Neuro Case Presentation

During 3-4 hours of case presentation, the BSN4-Echo will be able to: 1. Review the anatomy and physiology

of the brain

2.. Identify the subjective data collected from significant others while gathering information for the nursing history. 3.. Identify the deviation from the normal using Inspection, percussion, palpations and auscultation to elicit the objective data while performing nursing assessment. 4.. State the normal values and interpret findings with significant deviation of laboratory and diagnostic results. 5. Trace the pathophysiology of Traumatic Brain Injury. 6. Formulate nursing care plan as a framework of care according to priority. 7. Tabulate the drugs given to the patient according to its name, content, action, mechanism of action, indication contraindication, adverse effect and nursing consideration 8.. Appreciate the role of the nurse in caring Traumatic Brain Injury

for patient with

THE HUMAN BRAIN Brain The brain keeps the body in order. It helps to control all of the body systems and organs, keeping them working like they should. The brain also allows us to think, feel, remember and imagine. In general, the brain is what makes us behave as human beings. The brain communicates with the rest of the body through the spinal cord and the nerves. They tell the brain what is going on in the body at all times. This system also gives instructions to all parts of the body about what to do and when to do it.

The central nervous system (CNS) represents the largest part of the nervous system, including the brain and the spinal cord. Together with the peripheral nervous system, it has a fundamental role in the control of behavior. The CNS is contained within the dorsal cavity, with the brain within the cranial subcavity, and the spinal cord in the spinal cavity. The CNS is covered by the meninges. The brain is also protected by the skull, and the spinal cord is also protected by the vertebrae. Peripheral nervous system In humans, the brain consists of cerebrum (center for thought and memory association); hypothalamus-thalamus (center for processing information), cerebellum and brain stem (center for locomotion and coordination) and the spinal cord, an extension of the brain consists of motor and sensory nerves in the cervical, thoracic and lumber regions of the spine.

A. • • • • • •

Embryological Development During the development stages, the brain starts out as a tube in most mammals. The tube has three bulges or balloon-like structures at one end of the third week of conception. The first part is prosencephalon (forebrain); mesencephalon (midbrain) and rhobemencephalon (hindbrain). After 5wks, telencephalon and diencephalons form develop from the forebrain (prosencephalon); the hind brain forms metencephalon (afterbrain) and myelin-cephalon (form spinal cord). These structures form the brain and the other end forms the spinal cord. The cerebrum develop from telencephalon; diencephalons forms the hypothalamus, thalamus and epithalamus. Mesencephalon, metencephalon and myelencephalon develop into cerebellum and midbrain or brain stem (pons and medulla oblongata).

B.

Characteristics of the CNS

The entire CNS is protected by a bony capsule – the cranium and the vertebral column protects the spinal cord. The cranium is covered with membrane called meninges of which there are three: dura mater (out layer), arachnoid (middle) and pia mater (interior layer). The surface of brain contains ridges called gyri (gyrus, singular) and are separated by valleys called sulci and deeper valleys or grooves are called fissure. There are five lobes: frontal, parietal, occipital, temporal and the insula lobe. Two cerebral hemispheres exist which are mirrow images and are connected in the middle by a bundle of nerves called corpus collasum.

C.

Functions of the Brain

1. Cerebrum Cerebrum is the center for control, thought and associations. Command center: It serves as the command center of the brain. All information from the periphery nervous system (PNS), motor functions and sensory activities are received, processed, analyzed and relayed or commands are issued for their respective responses. Other functions include development, vision, speech, memory, thought, and association. The cerebrum is divided into left and right hemispheres and these hemispheres contain fibers or tracts, which cross over each half of the hemispheres The association of the tract with each half of the cerebral hemispheres is very important. During an accident or removal of tumor, the tracts can be cut accidentally. When the cut is not repairable, it may leave permanent damage that could lead to loss of function or paralysis of the functions related to that area.

2. Thalamus and hypothalamus • • • • • • •

Thalamus and hypothalamus are centers for processing information. The thalamus and hypothalamus are collectively called diencephalons. These organs regulate bodily functions and motor activities (motion), therefore, process information related to bodily functions and motor activities. The thalamus and hypothalamus are located immediately below the corpus callosum. The thalamus represents the last center where all sensory signals (except those associated with the sense of smell) are processed before they are passed on to the cerebrum. The hypothalamus maintains homeostasis (that is maintenance of constant body temperature) and contains centers for regulating hunger, sleep, thirst, temperature, water balance and blood pressure. It also regulates the pituitary gland, which secretes hormones, thereby maintaining regulation of hormones.

3. Cerebellum • • • • •

4. • • • • • •

Cerebellum coordinates motor functions. The cerebellum is located at the back of the brain below the cerebrum and appears partially separated from the cerebrum by the fourth ventricle. The surface of the cerebellum is made of gray matter and the interior is white matter. It functions mainly in muscle coordination and integrating all motor activities. It also maintains normal muscle tone and posture and balance.

The brainstem The brainstem has centers for breathing (pneumatic center), digestive functions, heartbeat (rhythmic center) and blood pressure. The brain stem consists of the midbrain, pons and medulla oblongata. These organs are located in front of the cerebellum and below the hypothalamus and thalamus. The medulla oblongata contains centers which regulate breathing (Pneumonic center), heartbeat and vasoconstriction. Other centers include vomiting, coughing, sneezing and hiccups. The pons functions in collaboration with the medulla, regulating breathing and reflex actions in response to auditory and visual stimuli. It contains bundles of nerves that transmit information between the cerebellum and the CNS. The midbrain functions as a relay station. Nerve tracts pass between the spinal cord and cerebrum or cerebellum. It also maintains centers for vision, auditory and tactile stimulations.

The nervous system is made up of nerve cells or neurons that are "wired" together throughout the body, somewhat like communication system. Neurons carry messages in the form of an electrical impulses. The messages move from one neuron to another to keep the body functioning. Neurons have a limited ability to repair themselves. Unlike other body tissues, nerve cells cannot also be repaired if damaged due to injury or disease. The PNS consists of all other nerves and neurons that do not lie within the CNS. The large majority of what are commonly called nerves (which are actually axonal processes of nerve cells) are considered to be PNS. The peripheral nervous system can be further classified either by direction of neurons and by function. The peripheral nervous system uses special senses to connect the body to the outside environment. Spinal cord relays sensory and motor signals to the brain. The spinal cord is the center for many reflex actions. It also functions as a center providing communication between the brain and the spinal nerves that leave the spinal cord. It contains unmyelinated cell bodies and short fibers that give the gray appearance inside. The outside of the spinal cord contains bundles of myelinated long fibers of interneurons. These tracts give the bundles a white color outside.

FRONTAL LOBE Located in front of the central sulcus. Concerned with reasoning, planning, parts of speech and movement (motor cortex), emotions, and problem-solving. PARIETAL LOBE Located behind the central sulcus. Concerned with perception of stimuli related to touch, pressure, temperature and pain. TEMPORAL LOBE Located below the lateral fissure. Concerned with perception and recognition of auditory stimuli (hearing) and memory (hippocampus). OCCIPITAL LOBE Located at the back of the brain, behind the parietal lobe and temporal lobe. Concerned with many aspects of vision.

By direction There are three types of directions of the neurons: Sensory system by sensory neurons, which carry impulses from a receptor to the CNS Efferent system by motor neurons, which carry impulses from the CNS to an effector Relay system by relay neurons, which transmit impulses between the sensory and motor neurons. However, there are relay neurons in the CNS as well. The junction between two neurons is called a synapse. There is a very narrow gap between the neurons - the synaptic cleft. By function By function, the peripheral nervous system is divided into the somatic nervous system and the autonomic nervous system. The somatic nervous system is responsible for coordinating the body's movements, and also for receiving external stimuli. It is the system that regulates activities that are under conscious control. The autonomic nervous system is then split into the sympathetic division, parasympathetic division, and enteric division. The sympathetic nervous system responds to impending danger or stress, and is responsible for the increase of one's heartbeat and blood pressure, among other physiological changes, along with the sense of excitement one feels due to the increase of adrenaline in the system. The parasympathetic nervous system, on the other hand, is evident when a person is resting and feels relaxed, and is responsible for such things as the constriction of the pupil, the slowing of the heart, the dilation of the blood vessels, and the stimulation of the digestive and genitourinary systems. The role of the enteric nervous system is to manage every aspect of digestion, from the esophagus to the stomach, small intestine and colon.

Name: Captain Hook Age: 6 years old Address: Canetown Subdivision Victorias, City Negros Occidental Religion: Roman Catholic Citizen: Filipino citizen Birthday: August 27,2001 Fathers name: Peterpan Mothers name: Tinkerbell Chief Complaint: Vehicular Accident Diagnosis: 1. Multi-system trauma with Brain Injury Acute Subdural Hematoma right fronto temporo- parietal and multiple hemorrhagic concussions severe diffuse cerebral edema; diffuse subarachnoid hemorrhage. 2. Fracture midshaft right femur. 3. Multiple contusion/ abrasion in faces and extremities 4. Post craniotomy evacuation of subdural hematoma right temporal.

>Post decompression craniotomy,

dural entry, evacuation of acute subdural hematoma. >Post application of long leg posterior mold. >Post IV cutdown at right arm. >Post application of skeletal traction. >Post suturing of 7cm lacerated wound at right temporal area.

At 6 am, 2 hours prior to admission, patient was riding in a

vehicle (Toyota revo) driven by his father from Victorias going to Bacolod to fetch his sister. He was sleeping at the back passenger seat, with no seatbelt on, when another 4 wheeled vehicle (land cruiser) hit them head on at EB Magalona. Luckily, one of there neighbor was passing by on the time of the accident and with the help of the bystander patient and his father was rushed to the nearest Hospital (Teresita Lopez Jalandoni Provincial Hospital).Patient was unconscious and suffered bleeding and multiple abrasion, he was immediately given first aid, was intubated and transferred to Dr. Pablo O. Torre Memorial Hospital for further evaluation and management together with his father.

Patient’s mother verbalized that patient was delivered via caesarian section secondary to transverse.Mother had gestational diabetes during pregnancy.Patient had complete immunizations, no history of hospitalizations and no known allergy.

Paternal side

Maternal side

Diabetes mellitus

X

√

Hypertension

√

√

Cancer

X

√

Asthma

X

X

Captain Hook is a grade 1 student in Jack and Jill Victorias He is the only boy and the youngest among the 2 siblings. His father and mother are businessmen. On the time of the accident, his mother was in the USA for some business matter. Tinkerbell verbalized that her son is a normal active school grader before the accident happen.

As a child , captain hooks usual activity is playing on their school and at there house together with his neighbors. He and his dad love to drive everywhere. They usually practice safety measures such as wearing of seatbelts. But during the time of the accident, his dad was the only one who was able to wear a seatbelt because he was sleeping at the backseat of there car.

Eating/drinking

√

Bathing

√

Dressing/groo ming

√

toileting

√

Bed Mobility

√

StairClimbing

√

Ambulating

√

Normal appetite No swallowing difficulty Ate a well balance diet Loves to eat chicken

Prior to accident patient has a normal bowel (once a day ) and bladder pattern ( 5-6 times a day) Presently, with an indwelling catheter attached to drainage bag and a diaper Has a normal sleep and rest pattern, he usually sleeps more than 8 hours a day.

A. General Appearance Patient lies in a supine position, head of bed is slightly elevated with a decerebrate posture;, attached to cardiac monitor, with endotracheal tube to mechanical ventilator. Tidal volume of 400, FIO2 of 60%, BUR of 20, with NGT in placed, with IVF via IV cutdown at right arm, with IVF set B cycle 33 D5NSS 1L + 2 meq KCL @ 43 cc/hr , with skeletal traction attach to 8 lbs.wt elevated right lower extremities, with pulse oximeter, with foley catheter attach to drainage bag, with suction machine on bedside, with hematoma right temporal area, punctured left cheek, hematoma left cheek, dried bloody ear discharges is presence on the right ear. Hematoma on the left auricle, disproportionate head shape, presence of white dressing in the head, positive for ptosis, eyelids are taped, non pitting edema is present in left upper extremities.

Level IV- light coma Glasgow Coma Scale of 6

Cranial nerve I

cannot be assess

Cranial nerve II

cannot be assess

Cranial nerve III, IV, VI

Anisocoria (left pupil-2mm. right pupil4mm ) Presence of ptosis

Cranial nerve V

sensory: cannot be assess Motor: positive corneal reflex Lacks facial sensation

Cranial Nerve VII

sensory: cannot be assess Motor- Mask-like face

Cranial nerve VIII

Patient follows some command

Cranial nerve IX and X

presence of gag reflex upon suctioning

Cranial nerve XI

cannot be assess

Cranial nerve XII

cannot be assess

Asymmetrical- left upper extremities has presence of non-pitting edema

3/5- lower extremities 1/5- upper extremities

Hypotonicity (flaccidity)

a.Pupillary reflexes – pupils round, unequal L- 2mm R4mm, reactive to light, don’t accommodate b.Positive corneal reflex c.Positive abdominal reflex d. Negative cremasteric reflex e. Negative babinski reflex f. Deep tendon reflex 1. Biceps- 1/5 2. Triceps- 3/5 3. Brachioradialis- 1/5 4. patellar reflex-2/5 5. Achilles Tendon Reflex- 1/5 g. negative meningeal irritation h. negative oculovestibular reflex

1. EENT

☺presence of white dressing in the head ☺ disproportionate head shape ☺ presence of ptosis ☺ eyelid is tape ☺ dry eyes ☺ no movement of eyeballs ☺ Anisocoria- pupils round, unequal L- 2mm R- 4mm, reactive to light, don’t accommodate ☺ Pale conjunctiva ☺ White sclera ☺ Comminuted right cheek ☺ Presence of endotracheal tube attach to mechanical ventilator ☺ Dry lips ☺ Hematoma right temporal area ☺ Punctured wound in left cheek ☺ Hematoma on left cheek ☺ Hematoma on the left auricle ☺ Dried bloody ear discharges ☺ Mask like face

2.Circulatory

☺ Blood pressure of 150/100 mmHg ☺ Pulse pressure of 40 mmHg ☺ Pulse rate of 160 beats/min. ☺ Temperature of 38.5 ☺ Capillary refill of 4 seconds ☺ Non-pitting edema is presence on the left upper extremities ☺ Dry lips ☺ Pale conjunctiva ☺ White sclera ☺ Skin is warm to touch

3. Respiration ☺ Presence of endotracheal tube attach to mechanical ventilator ☺ Respiratory rate of 20 breaths/min-assisted ventilation

4.Musculoskeletal ☺ Increase muscle size in left

upper extremities due to non pitting edema ☺ Absent range of motion ☺ Weak muscle strength ☺ Hypotonicity ( flaccidity ) ☺ Presence of skeletal traction attach to 8 lbs. wt ☺ Redness on the skeletal traction area

5.Elimination ☺ Laxative use: none ☺ Character of stool: mushy ☺ With foley catheter attach to

drainage bag ☺ Color of urine: light yellow ☺ Has a normal urine output

6.Integumentary

☺ Presence of hematoma on the face ☺ Presence of broken skin on the groin area ☺ Multiple abrasions and bruises on the face

and extremities ☺ Skin is warm to touch ☺ Presence of redness on the skeletal traction area

7. Neurosensory ☺ Decrease level of consciousness ☺ Patient is in light coma ☺ pupils round, unequal L- 2mm R-

4mm, reactive to light, don’t ☺ accommodate ☺ weak handgrasp ☺ decerebrate posture

JULY 07 2007 July 07 2007 10 : 27 am Hemoglobin Hematocrit Red blood cell White blood cell Segmenters Lymphocytes Eosinophils Monocytes Platelet

59 .20 2.28 26.6 .72 .21 .01 .06 Adequate

Arterial Blood Gas pH PCO2 PO2 HCO3 BE O2 sat

Results

Normal value ( 120- 170 g/l) ( .40-.54) ( 4.60-6.00 x 10 12/L ( 5.00-10.00 x 10 9/L ( .50-.70 ) ( .20-.40 ) ( .00-.05 ) ( .00-.09 )

10: 50 am

Results

Normal value

7.01 49.6 362.1 12.5 18.5 99.5

( 7.35-7.45 ) ( 35-45 mmHg ) ( 80- 100 mmHg ) ( 22- 26 meq/L ) ( ± 2 meq/L ) ( 97 % )

Multiple axial tomographic sections of the head were obtained without intravenous contrast material due to craniocerebral trauma secondary to vehicular accident. CT image reveal the following findings: 1. there is DIFFUSE CEREBRAL EDEMA with “ white cerebellum” signs for which HYPOXIC ISCHEMIC ENCEPHALOPATHY is considered. The sulci and fissure are effaced. The supracellular cisterns are likewise slightly effaced. 2.ACUTE SUBDURAL HEMATOMA is noted in the right fronto-temporo parietal convexity a widest transverse diameter of 0.7 cm. there is midline shift of 0.9 cm to the left. 3. A few small hyper dense foci are seen in the right temporal likely CORTICAL CONTUSION HEMATOMAS. 4,MINIMAL SUBARACHNOID HEMMORRHAGE is also noted. 5. A COMMINUTED FRACTURE is seen in the right temporal bone extending into the upper portion of the right mastoid. A linear fracture is also seen in the right side of the occipital bone. 6. SCALP SOFT TISSUE SWELLING AND HEMATOMA is seen in the right temporo-parietal regions. 7. VERY MINIMAL INTERSTITIAL EMPHYSEMA is seen in the right temporal extracalvarial soft tissue. NO OTHER REMARKABLE FINDING

pH PCO2 PO2 HCO3 BE O2 sat

Results 7.35 23.9 218.5 13.1 -12.4 99.4

Normal value ( 7.35-7.45 ) ( 35-45 mmHg ) ( 80- 100mmHg ) ( 22- 26 meq/L ) ( ± 2 meq/L ) ( 97 % )

Metabolic acidosis compensated Overcorrected hypoxemia @ 60% FIO2

EXAMINATION-CHEST BUCKY CHEST BUCKY-negative for fracture or subluxation in the ribs and thoracic spine No evidence of pneumothorax or pulmonary contusions. FEMUR APL/THIGH APL Right thigh APL shows complete fracture with tiny comminuted in the midshaft femur with overriding as the distal fragment slipped posterior. Hip and knee joint are intact PELVIS OR BOTH HIPS AP Pelvis AP shows no fracture or synchronal dehiscence. Sacrum and hip joints are unremarkable as well as the included upper femora. CERVICAL SPINE APL OR BOTH OBL Cervical spine APL shows no abnormal curvatures. Normal weight and contour of the vertebral bodies and disc spaces Pedicles and spinous processes are intact Prevertal soft tissue thickness is with in normal REMARKS: no remarkable finding in the cervical spine

July 08 2007 9: 58 am

Results

Normal value

Results

Normal value

Calcium

1.90

( 2.10-2.60 )

7.60

(8.40-10.40)

Potassium

4.20

( 3.50-5.50)

4.20

(3.50-5.50)

sodium

145

( 136.00145.00)

145.00

( 136.00145.00)

COMPLETE BLOOD COUNT July 08 2007 10:48am Hemoglobin Hematocrit Red blood cell White blood cell Segmenters Lymphocytes Eosinophils Monocytes Platelet

Results 114 .34 3.78 11.9 .74 .16 .09 109

Platelet: decreased RBC: Normal

Normal value ( 120- 170 g/l) ( .40-.54) ( 4.60-6.00 x 10 12/L ( 5.00-10.00 x 10 9/L ( .50-.70 ) ( .20-.40 ) ( .00-.05 ) ( .00-.09 ) ( 150-400 )

JULY 09 2007 July 092007 7:19 PM

Results

Normal value

Results

Normal value

Calcium

2.01

( 2.10-2.60 )

8.04

(8.40-10.40)

CHEST PA OR AP ( CONVENTIONAL ) CHEST PA PORTABLE: Essentially normal chest findings.Endotracheal tube in place and tip straddling the carina RIGHT FEMUR APL PORTABLE shows it is in position mold. There is complete transverse fracture in the midshaft with tiny comminutions. There is mild over riding as the distal fragment is isplace posterior. Pin across the tibia is for traction.

July 10 2007 9:53 am

Results

Normal value

Potassium

3.19

( 3.50-5.50)

July 10 2007 12:22 pm

Results

Normal Value

Sodium

164.00

( 136.00-145.00)

July 10 2007 7:19 pm

Results

Normal value

Calcium

2.01

( 2.10-2.60 )

July 10 2007

Results

Urine specific Gravity

1.010

COMPLETE BLOOD COUNT July 11 2007 9:21 am

Results

Hemoglobin Hematocrit Red blood cell White blood cell stabs Segmenters Lymphocytes Monocytes Platelet

66 .23 2.3 11.1 .04 ..64 .31 .02 129

Normal value ( 120- 170 g/l) ( .40-.54) ( 4.60-6.00 x 10 12/L ( 5.00-10.00 x 10 9/L (.03-0.05) ( .50-.70 ) ( .00-.05 ) ( .00-.09 ) ( 150-400 )

July 11 2007 7:47 am

Results

Normal value

Calcium

3.19

(3.20-5.50 mmol/L)

July 11 2007

3.21 pm

Urine specific Gravity

July 11 2007

6:25 pm

Urine specific Gravity

Results 1.010

Results 1.020

July 12 2007 9:37 am

Results

Normal value

Potassium

2.92

( 3.50-5.50)

July 12 2007 9.38 Am

Results

Normal Value

Sodium

144.6

( 136.00-145.00)

Results

Normal value

20.8

( 37.00- 53.00 g/l

July 12 2007

9:38 am

Albumin

COMPLETE BLOOD COUNT July 12 2007 10:37 am Hemoglobin Hematocrit Red blood cell White blood cell Segmenters Lymphocytes Monocytes Platelet

Results 84 .28 2.8 13.3 .72 .19 .08 146

PLATELET:DECREASED RED BLOOD CELL: NORMAL

Normal value ( 120- 170 g/l) ( .40-.54) ( 4.60-6.00 x 10 12/L ( 5.00-10.00 x 10 9/L ( .50-.70 ) ( .00-.05 ) ( .00-.09 ) ( 150-400 )

July 13 2007 8:45 am

Results

Normal Value

Sodium

134

( 136.00-145.00)

results

Normal value

6.82

( 00-00 )

July 13 2007

9:38 am

Glucose RBS

COMPLETE BLOOD COUNT July 13 2007 11:04 am Hemoglobin Hematocrit Red blood cell White blood cell Metamyelocytes Segmenters Lymphocytes Monocytes Atypical Platelet

Results 103 31 3.4 18.8 .02 .79 .16 .02 .01 156

July 13 2007

Results

Urine specific Gravity

1.010

Normal value ( 120- 170 g/l) ( .40-.54) ( 4.60-6.00 x 10 12/L ( 5.00-10.00 x 10 9/L ( .00-.01) ( .50-.70 ) ( .00-.05 ) ( .00-.09 ) (.00-.00) ( 150-400 )

July 14 2007

8:25 am

Urine specific Gravity

Results 1.005