Patients with craniocerebral injury are often injured suddenly p heavy condition p fast change p long course p many complications, which requires nursing staff must master solid theoretical knowledge p skillful operating techniques, closely observe changes in the condition, take correct and effective nursing measures, actively cooperate with doctors in treatment, reduce complications, reduce disability and mortality rates, and improve the quality of life of patients.
Contents
Care of craniocerebral injury
First-aid care
Second, postoperative care of craniocerebral injury
Third, the care of complications
IV. Nursing care of ventricular drainage
V. Tracheotomy care
Craniocerebral injury care
Patients with craniocerebral injury are often injured suddenly, their condition is heavy, they change quickly, their course is long, and they have many complications, which requires nursing staff to master solid theoretical knowledge and skillful operating techniques, to closely observe changes in their condition, to take correct and effective nursing measures, to actively cooperate with doctors, to reduce complications, to reduce disability and mortality, and to improve the quality of life of patients.
Nursing care for cranial brain injury
First aid care
Postoperative care of craniocerebral injury
Complication care
Nursing care of ventricular drainage
Tracheotomy care
I. Emergency care
Resuscitation work must be stable p accurate p fast.
1. Make adequate preparation of mind, preparation of articles and preparation of resuscitation, such as oxygen p suction device p resuscitation car p treatment tray p tongue depressor, etc. Place the patient in the resuscitation room or flat car in place to resuscitate, minimize moving, so as not to aggravate the condition.
2, immediately observe the consciousness p pupil p blood pressure and limb activity and make a record. At the same time, ask the medical history, understand the time of injury, the nature of the external force, the site of action, the post-injury state of consciousness and clinical manifestations.
3, keep the airway open, vomiting should be tilted to the side of the head, timely suction out of the mouth and respiratory tract of vomit. If the back of the tongue is obvious and obstruct the airway, you should go to the pillow and hold up the lower jaw, if necessary, apply the airway, give oxygen inhalation. In severe respiratory failure, immediately give respiratory stimulants, if necessary, tracheal intubation, artificially assisted breathing.
4, intracranial pressure increased significantly or has occurred brain herniation, should be rapid sedation 20% mannitol 250 ~ 500 ml, add dexamethasone 5 ~ 10 mg, can enhance the effect of dehydration, in order to strive for the timing of surgery.
5, immediately correct shock. Patients with open craniocerebral injury should be quickly treated wounds, effective hemostasis, if combined with shock, establish intravenous access as soon as possible, timely replenishment of blood volume, pay attention to check whether there are compound injuries of the thoracic p abdominal organs and extremities spine.
6. Immediately do penicillin p procaine test, prepare blood, shave the head and leave a urinary catheter in place. Change the clean patient’s gown and prepare for surgery.
Second, postoperative care of craniocerebral injury
To understand the intraoperative situation to the doctor in a timely manner, so as to have a good idea of the targeted care of the patient.
1. Proper placement, close observation:
Place the patient in the intensive care unit, dedicated care. Immediately observe the consciousness, pupil, respiration, blood pressure and limb movement and record. Observe and record once every 15~30 minutes until the condition is stable.
2.Posture:
Postoperative decubitus lying flat for 6 small operations, comatose patients should tilt their heads to the side to prevent vomit from being accidentally inhaled into the trachea. The head of the bed should be elevated 15°~30° early after the condition is stabilized to promote venous reflux and reduce cerebral edema.
3. Respiration.
Continuous low-flow oxygenation after surgery to keep the airway open, improve cerebral hypoxia, and primary damaged brain cells repair. If the patient returns to the ward with tracheal intubation, oxygen saturation should be monitored and sputum should be aspirated promptly and thoroughly to prevent sputum crust from blocking the intubation tube. If the patient is obviously irritable, gradually conscious, and the cough reflex exists, the physician should be notified promptly and the tracheal intubation should be removed after thorough aspiration. If the patient is deeply comatose and the cough reflex and swallowing reflex disappear, tracheotomy should be prepared as soon as possible.
4. Drinking and eating.
Fasting for 6 hours after surgery. The awake patient can have a liquid diet the next day, and gradually change to semi-liquid diet and normal diet. Gastric tube should be placed as early as possible in comatose patients, not only to give nasal fluid to solve the nutritional problems, but also to observe the nature of gastric juice and detect gastrointestinal bleeding early. The initial 2 days of nasal feeding should be given ordinary milk, and the amount should not exceed 100 each time to prevent acute gastric dilatation, and to observe any indigestion performance. If the gastrointestinal function is normal, pre-mixed milk can be given, i.e., eggs can be boiled together with milk after being broken by a processor, and mashed meat, fish and fresh fruit juice can be added gradually to meet the body’s high calorie and high protein needs, promote the body’s repair, and prevent disuse atrophy of the digestive tract. During nasal feeding should be saline cotton ball oral care twice a day.
5.Large p urine care.
Patients should be kept loose stools, prevent constipation, can eat fresh fruits and vegetables. Constipation can be given laxatives or corkage, enemas are strictly prohibited to avoid large amounts of water reabsorption and aggravate cerebral edema. For fecal incontinence, the skin should be washed and dried in time. For urinary incontinence, catheterization can be left in place to keep the area clean and the catheter unobstructed, and the urine bag should be changed regularly. If the urine is cloudy or flocculent, the bladder should be flushed promptly. The color and volume of urine should be closely observed and recorded. For long-term heavy use of mannitol, if hematuria is found, the doctor should be notified in time.
6. Observation of secondary intracranial hemorrhage.
If the patient is conscious after surgery and reappears with symptoms of impaired consciousness p increased intracranial pressure, along with symptoms of local brain injury; or if the condition does not improve and progressively worsens at the same time, the doctor should be notified in time. Especially within 24 hours after surgery should be particularly responsible, pay attention to the changes in consciousness p pupil and limb activity.
7. Care of the irritable patient.
Patients with severe cerebral contusions often show significant irritability, and precautions should be strengthened. Use bed block to prevent falling out of bed. Restraint belt can be used to appropriately restrict the movement of agitated limbs to prevent the drainage tube from being pulled out. For those with Frey’s urinary catheter, hands should be placed outside the cover to prevent scratching of the urinary catheter leading to urethral tear.
8. Care of hyperthermia.
Due to brain tissue injury and trauma resulting in impaired function of the thermoregulatory center, patients may develop central hyperthermia, and effective cooling methods must be taken to reduce the cerebral metabolic rate and alleviate cerebral hypoxia.
The head p neck p groin p axillae and other large blood vessel alignments are applied externally or alcohol warm water baths. Ice bag should be wrapped with a thin towel and placed with the local and regular replacement of cold compress parts to avoid frostbite local skin. Chest and abdomen are not allowed to rub baths and cold compresses.
Electronic ice cap or ice blanket can control the temperature to achieve the effect of long-term constant low temperature, cooling effect is obvious. Note when applying ice cap: the helmet and head should be sealed to prevent the air from entering the cap to occur condensation phenomenon and wet wound dressing, need to regularly check to keep the dressing clean and dry; ear and back of the pillow pad antifreeze pad; check whether the connecting tube is pressed or bent. Attention should be paid when applying ice blanket: the waist and back level abdomen is protected with towel quilt to prevent diarrhea; if the indicated temperature does not match with the actual temperature, it should be carefully checked and repositioned if necessary.
Hibernation drugs: application of hibernation spirit with ice blanket ice cap is effective in cooling, but respiratory p heart rate p blood pressure changes should be closely monitored and recorded every 15~30 minutes.
9. Observation and care of cerebral edema.
The peak period of cerebral edema is 72 hours after injury or surgery, so close attention should be paid to the observation of changes in the condition to prevent the occurrence of brain herniation. The patient should adopt a head-high-foot-low position to facilitate venous reflux in the head. Apply dehydrating agent on time according to the doctor’s prescription, and control the daily infusion volume to 1500~2000 ml, and a light diet should be given. During the application of dehydrating agent, potassium salt should be supplemented and blood biochemistry should be checked to prevent electrolyte disorders. When infusing potassium, the concentration should not be too high and the speed should not be too fast, and potassium should be replenished when seeing urine.
Third, the care of complications
1. Decubitus ulcers.
Patients with coma paraplegia and hemiplegia should be turned once every 1~3 hours and the skin of the pressurized parts should be massaged. Padded cushions should be used at the protruding bones and other pressure-prone areas, and electric air beds should be used to reduce local pressure if available. Keeping the bed clean and dry and the skin clean, giving supportive therapy, and improving the nutritional status of the whole body are the main measures to prevent bedsores.
2. Pulmonary infection.
As the cough reflex and swallowing reflex are weakened or disappeared, oral and respiratory secretions and vomit can easily be accidentally inhaled or accumulated in the lungs and cause lung infections. Attention should be paid to buckling the back when turning to facilitate drainage of secretions, and timely and thorough aspiration of sputum. Nebulized inhalation can be given twice a day if the sputum is sticky. If necessary, tracheotomy should be performed as early as possible and its nursing routine should be strictly enforced, and oral care should be strengthened by scrubbing with saline cotton balls twice a day.
Care of complications
3. Stress ulcers.
It is a common complication of neutral craniosynostosis and one of the main factors leading to death. The main manifestations are: coffee-colored gastric juice and tarry stool p intestinal paralysis can be due to bleeding stored in the intestinal cavity and abdominal distension, bleeding more can appear pale pulse fine speed blood pressure drop and other shock manifestations, comatose patients early placement of gastric tube is conducive to early detection of changes in the condition and take rescue measures. The patient’s blood pressure, heart rate, urine volume and the color and amount of gastric juice should be closely observed. If the amount of bleeding is greater than 400 ml, fresh blood should be transfused, and if the bleeding does not stop, open surgery should be performed to stop the bleeding.
4. Erratic reflux.
Diaphragmatic spasm is also a common clinical manifestation of post-cranial injury vegetative nerve disorder can induce or aggravate gastric bleeding, and can also affect the patient’s breathing and diet. Commonly used clinical methods include: Lopressor 3 mg or Ritalin 0.25 g line of Neiguan or Foot San Li closed. Pressing the supraorbital nerve on both sides or acupuncture. Musk 1 gram ice chips 1 gram Zhenjiang plaster 1 patch, external application at the navel.
5. Care of skull base fracture.
Three prohibitions and one morning. That is: forbidden to wash, forbidden to block, forbidden to cough p blow nose, early application of antibiotics. To keep the local clean, use sterile cotton balls or cotton testers to wipe.
6. Traumatic epilepsy.
In case of seizure, apply gauze wrapped tongue depressor to be inserted between the upper and lower teeth of the patient to prevent tongue bite, remove oral secretions in time, untie the collar, lay the patient flat, immediately press the man center point, push Valium 10 mg intravenously, and give Valium 20 mg into 500 ml of liquid for sedation when seizures persist, and give oxygen inhalation. Add bed stall to prevent the patient from falling into bed.
7. Paraplegia.
Paraplegia can occur when the spinal injury compresses the spinal cord during cranio-cerebral injury. Turning should be consistent with the upper and lower body does not twist, and let the patient lie on a hard bed. Strengthen skin care and prevent decubitus ulcers; strengthen the active and passive activities of paralyzed limbs and maintain the functional position to prevent muscle atrophy, joint stiffness and foot prolapse. Prevent the occurrence of urinary and pulmonary complications, enhance nutrition, and encourage patients to establish confidence in overcoming the disease.
Breathing
Continuous low-flow oxygenation after surgery to keep the airway open, improve cerebral hypoxia, and repair damaged brain cells in the primary. If the patient returns to the ward with tracheal intubation, monitor the oxygen saturation and promptly aspirate sputum, which should be thorough to prevent sputum crust from blocking the intubation tube. If the patient is obviously irritable, gradually conscious, and the cough reflex exists, the physician should be notified promptly and the tracheal tube should be removed after thorough aspiration. If the patient is deeply comatose and the cough reflex and swallowing reflex disappear, tracheotomy should be prepared as soon as possible.
IV. Care of ventricular drainage
Ventricular drainage is the placement of a drainage tube after lateral ventricular puncture via skull drilling to drain cerebrospinal fluid outside the body, effectively reducing intracranial pressure and preventing brain herniation. The following observations and care should be noted.
1, strict aseptic operation, connecting the ventricular drainage bottle and fixing it properly to prevent dislodgement.
2. The drainage bottle is hung at the head of the bed, and the highest point of the drainage tube is 10-15 cm from the lateral ventricle to maintain the normal intracranial pressure. In the early stage of drainage, special attention should be paid to the speed of drainage should not be too fast to avoid collapse of the enlarged ventricle after sudden drainage of a large amount of cerebrospinal fluid and formation of epidural snow in or subdural hematoma. The daily drainage flow should not exceed 500 ml.
3, close observation of cerebrospinal fluid properties: If the color of the cerebrospinal fluid is cloudy should immediately notify the doctor to retain the cerebrospinal fluid for routine laboratory tests. Also closely observe the temperature change and consider whether it is an infection.
4. Keep the drainage tube unobstructed, prevent distortion and pressure, and avoid pulling the drainage tube when turning over. If the drainage tube is obstructed and flushing is contraindicated, use a sterile syringe to gently suction outward under strict aseptic operation and adjust the height of the drainage tube appropriately.
5.Keep the local dressing dry and change it in time if it is wet; keep the bed clean and dry, and do not place miscellaneous objects at the head of the bed.
6.Change the drainage bottle daily and record the drainage flow. Strictly aseptic operation to prevent the joint from being contaminated.
7, minimize the number of indoor companions, open the windows regularly every day, scrub the floor with 1:200 84 disinfectant, and disinfect the air with ultraviolet light once a day.
8, the ventricular drainage time is too long, there is a risk of intracranial infection, generally not more than a week. Before extubation, the drainage bottle should be elevated and observed for 24 hours. If there is no symptom of increased intracranial pressure, the tube should be closed and observed for 24~48 hours, if the patient has no headache, vomiting and other discomfort before extubation. After extubation, pay attention to observe whether there is cerebrospinal fluid leakage at the incision, if there is overflow, notify the doctor to do the necessary treatment in time.
V. Tracheotomy care
Tracheotomy is an effective method to lift the obstruction of the airway p to improve ventilation disorders, and is a measure often used in brain surgery. The postoperative care routine must be strictly implemented to prevent or reduce the occurrence of pulmonary infection.
1, ward environment requirements. Room temperature requirements in 20 ~ 22 ℃ , humidity 60% ~ 80%, regular ventilation, daily ultraviolet radiation 30 minutes, the ground with 1: 200 84 disinfectant scrubbed 3 times. Reduce the number of accompanying people.
2.Timely aspiration to keep the respiratory tract unobstructed, turning p-back is conducive to sputum drainage and prevention of pulmonary atelectasis. The duration of sputum aspiration should not exceed 15 seconds. Aspiration should be operated strictly aseptically, and materials should be used exclusively. The suction tube that touches the oral and nasal cavities cannot be used again for suctioning outside the cannula, one tube at a time, and the used suction tube is soaked in 1:200 84 disinfectant for 30 minutes and then the cavity is rinsed, and then boiled for disinfection. The glass tubing connected to the suction tube is soaked in 1:200 84 disinfectant solution. When suctioning sputum, the action should be gentle, and the depth of the tube should be inserted to stimulate the patient to cough effectively, and rotate the suction tube while suctioning sputum to thoroughly wash the sputum.
3.Oral care twice a day to keep the oral cavity clean.
4.Wet the airway to protect the tracheal mucosa, dilute the sputum and prevent the formation of sputum crust. You can apply saline 30 ml plus gentamicin 80,000 units p dexamethasone 5 mg p chymotrypsin 1, nebulized inhalation, 20 minutes each time, 2~3 times a day. Tracheal drip can also be applied, 4~6 sticks each time p once every 2 hours, care should be taken to fix the needle when dripping to prevent it from falling off, and the patient should drip the medicine when inhaling and stop when exhaling.
5.Cannula care
1, fixed belt elasticity to allow the insertion of 1 finger is appropriate, should pay attention to frequent inspection and adjustment. To prevent twisting of the trocar, it should not be twisted too much when turning over, and the action should be gentle when taking and placing the inner trocar.
2, the outer mouth of the trocar is covered with sterile wet gauze, which can wet the airway and prevent dust and foreign body inhalation.
3, incision gauze should be routinely changed once a day, if wet and contaminated should be replaced at any time to keep the local clean and dry. Put a layer of petroleum jelly sand cloth p in the middle of the gauze can avoid wound moisture.
4, 4 ~ 6 hours to disinfect the internal cannula 1 time. Disinfection method: boil and clean then boil. The cotton ball should not be too large and tight when cleaning the lumen to prevent deformation of the lumen. After cleaning, check whether the official cavity is smooth to prevent the cotton ball from being missed inside, and first aspirate the sputum from the outer tube wall before placing the disinfected inner tube.
5. Pay attention to the occurrence of complications, such as subcutaneous emphysema p wound bleeding, etc., and report to the physician immediately after discovery. The iodoform gauze stuffed locally after surgery should be removed after 48~72 hours and the number should be counted.
6, the patient gradually awake, cough reflex and swallowing reflex restored, not much sputum, auscultation respiratory sounds gradually clear, body temperature normal can consider extubation. The tube should be blocked for 24~48 hours before extubation, and can be extubated if the respiratory condition is stable.