. The patient’s requirements for self-care.

Recall from our discussion that Orem’s self care requisites demand that we address the need for air (oxygen) before all others.

Oxygenation of the brain tissue, is vital at this point. Perfusion is compromised secondary to brain swelling related to the trauma. This is a serious priority at this point.

6. The person’s capacity to perform self-careThe nurse seeks to answer the following questions:

•What is the patient’s present therapeutic care demand?

•Does the patient have a deficit for engaging in self-care to meet the therapeutic self-care demand?

•What is the patient’s potential for engaging ins self-care at a future time period?

Based on our patient’s primary need for oxygen to the brain tissues, maintaining his ICP and his oxygenation to the brain are the most critical demands at this time.

Because the patient’s needs outweigh his abilities to engage in self-care, as our scale illustration shows, the patient does have a self-care deficit, requiring nursing intervention.

This patient has sustained a head injury, and his cognitive abilities may be impaired when he regains consciousness. Furthermore, he has a C-spine injury, which may result in physical paralysis.

(George, 2002, p. 139)

Since our patient’s abilities are extremely limited and his needs are significantly increased, according to Orem’s nursing systems, our patient requires the help of a

“wholly compensatory nursing system”

at this point.

Patient needs

(George, 2002, p. 131)

Patient abilities

◦ related to increased pressure in brain secondary to cerebral edema from traumatic brain

injury.

Think about it:

When there’s too much edema and swelling, the volume of brain tissue

increases… Without proper compensation, this leads to increased

intracranial pressure, which means more resistance for the blood to fight against in order to perfuse the brain. This leads to decreased oxygenation.

I need to keep the ICP down and the PbtO2 up in order to meet the patient’s self-care requisite for air (oxygen) to

the brain tissue.

Impaired cerebral tissue perfusion and oxygenation

Orem wants us to focus on the etiology portion of the diagnosis and try to treat it in order to resolve the nursing diagnosis:

Adequate cerebral tissue oxygenation. ◦ The patient will have PbtO2 greater than ____ mm

Hg maintained throughout the shift.

Adequate cerebral perfusion. ◦ The patient will have an ICP less than ____mm Hg

and a CPP of ____ + or – 5 mm Hg throughout the shift.

2060

20

100% A +


•Drain CSF


needs.


•If PbtO2 remains <20 mm Hg after above interventions, transfuse

2 units PRBC if hemoglobin <10gm/dL



current reading











•IVF NS bolus




If PbtO2 is <20 mm Hg and ICP is <20 mm Hg

•Increase FiO2 to 100% x 15 minutes. Titrate FiO2 per O2 needs

•If PCO2 < 35 mm Hg, decrease respiratory rate by 2 breaths/min to increase PCO2

(not to exceed 45 mm Hg) Goal PbtO2 >20, stop if ICP >20.


•Consider PRBC


•Call MD if none of the above is effective


Recall our discussion on this critical care protocol

During the Planning phase, the nurse decides what support is needed and how

much.

We have already selected goals, now we will think through some

interventions that will help us reach our goals.

We’ll discuss some of the interventions performed during the shift, taken from the Critical Care Protocol on previous slides.

--------------------------------------

--------------------------------------

--------------------------------------

Critical Care Protocol

NursingSupport

NursingSupport

To ensure adequate cerebral perfusion:

Monitor ICP and CPP continuously using ventriculostomy

Monitor and maintain MAP to achieve desired

CPP by:Monitor CVP and administer fluids as necessary to keep MAP adequate to achieve desired CPP

If CVP > 10 and CPP remains low, increase MAP by titrating levophed drip

Maintain open CSF drainage to 15 mm Hg from ventriculostomy

To achieve adequate cerebral

tissue oxygenation:

Continuously monitor PbtO2 with LICOX monitor

Maximize oxygen supply/delivery by:

Maintain therapeutic vasodilation by adjusting respiratory rate to CO2 25-30 as long as ICP <20

Adjust FiO2 and PEEP to maximize oxygenation to tissues.

Monitor H/H to keep Hct above 33% and transfuse PRBC if required

Minimize oxygen demand by:Monitor and maintain core temperature at less than 96.5O F using continuous intravenous fluid cooler.

Titrate propofol and thiopental to BIS 10-20 and EEG BSR 3/5 to maintain coma and reduce metabolic rate.

Maintain paralysis, titrate atracrium to Train of four 2/4

Premedicate/bolus with propofol prior to noxious activities (e.g. bathing, suctioning) to reduce reactions which would increase ICP or oxygen demand.

NursingSupport

NursingSupport

Medicationswith Rationale

Fentanyl 1 mcg/minUsed for pain control and assists with sedation. May increase intracranial pressure by causing vasodilation of cerebral blood vessels, so should be used with caution. Also causes decrease in CPP by decreasing MAP (Krell, 2004)

Fentanyl 1mcg/min

Propofol is commonly used in ICU patients for sedation. Sedation is desirable in this patient for many reasons. In ventilated patients, it allows the patient to work with the ventilator. This benefits this patient because working with the ventilator allows for improved ventilation, which delivers more oxygen to the patient’s brain. Sedation decreases brain activity, reducing blood flow to the brain and oxygen demand of the brain. Monitoring the BIS level is important to avoid over or undersedation and to know to what extent the propofol can be titrated.

Propofol 10.7 mcg/kg/min

Atracrium besylate 6 mcg/kg/min

Fentanyl 1mcg/minPropofol 10.7 mcg/kg/min

Used for paralysis. Titrated to Train of four test. “Continued neuromuscular blockade may be indicated for…intracranial hypertension, where it has been shown to be effective” (Krell, 2004).

Thiopental 5 mcg/kg/hr

Fentanyl 1mcg/minPropofol 10.7 mcg/kg/minAtracrium besylate 6 mcg/kg/min

Usually a last-ditch effort when conventional methods to prevent intracranial hypertension have failed. This is a barbituate that is used to decrease oxygen and metabolic demand by placing the patient in a drug-induced coma. Since the comatose brain has very little activity, it’s oxygen and metabolic requirements are low (Urden et al., 2006). Level of sedation should be closely monitored with use of BIS and burst/suppression ratio as described previously. The medication may be titrated to these results in order to maintain desired level of sedation.

Fentanyl 1mcg/minPropofol 10.7 mcg/kg/minAtracrium besylate 6 mcg/kg/minThiopental 5 mcg/kg/hrDilantin 100 mg IV Q 8 hours

“Both the Brain Trauma Foundation and American Academy of Neurology recommend prophylaxis to prevent early post-traumatic seizures in patients at high risk following TBI…such therapy should be discontinued after seven days” (Krell, 2004).

Post-traumatic seizures are a complication of head injury, and these seizures can tend to increase metabolic demand, it is important that seizures be treated prophylactically. This helps ensure that metabolic demand does not exceed availability of blood flow and oxygen (Urden et al., 2006).

Norepinephrine 25.6 mcg/min

Fentanyl 1mcg/minPropofol 10.7 mcg/kg/minAtracrium besylate 6 mcg/kg/minThiopental 5 mcg/kg/hrDilantin 100 mg IV Q 8 hours

One way to maintain cerebral perfusion pressure (MAP-ICP) in the presence of high intracranial pressure is to increase the MAP by fluid control and administering inotropic agents such as levophed (norepinephrine). This is a delicate balance, however, and the nurse should be careful not to allow the blood pressure to get too high, as this can adversely increase ICP in and of itself (Urden et al., 2006).

Fentanyl 1mcg/minPropofol 10.7 mcg/kg/minAtracrium besylate 6 mcg/kg/minThiopental 5 mcg/kg/hrDilantin 100 mg IV Q 8 hoursNorepinephrine 25.6 mcg/minInsulin drip

Maintenance of normal blood sugar levels has been shown to improve outcomes in surgical critical care patients in general. This also “improves immune function…decreases intracellular brain cell edema, and improves wound healing” (Krell, 2004).

NursingSupport

FentanylPropofolAtracrium besylateThiopentalDilantinNorepinephrineInsulin drip

Nursin

g

Support

NursingSupport

Patient needs

Patient needs

Patient abilities

Nursing support

Patient abilities

Nursing support

Adequate cerebral perfusion. ◦ The patient will have an ICP less than ____mm Hg

throughout the shift

Actual ICPremained between

17 and 19


20

<

Our interventions to maintain ICP

were effective to achieve our

desired outcome.

Adequate cerebral perfusion. ◦ The patient will have a CPP at ___ mm Hg + or – 5

mm Hg throughout the shift

Actual CPPremained

58 to 64


60

=

Our interventions to maintain CPP were effective to

achieve our desired outcome.

55 to 65

Actual PbtO2

remained between

21.5 and 25.3


Adequate cerebral tissue oxygenation. ◦ The patient will have PbtO2 greater than ____ mm

Hg maintained throughout the shift.

20

>Our interventions to maintain PbtO2 were effective to

achieve our desired outcome.

Patient needs Patient abilities

Nursing support

Patient needs

Patient abilities

Nursing support

Hooray!

Fill in the blank spaces provided with the appropriate phrase.

“___________ _________ ___________is the leading cause of hospital deaths following traumatic brain injury, resulting from brain swelling and an increase in intracranial pressure with the subsequent decrease in cerebral perfusion leading to brain ischemia” (Krell, 2004).

Secondary brain injury

This question demonstrates the outcome: “The nurse should be able to explain how secondary brain injury results from primary injury”

Brain tissue

CSF

Blood

When one of these components increases, the brain compensates

by decreasing the other two. However, if brain injury is too severe, the brain is unable to

compensate (or has “decreased compliance”). Interventions to

reduce ICP are all directed at reducing one or more of the

components of the intracranial vault.

This question demonstrates the outcome: “The nurse should be able to explain how the concept of brain compliance relates to ICP levels.”

Click the most correct response.Which of the following formulas

is correct?

a. CPP=MAP + ICP

d. CPP=PbtO 2 -ICP

b. ICP=PbtO 2 + CPPc. CPP=MAP - ICP

The cerebral perfusion pressure is the amount of the blood pressure that is perfusing the brain. If the “downward” pressure from the brain is too high, a low blood pressure would not support brain perfusion. Ways to manipulate the CPP include decreasing the ICP and increasing the MAP with vasopressors and volume expanders.

This question demonstrates the outcome: “The nurse should be able to calculate cerebral perfusion pressure and identify the relationship between CPP and ICP and between CPP and blood pressure.”

Click the most correct response.The image to the left is of which

piece of equipment?

a. LICOX PbtO 2 monitorc. EEGb. Train of Four

d. BIS monitor

This is a BIS monitor. It’s one method of reading brain activity. It’s used to closely monitor level of sedation and propofol and thiopental are titrated according to its readings.

This question demonstrates the outcome: “The nurse should be able to identify equipment used in caring for patients with STBI.”

Click the most correct response.Which of the following

neurologic findings meets appropriate expected

outcomes?a. GCS: 8

d. PbtO2: 15 mm Hg

b. CPP: 45 mm Hgc. ICP:17 mm Hg

This question demonstrates the outcome: “The nurse should be able to identify abnormal neurologic findings in a patient with STBI.”

Normal GCS is 15. An expected CPP is 60 + or – 5 mm Hg. An expected PbtO2 is >20 mm Hg.

An expected ICP is <20 mm Hg. This value of 17 mm Hg meets our expected outcome.

Click the most correct response.Which of the following lab

values are of particular concern in a patient with a PbtO 2 of 13

mm Hg.

a. CO 2 : 43 mm Hg

c. Total Protein: 5.5 g/dL

b. Na:150 mEq/L

d. Hgb: 9 gm/dL

CO 2 is high normal. This means the vessels are vasodilated, so blood flow to the brain is likely not the problem.

Na and Total protein have little to do with the oxygenation of the brain.

A low hemoglobin contributes to low oxygen carrying capacity in the blood. This will reflect as low partial brain tissue oxygenation values.

This question demonstrates the outcome: “The nurse should be able to state how abnormal lab values including sodium, hct, hgb, potassium, and abnormal ABG’s are affected by and how they affect a patient with an STBI.”

Click the most correct response.An appropriate expected

outcome for a patient with an STBI would be PbtO 2 ___ 20 mm

Hg

c. =

d. (+ or -)

b. <

a. >Expected values:ICP <20 mm HgCPP 60 + or – 5 mm HgPbtO 2 >20 mm Hg

This question demonstrates the outcome: “The nurse should be able to state expected ranges for ICP, CPP, and PbtO 2 for a patient with STBI.”

Try to guess where the following will be sorted.

Interventions to reduce ICP are aimed at either decreasing blood flow, decreasing brain tissue or

decreasing CSF. Sort the following interventions into the appropriate

rationale boxes.

Decrease brain tissue Decrease CSF Decrease blood flow

•Draining open ventriculostomy

•Decrease PCO 2 by slowly increasing respiratory rate 2breaths/min until ICP <20. Stop if PbtO 2 < 20.

•Use IVF crystalloids to

increase CVP to 10


Decrease brain tissue Decrease CSF Decrease blood flow

This question demonstrates the outcome: “The nurse should be able to state rationales for interventions listed in Critical Care Protocol and Critical Care Algorithms provided.”

To review these rationales, refer to slides 28-32 after the slide show.

Click True or False.High ICP is always associated with

low brain tissue oxygenation (PbtO2)

TRUE FALSEWhen high ICP is associated with increased brain tissue or

increased CSF, blood flow is usually reduced to compensate, leading to low PbtO2. However, when high ICP is due to high blood flow to the brain, it can be associated with normal levels of PbtO2. An algorithm exists for treatment of patients with good ICP and bad PbtO2, one for bad ICP and good PbtO2 and one when both are bad. This question demonstrates the outcome: “The nurse should be

able to describe the complex relationship between ICP and PbtO2.”

Click True or False.Increasing the respiratory rate can

help reduce ICP, but it may also cause a decrease in PbtO2.

FALSE

TRUEIncreasing the respiratory rate on the ventilator results in decreased levels of CO2 as the patient “blows it off”. Decreased CO2 leads to vasoconstriction. (I like to think of it as the CO2 is directly related to the diameter of the vessel). Since vasoconstriction reduces blood flow to the brain, the ICP will go down, but with decreased perfusion, the PbtO2 may suffer as well.

Try to guess where the following will be sorted.

The following interventions help improve PbtO2 in different ways. Sort

the interventions into the appropriate rationale boxes.

Increase oxygen supply

Decrease oxygen demand

Increase oxygen delivery

•Increase PCO2 by adjusting respiratory rate by 2 breaths/min.

•Place patient on 100% FiO2 x 15 minutes. Titrate FiO2 per O2 needs.

•Increase propofol or thiopental to deepen sedation

•Transfuse 2 units PRBC if hemoglobin <10gm/dL

•Maintain core temperature <96.5 F

To review these rationales, refer to slides 27-29 after the slide show.

This question demonstrates the outcome: “The nurse should be able to state rationales for interventions listed in Critical Care Protocol and Critical Care Algorithms provided.”

Medication:

Propofol

Norepinephrine

Thiopental

Insulin

Atracrium

Fentanyl

Purpose:

Glucose

Coma induction

Paralysis

Sedation

Pain control

CPP

maintenance

Titrate to:

Train of four

Blood sugar

Pain

MAP

BIS

EEG

This question demonstrates the outcome: “The nurse should be able to list medications commonly used in cases of STBI with their indications.” AND “The nurse should be able to determine which medication drip is associated with which assessment variable.”

Having reviewed this slide show, the nurse should be able to:

•Explain how secondary brain injury results from primary

injury

•Explain how the concept of brain compliance relates to ICP

levels.

•Calculate cerebral perfusion pressure and identify the

relationship between CPP and ICP and between CPP and

blood pressure.

•Identify equipment used in caring for patients with STBI.

•Identify abnormal neurologic findings in a patient with STBI.

•State how abnormal lab values including sodium, hct, hgb,

potassium, and abnormal ABG’s are affected by and how

they affect a patient with an STBI.

•State expected ranges for ICP, CPP, and PbtO2 for a patient

with STBI

•State rationales for interventions listed in Critical Care

Protocol and Critical Care Algorithms provided.

•List medications commonly used in cases of STBI with their

indications.

•Determine which medication drip is associated with which

assessment variable.

•Discuss the complex role of the critical care nurse in caring

for a patient with STBI

You have successfully achieved the objectives of this slideshow. If you feel you need to review any portion of this slide show, feel free to explore the slide show in the “edit slideshow” mode by pushing the escape key and scrolling through the slides.

If you’d like to review the information on an individual slide, it may be helpful to click on the appropriate slide, then under “animations” menu, click “custom animation” and then the button that says “slide show” on the bottom right of the screen. Good luck.

Thank you for viewing this slide

show. I hope that you were able to

expand your knowledge regarding

the critical care nurse’s role in care

of the patient with a severe

traumatic brain injury. Please feel

free to post questions on this

presentation on the discussion board

and I will reply as soon as possible.

Cook, L. (1999). The value of lab values: Incorporate lab results into the nursing diagnois. The American Journal of Nursing, 99(5) 66-69, 71, 73, 75.

Franges, E. (2006). BIS monitoring migrates from OR to ICU: Bispectral index monitoring is used in the ICU to provide objective measures of he level of sedation in patients. Nursing2006, 1(5) 58-61.

George, J. (2002). Nursing Theories: The Base for Professional Nursing Pactice. Upper Saddle River, NJ: Pearson Education

Glauser, J. (2005). Renal Failure. Issues in Critical Care Nursing, volume(number) March 30, 2005, 17-36.

Hills, T. (2006). Understand severe traumatic brain injury. Nursing2006, 1(4) 38-45.

Kee, J. (1999). Laboratory & Diagnostic Tests with Nursing Implications. Stanford, CT: Appleton & Lange.

Krell, K. (2004). Clinical guidelines for traumatic brain injury. Eastern Idaho Regional Medical Center Clinical Guidelines.

Littlejohns, L., Bader, M. K., & March, K. (2003). Brain tissue oxygen monitoring in severe brain injury, I: Research and usefulness in critical care. Critical Care Nurse, 23(4) 17-24

http://ccn.aacnjournals.org/cgi/content/full/23/4/17 Patterson, J., Bloom, S., Coyle, B., Mouradjian, D., &

Wilensky, E. M. (2005). Successful outcomes in severe traumatic brain injury: A case study. Journal of Neuroscience Nursing, 37(5) 236-242.

Urden, L., Stacy, K., & Lough, M. (2006). Thelan’s critical care nursing: Diagnosis and management. St Louis, MO: Mosby Elsevier p. 774-780, 797.

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Nursing Case Study of a Patient with Severe Traumatic Brain Injury

Health & Medicine