Neurosensory:
Traumatic Brain Injury (TBI)
& Brain Tumors
Marnie Quick, RN, MSN, CNRN
Normal brain protected by:
Normal brain
Traumatic Brain Injury (TBI):
Etiology/Pathophysiology
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Risk factors- MVA; elevated blood alcohol;
contact sports; acts of violence- gun, knife
Mechanism of craniocerebral trauma
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Acceleration (movement)-deceleration (stationary)
Coup (impact)-contrecoup (opposite) phenomenon
Blunt or penetrating injury
Closed head injury
Scalp lacerations
Skull fractures- Linear; comminuted; depressed;
basilar; open/closed
Coup-contracoup injury
Penetrating injury- Gunshot to brain
Penetrating injury: Knife in brain
Basilar skull fracture- Base of skull fractured
Basilar skull fracture is base of skull if posterior>
Battle sign- ecchymosis behind the ear
Basilar skull fracture is more anterior
Raccoon eyes- periorbital ecchymosis
Basilar Skull fractures can cause
leakage of CSF from meninges
Minor Brain Injury
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Concussion- sudden transient disruption of
neural activity in the brain with change in
LOC
Post Concussion Syndrome- may occur
after other brain injuries- severity of
symptoms are not related to severity of
brain injury. Sym may persist wks-months
Major Brain Injury- Focal injury
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Brain contusion- bruising; coup-contracoup
Brain laceration- tearing brain tissue, ICH
DAI- diffuse axonal injruy
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Widespread disruption of axons
Poor prognosis
Brain bleeds- Note meninges in relation to
bleeds on following slides
Epidural hematoma
Subdural hematoma (SDH)
Intracerebral hematoma
Secondary brain injury
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Cerebral edema
 Localized or diffuse
 Peaks 24-72 hrs
 Occurs with CHI; open head injury; anoxia
 May in itself cause death by pressure> herniation
Increased ICP
Herniation Syndromes
Traumatic Brain Injury (TBI):
Common Manifestations/Complications
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Increased ICP symptoms general and specific
Restlessness- R/O respiratory; waking up
Systemic effects of acute brain injuryhypermetabolism, brainstorming, SIADH
Brainstorming- hypothalamic stimulation-ANS
CSF leak- rhinorrhea/otorrhea- basal skull Fx
Post concussion Syndrome
Associated cervical spinal cord injury
Collaborative Care: Traumatic Brain Injury (TBI):
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Diagnostic studies (similar to ICP)
Emergency management: assessment and interventions
(Lewis 1442 Table 57-9)
Treat IICP- airway; fluid; positioning; temp reg; meds
Prevention of complications
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Medications: IICP; seizures; stress ulcer;straining;brainstorming
Diet/calories: hypermetabolic state; ileus; swallow/gag
CSF leak: glucose; halo; HOB 30; no nasal suction
Other: SIADH> hyponatremia
Surgery: bone repair; evacuation clot; craniotomy/ectomy;
burr hole; cranioplasty; monitor placement
Burr holes
craniotomy
Place monitors/intraventricular drain:
Crainectomy- bone flap out to allow for brain
expansion post op
Post crani
Traumatic Brain Injury (TBI):
Nursing assessment specific to TBI
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Health history
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Description of accident; past medical history
NVS and Glasgow Coma
http://www.trauma.org/scores/gcs.html
Brainstem reflexes
VS- Late sign is Cushing reflex
Skull/face; CSF leak; SCI
Consider older adult finding
Pertinent Nursing Problems Specific to
Traumatic Brain Injury (TBI):
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Health promotion
Ineffective tissue perfusion, cerebral (decreased
intracranial adaptive capacity)
Ineffective airway clearance/breathing pattern
Hypothermia
Pain
Impaired physical mobility
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Anxiety
Decreased cerebral perfusion (IICP)
Brain death (ethical dilemmas p.1450)
Home care
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Home evaluation/rehab/nursing home
Teach about post concussion syndrome; B&B;
spasticity; dysphagia; nutrition; seizure disorder;
personality changes; family role changes
6 months typical plateau period
Community agencies/support groups
http://library.med.utah.edu/kw/animations/hyperbrain/oculo_r
eflex/oculocephalic2.html
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http://cim.ucdavis.edu/eyes/version15/eyesim.html
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http://www.softwarefornurses.com/access/index.asp
Primary
brain tumors
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Arise from support
cells, neurogilia cells;
the meninges; or
blood vessels
Do not metastasize
outside cranium
Cause unknown
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Grade I and II gilomas (astrocytoma) made up of
astrocytes; are benign, slow-growing tumors
Grade III and IV gliomas (glioblastoma
Multiforme are invasive and fast-growing
Meningiomas arise from the meninges; slowgrowing; benign, encapsulated and compress the
brain
Brain tumors may be lethal due to their location
Gioblastoma
Meningioma
Metastatic (secondary) brain tumors
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Originate from outside
the brain- lung and breast
most common sites
Single or multiple
Becoming more common
as individual with cancer
in other parts of the body
are living longer
Clinical Manifestations/complications of
Brain tumors
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General ICP symptoms
Common early symptoms: headache; vomiting;
papilledema (visual changes)
Seizures- partial classification in type
Brain tumor symptoms occur due to their ability
to compress or destroy brain tissue; edema that
forms around the tumor; hemorrhage; &
obstruction of CSF flow
Specific symptoms as to the lobe affected>
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Frontal lobe: personality changes; inappropriate
behavior; inability to concentrate; impaired
judgment; headache; expressive aphasia if
dominant hemisphere; motor weakness or
paralysis from motor strip
Parietal lobe: sensory deficits- paresthesia, visual
field deficits; contralateral sensory disturbances
from sensory strip; loss of interpretation and
discrimination for sensing input; perceptual
problems
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Occipital lobe: visual disturbances; visual agnosia
Temporal lobe: complex partial (psychomotor)
seizures; auditory hallucinations; memory
problems; Wernicke aphasia if dominant
hemisphere
Cerebellum: gait distrubances; balance and
coordination problems
Brain stem: cranial nerve dysfunction; vital signs
Complications of Brain Tumors
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Hydrocephalus
Infection
Death is usually caused by IICP/hermiation
Collaborative Care for Brain Tumors
Diagnostic tests
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CT/MRI
EEG
PET
Angiogram
Tissue biopsy
Collaborative Care for brain tumors
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Surgery
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To remove or debulk
Supratentorial- above
tentorium
Infratentorial-below
Stereotaxic-localized
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Radiation
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Medications
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Used alone or with other therapies
Gamma or Cyber-knife
Complication- increased cerebral edema
Chemotherapy: IV; intraventricular (ommaya
Reservoir) or by wafer implanted
Corticosteroids to treat brain edema
Anticonvulsants to prevent seizures
Rehab- outpatient or in house
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Health history: progression of symptoms; other
cancers, disease
Physical exam
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Neuro vital signs
Specific signs of the local functions of different parts
of the brain
Similar neuro deficits as the individual with a stroke
Signs of increased intracranial pressure/herniation
Pertinent Nursing Problems for Brain Tumor
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Impaired tissue perfusion, cerebral
Self-care deficits
Anxiety
Risk for infection-post crani
Acute pain
Disturbed self-esteem
Nutrition
Home care- rehab; home eval; support groups