Neurological Case Study #1
A 28-year-old client with a
Past Medical History of seizure disorder that is controlled with Tegretol® (last seizure was 5 years ago), hypothyroidism
that is controlled with Synthroid®, and has had a
recent urinary tract infection slipped and fell hitting her head while on a
family outing. She experienced loss of consciousness at the scene. She was
taken to a local hospital where a CT scan revealed a Left Subdural hematoma.
She has been transferred to your regional medical center, which has
neurosurgeon on call.
The RN needs to assess about the patient’s current
LOC, medications, and plan of treatment at this time. What are the pt’s most
current VS, cardiac rhythm/rate, and oxygen requirements? Lab work also needs
to be assessed to ensure the patient’s F/E status are
within expected limits. Psychosocial
parameters also need to be addressed. Is the patient married? Partnered? Is
there family that will also be helping to care for the patient?
Subdural hematoma (SDH) is
the most common extra-axial collection and is seen in 5% of head trauma
patients. SDH occurs between the dura and the arachnoid membrane, most often due to venous bleeding from
the "bridging" subdural veins which connect the cerebral cortex to
the dural sinuses. However, SDH may also result from
disruption of the penetrating branches of superficial cerebral arteries. These collections
tend to conform to the shape of the brain and the cranial vault, exhibiting
concave inner margins and convex outer margins. Occasionally, SDH may be
straight or even concave in appearance.
Patients
with SDH commonly present after acute deceleration injury from a fall or motor
vehicle accident, but are rarely associated with skull fracture. More rarely, coagulopathies, tumors, or aneurysms may be responsible for
SDH.
SDH may be
classified as hyperacute (low density) if less than
12 hours from the acute event, acute (high density) if less than few days,
subacute (isodense) from a few days to 2-3 weeks, and
chronic (low density) if more than 3 weeks after the time of injury.
SDH may be
classified as hyperacute (low density) if less than
12 hours from the acute event, acute (high density) if less than few days,
subacute (isodense) from a few days to 2-3 weeks, and
chronic (low density) if more than 3 weeks after the time of injury.
Risk factors include:
Any change in the patient’s level of consciousness
(LOC) needs to be monitored closely. The RN would want to follow unit protocol
to ensure that the patient’s neurological status is being regularly assessed
(at least every 2 hours). Sudden changes in LOC, confusion, dizziness, vertigo,
slurred speech, or drowsiness indicates a possible increase in ICP (normally
10-15 mm Hg). Late and ominous findings of increased ICP include Cushing’s
Triad (Widening Pulse Pressure with acute HTN, Erratic Respirations, and Bradycardia).
Tegretol® is an antiepileptic medication that
should be kept at a constant serum level to help control seizure activity by
increasing the threshold of excitation at neuronal synaptic clefts through
alteration of Na+ channels in neurons. Seizure activity can lead to potentially
lethal effects in this patient as tonic-clonic
associated movements can result in further tearing of the vascular network and
cause increased hemorrhage, increased ICP, and death.
Faculty Note: Discuss the role of seizure
precautions, a brief history of antiepileptic medications (Dilantin®
= Hyperplasia of Gingiva; Phenobarbitol®
= Decreased Intelligence Quotient).
Ataxia and Drowsiness are most common adverse effects of Tegretol®.
Large hematomas or solid blood clots may need to be
removed through a larger opening in the skull (craniotomy). The decision not to perform
this procedure on this patient indicates that the Subdural Hematoma isn’t
significant enough to require craniotomy. Small Subdural Hematomas can reaborb
into the vasculature tree of the brain without complications. Subacute and chronic subdural hematomas have
good outcomes in most cases, with symptoms going away after drainage of the
blood collection. There is a high frequency of seizures following subdural
hematoma; however, these seizures are usually well controlled with medication.
The reasoning for this stems from the
amount of blood collection that presents during these various bleeds. Acute
Subdural Hematomas typically have smaller amounts of collecting blood compared
to subacute and chronic. Additionally, there is Less frequent association of
chronic intracranial Subdural Hematoma evacuation
with cerebral edema than for acute Subdural Hematoma
(cerebral edema frequently associated). Risk of herniation is lower than with acute. The chronic subdural hematoma is completely liquefied and can be evacuated
through a tube (craniostomy) or through small
trephinations. It is difficult to treat an acute
subdural hematoma with burr holes because the clot
cannot be evacuated well).
Hypotonic fluids will increase cerebral edema—Fluid
is pulled into the cell to help create an isotonic environment for both sides
of the cellular membrane resulting in an increased cerebral edema. Maintain euvolemia, using normotonic
rather than hypotonic fluids, to maintain brain perfusion without exacerbating
brain edema.
The patient should have the HOB elevated about 45
degrees to help decrease ICP and help facilitate reabsorption
of blood.
You would want to explain the current clinical
picture to the neurosurgeon. What have the precise changes in LOC been? What
are the patient’s current vital signs?
What is the client’s affect at THIS time? If an ICP monitor is being
used, what is the exact ICP measurement at this time?
Families need information! Studies indicate that
families of patients in ICU lack information; that is the most important
intervention the RN can perform for family members. Also, explaining the course
of Tx and expectations of
the patient and family is an important psychosocial intervention for both the
family and the patient.
Codeine works as a cough suppressant. Coughing can
increase ICP so at this time, both decreasing nervous stimuli in the coughing
reflex of the carina while controlling pain is most beneficial.