Weight / severity of injury depends on:1. Area affected:Skin injury.Bone tissue injury.Brain tissue injury.2. The state's head during impact.The main problem is the increase in intracranial pressure (PTIK)
ICT maintained by 3 components:1. The volume of blood / blood vessels (75-150 ml).2. Brain Network Volume (. 1200 to 1400 ml).3. CSF volume (75-150 ml).
B. Etiology
1. Accident2. Fall3. The trauma of childbirth.
Biological Response
Symptoms:1. If the client is aware ----- headache.2. Gag4. Awareness decline.5. Change the type of consciousness.6. Decreased blood pressure, bradycardia.7. isokor8. Body temperature that is difficult to control.
Type of head trauma:1. Open head trauma.2. Closed head trauma.
Open head trauma:Brain damage can occur when the skull into the brain tissue and hurt / ripped dura
Closed Head Trauma:
1. Komosio2. Kontosio.3. Epidural hematoma.4. Subdural hematoma.5. Intracranial hematoma.
Komosio / concussion:Mild head injuryTemporary neurologic dysfunction and can recover.Temporary loss of consciousness, less than 10-20 minutes.Without permanent brain damage.Symptoms of headache, dizziness, vomiting.control 24 hours I, observation of vital signs.There is no specific therapy.Absolute break ---- after missing complaint try mobilization stages, sitting --- stand - home.Once home ---- control, appropriate activity, adequate rest, diet enough.
Kontosio Cerebri / bruising of the brain:
There was bruising of the brain.Bleeding local small / diffuse ---- Local --- bleeding disorders.Symptoms:- Disorders of consciousness longer.- Neurologic Abnormalities positive, positive pathologic reflexes, paralysis, convulsions.- Symptoms of ICT increases.
Epidural hematoma:Anatara bleeding skull and dura mater.What common temporal and frontal.Sources: meningeal blood vessels rupture.Subdural hematoma:Bleeding between the dura and arachnoid.Usually ruptured vein --- acute, sub-acute, chronic.Acute:- Symptoms 24-48 hours.- Often associated circuitry brain injury and medulla oblongata.- ICT increases.- Headache, drowsiness, slowed reflexes, confusion, slow pupillary reflexes.
Sub Acute:- Evolving 7-10 days, kontosio bit heavy, the increased ICT gejal --- decreased consciousness.
Chronic:- Lightweight, 2 weeks - 3-4 months.- Bleeding into small pieces and spread slowly gathered.- Symptoms of headache, lethargy, mental mess, seizures, dysphagia.
Intracranial hematomas:Intracerebral hemorrhage ± 25 cc or more.Always followed by kontosio.The cause, a blood clot, local edema.
Effect of Head Trauma
Respiratory SystemCardiovascular system..
Respiratory System:
Hypoxemia, hypercapnia Increases Sympathetic stimulationImproved diffusion barriers O2 - Co2.Improve Pulmonary Edema vask prisoners. and systemic blood tekImprove tek, hydrostaticCapillary fluid leakageTek pulmonary vascular system. lower.Because of the direct compression on the brain stem respiratory symptoms ---- abnormal:Chyne stokes.Hyperventilation.Apneu.
Cardiovascular system:Trauma to the head --- changes in the function of the heart: contraction, pulmonary edema, tek. Vascular.Otonoom neural changes in ventricular function:- Dysrhythmias.- Fibrillation.- Tachycardia.The absence of endogenous sympathetic stimulus --- a decline in ventricular contractility. ---- --- Boost cardiac arrest decreased left ventricular --- pulmonary edema.
Assessment
The collection of patient data either subjective or objective in relation to system disturbances persyarafan head trauma is as follows:1. The identity of the patient and family (person in charge)
2. Medical History:In general, patients with head injury, came to the hospital with a decreased level of consciousness (GCS below 15), confusion, vomiting, dyspnea / tachypnea, headache,, weakly, paralise, head injuries, spuntum accumulation in the respiratory tract, the liquor from the nose and ears, and the presence of seizures.
Medical history first:It should be well known to the system associated neural circuitry system and other systemic diseases. Similarly, a family history of disease, especially those having a contagious disease. Health history can be assessed from the patient or the family as a data subjective. These data are very significant because it can affect pronosa patients.
3. Physical Examination:Neurological aspects:Studied is the level of consciousness, usually GCS less than 15, disorentasi person / place and time, a positive Babinski reflex, changes in the value of vital signs, the movement decebrasi or decortication and possible neck stiffness obtained with positive Brudzinski. The existence hemiparese.In conscious patients, it can not distinguish between different stimuli / stimulus taste, touch, temperature and vibration. Occurs involuntary movements, seizures due to impaired coordination. Patients also can not remember the events before and sesuadah trauma. Balance disorders in which the patient is awake, it can be seen or not be mempertahankana unsteady balance.
Cranial nerve may be disrupted if the head trauma to the brain stem due to widespread brain edema or brain hemorrhage.
Damage to nerve I (olfactory): showed symptoms of decreased sense of smell and bilateral anosmia. Nerve II (optic), the frontal trauma, show symptoms of decreased visual symptoms.Nerve III (Okulomotorius)
Nerve IV (Trokhlearis)Nerve VI (abducens), the damage will cause a decrease in visual field, light reflex, decreased, changes in pupil size, eye can not follow orders, anisokor.Nerve V (trigeminal), disorders characterized; any anesthetic forehead area.
Nerve VII (facial), in which the trauma capitis upper motor neuron can unilaterally decrease its function, the absence of nasolabial folds, eyelid closure weakness and loss of feeling on the 2/3 parts of the tongue anterior tongue.Nerve VIII (acoustic), in patients with symptoms of lower realized power of hearing and balance the body.
Nerve IX (Glosofaringeus).
Nerve X (vagus)
Nerve XI (Assesorius), symptoms are rarely found because the patient will die if the trauma of the nerve. The existence Hiccuping (basin) due to compression of the vagus nerve, which causes compression of the diaphragm and spasmodic. This occurs due to compression of the brain stem. Basin that occurs, it is usually at risk of increased intracranial pressure.Nerve XII (hipoglosus), common symptoms arise, is the fall of the tongue to one side, dysphagia and dysarthria. This causes a difficulty in swallowing.
Cardiovascular aspects:Learned changes in blood pressure decreases, unless an increase in the intracranial blood pressure increased, bradycardia pulse, then takhikardia, or irregular rhythm. In addition to other assessments collected are bleeding or discharge from the mouth, nose, ears, eyes. Hipereskresi presence in the oral cavity. Open bleeding / hematoma on other body parts. This needs assessment from head to toe.
Aspects of the respiratory system:Changes in breathing pattern, good rhythm, depth and frequency that is fast and shallow, irregular rhythm (chyne stokes, ataxia brething), ronchi breath sounds, wheezing. The presence of secretions in the tracheo brokhiolus. Increased body temperature can occur because of infection or stimulation of the hypothalamus as a central regulator of body temperature.Aspects elimination system:Will get the retention / incontinence in small or large bowel. There is a fluid and electrolyte imbalance, where there hyponatremia or hypokalemia. In the gastro-intestinal system is necessary to study the signs of decreased function of the gastrointestinal tract such as bowel sounds were not audible / weak, the nausea and vomiting. This is the basis for the provision of food.
Glasgow Coma Scale:I. Eye-Opening Reaction.4. Open your eyes spontaneously.3. Open your eyes when invoked / sound stimuli.2. Open your eyes when stimulated pain.1.Tidak reaction to any stimulus.
II. Speaking Reaction4. Good verbal communication, the right answer.3. Confused, disorentasi time, place and person.2. With the stimulus, the reaction is not just a word to form a sentence.III. Movement Reaction Arm / Leg6. Following orders.5. With pain stimuli can find out where the stimulus.4. With the stimulus of pain, pulling limbs.3. With painful stimuli, a reaction abnormal flexion.2. With the stimulus of pain, abnormal extension reactions arise.1. With painful stimuli, no reaction
4. Psychological Assessment:Where patients circuitry decreased level of consciousness, the psychological to the data can not be assessed, whereas in patients with normal levels of consciousness would look somewhat emotional disturbance, changes in behavior, emotions are unstable, irritable, apathy, delirium, and confusion for the patient's family anxiety connection with the illness.Social data that is needed is how psien dealing with people nearby and the other, the ability to communicate and their role in the family. As well as a patient's view of him after suffering head trauma and a sense of security.
5. Data spiritual:Required is adherence to the religion, the spirit and philosophy of life of patients and the deity he believes. Of course, the data collected in the absence of loss of consciousness.
6. Diagnostic Examination:Diagnostic tests performed in medical diagnosis is:X-Ray skull.CT-Scan.Angiography.
7. The Medical Management of Head Trauma:Drugs:Dexamethason / kalmethason: anti cerebral edema, in accordance with a heavy dose ringanya trauma.Hyperventilation therapy (severe head trauma), for mengurnagi vasodilation.Anti-edema treatment circuitry that hypertonic solutions of mannitol 20% or 40% glucose or 10% glycerol.Antibiotics containing the blood brain barrier (penicillin) or to be given metronidasol anaerobic infections.Food or liquid, the mild trauma when vomiting can not be given anything, only 5% dextrose intravenous fluids, aminofusin, aminofel (18 first hours of the accident), 2-3 days later given soft food.In severe trauma. Since the first days of the patient obtained decreased consciousness and tend to occur retention of sodium and electrolytes the first few days (2-3 days) is not too much fluid
Priority Nursing Diagnosis:1. Impaired brain tissue perfusion associated with circulatory disorders because the emphasis of the lesions (hemorrhage, hematoma).2. Potential or actual ineffectiveness breathing pattern, associated with damage to the respiratory centers in the medulla oblongata.3. Potential occurrence of increased intracranial pressure associated with the process of prodded space due to accumulation of blood in the brain fluid.4. Fluid and electrolyte balance disorders associated circuitry decreased production of anti-diuretic hormone (ADH) from the hypothalamus terfiksasinya.5. Actual / Potential disruption kebutuhannutrisi: Less than the needs associated with reduced ability to receive nutrients by decreasing awareness.6. Impaired physical mobilization associated with immobilization, bed rest rules for therapy.7. Disorders associated with decreased sensory perception sensory arrest power.8. Potential occurrence of infection associated circuitry entry of germs through the damaged tissue or continuity.9. Impaired sense of comfort: Headache berhubunagn circuitry damage brain tissue and brain hemorrhage / increased intracranial pressure.10. Impaired sense of security: Worried family of uncertainty associated with the treatment and care as well as a change and crisis situations.
Intervention:1. Examine the causes of the situation / circumstances of the individual / cause coma / decreased tissue perfusion and possible causes of increased ICP.R / Early detection for prioritizing interventions, assess neurologic status / signs of failure to determine the severity of treatment or surgery.2. Monitor and record GCS.R / Analyzing the level of awareness and the possibility of increased ICP and determine the location of the lesion.3. Monitor vital signs.R / A kedaan normal when the cerebral circulation is well maintained or marked fluctuations in systemic blood pressure, a decrease of outoregulator mostly a sign of lowering the diffusion of local cerebral blood vascularization. With the increase in blood pressure (diatolik) then coupled with increased intra-cranial blood pressure. Hipovolumik / hypotension is a manifestation of multiple trauma can cause cerebral ischemia. HR and disrhytmia an outgrowth of the brain stem disorders.4. Evaluation pupil.R / pupil reactions and eye movements of the back is a sign of impaired nerve / brainstem neuronal if torn. The balance between the sympathetic and parasympathetic nerves are cranial nerve reflex responses.5. Assess vision, memory, eye movements and Babinski reflex reaction.R / possibility of injury to the brain or brain stem. The decrease reflex sight is a sign of trauma pons and medulla. Coughing is a reflex of the notch and the disturbance medulla.Adanya Babinski reflex indications of brain injury in pyramidal.6. Monitor the temperature and temperature regulation.R / Summer is a reflex of the hypothalamus. Increased metabolic needs and O2 will support increased ICP.7. Monitor intake and output: my skin turgor, mucous membranes keadaa.R / Indication of impaired tissue perfusion head trauma can cause diabetes insipedus or syndroma increased secretion of ADH.8. Keep the head / neck in a neutral position, try a little circuitry pillow. Avoid using a lot of cushion on the head.R / Navigate datu head to one side of the jugular veins and impede cerebral venous drainage and increased ICP.9. Provide rest periods anatara care measures and limit the length of the procedure.R. Actions that can constantly improve ICP by cumulative effects of stimulation.10. Reduce Extra stimulation and provide a sense of comfort such as back massage, a quiet, friendly touch and atmosphere / talks were not rowdy.R / Giving atmosphere tenag (colming effect) can reduce psychological response and provide a break to maintain / low ICP.11. Help the patient when coughing, vomiting.R / activity may increase intra thoracic / pressure in the piston and pressure in the abdomen where it can increase pressure akitivitas ICP.12. Assess behavior enhancement and rest in the morning.R / non-verbal behavior is an indication of increased ICP dpat or give pain reflex in which the patient is unable to express verbally complaints, pain does not decrease to Increasing ICP.13. Palpation of the enlargement / widening blader, maintain a patent urinary drainage when used and also monitors the presence of constipation.R / May increase potential automatic response raised ICP.Collaboration:14. Raise the head of the bed / bed 15-45 degrees according to tolenransi / indication.R / Improved drainage / venous outflow from the head, reducing congestion and cerebral edema / risk of ICP.15. Give intravenous fluids according to the dindikasikan.R / Fluid may be desirable to menguransi cerebral edema, an increase in the minimum of the blood vessels, blood pressure and ICP.16. Give Oxygen.R / Reduce hipoxemia, which can increase cerebral vasodilation and increase blood volume and ICP.17. Give Diuretic drugs eg mannitol, furoscide.R / Diuretics may be used in acute pase to drain water from brain cells, and reduces cerebral edema and ICP.18. Steroids give an example: Dextamethason, methyl prednisolone.R / To reduce inflammation (inflammation) and reduces tissue edema.19. Give an example of high-dose painkillers: codeine.R / It may be indicated to reduce pain and drug negative effect on ICP but can be used with the cause to prevent.20. Sedatives Give examples: Benadryl.R / may be used to control the lack of rest and agitation.21. Give antipyretics, for example: aseptaminophen.R / Reduce / control day and on cerebral metabolism / oxygen is desired.
REFERENCES
Carpenito, L.P. (1999). Nursing Care Plans and Documentation, Nursing Diagnosis and Collaborative Problems. Ed.2. Jakarta: EGC.
Hospital Nursing Committee Dr. Soedono Madison. (1999). In the case of Head Trauma Management. Papers Kegawat daruratan in the surgical field. Not published.
Long, B.C. (1996). Medical Surgical Nursing (A Process Approach Kperawatan). New York: Foundation for Nursing Education Alumni Association Bandung.
Papers Lectures Medical Surgical PSIK Unair Surabaya. Not Published
Reksoprodjo, S. et al. (1995). Lecture set of Surgery. Jakarta: Bina Literacy way.
Rothrock, J.C. (1999). Perioperative Nursing Care Planning. Jakarta: EGC.
Tucker, B.C. (1998). Standard Care: Nursing Process, Diagnosis and Evaluation. Ed. 1. Jakarta: ECG.Posted by gayuh at 11:56
NURSING CARE TO CLIENTS HEAD TRAUMA
Weight / severity of injury depends on:
1. Area affected:Skin injury.Bone tissue injury.Brain tissue injury.2. The state's head during impact.The main problem is the increase in intracranial pressure (PTIK)
ICT maintained by 3 components:1. The volume of blood / blood vessels (75-150 ml).2. Brain Network Volume (. 1200 to 1400 ml).3. CSF volume (75-150 ml).
B. Etiology
1. Accident2. Fall3. The trauma of childbirth.
Biological Response
Symptoms:1. If the client is aware ----- headache.2. Gag4. Awareness decline.5. Change the type of consciousness.6. Decreased blood pressure, bradycardia.7. isokor8. Body temperature that is difficult to control.
Type of head trauma:1. Open head trauma.2. Closed head trauma.
Open head trauma:Brain damage can occur when the skull into the brain tissue and hurt / ripped dura
Closed Head Trauma:
1. Komosio2. Kontosio.3. Epidural hematoma.4. Subdural hematoma.5. Intracranial hematoma.
Komosio / concussion:Mild head injuryTemporary neurologic dysfunction and can recover.Temporary loss of consciousness, less than 10-20 minutes.Without permanent brain damage.Symptoms of headache, dizziness, vomiting.control 24 hours I, observation of vital signs.There is no specific therapy.Absolute break ---- after missing complaint try mobilization stages, sitting --- stand - home.Once home ---- control, appropriate activity, adequate rest, diet enough.
Kontosio Cerebri / bruising of the brain:
There was bruising of the brain.Bleeding local small / diffuse ---- Local --- bleeding disorders.Symptoms:- Disorders of consciousness longer.- Neurologic Abnormalities positive, positive pathologic reflexes, paralysis, convulsions.- Symptoms of ICT increases.
Epidural hematoma:Anatara bleeding skull and dura mater.What common temporal and frontal.Sources: meningeal blood vessels rupture.Subdural hematoma:Bleeding between the dura and arachnoid.Usually ruptured vein --- acute, sub-acute, chronic.Acute:- Symptoms 24-48 hours.- Often associated circuitry brain injury and medulla oblongata.- ICT increases.- Headache, drowsiness, slowed reflexes, confusion, slow pupillary reflexes.
Sub Acute:- Evolving 7-10 days, kontosio bit heavy, the increased ICT gejal --- decreased consciousness.
Chronic:- Lightweight, 2 weeks - 3-4 months.- Bleeding into small pieces and spread slowly gathered.- Symptoms of headache, lethargy, mental mess, seizures, dysphagia.
Intracranial hematomas:Intracerebral hemorrhage ± 25 cc or more.Always followed by kontosio.The cause, a blood clot, local edema.
Effect of Head Trauma
Respiratory SystemCardiovascular system..
Respiratory System:
Hypoxemia, hypercapnia Increases Sympathetic stimulationImproved diffusion barriers O2 - Co2.Improve Pulmonary Edema vask prisoners. and systemic blood tekImprove tek, hydrostaticCapillary fluid leakageTek pulmonary vascular system. lower.Because of the direct compression on the brain stem respiratory symptoms ---- abnormal:Chyne stokes.Hyperventilation.Apneu.
Cardiovascular system:Trauma to the head --- changes in the function of the heart: contraction, pulmonary edema, tek. Vascular.Otonoom neural changes in ventricular function:- Dysrhythmias.- Fibrillation.- Tachycardia.The absence of endogenous sympathetic stimulus --- a decline in ventricular contractility. ---- --- Boost cardiac arrest decreased left ventricular --- pulmonary edema.
Assessment
The collection of patient data either subjective or objective in relation to system disturbances persyarafan head trauma is as follows:1. The identity of the patient and family (person in charge)
2. Medical History:In general, patients with head injury, came to the hospital with a decreased level of consciousness (GCS below 15), confusion, vomiting, dyspnea / tachypnea, headache,, weakly, paralise, head injuries, spuntum accumulation in the respiratory tract, the liquor from the nose and ears, and the presence of seizures.
Medical history first:It should be well known to the system associated neural circuitry system and other systemic diseases. Similarly, a family history of disease, especially those having a contagious disease. Health history can be assessed from the patient or the family as a data subjective. These data are very significant because it can affect pronosa patients.
3. Physical Examination:Neurological aspects:Studied is the level of consciousness, usually GCS less than 15, disorentasi person / place and time, a positive Babinski reflex, changes in the value of vital signs, the movement decebrasi or decortication and possible neck stiffness obtained with positive Brudzinski. The existence hemiparese.In conscious patients, it can not distinguish between different stimuli / stimulus taste, touch, temperature and vibration. Occurs involuntary movements, seizures due to impaired coordination. Patients also can not remember the events before and sesuadah trauma. Balance disorders in which the patient is awake, it can be seen or not be mempertahankana unsteady balance.
Cranial nerve may be disrupted if the head trauma to the brain stem due to widespread brain edema or brain hemorrhage.
Damage to nerve I (olfactory): showed symptoms of decreased sense of smell and bilateral anosmia. Nerve II (optic), the frontal trauma, show symptoms of decreased visual symptoms.Nerve III (Okulomotorius)
Nerve IV (Trokhlearis)Nerve VI (abducens), the damage will cause a decrease in visual field, light reflex, decreased, changes in pupil size, eye can not follow orders, anisokor.Nerve V (trigeminal), disorders characterized; any anesthetic forehead area.
Nerve VII (facial), in which the trauma capitis upper motor neuron can unilaterally decrease its function, the absence of nasolabial folds, eyelid closure weakness and loss of feeling on the 2/3 parts of the tongue anterior tongue.Nerve VIII (acoustic), in patients with symptoms of lower realized power of hearing and balance the body.
Nerve IX (Glosofaringeus).
Nerve X (vagus)
Nerve XI (Assesorius), symptoms are rarely found because the patient will die if the trauma of the nerve. The existence Hiccuping (basin) due to compression of the vagus nerve, which causes compression of the diaphragm and spasmodic. This occurs due to compression of the brain stem. Basin that occurs, it is usually at risk of increased intracranial pressure.Nerve XII (hipoglosus), common symptoms arise, is the fall of the tongue to one side, dysphagia and dysarthria. This causes a difficulty in swallowing.
Cardiovascular aspects:Learned changes in blood pressure decreases, unless an increase in the intracranial blood pressure increased, bradycardia pulse, then takhikardia, or irregular rhythm. In addition to other assessments collected are bleeding or discharge from the mouth, nose, ears, eyes. Hipereskresi presence in the oral cavity. Open bleeding / hematoma on other body parts. This needs assessment from head to toe.
Aspects of the respiratory system:Changes in breathing pattern, good rhythm, depth and frequency that is fast and shallow, irregular rhythm (chyne stokes, ataxia brething), ronchi breath sounds, wheezing. The presence of secretions in the tracheo brokhiolus. Increased body temperature can occur because of infection or stimulation of the hypothalamus as a central regulator of body temperature.Aspects elimination system:Will get the retention / incontinence in small or large bowel. There is a fluid and electrolyte imbalance, where there hyponatremia or hypokalemia. In the gastro-intestinal system is necessary to study the signs of decreased function of the gastrointestinal tract such as bowel sounds were not audible / weak, the nausea and vomiting. This is the basis for the provision of food.
Glasgow Coma Scale:I. Eye-Opening Reaction.4. Open your eyes spontaneously.3. Open your eyes when invoked / sound stimuli.2. Open your eyes when stimulated pain.1.Tidak reaction to any stimulus.
II. Speaking Reaction4. Good verbal communication, the right answer.3. Confused, disorentasi time, place and person.2. With the stimulus, the reaction is not just a word to form a sentence.III. Movement Reaction Arm / Leg6. Following orders.5. With pain stimuli can find out where the stimulus.4. With the stimulus of pain, pulling limbs.3. With painful stimuli, a reaction abnormal flexion.2. With the stimulus of pain, abnormal extension reactions arise.1. With painful stimuli, no reaction
4. Psychological Assessment:Where patients circuitry decreased level of consciousness, the psychological to the data can not be assessed, whereas in patients with normal levels of consciousness would look somewhat emotional disturbance, changes in behavior, emotions are unstable, irritable, apathy, delirium, and confusion for the patient's family anxiety connection with the illness.Social data that is needed is how psien dealing with people nearby and the other, the ability to communicate and their role in the family. As well as a patient's view of him after suffering head trauma and a sense of security.
5. Data spiritual:Required is adherence to the religion, the spirit and philosophy of life of patients and the deity he believes. Of course, the data collected in the absence of loss of consciousness.
6. Diagnostic Examination:Diagnostic tests performed in medical diagnosis is:X-Ray skull.CT-Scan.Angiography.
7. The Medical Management of Head Trauma:Drugs:Dexamethason / kalmethason: anti cerebral edema, in accordance with a heavy dose ringanya trauma.Hyperventilation therapy (severe head trauma), for mengurnagi vasodilation.Anti-edema treatment circuitry that hypertonic solutions of mannitol 20% or 40% glucose or 10% glycerol.Antibiotics containing the blood brain barrier (penicillin) or to be given metronidasol anaerobic infections.Food or liquid, the mild trauma when vomiting can not be given anything, only 5% dextrose intravenous fluids, aminofusin, aminofel (18 first hours of the accident), 2-3 days later given soft food.In severe trauma. Since the first days of the patient obtained decreased consciousness and tend to occur retention of sodium and electrolytes the first few days (2-3 days) is not too much fluid
Priority Nursing Diagnosis:1. Impaired brain tissue perfusion associated with circulatory disorders because the emphasis of the lesions (hemorrhage, hematoma).2. Potential or actual ineffectiveness breathing pattern, associated with damage to the respiratory centers in the medulla oblongata.3. Potential occurrence of increased intracranial pressure associated with the process of prodded space due to accumulation of blood in the brain fluid.4. Fluid and electrolyte balance disorders associated circuitry decreased production of anti-diuretic hormone (ADH) from the hypothalamus terfiksasinya.5. Actual / Potential disruption kebutuhannutrisi: Less than the needs associated with reduced ability to receive nutrients by decreasing awareness.6. Impaired physical mobilization associated with immobilization, bed rest rules for therapy.7. Disorders associated with decreased sensory perception sensory arrest power.8. Potential occurrence of infection associated circuitry entry of germs through the damaged tissue or continuity.9. Impaired sense of comfort: Headache berhubunagn circuitry damage brain tissue and brain hemorrhage / increased intracranial pressure.10. Impaired sense of security: Worried family of uncertainty associated with the treatment and care as well as a change and crisis situations.
Intervention:1. Examine the causes of the situation / circumstances of the individual / cause coma / decreased tissue perfusion and possible causes of increased ICP.R / Early detection for prioritizing interventions, assess neurologic status / signs of failure to determine the severity of treatment or surgery.2. Monitor and record GCS.R / Analyzing the level of awareness and the possibility of increased ICP and determine the location of the lesion.3. Monitor vital signs.R / A kedaan normal when the cerebral circulation is well maintained or marked fluctuations in systemic blood pressure, a decrease of outoregulator mostly a sign of lowering the diffusion of local cerebral blood vascularization. With the increase in blood pressure (diatolik) then coupled with increased intra-cranial blood pressure. Hipovolumik / hypotension is a manifestation of multiple trauma can cause cerebral ischemia. HR and disrhytmia an outgrowth of the brain stem disorders.4. Evaluation pupil.R / pupil reactions and eye movements of the back is a sign of impaired nerve / brainstem neuronal if torn. The balance between the sympathetic and parasympathetic nerves are cranial nerve reflex responses.5. Assess vision, memory, eye movements and Babinski reflex reaction.R / possibility of injury to the brain or brain stem. The decrease reflex sight is a sign of trauma pons and medulla. Coughing is a reflex of the notch and the disturbance medulla.Adanya Babinski reflex indications of brain injury in pyramidal.6. Monitor the temperature and temperature regulation.R / Summer is a reflex of the hypothalamus. Increased metabolic needs and O2 will support increased ICP.7. Monitor intake and output: my skin turgor, mucous membranes keadaa.R / Indication of impaired tissue perfusion head trauma can cause diabetes insipedus or syndroma increased secretion of ADH.8. Keep the head / neck in a neutral position, try a little circuitry pillow. Avoid using a lot of cushion on the head.R / Navigate datu head to one side of the jugular veins and impede cerebral venous drainage and increased ICP.9. Provide rest periods anatara care measures and limit the length of the procedure.R. Actions that can constantly improve ICP by cumulative effects of stimulation.10. Reduce Extra stimulation and provide a sense of comfort such as back massage, a quiet, friendly touch and atmosphere / talks were not rowdy.R / Giving atmosphere tenag (colming effect) can reduce psychological response and provide a break to maintain / low ICP.11. Help the patient when coughing, vomiting.R / activity may increase intra thoracic / pressure in the piston and pressure in the abdomen where it can increase pressure akitivitas ICP.12. Assess behavior enhancement and rest in the morning.R / non-verbal behavior is an indication of increased ICP dpat or give pain reflex in which the patient is unable to express verbally complaints, pain does not decrease to Increasing ICP.13. Palpation of the enlargement / widening blader, maintain a patent urinary drainage when used and also monitors the presence of constipation.R / May increase potential automatic response raised ICP.Collaboration:14. Raise the head of the bed / bed 15-45 degrees according to tolenransi / indication.R / Improved drainage / venous outflow from the head, reducing congestion and cerebral edema / risk of ICP.15. Give intravenous fluids according to the dindikasikan.R / Fluid may be desirable to menguransi cerebral edema, an increase in the minimum of the blood vessels, blood pressure and ICP.16. Give Oxygen.R / Reduce hipoxemia, which can increase cerebral vasodilation and increase blood volume and ICP.17. Give Diuretic drugs eg mannitol, furoscide.R / Diuretics may be used in acute pase to drain water from brain cells, and reduces cerebral edema and ICP.18. Steroids give an example: Dextamethason, methyl prednisolone.R / To reduce inflammation (inflammation) and reduces tissue edema.19. Give an example of high-dose painkillers: codeine.R / It may be indicated to reduce pain and drug negative effect on ICP but can be used with the cause to prevent.20. Sedatives Give examples: Benadryl.R / may be used to control the lack of rest and agitation.21. Give antipyretics, for example: aseptaminophen.R / Reduce / control day and on cerebral metabolism / oxygen is desired.
REFERENCES
Carpenito, L.P. (1999). Nursing Care Plans and Documentation, Nursing Diagnosis and Collaborative Problems. Ed.2. Jakarta: EGC.
Hospital Nursing Committee Dr. Soedono Madison. (1999). In the case of Head Trauma Management. Papers Kegawat daruratan in the surgical field. Not published.
Long, B.C. (1996). Medical Surgical Nursing (A Process Approach Kperawatan). New York: Foundation for Nursing Education Alumni Association Bandung.
Papers Lectures Medical Surgical PSIK Unair Surabaya. Not Published
Reksoprodjo, S. et al. (1995). Lecture set of Surgery. Jakarta: Bina Literacy way.
Rothrock, J.C. (1999). Perioperative Nursing Care Planning. Jakarta: EGC.
Tucker, B.C. (1998). Standard Care: Nursing Process, Diagnosis and Evaluation. Ed. 1. Jakarta: ECG.Posted by gayuh at 11:56 NURSING CARE TO CLIENTS HEAD TRAUMA
Weight / severity of injury depends on:
1. Area affected:Skin injury.Bone tissue injury.Brain tissue injury.2. The state's head during impact.The main problem is the increase in intracranial pressure (PTIK)
ICT maintained by 3 components:1. The volume of blood / blood vessels (75-150 ml).2. Brain Network Volume (. 1200 to 1400 ml).3. CSF volume (75-150 ml).
B. Etiology
1. Accident2. Fall3. The trauma of childbirth.
Biological Response
Symptoms:1. If the client is aware ----- headache.2. Gag4. Awareness decline.5. Change the type of consciousness.6. Decreased blood pressure, bradycardia.7. isokor8. Body temperature that is difficult to control.
Type of head trauma:1. Open head trauma.2. Closed head trauma.
Open head trauma:Brain damage can occur when the skull into the brain tissue and hurt / ripped dura
Closed Head Trauma:
1. Komosio2. Kontosio.3. Epidural hematoma.4. Subdural hematoma.5. Intracranial hematoma.
Komosio / concussion:Mild head injuryTemporary neurologic dysfunction and can recover.Temporary loss of consciousness, less than 10-20 minutes.Without permanent brain damage.Symptoms of headache, dizziness, vomiting.control 24 hours I, observation of vital signs.There is no specific therapy.Absolute break ---- after missing complaint try mobilization stages, sitting --- stand - home.Once home ---- control, appropriate activity, adequate rest, diet enough.
Kontosio Cerebri / bruising of the brain:
There was bruising of the brain.Bleeding local small / diffuse ---- Local --- bleeding disorders.Symptoms:- Disorders of consciousness longer.- Neurologic Abnormalities positive, positive pathologic reflexes, paralysis, convulsions.- Symptoms of ICT increases.
Epidural hematoma:Anatara bleeding skull and dura mater.What common temporal and frontal.Sources: meningeal blood vessels rupture.Subdural hematoma:Bleeding between the dura and arachnoid.Usually ruptured vein --- acute, sub-acute, chronic.Acute:- Symptoms 24-48 hours.- Often associated circuitry brain injury and medulla oblongata.- ICT increases.- Headache, drowsiness, slowed reflexes, confusion, slow pupillary reflexes.
Sub Acute:- Evolving 7-10 days, kontosio bit heavy, the increased ICT gejal --- decreased consciousness.
Chronic:- Lightweight, 2 weeks - 3-4 months.- Bleeding into small pieces and spread slowly gathered.- Symptoms of headache, lethargy, mental mess, seizures, dysphagia.
Intracranial hematomas:Intracerebral hemorrhage ± 25 cc or more.Always followed by kontosio.The cause, a blood clot, local edema.
Effect of Head Trauma
Respiratory SystemCardiovascular system..
Respiratory System:
Hypoxemia, hypercapnia Increases Sympathetic stimulationImproved diffusion barriers O2 - Co2.Improve Pulmonary Edema vask prisoners. and systemic blood tekImprove tek, hydrostaticCapillary fluid leakageTek pulmonary vascular system. lower.Because of the direct compression on the brain stem respiratory symptoms ---- abnormal:Chyne stokes.Hyperventilation.Apneu.
Cardiovascular system:Trauma to the head --- changes in the function of the heart: contraction, pulmonary edema, tek. Vascular.Otonoom neural changes in ventricular function:- Dysrhythmias.- Fibrillation.- Tachycardia.The absence of endogenous sympathetic stimulus --- a decline in ventricular contractility. ---- --- Boost cardiac arrest decreased left ventricular --- pulmonary edema.
Assessment
The collection of patient data either subjective or objective in relation to system disturbances persyarafan head trauma is as follows:1. The identity of the patient and family (person in charge)
2. Medical History:In general, patients with head injury, came to the hospital with a decreased level of consciousness (GCS below 15), confusion, vomiting, dyspnea / tachypnea, headache,, weakly, paralise, head injuries, spuntum accumulation in the respiratory tract, the liquor from the nose and ears, and the presence of seizures.
Medical history first:It should be well known to the system associated neural circuitry system and other systemic diseases. Similarly, a family history of disease, especially those having a contagious disease. Health history can be assessed from the patient or the family as a data subjective. These data are very significant because it can affect pronosa patients.
3. Physical Examination:Neurological aspects:Studied is the level of consciousness, usually GCS less than 15, disorentasi person / place and time, a positive Babinski reflex, changes in the value of vital signs, the movement decebrasi or decortication and possible neck stiffness obtained with positive Brudzinski. The existence hemiparese.In conscious patients, it can not distinguish between different stimuli / stimulus taste, touch, temperature and vibration. Occurs involuntary movements, seizures due to impaired coordination. Patients also can not remember the events before and sesuadah trauma. Balance disorders in which the patient is awake, it can be seen or not be mempertahankana unsteady balance.
Cranial nerve may be disrupted if the head trauma to the brain stem due to widespread brain edema or brain hemorrhage.
Damage to nerve I (olfactory): showed symptoms of decreased sense of smell and bilateral anosmia. Nerve II (optic), the frontal trauma, show symptoms of decreased visual symptoms.Nerve III (Okulomotorius)
Nerve IV (Trokhlearis)Nerve VI (abducens), the damage will cause a decrease in visual field, light reflex, decreased, changes in pupil size, eye can not follow orders, anisokor.Nerve V (trigeminal), disorders characterized; any anesthetic forehead area.
Nerve VII (facial), in which the trauma capitis upper motor neuron can unilaterally decrease its function, the absence of nasolabial folds, eyelid closure weakness and loss of feeling on the 2/3 parts of the tongue anterior tongue.Nerve VIII (acoustic), in patients with symptoms of lower realized power of hearing and balance the body.
Nerve IX (Glosofaringeus).
Nerve X (vagus)
Nerve XI (Assesorius), symptoms are rarely found because the patient will die if the trauma of the nerve. The existence Hiccuping (basin) due to compression of the vagus nerve, which causes compression of the diaphragm and spasmodic. This occurs due to compression of the brain stem. Basin that occurs, it is usually at risk of increased intracranial pressure.Nerve XII (hipoglosus), common symptoms arise, is the fall of the tongue to one side, dysphagia and dysarthria. This causes a difficulty in swallowing.
Cardiovascular aspects:Learned changes in blood pressure decreases, unless an increase in the intracranial blood pressure increased, bradycardia pulse, then takhikardia, or irregular rhythm. In addition to other assessments collected are bleeding or discharge from the mouth, nose, ears, eyes. Hipereskresi presence in the oral cavity. Open bleeding / hematoma on other body parts. This needs assessment from head to toe.
Aspects of the respiratory system:Changes in breathing pattern, good rhythm, depth and frequency that is fast and shallow, irregular rhythm (chyne stokes, ataxia brething), ronchi breath sounds, wheezing. The presence of secretions in the tracheo brokhiolus. Increased body temperature can occur because of infection or stimulation of the hypothalamus as a central regulator of body temperature.Aspects elimination system:Will get the retention / incontinence in small or large bowel. There is a fluid and electrolyte imbalance, where there hyponatremia or hypokalemia. In the gastro-intestinal system is necessary to study the signs of decreased function of the gastrointestinal tract such as bowel sounds were not audible / weak, the nausea and vomiting. This is the basis for the provision of food.
Glasgow Coma Scale:I. Eye-Opening Reaction.4. Open your eyes spontaneously.3. Open your eyes when invoked / sound stimuli.2. Open your eyes when stimulated pain.1.Tidak reaction to any stimulus.
II. Speaking Reaction4. Good verbal communication, the right answer.3. Confused, disorentasi time, place and person.2. With the stimulus, the reaction is not just a word to form a sentence.III. Movement Reaction Arm / Leg6. Following orders.5. With pain stimuli can find out where the stimulus.4. With the stimulus of pain, pulling limbs.3. With painful stimuli, a reaction abnormal flexion.2. With the stimulus of pain, abnormal extension reactions arise.1. With painful stimuli, no reaction
4. Psychological Assessment:Where patients circuitry decreased level of consciousness, the psychological to the data can not be assessed, whereas in patients with normal levels of consciousness would look somewhat emotional disturbance, changes in behavior, emotions are unstable, irritable, apathy, delirium, and confusion for the patient's family anxiety connection with the illness.Social data that is needed is how psien dealing with people nearby and the other, the ability to communicate and their role in the family. As well as a patient's view of him after suffering head trauma and a sense of security.
5. Data spiritual:Required is adherence to the religion, the spirit and philosophy of life of patients and the deity he believes. Of course, the data collected in the absence of loss of consciousness.
6. Diagnostic Examination:Diagnostic tests performed in medical diagnosis is:X-Ray skull.CT-Scan.Angiography.
7. The Medical Management of Head Trauma:Drugs:Dexamethason / kalmethason: anti cerebral edema, in accordance with a heavy dose ringanya trauma.Hyperventilation therapy (severe head trauma), for mengurnagi vasodilation.Anti-edema treatment circuitry that hypertonic solutions of mannitol 20% or 40% glucose or 10% glycerol.Antibiotics containing the blood brain barrier (penicillin) or to be given metronidasol anaerobic infections.Food or liquid, the mild trauma when vomiting can not be given anything, only 5% dextrose intravenous fluids, aminofusin, aminofel (18 first hours of the accident), 2-3 days later given soft food.In severe trauma. Since the first days of the patient obtained decreased consciousness and tend to occur retention of sodium and electrolytes the first few days (2-3 days) is not too much fluid
Priority Nursing Diagnosis:1. Impaired brain tissue perfusion associated with circulatory disorders because the emphasis of the lesions (hemorrhage, hematoma).2. Potential or actual ineffectiveness breathing pattern, associated with damage to the respiratory centers in the medulla oblongata.3. Potential occurrence of increased intracranial pressure associated with the process of prodded space due to accumulation of blood in the brain fluid.4. Fluid and electrolyte balance disorders associated circuitry decreased production of anti-diuretic hormone (ADH) from the hypothalamus terfiksasinya.5. Actual / Potential disruption kebutuhannutrisi: Less than the needs associated with reduced ability to receive nutrients by decreasing awareness.6. Impaired physical mobilization associated with immobilization, bed rest rules for therapy.7. Disorders associated with decreased sensory perception sensory arrest power.8. Potential occurrence of infection associated circuitry entry of germs through the damaged tissue or continuity.9. Impaired sense of comfort: Headache berhubunagn circuitry damage brain tissue and brain hemorrhage / increased intracranial pressure.10. Impaired sense of security: Worried family of uncertainty associated with the treatment and care as well as a change and crisis situations.
Intervention:1. Examine the causes of the situation / circumstances of the individual / cause coma / decreased tissue perfusion and possible causes of increased ICP.R / Early detection for prioritizing interventions, assess neurologic status / signs of failure to determine the severity of treatment or surgery.2. Monitor and record GCS.R / Analyzing the level of awareness and the possibility of increased ICP and determine the location of the lesion.3. Monitor vital signs.R / A kedaan normal when the cerebral circulation is well maintained or marked fluctuations in systemic blood pressure, a decrease of outoregulator mostly a sign of lowering the diffusion of local cerebral blood vascularization. With the increase in blood pressure (diatolik) then coupled with increased intra-cranial blood pressure. Hipovolumik / hypotension is a manifestation of multiple trauma can cause cerebral ischemia. HR and disrhytmia an outgrowth of the brain stem disorders.4. Evaluation pupil.R / pupil reactions and eye movements of the back is a sign of impaired nerve / brainstem neuronal if torn. The balance between the sympathetic and parasympathetic nerves are cranial nerve reflex responses.5. Assess vision, memory, eye movements and Babinski reflex reaction.R / possibility of injury to the brain or brain stem. The decrease reflex sight is a sign of trauma pons and medulla. Coughing is a reflex of the notch and the disturbance medulla.Adanya Babinski reflex indications of brain injury in pyramidal.6. Monitor the temperature and temperature regulation.R / Summer is a reflex of the hypothalamus. Increased metabolic needs and O2 will support increased ICP.7. Monitor intake and output: my skin turgor, mucous membranes keadaa.R / Indication of impaired tissue perfusion head trauma can cause diabetes insipedus or syndroma increased secretion of ADH.8. Keep the head / neck in a neutral position, try a little circuitry pillow. Avoid using a lot of cushion on the head.R / Navigate datu head to one side of the jugular veins and impede cerebral venous drainage and increased ICP.9. Provide rest periods anatara care measures and limit the length of the procedure.R. Actions that can constantly improve ICP by cumulative effects of stimulation.10. Reduce Extra stimulation and provide a sense of comfort such as back massage, a quiet, friendly touch and atmosphere / talks were not rowdy.R / Giving atmosphere tenag (colming effect) can reduce psychological response and provide a break to maintain / low ICP.11. Help the patient when coughing, vomiting.R / activity may increase intra thoracic / pressure in the piston and pressure in the abdomen where it can increase pressure akitivitas ICP.12. Assess behavior enhancement and rest in the morning.R / non-verbal behavior is an indication of increased ICP dpat or give pain reflex in which the patient is unable to express verbally complaints, pain does not decrease to Increasing ICP.13. Palpation of the enlargement / widening blader, maintain a patent urinary drainage when used and also monitors the presence of constipation.R / May increase potential automatic response raised ICP.Collaboration:14. Raise the head of the bed / bed 15-45 degrees according to tolenransi / indication.R / Improved drainage / venous outflow from the head, reducing congestion and cerebral edema / risk of ICP.15. Give intravenous fluids according to the dindikasikan.R / Fluid may be desirable to menguransi cerebral edema, an increase in the minimum of the blood vessels, blood pressure and ICP.16. Give Oxygen.R / Reduce hipoxemia, which can increase cerebral vasodilation and increase blood volume and ICP.17. Give Diuretic drugs eg mannitol, furoscide.R / Diuretics may be used in acute pase to drain water from brain cells, and reduces cerebral edema and ICP.18. Steroids give an example: Dextamethason, methyl prednisolone.R / To reduce inflammation (inflammation) and reduces tissue edema.19. Give an example of high-dose painkillers: codeine.R / It may be indicated to reduce pain and drug negative effect on ICP but can be used with the cause to prevent.20. Sedatives Give examples: Benadryl.R / may be used to control the lack of rest and agitation.21. Give antipyretics, for example: aseptaminophen.R / Reduce / control day and on cerebral metabolism / oxygen is desired.
REFERENCES
Carpenito, L.P. (1999). Nursing Care Plans and Documentation, Nursing Diagnosis and Collaborative Problems. Ed.2. Jakarta: EGC.
Hospital Nursing Committee Dr. Soedono Madison. (1999). In the case of Head Trauma Management. Papers Kegawat daruratan in the surgical field. Not published.
Long, B.C. (1996). Medical Surgical Nursing (A Process Approach Kperawatan). New York: Foundation for Nursing Education Alumni Association Bandung.
Papers Lectures Medical Surgical PSIK Unair Surabaya. Not Published
Reksoprodjo, S. et al. (1995). Lecture set of Surgery. Jakarta: Bina Literacy way.
Rothrock, J.C. (1999). Perioperative Nursing Care Planning. Jakarta: EGC.
Tucker, B.C. (1998). Standard Care: Nursing Process, Diagnosis and Evaluation. Ed. 1. Jakarta: ECG.Posted by gayuh at 11:56NURSING CARE TO CLIENTS HEAD TRAUMA
Weight / severity of injury depends on:
1. Area affected:Skin injury.Bone tissue injury.Brain tissue injury.2. The state's head during impact.The main problem is the increase in intracranial pressure (PTIK)
ICT maintained by 3 components:1. The volume of blood / blood vessels (75-150 ml).2. Brain Network Volume (. 1200 to 1400 ml).3. CSF volume (75-150 ml).
B. Etiology
1. Accident2. Fall3. The trauma of childbirth.
Biological Response
Symptoms:1. If the client is aware ----- headache.2. Gag4. Awareness decline.5. Change the type of consciousness.6. Decreased blood pressure, bradycardia.7. isokor8. Body temperature that is difficult to control.
Type of head trauma:1. Open head trauma.2. Closed head trauma.
Open head trauma:Brain damage can occur when the skull into the brain tissue and hurt / ripped dura
Closed Head Trauma:
1. Komosio2. Kontosio.3. Epidural hematoma.4. Subdural hematoma.5. Intracranial hematoma.
Komosio / concussion:Mild head injuryTemporary neurologic dysfunction and can recover.Temporary loss of consciousness, less than 10-20 minutes.Without permanent brain damage.Symptoms of headache, dizziness, vomiting.control 24 hours I, observation of vital signs.There is no specific therapy.Absolute break ---- after missing complaint try mobilization stages, sitting --- stand - home.Once home ---- control, appropriate activity, adequate rest, diet enough.
Kontosio Cerebri / bruising of the brain:
There was bruising of the brain.Bleeding local small / diffuse ---- Local --- bleeding disorders.Symptoms:- Disorders of consciousness longer.- Neurologic Abnormalities positive, positive pathologic reflexes, paralysis, convulsions.- Symptoms of ICT increases.
Epidural hematoma:Anatara bleeding skull and dura mater.What common temporal and frontal.Sources: meningeal blood vessels rupture.Subdural hematoma:Bleeding between the dura and arachnoid.Usually ruptured vein --- acute, sub-acute, chronic.Acute:- Symptoms 24-48 hours.- Often associated circuitry brain injury and medulla oblongata.- ICT increases.- Headache, drowsiness, slowed reflexes, confusion, slow pupillary reflexes.
Sub Acute:- Evolving 7-10 days, kontosio bit heavy, the increased ICT gejal --- decreased consciousness.
Chronic:- Lightweight, 2 weeks - 3-4 months.- Bleeding into small pieces and spread slowly gathered.- Symptoms of headache, lethargy, mental mess, seizures, dysphagia.
Intracranial hematomas:Intracerebral hemorrhage ± 25 cc or more.Always followed by kontosio.The cause, a blood clot, local edema.
Effect of Head Trauma
Respiratory SystemCardiovascular system..
Respiratory System:
Hypoxemia, hypercapnia Increases Sympathetic stimulationImproved diffusion barriers O2 - Co2.Improve Pulmonary Edema vask prisoners. and systemic blood tekImprove tek, hydrostaticCapillary fluid leakageTek pulmonary vascular system. lower.Because of the direct compression on the brain stem respiratory symptoms ---- abnormal:Chyne stokes.Hyperventilation.Apneu.
Cardiovascular system:Trauma to the head --- changes in the function of the heart: contraction, pulmonary edema, tek. Vascular.Otonoom neural changes in ventricular function:- Dysrhythmias.- Fibrillation.- Tachycardia.The absence of endogenous sympathetic stimulus --- a decline in ventricular contractility. ---- --- Boost cardiac arrest decreased left ventricular --- pulmonary edema.
Assessment
The collection of patient data either subjective or objective in relation to system disturbances persyarafan head trauma is as follows:1. The identity of the patient and family (person in charge)
2. Medical History:In general, patients with head injury, came to the hospital with a decreased level of consciousness (GCS below 15), confusion, vomiting, dyspnea / tachypnea, headache,, weakly, paralise, head injuries, spuntum accumulation in the respiratory tract, the liquor from the nose and ears, and the presence of seizures.
Medical history first:It should be well known to the system associated neural circuitry system and other systemic diseases. Similarly, a family history of disease, especially those having a contagious disease. Health history can be assessed from the patient or the family as a data subjective. These data are very significant because it can affect pronosa patients.
3. Physical Examination:Neurological aspects:Studied is the level of consciousness, usually GCS less than 15, disorentasi person / place and time, a positive Babinski reflex, changes in the value of vital signs, the movement decebrasi or decortication and possible neck stiffness obtained with positive Brudzinski. The existence hemiparese.In conscious patients, it can not distinguish between different stimuli / stimulus taste, touch, temperature and vibration. Occurs involuntary movements, seizures due to impaired coordination. Patients also can not remember the events before and sesuadah trauma. Balance disorders in which the patient is awake, it can be seen or not be mempertahankana unsteady balance.
Cranial nerve may be disrupted if the head trauma to the brain stem due to widespread brain edema or brain hemorrhage.
Damage to nerve I (olfactory): showed symptoms of decreased sense of smell and bilateral anosmia. Nerve II (optic), the frontal trauma, show symptoms of decreased visual symptoms.Nerve III (Okulomotorius)
Nerve IV (Trokhlearis)Nerve VI (abducens), the damage will cause a decrease in visual field, light reflex, decreased, changes in pupil size, eye can not follow orders, anisokor.Nerve V (trigeminal), disorders characterized; any anesthetic forehead area.
Nerve VII (facial), in which the trauma capitis upper motor neuron can unilaterally decrease its function, the absence of nasolabial folds, eyelid closure weakness and loss of feeling on the 2/3 parts of the tongue anterior tongue.Nerve VIII (acoustic), in patients with symptoms of lower realized power of hearing and balance the body.
Nerve IX (Glosofaringeus).
Nerve X (vagus)
Nerve XI (Assesorius), symptoms are rarely found because the patient will die if the trauma of the nerve. The existence Hiccuping (basin) due to compression of the vagus nerve, which causes compression of the diaphragm and spasmodic. This occurs due to compression of the brain stem. Basin that occurs, it is usually at risk of increased intracranial pressure.Nerve XII (hipoglosus), common symptoms arise, is the fall of the tongue to one side, dysphagia and dysarthria. This causes a difficulty in swallowing.
Cardiovascular aspects:Learned changes in blood pressure decreases, unless an increase in the intracranial blood pressure increased, bradycardia pulse, then takhikardia, or irregular rhythm. In addition to other assessments collected are bleeding or discharge from the mouth, nose, ears, eyes. Hipereskresi presence in the oral cavity. Open bleeding / hematoma on other body parts. This needs assessment from head to toe.
Aspects of the respiratory system:Changes in breathing pattern, good rhythm, depth and frequency that is fast and shallow, irregular rhythm (chyne stokes, ataxia brething), ronchi breath sounds, wheezing. The presence of secretions in the tracheo brokhiolus. Increased body temperature can occur because of infection or stimulation of the hypothalamus as a central regulator of body temperature.Aspects elimination system:Will get the retention / incontinence in small or large bowel. There is a fluid and electrolyte imbalance, where there hyponatremia or hypokalemia. In the gastro-intestinal system is necessary to study the signs of decreased function of the gastrointestinal tract such as bowel sounds were not audible / weak, the nausea and vomiting. This is the basis for the provision of food.
Glasgow Coma Scale:I. Eye-Opening Reaction.4. Open your eyes spontaneously.3. Open your eyes when invoked / sound stimuli.2. Open your eyes when stimulated pain.1.Tidak reaction to any stimulus.
II. Speaking Reaction4. Good verbal communication, the right answer.3. Confused, disorentasi time, place and person.2. With the stimulus, the reaction is not just a word to form a sentence.III. Movement Reaction Arm / Leg6. Following orders.5. With pain stimuli can find out where the stimulus.4. With the stimulus of pain, pulling limbs.3. With painful stimuli, a reaction abnormal flexion.2. With the stimulus of pain, abnormal extension reactions arise.1. With painful stimuli, no reaction
4. Psychological Assessment:Where patients circuitry decreased level of consciousness, the psychological to the data can not be assessed, whereas in patients with normal levels of consciousness would look somewhat emotional disturbance, changes in behavior, emotions are unstable, irritable, apathy, delirium, and confusion for the patient's family anxiety connection with the illness.Social data that is needed is how psien dealing with people nearby and the other, the ability to communicate and their role in the family. As well as a patient's view of him after suffering head trauma and a sense of security.
5. Data spiritual:Required is adherence to the religion, the spirit and philosophy of life of patients and the deity he believes. Of course, the data collected in the absence of loss of consciousness.
6. Diagnostic Examination:Diagnostic tests performed in medical diagnosis is:X-Ray skull.CT-Scan.Angiography.
7. The Medical Management of Head Trauma:Drugs:Dexamethason / kalmethason: anti cerebral edema, in accordance with a heavy dose ringanya trauma.Hyperventilation therapy (severe head trauma), for mengurnagi vasodilation.Anti-edema treatment circuitry that hypertonic solutions of mannitol 20% or 40% glucose or 10% glycerol.Antibiotics containing the blood brain barrier (penicillin) or to be given metronidasol anaerobic infections.Food or liquid, the mild trauma when vomiting can not be given anything, only 5% dextrose intravenous fluids, aminofusin, aminofel (18 first hours of the accident), 2-3 days later given soft food.In severe trauma. Since the first days of the patient obtained decreased consciousness and tend to occur retention of sodium and electrolytes the first few days (2-3 days) is not too much fluid
Priority Nursing Diagnosis:1. Impaired brain tissue perfusion associated with circulatory disorders because the emphasis of the lesions (hemorrhage, hematoma).2. Potential or actual ineffectiveness breathing pattern, associated with damage to the respiratory centers in the medulla oblongata.3. Potential occurrence of increased intracranial pressure associated with the process of prodded space due to accumulation of blood in the brain fluid.4. Fluid and electrolyte balance disorders associated circuitry decreased production of anti-diuretic hormone (ADH) from the hypothalamus terfiksasinya.5. Actual / Potential disruption kebutuhannutrisi: Less than the needs associated with reduced ability to receive nutrients by decreasing awareness.6. Impaired physical mobilization associated with immobilization, bed rest rules for therapy.7. Disorders associated with decreased sensory perception sensory arrest power.8. Potential occurrence of infection associated circuitry entry of germs through the damaged tissue or continuity.9. Impaired sense of comfort: Headache berhubunagn circuitry damage brain tissue and brain hemorrhage / increased intracranial pressure.10. Impaired sense of security: Worried family of uncertainty associated with the treatment and care as well as a change and crisis situations.
Intervention:1. Examine the causes of the situation / circumstances of the individual / cause coma / decreased tissue perfusion and possible causes of increased ICP.R / Early detection for prioritizing interventions, assess neurologic status / signs of failure to determine the severity of treatment or surgery.2. Monitor and record GCS.R / Analyzing the level of awareness and the possibility of increased ICP and determine the location of the lesion.3. Monitor vital signs.R / A kedaan normal when the cerebral circulation is well maintained or marked fluctuations in systemic blood pressure, a decrease of outoregulator mostly a sign of lowering the diffusion of local cerebral blood vascularization. With the increase in blood pressure (diatolik) then coupled with increased intra-cranial blood pressure. Hipovolumik / hypotension is a manifestation of multiple trauma can cause cerebral ischemia. HR and disrhytmia an outgrowth of the brain stem disorders.4. Evaluation pupil.R / pupil reactions and eye movements of the back is a sign of impaired nerve / brainstem neuronal if torn. The balance between the sympathetic and parasympathetic nerves are cranial nerve reflex responses.5. Assess vision, memory, eye movements and Babinski reflex reaction.R / possibility of injury to the brain or brain stem. The decrease reflex sight is a sign of trauma pons and medulla. Coughing is a reflex of the notch and the disturbance medulla.Adanya Babinski reflex indications of brain injury in pyramidal.6. Monitor the temperature and temperature regulation.R / Summer is a reflex of the hypothalamus. Increased metabolic needs and O2 will support increased ICP.7. Monitor intake and output: my skin turgor, mucous membranes keadaa.R / Indication of impaired tissue perfusion head trauma can cause diabetes insipedus or syndroma increased secretion of ADH.8. Keep the head / neck in a neutral position, try a little circuitry pillow. Avoid using a lot of cushion on the head.R / Navigate datu head to one side of the jugular veins and impede cerebral venous drainage and increased ICP.9. Provide rest periods anatara care measures and limit the length of the procedure.R. Actions that can constantly improve ICP by cumulative effects of stimulation.10. Reduce Extra stimulation and provide a sense of comfort such as back massage, a quiet, friendly touch and atmosphere / talks were not rowdy.R / Giving atmosphere tenag (colming effect) can reduce psychological response and provide a break to maintain / low ICP.11. Help the patient when coughing, vomiting.R / activity may increase intra thoracic / pressure in the piston and pressure in the abdomen where it can increase pressure akitivitas ICP.12. Assess behavior enhancement and rest in the morning.R / non-verbal behavior is an indication of increased ICP dpat or give pain reflex in which the patient is unable to express verbally complaints, pain does not decrease to Increasing ICP.13. Palpation of the enlargement / widening blader, maintain a patent urinary drainage when used and also monitors the presence of constipation.R / May increase potential automatic response raised ICP.Collaboration:14. Raise the head of the bed / bed 15-45 degrees according to tolenransi / indication.R / Improved drainage / venous outflow from the head, reducing congestion and cerebral edema / risk of ICP.15. Give intravenous fluids according to the dindikasikan.R / Fluid may be desirable to menguransi cerebral edema, an increase in the minimum of the blood vessels, blood pressure and ICP.16. Give Oxygen.R / Reduce hipoxemia, which can increase cerebral vasodilation and increase blood volume and ICP.17. Give Diuretic drugs eg mannitol, furoscide.R / Diuretics may be used in acute pase to drain water from brain cells, and reduces cerebral edema and ICP.18. Steroids give an example: Dextamethason, methyl prednisolone.R / To reduce inflammation (inflammation) and reduces tissue edema.19. Give an example of high-dose painkillers: codeine.R / It may be indicated to reduce pain and drug negative effect on ICP but can be used with the cause to prevent.20. Sedatives Give examples: Benadryl.R / may be used to control the lack of rest and agitation.21. Give antipyretics, for example: aseptaminophen.R / Reduce / control day and on cerebral metabolism / oxygen is desired.
REFERENCES
ICT maintained by 3 components:1. The volume of blood / blood vessels (75-150 ml).2. Brain Network Volume (. 1200 to 1400 ml).3. CSF volume (75-150 ml).
B. Etiology
1. Accident2. Fall3. The trauma of childbirth.
Biological Response
Symptoms:1. If the client is aware ----- headache.2. Gag4. Awareness decline.5. Change the type of consciousness.6. Decreased blood pressure, bradycardia.7. isokor8. Body temperature that is difficult to control.
Type of head trauma:1. Open head trauma.2. Closed head trauma.
Open head trauma:Brain damage can occur when the skull into the brain tissue and hurt / ripped dura
Closed Head Trauma:
1. Komosio2. Kontosio.3. Epidural hematoma.4. Subdural hematoma.5. Intracranial hematoma.
Komosio / concussion:Mild head injuryTemporary neurologic dysfunction and can recover.Temporary loss of consciousness, less than 10-20 minutes.Without permanent brain damage.Symptoms of headache, dizziness, vomiting.control 24 hours I, observation of vital signs.There is no specific therapy.Absolute break ---- after missing complaint try mobilization stages, sitting --- stand - home.Once home ---- control, appropriate activity, adequate rest, diet enough.
Kontosio Cerebri / bruising of the brain:
There was bruising of the brain.Bleeding local small / diffuse ---- Local --- bleeding disorders.Symptoms:- Disorders of consciousness longer.- Neurologic Abnormalities positive, positive pathologic reflexes, paralysis, convulsions.- Symptoms of ICT increases.
Epidural hematoma:Anatara bleeding skull and dura mater.What common temporal and frontal.Sources: meningeal blood vessels rupture.Subdural hematoma:Bleeding between the dura and arachnoid.Usually ruptured vein --- acute, sub-acute, chronic.Acute:- Symptoms 24-48 hours.- Often associated circuitry brain injury and medulla oblongata.- ICT increases.- Headache, drowsiness, slowed reflexes, confusion, slow pupillary reflexes.
Sub Acute:- Evolving 7-10 days, kontosio bit heavy, the increased ICT gejal --- decreased consciousness.
Chronic:- Lightweight, 2 weeks - 3-4 months.- Bleeding into small pieces and spread slowly gathered.- Symptoms of headache, lethargy, mental mess, seizures, dysphagia.
Intracranial hematomas:Intracerebral hemorrhage ± 25 cc or more.Always followed by kontosio.The cause, a blood clot, local edema.
Effect of Head Trauma
Respiratory SystemCardiovascular system..
Respiratory System:
Hypoxemia, hypercapnia Increases Sympathetic stimulationImproved diffusion barriers O2 - Co2.Improve Pulmonary Edema vask prisoners. and systemic blood tekImprove tek, hydrostaticCapillary fluid leakageTek pulmonary vascular system. lower.Because of the direct compression on the brain stem respiratory symptoms ---- abnormal:Chyne stokes.Hyperventilation.Apneu.
Cardiovascular system:Trauma to the head --- changes in the function of the heart: contraction, pulmonary edema, tek. Vascular.Otonoom neural changes in ventricular function:- Dysrhythmias.- Fibrillation.- Tachycardia.The absence of endogenous sympathetic stimulus --- a decline in ventricular contractility. ---- --- Boost cardiac arrest decreased left ventricular --- pulmonary edema.
Assessment
The collection of patient data either subjective or objective in relation to system disturbances persyarafan head trauma is as follows:1. The identity of the patient and family (person in charge)
2. Medical History:In general, patients with head injury, came to the hospital with a decreased level of consciousness (GCS below 15), confusion, vomiting, dyspnea / tachypnea, headache,, weakly, paralise, head injuries, spuntum accumulation in the respiratory tract, the liquor from the nose and ears, and the presence of seizures.
Medical history first:It should be well known to the system associated neural circuitry system and other systemic diseases. Similarly, a family history of disease, especially those having a contagious disease. Health history can be assessed from the patient or the family as a data subjective. These data are very significant because it can affect pronosa patients.
3. Physical Examination:Neurological aspects:Studied is the level of consciousness, usually GCS less than 15, disorentasi person / place and time, a positive Babinski reflex, changes in the value of vital signs, the movement decebrasi or decortication and possible neck stiffness obtained with positive Brudzinski. The existence hemiparese.In conscious patients, it can not distinguish between different stimuli / stimulus taste, touch, temperature and vibration. Occurs involuntary movements, seizures due to impaired coordination. Patients also can not remember the events before and sesuadah trauma. Balance disorders in which the patient is awake, it can be seen or not be mempertahankana unsteady balance.
Cranial nerve may be disrupted if the head trauma to the brain stem due to widespread brain edema or brain hemorrhage.
Damage to nerve I (olfactory): showed symptoms of decreased sense of smell and bilateral anosmia. Nerve II (optic), the frontal trauma, show symptoms of decreased visual symptoms.Nerve III (Okulomotorius)
Nerve IV (Trokhlearis)Nerve VI (abducens), the damage will cause a decrease in visual field, light reflex, decreased, changes in pupil size, eye can not follow orders, anisokor.Nerve V (trigeminal), disorders characterized; any anesthetic forehead area.
Nerve VII (facial), in which the trauma capitis upper motor neuron can unilaterally decrease its function, the absence of nasolabial folds, eyelid closure weakness and loss of feeling on the 2/3 parts of the tongue anterior tongue.Nerve VIII (acoustic), in patients with symptoms of lower realized power of hearing and balance the body.
Nerve IX (Glosofaringeus).
Nerve X (vagus)
Nerve XI (Assesorius), symptoms are rarely found because the patient will die if the trauma of the nerve. The existence Hiccuping (basin) due to compression of the vagus nerve, which causes compression of the diaphragm and spasmodic. This occurs due to compression of the brain stem. Basin that occurs, it is usually at risk of increased intracranial pressure.Nerve XII (hipoglosus), common symptoms arise, is the fall of the tongue to one side, dysphagia and dysarthria. This causes a difficulty in swallowing.
Cardiovascular aspects:Learned changes in blood pressure decreases, unless an increase in the intracranial blood pressure increased, bradycardia pulse, then takhikardia, or irregular rhythm. In addition to other assessments collected are bleeding or discharge from the mouth, nose, ears, eyes. Hipereskresi presence in the oral cavity. Open bleeding / hematoma on other body parts. This needs assessment from head to toe.
Aspects of the respiratory system:Changes in breathing pattern, good rhythm, depth and frequency that is fast and shallow, irregular rhythm (chyne stokes, ataxia brething), ronchi breath sounds, wheezing. The presence of secretions in the tracheo brokhiolus. Increased body temperature can occur because of infection or stimulation of the hypothalamus as a central regulator of body temperature.Aspects elimination system:Will get the retention / incontinence in small or large bowel. There is a fluid and electrolyte imbalance, where there hyponatremia or hypokalemia. In the gastro-intestinal system is necessary to study the signs of decreased function of the gastrointestinal tract such as bowel sounds were not audible / weak, the nausea and vomiting. This is the basis for the provision of food.
Glasgow Coma Scale:I. Eye-Opening Reaction.4. Open your eyes spontaneously.3. Open your eyes when invoked / sound stimuli.2. Open your eyes when stimulated pain.1.Tidak reaction to any stimulus.
II. Speaking Reaction4. Good verbal communication, the right answer.3. Confused, disorentasi time, place and person.2. With the stimulus, the reaction is not just a word to form a sentence.III. Movement Reaction Arm / Leg6. Following orders.5. With pain stimuli can find out where the stimulus.4. With the stimulus of pain, pulling limbs.3. With painful stimuli, a reaction abnormal flexion.2. With the stimulus of pain, abnormal extension reactions arise.1. With painful stimuli, no reaction
4. Psychological Assessment:Where patients circuitry decreased level of consciousness, the psychological to the data can not be assessed, whereas in patients with normal levels of consciousness would look somewhat emotional disturbance, changes in behavior, emotions are unstable, irritable, apathy, delirium, and confusion for the patient's family anxiety connection with the illness.Social data that is needed is how psien dealing with people nearby and the other, the ability to communicate and their role in the family. As well as a patient's view of him after suffering head trauma and a sense of security.
5. Data spiritual:Required is adherence to the religion, the spirit and philosophy of life of patients and the deity he believes. Of course, the data collected in the absence of loss of consciousness.
6. Diagnostic Examination:Diagnostic tests performed in medical diagnosis is:X-Ray skull.CT-Scan.Angiography.
7. The Medical Management of Head Trauma:Drugs:Dexamethason / kalmethason: anti cerebral edema, in accordance with a heavy dose ringanya trauma.Hyperventilation therapy (severe head trauma), for mengurnagi vasodilation.Anti-edema treatment circuitry that hypertonic solutions of mannitol 20% or 40% glucose or 10% glycerol.Antibiotics containing the blood brain barrier (penicillin) or to be given metronidasol anaerobic infections.Food or liquid, the mild trauma when vomiting can not be given anything, only 5% dextrose intravenous fluids, aminofusin, aminofel (18 first hours of the accident), 2-3 days later given soft food.In severe trauma. Since the first days of the patient obtained decreased consciousness and tend to occur retention of sodium and electrolytes the first few days (2-3 days) is not too much fluid
Priority Nursing Diagnosis:1. Impaired brain tissue perfusion associated with circulatory disorders because the emphasis of the lesions (hemorrhage, hematoma).2. Potential or actual ineffectiveness breathing pattern, associated with damage to the respiratory centers in the medulla oblongata.3. Potential occurrence of increased intracranial pressure associated with the process of prodded space due to accumulation of blood in the brain fluid.4. Fluid and electrolyte balance disorders associated circuitry decreased production of anti-diuretic hormone (ADH) from the hypothalamus terfiksasinya.5. Actual / Potential disruption kebutuhannutrisi: Less than the needs associated with reduced ability to receive nutrients by decreasing awareness.6. Impaired physical mobilization associated with immobilization, bed rest rules for therapy.7. Disorders associated with decreased sensory perception sensory arrest power.8. Potential occurrence of infection associated circuitry entry of germs through the damaged tissue or continuity.9. Impaired sense of comfort: Headache berhubunagn circuitry damage brain tissue and brain hemorrhage / increased intracranial pressure.10. Impaired sense of security: Worried family of uncertainty associated with the treatment and care as well as a change and crisis situations.
Intervention:1. Examine the causes of the situation / circumstances of the individual / cause coma / decreased tissue perfusion and possible causes of increased ICP.R / Early detection for prioritizing interventions, assess neurologic status / signs of failure to determine the severity of treatment or surgery.2. Monitor and record GCS.R / Analyzing the level of awareness and the possibility of increased ICP and determine the location of the lesion.3. Monitor vital signs.R / A kedaan normal when the cerebral circulation is well maintained or marked fluctuations in systemic blood pressure, a decrease of outoregulator mostly a sign of lowering the diffusion of local cerebral blood vascularization. With the increase in blood pressure (diatolik) then coupled with increased intra-cranial blood pressure. Hipovolumik / hypotension is a manifestation of multiple trauma can cause cerebral ischemia. HR and disrhytmia an outgrowth of the brain stem disorders.4. Evaluation pupil.R / pupil reactions and eye movements of the back is a sign of impaired nerve / brainstem neuronal if torn. The balance between the sympathetic and parasympathetic nerves are cranial nerve reflex responses.5. Assess vision, memory, eye movements and Babinski reflex reaction.R / possibility of injury to the brain or brain stem. The decrease reflex sight is a sign of trauma pons and medulla. Coughing is a reflex of the notch and the disturbance medulla.Adanya Babinski reflex indications of brain injury in pyramidal.6. Monitor the temperature and temperature regulation.R / Summer is a reflex of the hypothalamus. Increased metabolic needs and O2 will support increased ICP.7. Monitor intake and output: my skin turgor, mucous membranes keadaa.R / Indication of impaired tissue perfusion head trauma can cause diabetes insipedus or syndroma increased secretion of ADH.8. Keep the head / neck in a neutral position, try a little circuitry pillow. Avoid using a lot of cushion on the head.R / Navigate datu head to one side of the jugular veins and impede cerebral venous drainage and increased ICP.9. Provide rest periods anatara care measures and limit the length of the procedure.R. Actions that can constantly improve ICP by cumulative effects of stimulation.10. Reduce Extra stimulation and provide a sense of comfort such as back massage, a quiet, friendly touch and atmosphere / talks were not rowdy.R / Giving atmosphere tenag (colming effect) can reduce psychological response and provide a break to maintain / low ICP.11. Help the patient when coughing, vomiting.R / activity may increase intra thoracic / pressure in the piston and pressure in the abdomen where it can increase pressure akitivitas ICP.12. Assess behavior enhancement and rest in the morning.R / non-verbal behavior is an indication of increased ICP dpat or give pain reflex in which the patient is unable to express verbally complaints, pain does not decrease to Increasing ICP.13. Palpation of the enlargement / widening blader, maintain a patent urinary drainage when used and also monitors the presence of constipation.R / May increase potential automatic response raised ICP.Collaboration:14. Raise the head of the bed / bed 15-45 degrees according to tolenransi / indication.R / Improved drainage / venous outflow from the head, reducing congestion and cerebral edema / risk of ICP.15. Give intravenous fluids according to the dindikasikan.R / Fluid may be desirable to menguransi cerebral edema, an increase in the minimum of the blood vessels, blood pressure and ICP.16. Give Oxygen.R / Reduce hipoxemia, which can increase cerebral vasodilation and increase blood volume and ICP.17. Give Diuretic drugs eg mannitol, furoscide.R / Diuretics may be used in acute pase to drain water from brain cells, and reduces cerebral edema and ICP.18. Steroids give an example: Dextamethason, methyl prednisolone.R / To reduce inflammation (inflammation) and reduces tissue edema.19. Give an example of high-dose painkillers: codeine.R / It may be indicated to reduce pain and drug negative effect on ICP but can be used with the cause to prevent.20. Sedatives Give examples: Benadryl.R / may be used to control the lack of rest and agitation.21. Give antipyretics, for example: aseptaminophen.R / Reduce / control day and on cerebral metabolism / oxygen is desired.
REFERENCES
Carpenito, L.P. (1999). Nursing Care Plans and Documentation, Nursing Diagnosis and Collaborative Problems. Ed.2. Jakarta: EGC.
Hospital Nursing Committee Dr. Soedono Madison. (1999). In the case of Head Trauma Management. Papers Kegawat daruratan in the surgical field. Not published.
Long, B.C. (1996). Medical Surgical Nursing (A Process Approach Kperawatan). New York: Foundation for Nursing Education Alumni Association Bandung.
Papers Lectures Medical Surgical PSIK Unair Surabaya. Not Published
Reksoprodjo, S. et al. (1995). Lecture set of Surgery. Jakarta: Bina Literacy way.
Rothrock, J.C. (1999). Perioperative Nursing Care Planning. Jakarta: EGC.
Tucker, B.C. (1998). Standard Care: Nursing Process, Diagnosis and Evaluation. Ed. 1. Jakarta: ECG.Posted by gayuh at 11:56
NURSING CARE TO CLIENTS HEAD TRAUMA
Weight / severity of injury depends on:
1. Area affected:Skin injury.Bone tissue injury.Brain tissue injury.2. The state's head during impact.The main problem is the increase in intracranial pressure (PTIK)
ICT maintained by 3 components:1. The volume of blood / blood vessels (75-150 ml).2. Brain Network Volume (. 1200 to 1400 ml).3. CSF volume (75-150 ml).
B. Etiology
1. Accident2. Fall3. The trauma of childbirth.
Biological Response
Symptoms:1. If the client is aware ----- headache.2. Gag4. Awareness decline.5. Change the type of consciousness.6. Decreased blood pressure, bradycardia.7. isokor8. Body temperature that is difficult to control.
Type of head trauma:1. Open head trauma.2. Closed head trauma.
Open head trauma:Brain damage can occur when the skull into the brain tissue and hurt / ripped dura
Closed Head Trauma:
1. Komosio2. Kontosio.3. Epidural hematoma.4. Subdural hematoma.5. Intracranial hematoma.
Komosio / concussion:Mild head injuryTemporary neurologic dysfunction and can recover.Temporary loss of consciousness, less than 10-20 minutes.Without permanent brain damage.Symptoms of headache, dizziness, vomiting.control 24 hours I, observation of vital signs.There is no specific therapy.Absolute break ---- after missing complaint try mobilization stages, sitting --- stand - home.Once home ---- control, appropriate activity, adequate rest, diet enough.
Kontosio Cerebri / bruising of the brain:
There was bruising of the brain.Bleeding local small / diffuse ---- Local --- bleeding disorders.Symptoms:- Disorders of consciousness longer.- Neurologic Abnormalities positive, positive pathologic reflexes, paralysis, convulsions.- Symptoms of ICT increases.
Epidural hematoma:Anatara bleeding skull and dura mater.What common temporal and frontal.Sources: meningeal blood vessels rupture.Subdural hematoma:Bleeding between the dura and arachnoid.Usually ruptured vein --- acute, sub-acute, chronic.Acute:- Symptoms 24-48 hours.- Often associated circuitry brain injury and medulla oblongata.- ICT increases.- Headache, drowsiness, slowed reflexes, confusion, slow pupillary reflexes.
Sub Acute:- Evolving 7-10 days, kontosio bit heavy, the increased ICT gejal --- decreased consciousness.
Chronic:- Lightweight, 2 weeks - 3-4 months.- Bleeding into small pieces and spread slowly gathered.- Symptoms of headache, lethargy, mental mess, seizures, dysphagia.
Intracranial hematomas:Intracerebral hemorrhage ± 25 cc or more.Always followed by kontosio.The cause, a blood clot, local edema.
Effect of Head Trauma
Respiratory SystemCardiovascular system..
Respiratory System:
Hypoxemia, hypercapnia Increases Sympathetic stimulationImproved diffusion barriers O2 - Co2.Improve Pulmonary Edema vask prisoners. and systemic blood tekImprove tek, hydrostaticCapillary fluid leakageTek pulmonary vascular system. lower.Because of the direct compression on the brain stem respiratory symptoms ---- abnormal:Chyne stokes.Hyperventilation.Apneu.
Cardiovascular system:Trauma to the head --- changes in the function of the heart: contraction, pulmonary edema, tek. Vascular.Otonoom neural changes in ventricular function:- Dysrhythmias.- Fibrillation.- Tachycardia.The absence of endogenous sympathetic stimulus --- a decline in ventricular contractility. ---- --- Boost cardiac arrest decreased left ventricular --- pulmonary edema.
Assessment
The collection of patient data either subjective or objective in relation to system disturbances persyarafan head trauma is as follows:1. The identity of the patient and family (person in charge)
2. Medical History:In general, patients with head injury, came to the hospital with a decreased level of consciousness (GCS below 15), confusion, vomiting, dyspnea / tachypnea, headache,, weakly, paralise, head injuries, spuntum accumulation in the respiratory tract, the liquor from the nose and ears, and the presence of seizures.
Medical history first:It should be well known to the system associated neural circuitry system and other systemic diseases. Similarly, a family history of disease, especially those having a contagious disease. Health history can be assessed from the patient or the family as a data subjective. These data are very significant because it can affect pronosa patients.
3. Physical Examination:Neurological aspects:Studied is the level of consciousness, usually GCS less than 15, disorentasi person / place and time, a positive Babinski reflex, changes in the value of vital signs, the movement decebrasi or decortication and possible neck stiffness obtained with positive Brudzinski. The existence hemiparese.In conscious patients, it can not distinguish between different stimuli / stimulus taste, touch, temperature and vibration. Occurs involuntary movements, seizures due to impaired coordination. Patients also can not remember the events before and sesuadah trauma. Balance disorders in which the patient is awake, it can be seen or not be mempertahankana unsteady balance.
Cranial nerve may be disrupted if the head trauma to the brain stem due to widespread brain edema or brain hemorrhage.
Damage to nerve I (olfactory): showed symptoms of decreased sense of smell and bilateral anosmia. Nerve II (optic), the frontal trauma, show symptoms of decreased visual symptoms.Nerve III (Okulomotorius)
Nerve IV (Trokhlearis)Nerve VI (abducens), the damage will cause a decrease in visual field, light reflex, decreased, changes in pupil size, eye can not follow orders, anisokor.Nerve V (trigeminal), disorders characterized; any anesthetic forehead area.
Nerve VII (facial), in which the trauma capitis upper motor neuron can unilaterally decrease its function, the absence of nasolabial folds, eyelid closure weakness and loss of feeling on the 2/3 parts of the tongue anterior tongue.Nerve VIII (acoustic), in patients with symptoms of lower realized power of hearing and balance the body.
Nerve IX (Glosofaringeus).
Nerve X (vagus)
Nerve XI (Assesorius), symptoms are rarely found because the patient will die if the trauma of the nerve. The existence Hiccuping (basin) due to compression of the vagus nerve, which causes compression of the diaphragm and spasmodic. This occurs due to compression of the brain stem. Basin that occurs, it is usually at risk of increased intracranial pressure.Nerve XII (hipoglosus), common symptoms arise, is the fall of the tongue to one side, dysphagia and dysarthria. This causes a difficulty in swallowing.
Cardiovascular aspects:Learned changes in blood pressure decreases, unless an increase in the intracranial blood pressure increased, bradycardia pulse, then takhikardia, or irregular rhythm. In addition to other assessments collected are bleeding or discharge from the mouth, nose, ears, eyes. Hipereskresi presence in the oral cavity. Open bleeding / hematoma on other body parts. This needs assessment from head to toe.
Aspects of the respiratory system:Changes in breathing pattern, good rhythm, depth and frequency that is fast and shallow, irregular rhythm (chyne stokes, ataxia brething), ronchi breath sounds, wheezing. The presence of secretions in the tracheo brokhiolus. Increased body temperature can occur because of infection or stimulation of the hypothalamus as a central regulator of body temperature.Aspects elimination system:Will get the retention / incontinence in small or large bowel. There is a fluid and electrolyte imbalance, where there hyponatremia or hypokalemia. In the gastro-intestinal system is necessary to study the signs of decreased function of the gastrointestinal tract such as bowel sounds were not audible / weak, the nausea and vomiting. This is the basis for the provision of food.
Glasgow Coma Scale:I. Eye-Opening Reaction.4. Open your eyes spontaneously.3. Open your eyes when invoked / sound stimuli.2. Open your eyes when stimulated pain.1.Tidak reaction to any stimulus.
II. Speaking Reaction4. Good verbal communication, the right answer.3. Confused, disorentasi time, place and person.2. With the stimulus, the reaction is not just a word to form a sentence.III. Movement Reaction Arm / Leg6. Following orders.5. With pain stimuli can find out where the stimulus.4. With the stimulus of pain, pulling limbs.3. With painful stimuli, a reaction abnormal flexion.2. With the stimulus of pain, abnormal extension reactions arise.1. With painful stimuli, no reaction
4. Psychological Assessment:Where patients circuitry decreased level of consciousness, the psychological to the data can not be assessed, whereas in patients with normal levels of consciousness would look somewhat emotional disturbance, changes in behavior, emotions are unstable, irritable, apathy, delirium, and confusion for the patient's family anxiety connection with the illness.Social data that is needed is how psien dealing with people nearby and the other, the ability to communicate and their role in the family. As well as a patient's view of him after suffering head trauma and a sense of security.
5. Data spiritual:Required is adherence to the religion, the spirit and philosophy of life of patients and the deity he believes. Of course, the data collected in the absence of loss of consciousness.
6. Diagnostic Examination:Diagnostic tests performed in medical diagnosis is:X-Ray skull.CT-Scan.Angiography.
7. The Medical Management of Head Trauma:Drugs:Dexamethason / kalmethason: anti cerebral edema, in accordance with a heavy dose ringanya trauma.Hyperventilation therapy (severe head trauma), for mengurnagi vasodilation.Anti-edema treatment circuitry that hypertonic solutions of mannitol 20% or 40% glucose or 10% glycerol.Antibiotics containing the blood brain barrier (penicillin) or to be given metronidasol anaerobic infections.Food or liquid, the mild trauma when vomiting can not be given anything, only 5% dextrose intravenous fluids, aminofusin, aminofel (18 first hours of the accident), 2-3 days later given soft food.In severe trauma. Since the first days of the patient obtained decreased consciousness and tend to occur retention of sodium and electrolytes the first few days (2-3 days) is not too much fluid
Priority Nursing Diagnosis:1. Impaired brain tissue perfusion associated with circulatory disorders because the emphasis of the lesions (hemorrhage, hematoma).2. Potential or actual ineffectiveness breathing pattern, associated with damage to the respiratory centers in the medulla oblongata.3. Potential occurrence of increased intracranial pressure associated with the process of prodded space due to accumulation of blood in the brain fluid.4. Fluid and electrolyte balance disorders associated circuitry decreased production of anti-diuretic hormone (ADH) from the hypothalamus terfiksasinya.5. Actual / Potential disruption kebutuhannutrisi: Less than the needs associated with reduced ability to receive nutrients by decreasing awareness.6. Impaired physical mobilization associated with immobilization, bed rest rules for therapy.7. Disorders associated with decreased sensory perception sensory arrest power.8. Potential occurrence of infection associated circuitry entry of germs through the damaged tissue or continuity.9. Impaired sense of comfort: Headache berhubunagn circuitry damage brain tissue and brain hemorrhage / increased intracranial pressure.10. Impaired sense of security: Worried family of uncertainty associated with the treatment and care as well as a change and crisis situations.
Intervention:1. Examine the causes of the situation / circumstances of the individual / cause coma / decreased tissue perfusion and possible causes of increased ICP.R / Early detection for prioritizing interventions, assess neurologic status / signs of failure to determine the severity of treatment or surgery.2. Monitor and record GCS.R / Analyzing the level of awareness and the possibility of increased ICP and determine the location of the lesion.3. Monitor vital signs.R / A kedaan normal when the cerebral circulation is well maintained or marked fluctuations in systemic blood pressure, a decrease of outoregulator mostly a sign of lowering the diffusion of local cerebral blood vascularization. With the increase in blood pressure (diatolik) then coupled with increased intra-cranial blood pressure. Hipovolumik / hypotension is a manifestation of multiple trauma can cause cerebral ischemia. HR and disrhytmia an outgrowth of the brain stem disorders.4. Evaluation pupil.R / pupil reactions and eye movements of the back is a sign of impaired nerve / brainstem neuronal if torn. The balance between the sympathetic and parasympathetic nerves are cranial nerve reflex responses.5. Assess vision, memory, eye movements and Babinski reflex reaction.R / possibility of injury to the brain or brain stem. The decrease reflex sight is a sign of trauma pons and medulla. Coughing is a reflex of the notch and the disturbance medulla.Adanya Babinski reflex indications of brain injury in pyramidal.6. Monitor the temperature and temperature regulation.R / Summer is a reflex of the hypothalamus. Increased metabolic needs and O2 will support increased ICP.7. Monitor intake and output: my skin turgor, mucous membranes keadaa.R / Indication of impaired tissue perfusion head trauma can cause diabetes insipedus or syndroma increased secretion of ADH.8. Keep the head / neck in a neutral position, try a little circuitry pillow. Avoid using a lot of cushion on the head.R / Navigate datu head to one side of the jugular veins and impede cerebral venous drainage and increased ICP.9. Provide rest periods anatara care measures and limit the length of the procedure.R. Actions that can constantly improve ICP by cumulative effects of stimulation.10. Reduce Extra stimulation and provide a sense of comfort such as back massage, a quiet, friendly touch and atmosphere / talks were not rowdy.R / Giving atmosphere tenag (colming effect) can reduce psychological response and provide a break to maintain / low ICP.11. Help the patient when coughing, vomiting.R / activity may increase intra thoracic / pressure in the piston and pressure in the abdomen where it can increase pressure akitivitas ICP.12. Assess behavior enhancement and rest in the morning.R / non-verbal behavior is an indication of increased ICP dpat or give pain reflex in which the patient is unable to express verbally complaints, pain does not decrease to Increasing ICP.13. Palpation of the enlargement / widening blader, maintain a patent urinary drainage when used and also monitors the presence of constipation.R / May increase potential automatic response raised ICP.Collaboration:14. Raise the head of the bed / bed 15-45 degrees according to tolenransi / indication.R / Improved drainage / venous outflow from the head, reducing congestion and cerebral edema / risk of ICP.15. Give intravenous fluids according to the dindikasikan.R / Fluid may be desirable to menguransi cerebral edema, an increase in the minimum of the blood vessels, blood pressure and ICP.16. Give Oxygen.R / Reduce hipoxemia, which can increase cerebral vasodilation and increase blood volume and ICP.17. Give Diuretic drugs eg mannitol, furoscide.R / Diuretics may be used in acute pase to drain water from brain cells, and reduces cerebral edema and ICP.18. Steroids give an example: Dextamethason, methyl prednisolone.R / To reduce inflammation (inflammation) and reduces tissue edema.19. Give an example of high-dose painkillers: codeine.R / It may be indicated to reduce pain and drug negative effect on ICP but can be used with the cause to prevent.20. Sedatives Give examples: Benadryl.R / may be used to control the lack of rest and agitation.21. Give antipyretics, for example: aseptaminophen.R / Reduce / control day and on cerebral metabolism / oxygen is desired.
REFERENCES
Carpenito, L.P. (1999). Nursing Care Plans and Documentation, Nursing Diagnosis and Collaborative Problems. Ed.2. Jakarta: EGC.
Hospital Nursing Committee Dr. Soedono Madison. (1999). In the case of Head Trauma Management. Papers Kegawat daruratan in the surgical field. Not published.
Long, B.C. (1996). Medical Surgical Nursing (A Process Approach Kperawatan). New York: Foundation for Nursing Education Alumni Association Bandung.
Papers Lectures Medical Surgical PSIK Unair Surabaya. Not Published
Reksoprodjo, S. et al. (1995). Lecture set of Surgery. Jakarta: Bina Literacy way.
Rothrock, J.C. (1999). Perioperative Nursing Care Planning. Jakarta: EGC.
Tucker, B.C. (1998). Standard Care: Nursing Process, Diagnosis and Evaluation. Ed. 1. Jakarta: ECG.Posted by gayuh at 11:56 NURSING CARE TO CLIENTS HEAD TRAUMA
Weight / severity of injury depends on:
1. Area affected:Skin injury.Bone tissue injury.Brain tissue injury.2. The state's head during impact.The main problem is the increase in intracranial pressure (PTIK)
ICT maintained by 3 components:1. The volume of blood / blood vessels (75-150 ml).2. Brain Network Volume (. 1200 to 1400 ml).3. CSF volume (75-150 ml).
B. Etiology
1. Accident2. Fall3. The trauma of childbirth.
Biological Response
Symptoms:1. If the client is aware ----- headache.2. Gag4. Awareness decline.5. Change the type of consciousness.6. Decreased blood pressure, bradycardia.7. isokor8. Body temperature that is difficult to control.
Type of head trauma:1. Open head trauma.2. Closed head trauma.
Open head trauma:Brain damage can occur when the skull into the brain tissue and hurt / ripped dura
Closed Head Trauma:
1. Komosio2. Kontosio.3. Epidural hematoma.4. Subdural hematoma.5. Intracranial hematoma.
Komosio / concussion:Mild head injuryTemporary neurologic dysfunction and can recover.Temporary loss of consciousness, less than 10-20 minutes.Without permanent brain damage.Symptoms of headache, dizziness, vomiting.control 24 hours I, observation of vital signs.There is no specific therapy.Absolute break ---- after missing complaint try mobilization stages, sitting --- stand - home.Once home ---- control, appropriate activity, adequate rest, diet enough.
Kontosio Cerebri / bruising of the brain:
There was bruising of the brain.Bleeding local small / diffuse ---- Local --- bleeding disorders.Symptoms:- Disorders of consciousness longer.- Neurologic Abnormalities positive, positive pathologic reflexes, paralysis, convulsions.- Symptoms of ICT increases.
Epidural hematoma:Anatara bleeding skull and dura mater.What common temporal and frontal.Sources: meningeal blood vessels rupture.Subdural hematoma:Bleeding between the dura and arachnoid.Usually ruptured vein --- acute, sub-acute, chronic.Acute:- Symptoms 24-48 hours.- Often associated circuitry brain injury and medulla oblongata.- ICT increases.- Headache, drowsiness, slowed reflexes, confusion, slow pupillary reflexes.
Sub Acute:- Evolving 7-10 days, kontosio bit heavy, the increased ICT gejal --- decreased consciousness.
Chronic:- Lightweight, 2 weeks - 3-4 months.- Bleeding into small pieces and spread slowly gathered.- Symptoms of headache, lethargy, mental mess, seizures, dysphagia.
Intracranial hematomas:Intracerebral hemorrhage ± 25 cc or more.Always followed by kontosio.The cause, a blood clot, local edema.
Effect of Head Trauma
Respiratory SystemCardiovascular system..
Respiratory System:
Hypoxemia, hypercapnia Increases Sympathetic stimulationImproved diffusion barriers O2 - Co2.Improve Pulmonary Edema vask prisoners. and systemic blood tekImprove tek, hydrostaticCapillary fluid leakageTek pulmonary vascular system. lower.Because of the direct compression on the brain stem respiratory symptoms ---- abnormal:Chyne stokes.Hyperventilation.Apneu.
Cardiovascular system:Trauma to the head --- changes in the function of the heart: contraction, pulmonary edema, tek. Vascular.Otonoom neural changes in ventricular function:- Dysrhythmias.- Fibrillation.- Tachycardia.The absence of endogenous sympathetic stimulus --- a decline in ventricular contractility. ---- --- Boost cardiac arrest decreased left ventricular --- pulmonary edema.
Assessment
The collection of patient data either subjective or objective in relation to system disturbances persyarafan head trauma is as follows:1. The identity of the patient and family (person in charge)
2. Medical History:In general, patients with head injury, came to the hospital with a decreased level of consciousness (GCS below 15), confusion, vomiting, dyspnea / tachypnea, headache,, weakly, paralise, head injuries, spuntum accumulation in the respiratory tract, the liquor from the nose and ears, and the presence of seizures.
Medical history first:It should be well known to the system associated neural circuitry system and other systemic diseases. Similarly, a family history of disease, especially those having a contagious disease. Health history can be assessed from the patient or the family as a data subjective. These data are very significant because it can affect pronosa patients.
3. Physical Examination:Neurological aspects:Studied is the level of consciousness, usually GCS less than 15, disorentasi person / place and time, a positive Babinski reflex, changes in the value of vital signs, the movement decebrasi or decortication and possible neck stiffness obtained with positive Brudzinski. The existence hemiparese.In conscious patients, it can not distinguish between different stimuli / stimulus taste, touch, temperature and vibration. Occurs involuntary movements, seizures due to impaired coordination. Patients also can not remember the events before and sesuadah trauma. Balance disorders in which the patient is awake, it can be seen or not be mempertahankana unsteady balance.
Cranial nerve may be disrupted if the head trauma to the brain stem due to widespread brain edema or brain hemorrhage.
Damage to nerve I (olfactory): showed symptoms of decreased sense of smell and bilateral anosmia. Nerve II (optic), the frontal trauma, show symptoms of decreased visual symptoms.Nerve III (Okulomotorius)
Nerve IV (Trokhlearis)Nerve VI (abducens), the damage will cause a decrease in visual field, light reflex, decreased, changes in pupil size, eye can not follow orders, anisokor.Nerve V (trigeminal), disorders characterized; any anesthetic forehead area.
Nerve VII (facial), in which the trauma capitis upper motor neuron can unilaterally decrease its function, the absence of nasolabial folds, eyelid closure weakness and loss of feeling on the 2/3 parts of the tongue anterior tongue.Nerve VIII (acoustic), in patients with symptoms of lower realized power of hearing and balance the body.
Nerve IX (Glosofaringeus).
Nerve X (vagus)
Nerve XI (Assesorius), symptoms are rarely found because the patient will die if the trauma of the nerve. The existence Hiccuping (basin) due to compression of the vagus nerve, which causes compression of the diaphragm and spasmodic. This occurs due to compression of the brain stem. Basin that occurs, it is usually at risk of increased intracranial pressure.Nerve XII (hipoglosus), common symptoms arise, is the fall of the tongue to one side, dysphagia and dysarthria. This causes a difficulty in swallowing.
Cardiovascular aspects:Learned changes in blood pressure decreases, unless an increase in the intracranial blood pressure increased, bradycardia pulse, then takhikardia, or irregular rhythm. In addition to other assessments collected are bleeding or discharge from the mouth, nose, ears, eyes. Hipereskresi presence in the oral cavity. Open bleeding / hematoma on other body parts. This needs assessment from head to toe.
Aspects of the respiratory system:Changes in breathing pattern, good rhythm, depth and frequency that is fast and shallow, irregular rhythm (chyne stokes, ataxia brething), ronchi breath sounds, wheezing. The presence of secretions in the tracheo brokhiolus. Increased body temperature can occur because of infection or stimulation of the hypothalamus as a central regulator of body temperature.Aspects elimination system:Will get the retention / incontinence in small or large bowel. There is a fluid and electrolyte imbalance, where there hyponatremia or hypokalemia. In the gastro-intestinal system is necessary to study the signs of decreased function of the gastrointestinal tract such as bowel sounds were not audible / weak, the nausea and vomiting. This is the basis for the provision of food.
Glasgow Coma Scale:I. Eye-Opening Reaction.4. Open your eyes spontaneously.3. Open your eyes when invoked / sound stimuli.2. Open your eyes when stimulated pain.1.Tidak reaction to any stimulus.
II. Speaking Reaction4. Good verbal communication, the right answer.3. Confused, disorentasi time, place and person.2. With the stimulus, the reaction is not just a word to form a sentence.III. Movement Reaction Arm / Leg6. Following orders.5. With pain stimuli can find out where the stimulus.4. With the stimulus of pain, pulling limbs.3. With painful stimuli, a reaction abnormal flexion.2. With the stimulus of pain, abnormal extension reactions arise.1. With painful stimuli, no reaction
4. Psychological Assessment:Where patients circuitry decreased level of consciousness, the psychological to the data can not be assessed, whereas in patients with normal levels of consciousness would look somewhat emotional disturbance, changes in behavior, emotions are unstable, irritable, apathy, delirium, and confusion for the patient's family anxiety connection with the illness.Social data that is needed is how psien dealing with people nearby and the other, the ability to communicate and their role in the family. As well as a patient's view of him after suffering head trauma and a sense of security.
5. Data spiritual:Required is adherence to the religion, the spirit and philosophy of life of patients and the deity he believes. Of course, the data collected in the absence of loss of consciousness.
6. Diagnostic Examination:Diagnostic tests performed in medical diagnosis is:X-Ray skull.CT-Scan.Angiography.
7. The Medical Management of Head Trauma:Drugs:Dexamethason / kalmethason: anti cerebral edema, in accordance with a heavy dose ringanya trauma.Hyperventilation therapy (severe head trauma), for mengurnagi vasodilation.Anti-edema treatment circuitry that hypertonic solutions of mannitol 20% or 40% glucose or 10% glycerol.Antibiotics containing the blood brain barrier (penicillin) or to be given metronidasol anaerobic infections.Food or liquid, the mild trauma when vomiting can not be given anything, only 5% dextrose intravenous fluids, aminofusin, aminofel (18 first hours of the accident), 2-3 days later given soft food.In severe trauma. Since the first days of the patient obtained decreased consciousness and tend to occur retention of sodium and electrolytes the first few days (2-3 days) is not too much fluid
Priority Nursing Diagnosis:1. Impaired brain tissue perfusion associated with circulatory disorders because the emphasis of the lesions (hemorrhage, hematoma).2. Potential or actual ineffectiveness breathing pattern, associated with damage to the respiratory centers in the medulla oblongata.3. Potential occurrence of increased intracranial pressure associated with the process of prodded space due to accumulation of blood in the brain fluid.4. Fluid and electrolyte balance disorders associated circuitry decreased production of anti-diuretic hormone (ADH) from the hypothalamus terfiksasinya.5. Actual / Potential disruption kebutuhannutrisi: Less than the needs associated with reduced ability to receive nutrients by decreasing awareness.6. Impaired physical mobilization associated with immobilization, bed rest rules for therapy.7. Disorders associated with decreased sensory perception sensory arrest power.8. Potential occurrence of infection associated circuitry entry of germs through the damaged tissue or continuity.9. Impaired sense of comfort: Headache berhubunagn circuitry damage brain tissue and brain hemorrhage / increased intracranial pressure.10. Impaired sense of security: Worried family of uncertainty associated with the treatment and care as well as a change and crisis situations.
Intervention:1. Examine the causes of the situation / circumstances of the individual / cause coma / decreased tissue perfusion and possible causes of increased ICP.R / Early detection for prioritizing interventions, assess neurologic status / signs of failure to determine the severity of treatment or surgery.2. Monitor and record GCS.R / Analyzing the level of awareness and the possibility of increased ICP and determine the location of the lesion.3. Monitor vital signs.R / A kedaan normal when the cerebral circulation is well maintained or marked fluctuations in systemic blood pressure, a decrease of outoregulator mostly a sign of lowering the diffusion of local cerebral blood vascularization. With the increase in blood pressure (diatolik) then coupled with increased intra-cranial blood pressure. Hipovolumik / hypotension is a manifestation of multiple trauma can cause cerebral ischemia. HR and disrhytmia an outgrowth of the brain stem disorders.4. Evaluation pupil.R / pupil reactions and eye movements of the back is a sign of impaired nerve / brainstem neuronal if torn. The balance between the sympathetic and parasympathetic nerves are cranial nerve reflex responses.5. Assess vision, memory, eye movements and Babinski reflex reaction.R / possibility of injury to the brain or brain stem. The decrease reflex sight is a sign of trauma pons and medulla. Coughing is a reflex of the notch and the disturbance medulla.Adanya Babinski reflex indications of brain injury in pyramidal.6. Monitor the temperature and temperature regulation.R / Summer is a reflex of the hypothalamus. Increased metabolic needs and O2 will support increased ICP.7. Monitor intake and output: my skin turgor, mucous membranes keadaa.R / Indication of impaired tissue perfusion head trauma can cause diabetes insipedus or syndroma increased secretion of ADH.8. Keep the head / neck in a neutral position, try a little circuitry pillow. Avoid using a lot of cushion on the head.R / Navigate datu head to one side of the jugular veins and impede cerebral venous drainage and increased ICP.9. Provide rest periods anatara care measures and limit the length of the procedure.R. Actions that can constantly improve ICP by cumulative effects of stimulation.10. Reduce Extra stimulation and provide a sense of comfort such as back massage, a quiet, friendly touch and atmosphere / talks were not rowdy.R / Giving atmosphere tenag (colming effect) can reduce psychological response and provide a break to maintain / low ICP.11. Help the patient when coughing, vomiting.R / activity may increase intra thoracic / pressure in the piston and pressure in the abdomen where it can increase pressure akitivitas ICP.12. Assess behavior enhancement and rest in the morning.R / non-verbal behavior is an indication of increased ICP dpat or give pain reflex in which the patient is unable to express verbally complaints, pain does not decrease to Increasing ICP.13. Palpation of the enlargement / widening blader, maintain a patent urinary drainage when used and also monitors the presence of constipation.R / May increase potential automatic response raised ICP.Collaboration:14. Raise the head of the bed / bed 15-45 degrees according to tolenransi / indication.R / Improved drainage / venous outflow from the head, reducing congestion and cerebral edema / risk of ICP.15. Give intravenous fluids according to the dindikasikan.R / Fluid may be desirable to menguransi cerebral edema, an increase in the minimum of the blood vessels, blood pressure and ICP.16. Give Oxygen.R / Reduce hipoxemia, which can increase cerebral vasodilation and increase blood volume and ICP.17. Give Diuretic drugs eg mannitol, furoscide.R / Diuretics may be used in acute pase to drain water from brain cells, and reduces cerebral edema and ICP.18. Steroids give an example: Dextamethason, methyl prednisolone.R / To reduce inflammation (inflammation) and reduces tissue edema.19. Give an example of high-dose painkillers: codeine.R / It may be indicated to reduce pain and drug negative effect on ICP but can be used with the cause to prevent.20. Sedatives Give examples: Benadryl.R / may be used to control the lack of rest and agitation.21. Give antipyretics, for example: aseptaminophen.R / Reduce / control day and on cerebral metabolism / oxygen is desired.
REFERENCES
Carpenito, L.P. (1999). Nursing Care Plans and Documentation, Nursing Diagnosis and Collaborative Problems. Ed.2. Jakarta: EGC.
Hospital Nursing Committee Dr. Soedono Madison. (1999). In the case of Head Trauma Management. Papers Kegawat daruratan in the surgical field. Not published.
Long, B.C. (1996). Medical Surgical Nursing (A Process Approach Kperawatan). New York: Foundation for Nursing Education Alumni Association Bandung.
Papers Lectures Medical Surgical PSIK Unair Surabaya. Not Published
Reksoprodjo, S. et al. (1995). Lecture set of Surgery. Jakarta: Bina Literacy way.
Rothrock, J.C. (1999). Perioperative Nursing Care Planning. Jakarta: EGC.
Tucker, B.C. (1998). Standard Care: Nursing Process, Diagnosis and Evaluation. Ed. 1. Jakarta: ECG.Posted by gayuh at 11:56NURSING CARE TO CLIENTS HEAD TRAUMA
Weight / severity of injury depends on:
1. Area affected:Skin injury.Bone tissue injury.Brain tissue injury.2. The state's head during impact.The main problem is the increase in intracranial pressure (PTIK)
ICT maintained by 3 components:1. The volume of blood / blood vessels (75-150 ml).2. Brain Network Volume (. 1200 to 1400 ml).3. CSF volume (75-150 ml).
B. Etiology
1. Accident2. Fall3. The trauma of childbirth.
Biological Response
Symptoms:1. If the client is aware ----- headache.2. Gag4. Awareness decline.5. Change the type of consciousness.6. Decreased blood pressure, bradycardia.7. isokor8. Body temperature that is difficult to control.
Type of head trauma:1. Open head trauma.2. Closed head trauma.
Open head trauma:Brain damage can occur when the skull into the brain tissue and hurt / ripped dura
Closed Head Trauma:
1. Komosio2. Kontosio.3. Epidural hematoma.4. Subdural hematoma.5. Intracranial hematoma.
Komosio / concussion:Mild head injuryTemporary neurologic dysfunction and can recover.Temporary loss of consciousness, less than 10-20 minutes.Without permanent brain damage.Symptoms of headache, dizziness, vomiting.control 24 hours I, observation of vital signs.There is no specific therapy.Absolute break ---- after missing complaint try mobilization stages, sitting --- stand - home.Once home ---- control, appropriate activity, adequate rest, diet enough.
Kontosio Cerebri / bruising of the brain:
There was bruising of the brain.Bleeding local small / diffuse ---- Local --- bleeding disorders.Symptoms:- Disorders of consciousness longer.- Neurologic Abnormalities positive, positive pathologic reflexes, paralysis, convulsions.- Symptoms of ICT increases.
Epidural hematoma:Anatara bleeding skull and dura mater.What common temporal and frontal.Sources: meningeal blood vessels rupture.Subdural hematoma:Bleeding between the dura and arachnoid.Usually ruptured vein --- acute, sub-acute, chronic.Acute:- Symptoms 24-48 hours.- Often associated circuitry brain injury and medulla oblongata.- ICT increases.- Headache, drowsiness, slowed reflexes, confusion, slow pupillary reflexes.
Sub Acute:- Evolving 7-10 days, kontosio bit heavy, the increased ICT gejal --- decreased consciousness.
Chronic:- Lightweight, 2 weeks - 3-4 months.- Bleeding into small pieces and spread slowly gathered.- Symptoms of headache, lethargy, mental mess, seizures, dysphagia.
Intracranial hematomas:Intracerebral hemorrhage ± 25 cc or more.Always followed by kontosio.The cause, a blood clot, local edema.
Effect of Head Trauma
Respiratory SystemCardiovascular system..
Respiratory System:
Hypoxemia, hypercapnia Increases Sympathetic stimulationImproved diffusion barriers O2 - Co2.Improve Pulmonary Edema vask prisoners. and systemic blood tekImprove tek, hydrostaticCapillary fluid leakageTek pulmonary vascular system. lower.Because of the direct compression on the brain stem respiratory symptoms ---- abnormal:Chyne stokes.Hyperventilation.Apneu.
Cardiovascular system:Trauma to the head --- changes in the function of the heart: contraction, pulmonary edema, tek. Vascular.Otonoom neural changes in ventricular function:- Dysrhythmias.- Fibrillation.- Tachycardia.The absence of endogenous sympathetic stimulus --- a decline in ventricular contractility. ---- --- Boost cardiac arrest decreased left ventricular --- pulmonary edema.
Assessment
The collection of patient data either subjective or objective in relation to system disturbances persyarafan head trauma is as follows:1. The identity of the patient and family (person in charge)
2. Medical History:In general, patients with head injury, came to the hospital with a decreased level of consciousness (GCS below 15), confusion, vomiting, dyspnea / tachypnea, headache,, weakly, paralise, head injuries, spuntum accumulation in the respiratory tract, the liquor from the nose and ears, and the presence of seizures.
Medical history first:It should be well known to the system associated neural circuitry system and other systemic diseases. Similarly, a family history of disease, especially those having a contagious disease. Health history can be assessed from the patient or the family as a data subjective. These data are very significant because it can affect pronosa patients.
3. Physical Examination:Neurological aspects:Studied is the level of consciousness, usually GCS less than 15, disorentasi person / place and time, a positive Babinski reflex, changes in the value of vital signs, the movement decebrasi or decortication and possible neck stiffness obtained with positive Brudzinski. The existence hemiparese.In conscious patients, it can not distinguish between different stimuli / stimulus taste, touch, temperature and vibration. Occurs involuntary movements, seizures due to impaired coordination. Patients also can not remember the events before and sesuadah trauma. Balance disorders in which the patient is awake, it can be seen or not be mempertahankana unsteady balance.
Cranial nerve may be disrupted if the head trauma to the brain stem due to widespread brain edema or brain hemorrhage.
Damage to nerve I (olfactory): showed symptoms of decreased sense of smell and bilateral anosmia. Nerve II (optic), the frontal trauma, show symptoms of decreased visual symptoms.Nerve III (Okulomotorius)
Nerve IV (Trokhlearis)Nerve VI (abducens), the damage will cause a decrease in visual field, light reflex, decreased, changes in pupil size, eye can not follow orders, anisokor.Nerve V (trigeminal), disorders characterized; any anesthetic forehead area.
Nerve VII (facial), in which the trauma capitis upper motor neuron can unilaterally decrease its function, the absence of nasolabial folds, eyelid closure weakness and loss of feeling on the 2/3 parts of the tongue anterior tongue.Nerve VIII (acoustic), in patients with symptoms of lower realized power of hearing and balance the body.
Nerve IX (Glosofaringeus).
Nerve X (vagus)
Nerve XI (Assesorius), symptoms are rarely found because the patient will die if the trauma of the nerve. The existence Hiccuping (basin) due to compression of the vagus nerve, which causes compression of the diaphragm and spasmodic. This occurs due to compression of the brain stem. Basin that occurs, it is usually at risk of increased intracranial pressure.Nerve XII (hipoglosus), common symptoms arise, is the fall of the tongue to one side, dysphagia and dysarthria. This causes a difficulty in swallowing.
Cardiovascular aspects:Learned changes in blood pressure decreases, unless an increase in the intracranial blood pressure increased, bradycardia pulse, then takhikardia, or irregular rhythm. In addition to other assessments collected are bleeding or discharge from the mouth, nose, ears, eyes. Hipereskresi presence in the oral cavity. Open bleeding / hematoma on other body parts. This needs assessment from head to toe.
Aspects of the respiratory system:Changes in breathing pattern, good rhythm, depth and frequency that is fast and shallow, irregular rhythm (chyne stokes, ataxia brething), ronchi breath sounds, wheezing. The presence of secretions in the tracheo brokhiolus. Increased body temperature can occur because of infection or stimulation of the hypothalamus as a central regulator of body temperature.Aspects elimination system:Will get the retention / incontinence in small or large bowel. There is a fluid and electrolyte imbalance, where there hyponatremia or hypokalemia. In the gastro-intestinal system is necessary to study the signs of decreased function of the gastrointestinal tract such as bowel sounds were not audible / weak, the nausea and vomiting. This is the basis for the provision of food.
Glasgow Coma Scale:I. Eye-Opening Reaction.4. Open your eyes spontaneously.3. Open your eyes when invoked / sound stimuli.2. Open your eyes when stimulated pain.1.Tidak reaction to any stimulus.
II. Speaking Reaction4. Good verbal communication, the right answer.3. Confused, disorentasi time, place and person.2. With the stimulus, the reaction is not just a word to form a sentence.III. Movement Reaction Arm / Leg6. Following orders.5. With pain stimuli can find out where the stimulus.4. With the stimulus of pain, pulling limbs.3. With painful stimuli, a reaction abnormal flexion.2. With the stimulus of pain, abnormal extension reactions arise.1. With painful stimuli, no reaction
4. Psychological Assessment:Where patients circuitry decreased level of consciousness, the psychological to the data can not be assessed, whereas in patients with normal levels of consciousness would look somewhat emotional disturbance, changes in behavior, emotions are unstable, irritable, apathy, delirium, and confusion for the patient's family anxiety connection with the illness.Social data that is needed is how psien dealing with people nearby and the other, the ability to communicate and their role in the family. As well as a patient's view of him after suffering head trauma and a sense of security.
5. Data spiritual:Required is adherence to the religion, the spirit and philosophy of life of patients and the deity he believes. Of course, the data collected in the absence of loss of consciousness.
6. Diagnostic Examination:Diagnostic tests performed in medical diagnosis is:X-Ray skull.CT-Scan.Angiography.
7. The Medical Management of Head Trauma:Drugs:Dexamethason / kalmethason: anti cerebral edema, in accordance with a heavy dose ringanya trauma.Hyperventilation therapy (severe head trauma), for mengurnagi vasodilation.Anti-edema treatment circuitry that hypertonic solutions of mannitol 20% or 40% glucose or 10% glycerol.Antibiotics containing the blood brain barrier (penicillin) or to be given metronidasol anaerobic infections.Food or liquid, the mild trauma when vomiting can not be given anything, only 5% dextrose intravenous fluids, aminofusin, aminofel (18 first hours of the accident), 2-3 days later given soft food.In severe trauma. Since the first days of the patient obtained decreased consciousness and tend to occur retention of sodium and electrolytes the first few days (2-3 days) is not too much fluid
Priority Nursing Diagnosis:1. Impaired brain tissue perfusion associated with circulatory disorders because the emphasis of the lesions (hemorrhage, hematoma).2. Potential or actual ineffectiveness breathing pattern, associated with damage to the respiratory centers in the medulla oblongata.3. Potential occurrence of increased intracranial pressure associated with the process of prodded space due to accumulation of blood in the brain fluid.4. Fluid and electrolyte balance disorders associated circuitry decreased production of anti-diuretic hormone (ADH) from the hypothalamus terfiksasinya.5. Actual / Potential disruption kebutuhannutrisi: Less than the needs associated with reduced ability to receive nutrients by decreasing awareness.6. Impaired physical mobilization associated with immobilization, bed rest rules for therapy.7. Disorders associated with decreased sensory perception sensory arrest power.8. Potential occurrence of infection associated circuitry entry of germs through the damaged tissue or continuity.9. Impaired sense of comfort: Headache berhubunagn circuitry damage brain tissue and brain hemorrhage / increased intracranial pressure.10. Impaired sense of security: Worried family of uncertainty associated with the treatment and care as well as a change and crisis situations.
Intervention:1. Examine the causes of the situation / circumstances of the individual / cause coma / decreased tissue perfusion and possible causes of increased ICP.R / Early detection for prioritizing interventions, assess neurologic status / signs of failure to determine the severity of treatment or surgery.2. Monitor and record GCS.R / Analyzing the level of awareness and the possibility of increased ICP and determine the location of the lesion.3. Monitor vital signs.R / A kedaan normal when the cerebral circulation is well maintained or marked fluctuations in systemic blood pressure, a decrease of outoregulator mostly a sign of lowering the diffusion of local cerebral blood vascularization. With the increase in blood pressure (diatolik) then coupled with increased intra-cranial blood pressure. Hipovolumik / hypotension is a manifestation of multiple trauma can cause cerebral ischemia. HR and disrhytmia an outgrowth of the brain stem disorders.4. Evaluation pupil.R / pupil reactions and eye movements of the back is a sign of impaired nerve / brainstem neuronal if torn. The balance between the sympathetic and parasympathetic nerves are cranial nerve reflex responses.5. Assess vision, memory, eye movements and Babinski reflex reaction.R / possibility of injury to the brain or brain stem. The decrease reflex sight is a sign of trauma pons and medulla. Coughing is a reflex of the notch and the disturbance medulla.Adanya Babinski reflex indications of brain injury in pyramidal.6. Monitor the temperature and temperature regulation.R / Summer is a reflex of the hypothalamus. Increased metabolic needs and O2 will support increased ICP.7. Monitor intake and output: my skin turgor, mucous membranes keadaa.R / Indication of impaired tissue perfusion head trauma can cause diabetes insipedus or syndroma increased secretion of ADH.8. Keep the head / neck in a neutral position, try a little circuitry pillow. Avoid using a lot of cushion on the head.R / Navigate datu head to one side of the jugular veins and impede cerebral venous drainage and increased ICP.9. Provide rest periods anatara care measures and limit the length of the procedure.R. Actions that can constantly improve ICP by cumulative effects of stimulation.10. Reduce Extra stimulation and provide a sense of comfort such as back massage, a quiet, friendly touch and atmosphere / talks were not rowdy.R / Giving atmosphere tenag (colming effect) can reduce psychological response and provide a break to maintain / low ICP.11. Help the patient when coughing, vomiting.R / activity may increase intra thoracic / pressure in the piston and pressure in the abdomen where it can increase pressure akitivitas ICP.12. Assess behavior enhancement and rest in the morning.R / non-verbal behavior is an indication of increased ICP dpat or give pain reflex in which the patient is unable to express verbally complaints, pain does not decrease to Increasing ICP.13. Palpation of the enlargement / widening blader, maintain a patent urinary drainage when used and also monitors the presence of constipation.R / May increase potential automatic response raised ICP.Collaboration:14. Raise the head of the bed / bed 15-45 degrees according to tolenransi / indication.R / Improved drainage / venous outflow from the head, reducing congestion and cerebral edema / risk of ICP.15. Give intravenous fluids according to the dindikasikan.R / Fluid may be desirable to menguransi cerebral edema, an increase in the minimum of the blood vessels, blood pressure and ICP.16. Give Oxygen.R / Reduce hipoxemia, which can increase cerebral vasodilation and increase blood volume and ICP.17. Give Diuretic drugs eg mannitol, furoscide.R / Diuretics may be used in acute pase to drain water from brain cells, and reduces cerebral edema and ICP.18. Steroids give an example: Dextamethason, methyl prednisolone.R / To reduce inflammation (inflammation) and reduces tissue edema.19. Give an example of high-dose painkillers: codeine.R / It may be indicated to reduce pain and drug negative effect on ICP but can be used with the cause to prevent.20. Sedatives Give examples: Benadryl.R / may be used to control the lack of rest and agitation.21. Give antipyretics, for example: aseptaminophen.R / Reduce / control day and on cerebral metabolism / oxygen is desired.
REFERENCES
