脑外伤护理查房英文版本幻灯片课件

Nursing care of patient with TBI,Zhan Yu xin Neurosurgery Department 0109-,Definition,Traumatic Brain Injury: (外伤性脑损伤) Any external physical force traumatically injured the scalp, skull, or brain tissue,Incidence of TBI,Trauma can be classified by the affected area of the body (percentages of total incidence): Polytrauma (40%) (多发伤) Head injury (30%) Chest trauma (20%) （胸部外伤） Abdominal trauma (10%) （腹部外伤） Extremity trauma (2%) （四肢伤）,severe head injury Disability rate（致残率） Fatality rate （致死率）,Causes of TBI,CDC 2006,Anatomy and physiology review,Skull Anatomy,The skull is a rounded layer of bone designed to protect the brain from penetrating injuries,The base of the skull is rough, with many bony protuberances These ridges can result in injury to the temporal and frontal lobes of the brain during rapid acceleration,颅盖,颅底,Mater Anatomy,蛛网膜下腔,大脑皮层,硬脑膜,蛛网膜,软脑膜,Lobe Anatomy,额叶,颞叶,顶叶,枕叶,Brain Anatomy,Brain Function,Classifications of TBI,Scalp injury（头皮损伤） Skull fracture （颅骨骨折） Brain injury（脑损伤）,Type of Scalp Injury,Scalp laceration,Scalp hematoma,Scalp avulsion,Type of Skull Fracture,Linear fracture （线性骨折） Depressed fracture（凹陷性骨折） Fracture of skull vault（颅骨骨折） Fracture of skull base（颅底骨折） Closed fracture（开放性骨折） Open fracture (闭合性骨折),Fracture of Skull Base,Type of Brain Injury,Open head injury Closed head injury primary head injury secondary head injury,By mechanism,（due to the dura mater is torn or intact）,brain edema脑水肿,By development,Intracranial hematoma （颅内血肿）,concussion(脑震荡),Contusion(脑挫裂伤),By severity,mild brain injury,Severe brain injury,moderate brain injury,Type of Intracranial Hematoma,Extradural hematoma （硬膜外血肿） Subdural hematoma （硬膜下血肿） Intracerebral hematoma （脑内血肿）,Symptoms of Brain Injury,Increased intracranial pressure（颅内高压）、cerebral herniation（脑疝） Loss of consciousness（意识丧失） Headache、 nausea and vomiting、 accompany with the changes of vital signs（头痛、恶心呕吐、生命体征改变） Change of pupils（瞳孔变化） Local neurological symptoms（局灶症状）: e.g. aphasia（失语）、paralysis（瘫痪）、 motor and sensor dysfunction（运动感觉功能障碍）、 mood changes（情绪变化）,Intracranial Pressure（颅内压）,Increased Intracranial Pressure,Early time P R BP later time P R or R irregular 或arrest, BP，T,颅内高压： Cushings 反应： 血压增高 心率缓慢 呼吸变慢或不规则，甚 至暂停,Increased Intracranial Pressure,剧烈头痛,喷射性呕吐,视神经 乳头水肿,Etiology and Pathophysiology of Intracranial Hypertension,颅腔占位性 病变,脑组织增加,脑血流量增加,脑脊液增加,Cerebral Herniation,Assisted Examinations,CT of head Investigation of choice Considerable debate about who should be scanned MRI Blood tests Chest x-ray Lumber puncture(腰穿),Medical,Surgical,Nursing care of TBI,Nil,Glasgow Coma Scale,Case report 1,Name: Tim Sex: male Age: 17 Date: 2011-10-12 6pm Medical history: While riding a bicycle without a helmet on a busy street and was struck by a car Assisted examination: CT identified a brain contusion and left intracerebral hemorrhage Diagnosis: TBI,Vital signs: T: 36.5, P: 65 /min, R: 28/min, BP: 135/86 mmHg He was found semiconscious by emergency rescue personnel and transported to hospital. On arrival, the patient responded only to deep pain, was unable to follow commands. Pupils were unequal and nonreactive bilaterally. His breath was irregular and had difficulty in breathing. His Glasgow Coma Scale (GCS) score was 8 He was prepared to be operated through Craniotomy at 7pm immediately,Case report 1,Altered level of consciousness related to primary brain injury (意识改变) Ineffective tissue perfusion related to disruption in cerebral （组织灌注不足） blood flow Ineffective breathing pattern related to neurological （无效型呼吸形态） impairment of respiratory Potential complications cerebral herniation （潜在并发症）,Preoperative nursing diagnosis,Case report 2,10-12 11:30pm: operation was finished and Tim was sent to NICU with tracheal intubation and a drainage tube, and he was semicomatose and the pupils were 2.5 mm, and were equal and have reactions to light; vital signs were stable, the muscle strength of right limbs was grade 0 10-13 6am: still unconscious with tracheal intubation, his temperature was 38.8oC and was normal through physical methods 10-14 8am: level of consciousness was better, had reactions to verbal commands, and the tracheal intubation and drainage tube were pull out; his right limbs were unable to move 10-15 4pm: he complained the bad headache and vomiting, and was relieved after taking medications of mannitol and lasix 10-16 to 10-25: he had medications and rehabilitation exercise daily, his right limbs were able to move slightly 10-26 10am: Tim was discharged from the ward,Postoperative nursing diagnosis,Altered level of consciousness related to increased intracranial （意识改变） pressure resulting from brain injury Pain (headache) related to increased intracranial （疼痛） （头痛） pressure Ineffective tissue perfusion related to disruption in cerebral （组织灌注不足） blood flow Hyperthermia related to operation of absorption （高热） heat or central regulation of body temperature disorders,Potential complications,Cerebral herniation （脑疝） Risk for stress ulcers （应激性溃疡的危险） Risks for infection （感染的危险） Seizure disorder （癫痫） Impaired physical mobility（躯体活动障碍）,Altered nutrition （营养失调） Self care deficit (生活自理能力缺陷) Risk for impaired skin integrity （皮肤完整性受损的危险） Self-esteem disturbance （自我形象紊乱） Anxiety（焦虑）,Altered level of consciousness,Bed rest and safety （休息与安全护理） Keep airway patent （保持呼吸道通畅） Maintain personal hygiene （基础护理） Promote adequate nutrition, keep fluid and electrolyte balance （营养护理）,Promote elimination （大小便通畅） Maintain skin integrity （皮肤护理） Promote rehabilitation to maximal functioning （康复锻炼） Monitor and record clinical status to prevent complications （病情监测与记录）,Ineffective tissue perfusion,Assess neurological status of clients every 15 to 60 minutes（评估病情） Administer oxygen（给氧吸入） Position client with head of the head up 30 degree （抬高床头30度） Minimize physical activity to prevent increasing metabolic demands（急性期减少活动）,Ineffective breathing pattern,Assess respiratory status frequently(评估呼吸) Keep airway patent and administer oxygen (保持气道通畅和给氧) Continually assess and record the patterns of respiratory（动态监测并记录呼吸形态） If the breath arrest, rescue immediately (呼吸骤停时立即抢救),Pain,Assess and analyze the cause of pain （评估和分析疼痛程度与原因） Monitor the vital signs and other neurological symptoms (同时观察生命体征与其他症状) Psychological care（心理护理） Choose physical methods