Lewis: Medical-Surgical Nursing, 7th Edition Answer Guidelines for Case Studies in Textbook Chapter 57: Nursing Management:

Acute Intracranial Problems

Head Injury 1. T.Js hypoxia is directly related to the brain injury sustained in his accident. Increasing intracranial pressure as a result of hematoma formation as well as cerebral edema can result. With increasing intracranial pressure there is concern about the regulation of breathing. He has shallow and irregular respiration, which may reflect pressure on the brainstem breathing centers. Hypotension is also a result of increasing intracranial pressure and subsequent effects on the vasomotor center of the brainstem. Tachycardia represents a compensatory increase in heart rate in response to lowered blood pressure. 2. Hypotension and hypoxia can result in further increases in intracranial pressure. In response to lower oxygen levels and high carbon dioxide levels, cerebral vessels dilate and increase the intravascular volume. The lower systolic blood pressure reduces the cerebral perfusion pressure needed to adequately perfuse brain tissue. 3. The direct injury involved the left cerebral cortex, as evidenced by paralysis and lack of consciousness. The brainstem is also likely involved, as evidenced by lack of pupillary reactions, irregular respirations, and hypotension. 4. Maintenance of a patent airway is critical in the patient with increased ICP and is a primary nursing responsibility. The general goal of nursing management of the head-injured patient is to maintain cerebral perfusion and prevention of secondary cerebral ischemia. Surveillance or monitoring for changes in neurologic status is critically important. Neurologic assessments at intervals based on the patients condition are performed using a tool such as the Glasgow Coma Scale. Appropriate preoperative and postoperative nursing interventions are initiated if surgery is anticipated. Strategies to decrease intracranial pressure and maintain cerebral perfusion pressure are implemented. Because of the close association between hemodynamic status and cerebral perfusion, the nurse must be aware of any coexisting injuries or conditions. In the acute postinjury period, treating other life-threatening conditions (i.e., hemorrhage or hypoxia) may take initial priority in nursing care. 5. Nursing diagnoses: ineffective tissue perfusion (cerebral), acute pain (headache), self-care deficits, anxiety Collaborative problem: seizures, cerebral ischemia, hemorrhage
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