Potential concussion problems. Nursing care for a patient with severe head injury

2. Features of nursing care for a patient with a closed craniocerebral injury

Due to an accident, in the MOKB them. Boyandin, a patient was admitted to the OAR 3 department:

Statuspresents: The condition is serious, due to the severity of the injury, shock. The skin and visible mucous membranes are pale. BP 90/60 mmHg PS - 110 per minute, rhythmic. Heart sounds are muffled. Both half chest symmetrical, participate in the act of breathing. NPV 24 per minute. Breathing is carried out in all departments, there are no wheezing. The abdomen is soft, does not respond to palpation. Urine is light.

Conducted research:

1) May 1, 2011 MSCT of the brain and bones of the brain skull.

2) May 3, 2011 MSCT of the brain and bones of the brain skull.

Conclusion: hemorrhagic foci of contusion in both frontal lobes, more on the right. SAK. Edema of the fronto-parietal - occipital regions of both hemispheres.

3) May 3, 2011 X-ray on an open (paid) device.

Conclusion: C7 vertebra "not broken", its assessment is impossible. Violation of the integrity of bodies C2-6 was not revealed.

4) May 3, 2011 ECG in intensive care.

Conclusion: PQ = 0.18" RR = 0.72" HR = 83 per minute, sinus rhythm. Violations of the processes of repolarization in the myocardium.

5) May 10, 2011 MSCT of the brain and bones of the brain skull.

Conclusion: In comparison with the results of the study dated May 3, 2011, hemorrhagic foci of contusion in the media-basal parts of the frontal lobes of both hemispheres of the brain decreased in size, their cavity characteristics decreased due to reblooming and blood resorption. The degree of perifocal edema slightly decreased.

6) 1.05.2011 (67002) Blood test on a hematological analyzer - 1- indicators - semi-automatic.

7) (67097) Calcium - automatic.

8) Conclusion: calcium, mmol/l - 2.38.

9) (67120) Coagulogram in the OAR laboratory.

10) (67203) acid-base balance, blood gases, electrolytes, hemoglobin and hematocrit, glucose.

11) (67215) Comprehensive biochemical study No. 2 (glucose, urea, bilirubin, creatinine, protein, ALT, AST, alpha-amylase) automatic.

12) (83008) General analysis urine in the laboratory on duty - protein qualitatively.

13) (67004) KLA (clinical) - 12 impressions Blood analysis on a gem.analyzer + leukoformula + ESR.

Consultations:

Urologist from 05.05.2011.

Neurosurgeon dated May 25, 2011.

Neurologist 1 time in 6 months.

Patient monitoring

Disturbed Needs:

Eat, drink

sleep, rest

Move

To be healthy

Communicate

Problems:

Headaches due to closed craniocerebral injury.

Discomfort associated with restriction of movement, violation of the integrity of the skin, changes in blood pressure.

Restricted mobility due to connected ventilators, feeding tube, urinal.

Psychological problems:

Loss of consciousness, delirium due to trauma

Lack of knowledge about disease and condition

Priority issues:

Discomfort associated with movement restriction

Potential issues:

Risk of complications

Goals of nursing care:

The patient will feel satisfactorily by the time of discharge.

The patient will not experience complications after the nursing interventions

Prevention possible complications, prevention of bedsores

- (meningeal scars, subarachnoid and intracerebral cysts, aneurysms, lesions of cranial nerves)

Patient care

1) Informing relatives about the disease.

2) Ensuring the mode of motor activity - strict bed rest. Creating a comfortable position in bed - with a raised head end, on an anti-decubitus mattress.

3) Ensuring the sanitary and epidemiological regime in the ward.

4) Aerotherapy - airing 1-2 times a day

5) Control of wet cleaning in the ward

6) Compliance with asepsis and antisepsis

7) Ensuring sanitary and hygienic regime

8) Cutting nails, changing bed linen, hygienic treatment of the body and mucous membranes, caring for the subclavian and intravenous catheter, inserting and caring for the urinary catheter.

9) Condition control: blood pressure, respiratory rate, pulse, body temperature, consciousness, condition of the skin and visible mucous membranes, daily diuresis, localization and nature of pain, volume and composition of the fluid received per day, body weight.

10) Diet therapy of the patient

11) Refuses to eat on his own, switched to tube feeding. Receives meat meat broths, milk mixtures (through a probe).

12) Preparation of the patient for instrumental and laboratory examinations is not required due to the patient's condition. All procedures are carried out in the ward.

13) Fulfillment of medical prescriptions (drugs administered in case of illness), control of possible side effects.

14) Documenting the activities of a nurse:

15) Filling out the appointment sheet

16) Filling in the temperature sheet

17) Registration of applications to the pharmacy for medicines

18) Making directions

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Intensive care for head trauma

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Intensive care of severe traumatic brain injury

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• Introduction
• 1. Theoretical part
• 1.1 General information about traumatic brain injury
• 1.2 Classification of nursing practice
• 2. Practical part. Peculiarities of nursing care for patients with traumatic brain injury
• 2.1 Nursing process
• 2.2 Nursing diagnosis
• 2.3 Ethical and deontological foundations of nursing
• 2.4 Technologies first aid in emergency conditions in neurology
• conclusions
• Conclusion
• Literature

Introduction

Traumatic brain injury, a complex multidisciplinary problem at the intersection of medicine and sociology, is one of the most significant in public health and today has become the most actual problem of neurosurgery. This is due to:

1) the mass nature of its distribution (on average in the world 2-4 per 1000 population per year) with the greatest susceptibility to children, young and younger middle-aged people;

2) high mortality and disability of the victims, the severity of the consequences with permanent or temporary disability, extremely economically burdensome for the family, society and the state as a whole;

3) predominant anthropogenicity and technogenicity of traumatic brain injury.

In the world, trauma as a cause of death of the population ranks third, second only to cardiovascular and oncological diseases. However, among children, people of young and younger middle age, it leaves its "competitors" far behind, exceeding mortality due to cardiovascular diseases by 10, and cancer - by 20 times. At the same time, brain damage is the cause of death due to injuries in almost 50% of cases.

The tasks of primary prevention of traumatism in general and craniocerebral in particular lie beyond the limits of medicine and are closely related to the social structure and development of society. Treatment of victims with traumatic brain injury, secondary prevention of its consequences and complications are within the competence of public health and, above all, neurosurgeon clinicians, neurologists, psychiatrists, traumatologists, resuscitators, rehabilitologists, etc. Their proper training for traumatic brain injury is quite complex and far from being solved. problem.

The computer era has come with new possibilities for direct non-invasive brain imaging and monitoring of its functions for both diagnostic and research purposes. Knowledge on the pathogenesis and sanogenesis of CNS pathology, including traumatic ones, has significantly expanded. Neuroreanimation and neurorehabilitation have been developed. AT surgical treatment cerebral injuries and their consequences, minimally invasive techniques, reconstructive interventions, microneurosurgery, new technology and new medical technologies. Received confirmation and recognition of the concept of focal and diffuse lesions, primary and secondary lesions of the brain, phasic clinical course various forms traumatic brain injury. As a result, the tactics of treating patients with traumatic brain injury underwent significant changes. Clinical guide to traumatic brain injury. - Moscow: Antidor. - 1998. Correspondingly, the technologies for caring for victims should also change. This is what determines the relevance of this work.

Purpose and objectives of the study:

The purpose of this work is to study the features of caring for patients with traumatic brain injuries in the light of the modern model of nursing, to substantiate different approaches to the maintenance and provision of nursing care.

An objectresearch:

The object of the study is the nursing process and the method of organizing and performing nursing care for patients with traumatic brain injuries.

1. Theoretical part

nursing trauma

1.1 General information about traumatic brain injury

Traumatic brain injury (TBI) is one of the severe injuries received in various catastrophes and accidents. Among those who have received injuries and are subject to hospitalization, TBI accounts for 30-40% as a cause of death and disability in young people, ahead of oncological and cardiovascular diseases. The outcome of these severe injuries depends largely on timely and correct diagnosis, on the time and qualifications of first aid and treatment. First aid for TBI, on which the outcome often depends, is usually provided by general practitioners, they also solve transportation issues, as a result of which knowledge of the basic provisions of TBI is necessary for doctors of many specialties ( Ambulance surgeons, traumatologists, etc.)

According to the accepted classification, all TBIs are divided into brain concussion (CCM), brain contusion (CM) of mild, moderate and severe degree. Any brain injury can occur with or without compression of the brain. The so-called light injuries include concussions and mild brain contusions, injuries medium degree- bruises of the brain of an average degree, to severe injuries - severe and severe forms. Pathogenetically, in all TBIs, movement and rotation of the brain occurs, followed by impaired blood and liquor circulation (V.M. Babchin). In response to mechanical action, there is a violation of the hypothalamic-pituitary functions (V.M. Ugryumov), dysfunction of regulatory mechanisms, impaired patency of the blood-brain barrier (A.N. Konovalov, A.A. Potapov, L.I. Likhterman, I.V. Gannushkin). Mechanical impact leads to rupture of blood vessels and destruction of brain tissue (hemorrhages, contusion foci). Subsequently, cerebral edema, being not stopped, is the cause of compression of the brain stem. An extremely complicating factor is hypoxia (hypoxic, circulatory), as a result of which initially small contusion foci of traumatic necrosis can significantly increase in the coming hours and days. As studies of the microcirculatory bed of the brainstem in persons who died after traumatic brain injuries (M.G. Dralyuk) showed, severe blood flow disturbances occur in the brainstem, which plays an important role in the formation of the symptom complex of damage.

According to various statistics, concussion of the brain (CCM) accounts for up to 70% of all TBIs. Loss of consciousness in SGM is short-term, calculated in seconds, minutes. In the elderly and children, loss of consciousness may be absent. Neurological symptoms are not pronounced, vegetative reactions predominate. All symptoms disappear within 3-6 days. On a CT scan during a routine examination, changes in the brain are not detected. CGM is a functionally reversible injury. The outcome after SGM largely depends on the rate of restoration of cerebral blood flow. cerebral edema, increased intracranial pressure above even the first critical level (200-220 mm water column) is not typical for SGM. However, it should be taken into account that in 15-20% after SGM there are certain consequences. More often this is the result of an incorrectly diagnosed diagnosis (subarochnoid hemorrhage was not diagnosed), an unfavorable premorbid background.

Brain contusions, in contrast to CGM, are always accompanied by varying degrees of cerebral edema, hemorrhages, and fractures of the skull bones.

Mild contusion: loss of consciousness, as in SGM, is short-term, but retrograde amnesia is more pronounced, more stable neurological symptoms.

It should be noted that in recent years the number of chronic hematomas after the so-called mild traumatic brain injuries has significantly increased, where in the acute period the loss of consciousness was short-term, and neurological symptoms were not pronounced (A.A. Potapov, L.B. Likhterman, M. D. Kravchuk), which is clearly seen in our observations. Moreover, chronic hematomas manifested themselves not only in the coming weeks and months, but also after 6-12 months or more.

An example is a 35-year-old patient, hit by a car, short-term loss of consciousness. Minor neurological symptoms disappeared after a few days. There was no M-ECHO bias. No fractures of the vault and base of the skull were found. He was discharged in a quite satisfactory condition with a diagnosis of mild brain contusion. 4 weeks after discharge from the hospital, he was re-admitted to the hospital due to rather acute headaches and hemiparesis. Moderate meningeal syndrome. Initially hospitalized in vascular department diagnosed with cerebrovascular accident. Displacement M-ECHO -- 11 mm, vein expansion in the fundus. Operation. A hematoma with a volume of 150 ml was removed through the burr holes, followed by active drainage for the next day. The hematoma capsule corresponded to the time of injury. In the subsequent rapid reverse development neurological symptoms. Released in good condition. There was no recurrence on follow-up CT scans.

Moderate brain contusions - loss of consciousness more often within the sopor (hours, days) followed by a slow recovery of consciousness, as a rule, after a period of stunning and disorientation. Liquor pressure with moderate bruises rises quickly and reaches high, often critical figures. It should be noted that there may not be all the symptoms of an injury, therefore, when falling from a height of more than two meters, in car accidents at a speed of 60 km / h or more, if the victim has repeated vomiting, amnesia, regardless of the depth and duration of loss of consciousness, the injury should be qualified as brain contusion with subsequent clarification of its degree in the hospital.

Severe brain contusions account for 7-10% of all injuries, with this injury immediately dominated by primary stem symptoms, coma, and changes in muscle tone.

Brain compression. The causes of compression are different: extensive depressed fractures, pneumocephalus growing like a valve, progressive contusion foci, cerebral edema, hematomas. Undoubtedly, intracranial hematomas, as a rule, require emergency surgical intervention, but at the same time, the diagnosis of intracranial hematoma requiring emergency intervention should be as precise as possible, and this time should be used not only for diagnosis, but also for active therapeutic measures. The presence of progressive compression is indicated by a deepening of the disorder of consciousness, a deepening or the appearance of cerebral, dislocation symptoms. Diagnosis, in addition to clinical examination, should include craniography, examination by an ophthalmologist, ECHO-scopy. Offset M-ECHO more than 3 mm - an alarm. If necessary, angiography or CT is performed. With limited diagnostic capabilities, the imposition of search milling holes is still relevant. In our opinion, if the patient has not been on a ventilator before, it is advisable to place burr holes under local anesthesia with the subsequent, if necessary, the transition to surgery after giving anesthesia. The tactics of the doctor during the initial examination consists of:

1. Assessment of the state of life-supporting functions (respiration, cardiovascular system).

2. Evaluation of the disorder of consciousness in comparison with other manifestations of trauma.

3. General surgical examination (exclusion or confirmation of extracranial injuries).

4. General neurological examination, which every doctor who provides emergency assistance. Namely: the position of the eyeballs, the state of the pupils, facial muscles, the act of swallowing, the position of the limbs, meningeal syndrome. In the study of stiffness of the occipital muscles, it is first necessary to exclude a fracture of the cervical spine. Pay attention to the outflow of blood from the nose, ear canals. Unilateral bleeding from the nose positive symptom"double spot" indicates a fracture of the base of the skull. When releasing the victim from the blockage, attention should be paid to head compression, since the latter is quickly complicated by increasing cerebral edema, intoxication, and the formation of soft tissue necrosis.

Therefore, after solving the first group of questions, the following is determined:

1. What disorders does the victim have?

2. What type of injury are violations?

3. What causes these disorders (contusion foci, hematoma, etc.)?

4. What emergency care should be carried out?

5. Where to transport the victim?

The main mistakes in first aid: underestimation of respiratory disorders, improper manipulation of medications, insufficient anesthesia (coma is not anesthesia).

Upon admission of the victim to a specialized hospital, the neurosurgeon solves three main issues:

1. The operation is needed immediately.

2. Observation is necessary, surgery may be required.

3. Treatment is only conservative, given that the diagnosis of brain compression requiring surgery is very serious.

In the group of patients with combined injuries, the cause of brain compression was mainly intracerebral hematomas, contusion foci, and in some cases only cerebral edema was found with incarceration of the trunk and impaired blood circulation in it. Epidural hematomas in all cases were accompanied by fractures of the vault or base of the skull. In the most severe cases, the main accumulation of blood was noted at the base of the skull, as a result of which surgical intervention aimed at removing the epidural hematoma was often unsuccessful, and in some cases aggravated the condition. Rigidity of the occipital muscles, as a rule, prevailed over Kernig's symptom. Arterial pressure and pulse with epidural hematomas fluctuated widely. The displacement of M-ECHO was on average 3-5 mm.

Subdural hematomas had clearer conventional clinical signs. More than half had bradycardia, increased blood pressure, anisocaria. Meningeal symptoms were noted in almost all, with Kernig's sign predominating over stiff neck. The displacement of the M-ECHO reached 10-11 mm or more, and it was noted that the more severe the injury, the less the displacement of the M-ECHO. On the fundus, the majority had venous congestion, less often "stagnant" nipples optic nerves. Normal fundus was only in two people. The size of hematomas ranged from 60 to 250 ml. In persons admitted in a coma that arose immediately after the injury, besides hematoma, contusion foci, more often contusion and basal, were found.

Intracerebral and multiple hematomas in all cases were accompanied by foci of reproduction of various sizes and localizations. The removal of such hematomas and contusion foci was usually accompanied by a significant deepening of neurological prolapses (hemiplegia, etc.) while preserving the stem functions at the preoperative level, and therefore such operations should be performed only in absolute terms with a clear progression of symptoms.

Combined TBI. In the persons of this group, almost all of them were dominated by tachycardia, normal or low blood pressure, varying degrees anemia. Meningeal symptoms in most of the victims were not revealed. Almost all have bilateral persistent pathological symptoms. The displacement of M-ECHO ranged from 3 to 7 mm. Seven people from this group were not operated on. Subsequently, on CT scan conducted 3-4 weeks after the injury, quite satisfactory regression of contusion foci was stated.

Concussion of the brain - stay in the hospital with a safe course of 6-7 days. If there is no regression of symptoms in the next 3-4 days, a spinal puncture is performed. Patients in this group were prescribed light tranquilizers and drugs that improve cerebral blood flow. In the treatment of brain contusions, dehydration therapy was prescribed, vasoactive drugs, proteolysis inhibitors, antihistamines, psychotropic drugs, agents that improve the metabolism of neurotransmitters, a properly balanced diet. Severe brain contusions required resuscitation and, first of all, the restoration of adequate breathing. The treatment takes into account the prevention of complications, primarily pneumonia.

Diagnostic cerebrospinal puncture was performed according to the indications, quite widely for mild and moderate brain contusions. In the presence of symptoms of dislocation and infringement of the brain stem, with a diagnosis of hematoma, spinal puncture is dangerous and contraindicated. Drugs for severe injuries should be injected into the vascular system. We have developed a method of long-term intra-arterial and intra-aortic infusion in severe pathological processes in the brain. Introduction medicines in the regional arterial bed allows you to deliver the drug unchanged to the site of the disease, creating a stable concentration in it. Infusion with the establishment of a catheter in the aortic arch allows you to deliver the drug to the brain and lung tissue at the same time, which is especially advisable in severe concomitant injuries.

The infusion technique consists of the selection of a catheter, catheterization and connection of the infusion system. As a catheter, special cardiac probes with an average diameter of 2 mm are most convenient. For catheterization carotid artery five methods can be used: direct catheterization of the artery, passing the catheter along the seddinger through femoral artery, through one of the branches of the carotid artery in the neck, through the internal thoracic artery. The simplest, most accessible and in a safe way is the introduction of a catheter through the superficial temporal artery. After the artery is isolated, its distal end is ligated. For the subsequent stop of bleeding, an eight-shaped ligature is applied to the proximal end of the artery, the end of which is brought out next to the incision. Particular care should be taken to apply the eight-shaped ligature when passing the catheter through deep branches on the neck. The optimal frequency of drops is 18-22 per 1 minute, the duration of infusion is from 3 to 18 days, the average dose of heparin is 3 mg per 1 kg of body weight. The composition of the infusit depends on the disease. It is permissible to administer only compatible drugs that are approved for intravenous administration. The basis of the infusit can be saline solution, Ringer-Locke solution or 5% glucose solution. The key to the prevention of complications is a well-established technique, constant monitoring of the patient's condition, neurological data, and systematic monitoring of bleeding time.

A necessary condition for infusion after surgery is thorough hemostasis, the absence of rough drainage in the cavity, and a decrease in the dose of heparin in the first days of infusion. With the appearance of microhematuria, the infusion can be continued under the condition of constant monitoring of the blood coagulation system. The question of continuing the infusion depends on the patient's condition. When the first signs of individual intolerance to drugs appear, the infusion should be stopped immediately. The experience of more than 200 infusions shows that with proper observance of the infusion technique and timely prevention, there are no complications. Intra-aortic infusion has the same conditions. The catheter is inserted either through the femoral artery or through the right radial artery and placed in the aortic arch. In the latter case, X-ray control is not required, it is enough to measure the distance between the injection site on the forearm and the middle of the sternum, transferring this length to the catheter. According to anatomical structure the catheter is installed in the aortic arch, which was repeatedly confirmed by X-ray control. .Dralyuk M.G. Traumatic brain injuries (Overview, diagnosis, tactics, treatment) // Medical Journal. - 2002. - No. 13

Carefully thought-out tactics, timely diagnosis, targeted therapy and proper care will significantly reduce the percentage of adverse outcomes.

1.2 Classification of nursing practice

For many years, nurses in different countries wanted to be recognized for their profession. It was necessary to establish the boundaries of their professional activities, the differences between medical and nursing duties, to create a terminological and conceptual apparatus of the profession and to determine the scientific method of providing nursing care to patients.

Since the 1950s, scientific theories of nursing began to appear in the United States, and later in Europe, the authors of which tried to present their vision of the essence and main provisions of the profession. Common to all researchers was the desire to show the phenomenon of nursing and justify its fundamental difference from other professions. In a number of theories, similarities were recognized, in others, significant differences.

The theories of Virginia Hendersen, Dorothea Orem, Martha Rogers, Betty Newman and other nursing researchers are already known in Russia, they are not only studied in schools and colleges, nurses are trying to implement them in their practical work, as evidenced by the speeches of our colleagues from different regions countries at the scientific-practical conference, held in November of this year in Moscow.

An essential step taken by nurses to solve the problem of combining different scientific and theoretical approaches to nursing and create a common methodological basis for providing nursing care to patients was an attempt to apply nursing process in professional activities.

FROMnursing process, regarded by the international nursing community as scientifically based methodology of professional activity, can be used for any model and theory of nursing.

Sister process consists of 5 consecutive stages: examination of the patient; diagnosing his condition; planning necessary assistance to the patient; implementation of the nursing intervention plan; evaluation of the results.

The most serious shortcoming in the development of nursing as a profession and scientific discipline was the lack of a common terminological and conceptual apparatus for all nurses, in other words, a common professional language for all nurses. Terminological confusion created significant obstacles for professional communication and mutual understanding of nurses. The same phenomenon was given different names - a symptom, a syndrome, a need, a patient's problem, and so on. The lack of classification of these fundamental concepts for nursing practice, significant differences in their definition led to the fact that representatives of other specialties in health care, and primarily doctors, increasingly began to express their doubts about the independent status of the nursing profession.

After 8 years of hard work, MSM presented in 1996 for discussion the first version of the classification of nursing practice. National associations of nurses from Africa, Asia and Latin America, countries with different cultures, levels of economic and social development, indicators of morbidity, provision of the population with doctors and nursing staff. The classification has been translated into 16 world languages, including German, Spanish, French, Chinese, Danish, Greek, Italian, Japanese, Romanian, Swedish, Portuguese, Icelandic, Norwegian and others. The purpose of such a large-scale examination was to check the universal suitability of the classifier and the possibility of its universal use by all nurses.

In accordance with the professional approaches of MSM, nursing practice is described by 3 main components:

Sister phenomenon;

Nursing action(intervention);

Result actions of the nurse.

On the basis of which, the ICSP includes classifications for 3 blocks of components of nursing practice, determines and standardizes the structure of each block by headings and subheadings, establishes a system for coding them, and introduces clear definitions for all terms and concepts used in the classifier.

Consider general principles classification of nursing practice according to its main components.

Sister phenomenon

Phenomenon(Gr. phainomenon being) in the context of the ICSP means a phenomenon related to health or social process, in relation to which the professional actions of a nurse are directed. The ICSP defines the structure of the nursing phenomenon and all the elements included in it, gives clear definitions to the concepts and terms that describe the content of the phenomenon. The combination of individual terms from the classification of the nursing phenomenon defines the essence of nursing diagnoses. In the context of the ICFTU under Nursing diagnosis is the nurse's professional judgment about the phenomenon, representing object of nursing interventions.

sisterlyactions

In the context of the ICFTU nursing actions- the behavior of a nurse in the process of professional practice.

nursing intervention- an action taken by a nurse in accordance with the established nursing diagnosis, to achieve a certain result. The combination of individual terms from the classification of nursing activities defines the essence of nursing intervention.

Outcome of nursing actions/interventions

Definition of the concept in the context of the ICPF:

Result- measurement or state of nursing diagnosis after nursing intervention. It is clear that various factors influence the result.

Outcomes are measured by changes in nursing diagnoses, as shown below:

2. Practical part. Peculiarities of nursing care for patients with traumatic brain injury

2.1 Nursing Process

To successfully use the nursing process in neurological practice, the nurse must:

- master the basic manipulations of the sentry, procedural, ward nurse and emergency room nurse;

- understand and know the essence of the nursing process, its goals, stages and rules of implementation;

- know the main nosological forms of neurological diseases, the features of their course, complications, problems that arise in patients suffering from these diseases;

- to know the algorithms of emergency conditions encountered in neurological practice, to have the skills to implement them;

- know the main drugs used in neurological practice (doses, routes, speed, rules for their administration, side effects) to prevent the development of a relapse of the underlying or concomitant disease;

- the main restrictions on the types of diets (to prevent the deterioration of the patient's condition due to a possible complication of the underlying or concomitant disease);

- master the skill of specific manipulations (assisting during blockades, lumbar punctures);

- own ethical and deontological approach, taking into account the peculiarities of the course of neurological diseases;

- know the features of work in geriatric practice.

All manipulations performed by a nurse must comply with the "Standards for the Practice of a Nurse", a regulatory document adopted by the Russian Nurses Association on June 10, 1998.

For failure to follow the instructions and recommendations listed in the above document, the nurse is legally liable under the articles of the criminal code.

Nursing process - a scientific method of nursing practice, based on the standards of nursing interventions and directed to the individualization and systematization of patient care, a dynamic process, the last link of which is closely intertwined with the first.

1. collection of health information

2. nursing diagnosis

3. planning

4. implementation

5. evaluation

The nursing intervention plan is a written guide and should be documented in the nursing chart (which should not affect the timeliness of patient care).

Nursing care is planned based on the failure to meet the patient's needs, and not on the basis of a medical diagnosis.

The Purpose of the Nursing Process- maintaining and restoring the independence of the patient in meeting the basic needs of the body

Principles of nursing process:

The state of the functional system (BP, collection of information about temperature, respiratory rate, pulse, heart rate, rhythm)

Emotional background

intelligent background

Ability to serve yourself

Nursing diagnosis. The patient's response to his illness and priorities. Primary states:

urgent, functional impairment of body functions

intermediate

non-emergency, secondary psychological (anxiety, fear)

unrelated disease(spiritual depression)

sociallys(disability)

Planning Goal

short-term(to solve a problem)

long-term(prepare for further existence, teach self-help techniques, preventive measures outside the hospital)

Implementation. Implementation of the intervention in accordance with the standards of nursing care

Independent(not requiring a doctor's prescription - diet control, medical and protective measures, etc.)

Dependent(require doctor's instructions - assisting the doctor during manipulations, current correction of prescriptions by the doctor)

Interdependent(require the participation of a doctor and are carried out by a nurse - the implementation of medical appointments according to the procedure sheet)

Grade- tocriteria:

goal achievement

patient response

new problems

analysis

change of plan

its implementation

appraisal, etc.

2.2 Nursing diagnosis

Let's consider possible examples of nursing diagnoses based on the statistical data of the neurological department of the Medical Unit of the IAPO.

Transient ischemic attack- This is a short-term cerebral vascular insufficiency, most often caused by atherosclerosis and hypertension. Less commonly, heart disease, osteochondrosis of the cervical spine, and vascular and systemic diseases can become the cause.

Symptoms: development is most often acute; the patient complains of decreased sensitivity various fields, impaired mobility (arms, legs), speech disorder, sudden blindness, or blurred vision in one eye, severe dizziness, nausea, vomiting. The duration of the disease is from 10-15 minutes to a day. Rarely, when severe forms an ischemic attack, a violation of consciousness is possible up to a stupor.

- disturbance of consciousness (sopor)

- nausea, vomiting

- dizziness

- depression, etc.

subarachnoid hemorrhages

Rupture of an intracranial aneurysm, which is more often located on the arteries of the base of the brain or in the region of the branches of the middle cerebral artery.

Symptoms: sudden acute headache in the forehead, occiput, which then becomes diffuse. Almost simultaneously with a headache, nausea, repeated vomiting occur, loss of consciousness may occur (from 10-20 minutes to several days), a high probability of an epileptic seizure, the rapid development of meningeal symptoms (photophobia, general hyperesthesia, fever up to 38-39 o FROM).

Sometimes there is psychomotor agitation, mental disorders (from slight confusion, disorientation to severe psychosis).

Possible nursing diagnoses

- disturbance of consciousness (coma)

- headache

- nausea, vomiting

- the need for silence, darkness, rest

- lack of self-service (strict bed rest, paresis, paralysis)

- violation of urination and defecation

- heat

- psychomotor agitation

- anxiety about the disease and its consequences

- depression, etc.

ATintracerebral hemorrhage. Hemorrhages in the brain most often develop with arterial hypertension caused by kidney disease, with systemic vascular diseases accompanied by an increase in blood pressure. It can occur with congenital angioma, arteriovenous malformation, with microaneurysms formed after a traumatic brain injury or septic conditions, with diseases accompanied by hemorrhagic diathesis(leukemia, uremia, Werlhof's disease).

Symptoms: a combination of the development of cerebral and focal symptoms is characteristic.

- sudden headache

- vomit

- impaired consciousness (from mild deafness to deep coma)

- simultaneous development of hemiparesis or hemiplegia

- tachycardia with high blood pressure

- increased body temperature

Possible nursing diagnoses

- disturbance of consciousness (coma)

- headache

- nausea, vomiting

- lack of self-service (strict bed rest, paresis, paralysis)

- violation of urination and defecation

- state of epileptic seizure

- heat

- anxiety about the disease and its consequences

- depression, etc.

Andshemic stroke (brain infarction). Ischemic stroke occurs due to the complete or partial cessation of blood flow to the brain through any vessel as a result of thrombosis, embolism, vasospasm, pathology of the main vessels, or a sharp drop in blood pressure. The main cause of ischemic stroke is atherosclerosis of cerebral vessels. May develop at any time of the day. A distinctive feature of ischemic stroke is the predominance of focal symptoms over cerebral ones.

Symptoms: headache, vomiting, confusion (often observed with the rapid development of a stroke); urinary retention, paresis, paralysis, mental disorder, dizziness, hearing and vision impairment, vegetative disorders, possible development of coma with impaired vital functions

- respiration and cardiac activity.

Possible nursing diagnoses

- disturbance of consciousness (coma)

- headache

- nausea, vomiting

- lack of self-service (strict bed rest, paresis, paralysis)

- violation of urination and defecation

- state of epileptic seizure

- anxiety about the disease and its consequences

- depression, etc.

Discirculatory encephalopathy. Dyscirculatory encephalopathy is a clinical manifestation of cerebral atherosclerosis. Its initial stages are characterized by heaviness in the head, tinnitus, dizziness, headache, irritability, tearfulness, emotional instability, memory impairment, decreased performance, sleep disturbance. As atherosclerosis develops, the above symptoms increase and signs of an organic lesion of the nervous system appear: pathological reflexes, impaired coordination, writing, speech; the range of interests narrows, selfishness grows, efficiency decreases.

With a pronounced encephalopathy, memory is grossly impaired, intelligence decreases, Parkinson's syndrome, dementia, and strokes develop.

Possible nursing diagnoses

- lack of self-care (tremor, weakness)

- sleep disturbance

- headache

- state of epileptic seizure

- tearfulness

Bdiseases of the peripheral nervous system. The causes of damage to the peripheral nervous system can be acute and chronic infections, trauma, intoxication, hypovitaminosis, ischemia, hypothermia, compression, degenerative changes in the spine. Depending on the localization and pathogenesis, there are: neuritis, neuralgia, neuropathy, polyneuritis, plexitis, ganglionitis, sciatica, radiculoneuritis, myeloradicoloneuritis.

Symptoms: pains of various localization and intensity, mobility restrictions, forced position, motor and sensory disorders, impaired urination and defecation.

Possible nursing diagnoses

- sleep disturbance

- lack of self care

- severe pain in various localizations

- violation of urination and defecation

- depression

ATvegetative vascular dystonia: a set of symptoms that reflect dysfunction of autonomic regulation, more often manifested not so much as an independent disease, but as a syndrome caused by various factors: constitutional, endocrine changes in the body, pathology internal organs, diseases of the endocrine glands, organic lesions of the brain, neuroses.

The disease is manifested by various changes in the state of the autonomic system: a rapid change in skin color, sweating, fluctuations in pulse and blood pressure, gastrointestinal dyskinesia, nausea, attacks of general weakness, headache, irritability; chills, feeling of heat, tightness in the chest, shortness of breath.

Treatment is symptomatic. At the next crisis, the patient needs to be laid down, calmed down, administered drugs according to the nature of the crisis.

Possible nursing diagnoses

- sleep disturbance,

- increased irritability

- anxiety about the instability of the general condition

- liquid stool

- unreasonable refusal to take medication

- weakness

- headache caused by high blood pressure, low blood pressure

- shortness of breath

- feeling of fear

- nausea, etc.

Heuroz. Neuroses are reversible disorders of nervous activity caused by mental trauma. These include neurasthenia, hysteria and an obsessive state.

The symptoms of neurasthenia are diverse, most often patients complain of diffuse headache, palpitations, dyspepsia, sleep disturbance, decreased performance, increased irritability.

Obsessive-compulsive disorder is a type of neurosis that manifests itself in involuntary, irresistibly emerging, alien to the patient's personality doubts, fears, ideas, thoughts, memories, aspirations, attraction, movements and actions while maintaining a critical attitude towards them and attempts to fight them. Exacerbation is facilitated by overwork, infection, lack of sleep, unfavorable conditions in the family and at work.

Hysteria is one of the types of neurosis that is manifested by demonstrative emotional reactions (tears, laughter, screams), convulsive hyperkinesis, transient paralysis, loss of sensitivity, deafness, blindness, loss of consciousness, hallucinations, etc. the clinic is diverse and changeable, which is explained by the fact that very often the symptoms occur as self-hypnosis and usually correspond to the person's ideas about the manifestations of a particular disease.

Possible nursing diagnoses

- sleep disturbance

- various phobias

- liquid stool

- unreasonable drug withdrawal

- the patient's need for rest

- headache

- state of hysteria

- nausea, vomiting

- lack of self-service (paresis, paralysis), etc.

Actuallytraumatic brain injury. The main causes are transport, household and industrial injuries. Subdivided into concussion, bruise and compression of the brain. Depending on the severity of the injury, the symptom complex includes:

- loss of consciousness from a few minutes to several weeks or more

- dizziness, tinnitus, vomiting (single, repeated, repeated), meningeal symptoms

- disorder of vital functions (heartbeat, respiration, thermoregulation)

- violation of the sensitivity of speech, vision, hearing

- violation of urination and defecation

Possible nursing diagnoses :

- disturbance of consciousness (coma)

- headache

- nausea, vomiting

- lack of self care

- violation of urination and defecation

- state of epileptic seizure

- anxiety about the injury and its consequences

- depression, etc.

Hovogenesis. Tumors of the nervous system are neoplasms growing from the substance, membranes and vessels of the brain, peripheral nerves, as well as metastatic ones. There are hormonal, infectious, traumatic and radiation theories of origin. Distinguish tumors primary and secondary (metastatic). Benign and malignant, single and multiple. The pathogenetic effect on the brain is diverse: as it grows, it destroys brain tissue, decay products have a toxic effect, displaces the brain, compresses blood vessels, and disrupts the circulation of cerebrospinal fluid, which leads to impaired cerebral blood supply, cerebral edema and increased intracerebral pressure.

Tumors of the brain. Manifested by cerebral, local (focal) symptoms and the so-called symptoms at a distance.

Cerebral symptoms:

Headache (in the initial stage, local, boring, throbbing, jerking, paroxysmal, often occurs at night and early in the morning; the patient wakes up with a headache that lasts from several minutes to several hours and appears the next day; gradually becomes prolonged, diffuse, spreads over the entire head and may become constant; may be aggravated by physical exertion, excitement (coughing, sneezing, vomiting, head tilting forward, defecation, depending on posture and body position)

- vomiting (appears with an increase in intracranial pressure, its appearance is characteristic at the height of a headache attack, the ease of appearance out of touch with food intake, in the morning, with a change in the position of the head

- epileptic seizures (may be caused by intracranial hypertension and the direct effect of the tumor on the brain tissue)

- mental disorders (most often occur in middle and old age, patients are depressed, apathetic, drowsy, often yawn, get tired quickly, disoriented in time and space; memory impairment, slowness of mental processes, irritation, agitation or depression)

- dizziness, changes in heart rate, respiratory rate, pulse, impaired consciousness up to coma

Focal symptoms: depend on the localization of the tumor, its size and stage of development.

"Symptoms at a distance": taken into account when determining the localization of the tumor (damage to the cranial nerves, pyramidal and cerebellar symptoms).

Spinal cord tumors mainly affect young and middle-aged people.

Symptoms: slow steady increase in signs of compression

(compression) of the spinal cord, progressive motor and sensory disorders, urination and defecation disorders, the occurrence of bedsores.

Possible nursing diagnoses :

- disturbance of consciousness (coma)

- headache

- nausea, vomiting

- lack of self care

- Severe back pain

- violation of urination and defecation

- anxiety about the disease, upcoming surgery and prognosis

- state of epileptic seizure

- depression, a state of doom, etc.

Nervous diseases one of the most important medical disciplines, since the pathology of the central and peripheral nervous system causes a variety of disorders of the vital functions of the body, often determining the outcome of the disease.

Quite often, elderly and senile people suffer from neurological diseases, due to age-related metabolic disorders, the development of atherosclerosis, which is a favorable background for the development of the above diseases. Nurse neurological department should know the behavioral characteristics, course and complications of the disease of elderly and senile people.

Features of the work of a nurse in geriatric practice.

Modern gerontology is the science of aging, which includes elements of sociology, biology, hygiene, economics and psychology. Geriatrics is an integral part of gerontology and considers the medical aspects of aging.

In old age, there is a gradual restructuring of the entire mental activity of the body, its intensity is on the wane. Minor external stimuli cause nervousness and tearfulness in the elderly.

Often, elderly people "listen" to the work of internal organs, acutely experience various diseases and age-related changes in the body.

Gradually, a person notices that his memory is deteriorating. Emotional disturbances are the most common disorders of mental activity in the elderly. Therefore, older people need a special approach, care and participation.

In the elderly and, especially, senile age, metabolism is less active, redox reactions in tissues slow down, nutrients are absorbed worse and less intensively broken down to end products of metabolism, motor activity decreases, therefore, the energy value of the diet must also be reduced, otherwise the person will gain weight. An important requirement of gerodietics is the anti-sclerotic orientation of the diet, as well as an increase in the content in the diet of products that delay the aging process and increase life expectancy (vegetables, fruits, berries, as the main sources of antioxidants, vitamins and microelements). In addition, fruits and vegetables contain fiber that stimulates digestion, which is an effective help for constipation, often found in the elderly.

Diseases in old age develop in connection with the emerging age-related changes, which are often a background that facilitates the development of the pathological process. The most characteristic are atypicality, unresponsiveness, smoothness of clinical manifestations. The pathology of old patients is compared to an iceberg in which the main part of the volume is hidden under water. An elderly person often gets used to the deterioration of the functions of one or another organ and system, believing that this phenomenon is of a normal age-related nature, and in the meantime, the symptoms increase, and the disease becomes more pronounced, and then one has to deal not with the onset of the disease, but with chronic pathology, difficult, and sometimes completely incurable.

The use of drug therapy in the elderly and old people due to age-related changes organs and systems is associated with an increased risk of cumulation. The risk of side effects and complications of pharmacotherapy in people over 60 years of age is higher than in middle age (drug depression, hypotension, hypertension, nephrotic and general toxic syndrome). Elderly and senile people often forget to take their medication or take it again after a short time, forgetting that it has already been taken. In a hospital setting, the nurse must personally give the medicine to the patient and monitor its intake (especially if a liquid dosage form is prescribed, and the patient poor eyesight or hand tremor).

2. 3 Ethical and deontological foundations of nursing

Nursing deontology - the science of duty to the patient and society, professional behavior medical worker, is part of nursing ethics. A nurse must have professional observation skills that allow her to see, remember and evaluate in a nursing way the smallest changes in the physical, psychological state patient. She must be able to control herself, learn to control her emotions. The main principles of nursing ethics and deontology set forth in the Florence Nightingale Oath, the Code of Ethics of the International Council of Nurses and the Code of Ethics of Russian Nurses are:

1. Humanity and mercy, love and care

2. Compassion

3. Goodwill

4. Selflessness

5. Diligence

6. Courtesy, etc.

2.4 Technologies of first aid in emergency conditions in neurology

Epileptic status

Information to enable the nurse to determine status epilepticus.

Convulsive seizures, following one after another.

Lack of clarity of consciousness between seizures.

T. Actions. Rationale

-Call a doctor.

- Carry out activities according to the standard "convulsive seizure"

-Prevent tongue slipping

-Clean mouth from saliva

- Carrying out measures to prevent asphyxia of the secret in the interval between seizures.

Equipment, tools:

-Syringes, needles

Evaluation of what has been achieved:

-The condition has improved, the seizures have subsided or completely stopped

- The condition worsened, respiratory arrest occurred, act according to the standard of "clinical death"

- Acute neuralgic syndrome

Information that allows the nurse to suspect that the patient has acute radicular or musculoskeletal pain syndrome.

-Pain

-Acute in the cervical, thoracic or lumbar spine, aggravated by movement and impeded by movement.

- Irradiation of pain in the groin, in the legs with lumbosacral osteochondrosis; in the shoulder, shoulder blade, in the arm with cervical osteochondrosis.

- Anamnesis - anamnestic data on the disease of osteochondrosis of the cervical, thoracic, lumbar spine.

Tnurse practice technology. Actions. Rationale

-Call a doctor.

-Ensure peace, give a comfortable position for the patient.

Equipment, tools:

- Needles, syringes

Evaluation of what has been achieved.

-Pain has decreased

Information that allows a nurse to suspect a patient is having a migraine attack.

- Pulsating pain - only in one half of the head (frontal - temporal or occipital regions)

- Violation of visual function preceding pain: flashes of light before the eyes, changes in the field of vision, or others.

- Anamnesis - data on migraine pains in the past.

Tnurse practice technology. Actions. Rationale

- Reassure the patient and put him in a comfortable position

- Eliminate extreme visual and auditory irritations, darken the room

-Learn about self-help measures used by the patient. Individual character of measures

-Put mustard plasters to the feet, calf muscles; warm baths

- Carry out a tight bandaging of the head.

- Offer the patient caffeinated drinks, strong tea

-Remove dentures

- when vomiting, turn your head to one side, clear your mouth of vomit.

Prevention of respiratory failure, aspiration pneumonia.

Equipment, tools:

- Needles, syringes

Evaluation of what has been achieved:

- Condition improved, pain decreased

Information that allows the nurse to suspect a myasthenic crisis.

- Movement - almost complete impossibility of voluntary movements, especially repeated active movements.

- History - the presence of myasthenia gravis in history.

Tnurse practice technology. Actions. Rationale

-Call a doctor

- Provide the patient with physical emotional peace.

-Give the head a sublime

Saving the patient's life.

Perform ventilation when breathing is weakened

Equipment, tools:

- Needles, syringes

Evaluation of what has been achieved:

- Stable condition, no threat to life

-The condition worsened, respiratory arrest, action according to the standard "clinical death"

Information that allows the nurse to suspect hypertensive syndrome

-Headache, dizziness, vomiting without relief, convulsions, increasing depression of consciousness due to cerebral edema.

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Clinical manifestations of traumatic brain injury, its complications and consequences. Mechanism of pathology, symptoms, classification and treatment. Prevalence in the pediatric population. Rendering first medical care with concussions, bruises, compression of the brain.

Brain injuries are caused by a head injury or skull fracture. Distinguish concussion, bruise and compression of the brain.

Brain concussion

It is characterized by functional disorders of the brain, which are reversible. Short-term loss of consciousness, nausea, single vomiting, respiratory failure (frequent, superficial), headache, weakness, bradycardia are noted. The patient does not remember the events preceding the injury and during the injury.

After a concussion, headache, dizziness, tinnitus, irritability, sleep disturbance, sweating, that is, vegetative disorders of the cerebral vessels, persist for a long time. In the absence of treatment or inadequate treatment, the consequences of a concussion of the brain can manifest themselves even after decades with atherosclerosis of the cerebral vessels. hypertension.

First aid is to provide the patient with physical and mental rest. Transportation on a stretcher in the supine position with the head raised and turned to one side. Cold is applied to the head. Intramuscularly injected 5 ml of 50% analgin, intravenously - 40% glucose solution. X-ray of the skull is required.

Treatment

Bed rest, sleeping pills, vitamins, heart. If there are signs of increased intracranial pressure, take for diagnostic and therapeutic purposes spinal puncture. Carry out dehydration therapy.

brain contusion

Brain contusion is characterized by the presence of focal disorders due to damage to the substance of the brain. In the substance of the brain, there are ruptures, crushing and hemorrhages, which can be located both in the cortex and in the white matter of the brain. Edema develops, swelling of the brain, increased spinal pressure. Functional disorders are pronounced and stable.

Clinical picture

In the clinical picture, in addition to the general brain symptoms focal symptoms are clearly expressed, characteristic of a lesion of a part of the hemisphere or brain stem.

Distinguish between mild, moderate and severe injuries.

With mild degree moderate manifestations of cerebral and focal symptoms are noted: asymmetry of reflexes, mild central paresis of facial muscles and language, impaired speech and vision. The duration of loss of consciousness is 2-3 hours.

With an average degree- all symptoms are more pronounced, symptoms of damage to the brain stem appear. Consciousness may be absent for up to a day.

Severe degree characterized by a prolonged loss of consciousness (several weeks), marked and persistent stem symptoms (body temperature rises to 40 ° C, respiratory distress, tachycardia are observed).

There are neurodystrophic lesions of internal organs, hemorrhages, hemorrhages. The prognosis is always doubtful, since brain function may not be restored.

First aid is to ensure patency respiratory tract.

Treatment

Treatment in the neurosurgical department or intensive care unit. After intubation of the trachea, the patient is transferred to artificial ventilation of the lungs. Infusion therapy includes dehydration with hypertonic solutions, diuretics, hormones. Pain relief therapy is carried out, antipsychotics, antibiotics for the prevention of pneumonia, symptomatic therapy are prescribed. Treatment lasts at least a month, followed by observation by a psychoneurologist.

Brain compression

Compression of the brain occurs with severe traumatic brain injury, if it is accompanied by intracranial hemorrhage or cerebral edema.

Symptoms of compression increase with continued intracranial bleeding.

Clinical picture

Clinically, this is manifested by an increase in headache, weakness, repeated vomiting, short-term excitement, constriction of the pupils, their weak reaction to light, a rare and intense pulse, and rapid breathing.

Compression of the brain does not immediately appear with these symptoms, since the increase in the volume of intracranial contents is temporarily compensated by the extrusion of cerebrospinal fluid from the cranial cavity into the spinal space.

Therefore, there is a light gap after which the patient loses consciousness for the first time after the injury or again. The patient must be constantly monitored for 6-8 hours after injury, so as not to miss the increase in cerebral compression. There is a great danger of brain death due to ischemia from compression.

Hemorrhage (hematoma) can be located outward from the dura mater - epidural hematoma, under the dura mater - subdural hematoma, under the pia mater - subarachnoid hematoma, in the brain substance - intracerebral and in the ventricles of the brain. Presence of blood in the cerebrospinal fluid indicates a subarachnoid hemorrhage, while the absence of blood in the cerebrospinal fluid does not exclude the presence of intracranial hemorrhage.

Early occurrence of seizures indicates a rapid increase in intracranial pressure.

Special research methods for suspected brain compression:

• electroencephalography;
• x-ray of the skull in 2 projections; computed tomography;
• echoencephalography;
• CT scan;
• angiography.

First aid

The patient should be taken to the neurosurgical department as soon as possible. When diagnosing intracranial hemorrhage and clarifying the location of the hematoma above this place, a craniotomy is performed, the hematoma is emptied, and bleeding is stopped.

After the operation, bed rest is indicated for 3-6 weeks, dehydration therapy, symptomatic therapy, antibiotics, hypnotics and sedatives are carried out.

Care of patients with traumatic brain injury

When caring for such patients, the nurse monitors compliance with bed rest, explaining to the patient and his relatives the consequences of his violation: he fulfills the doctor's prescriptions.

bedsores are among the most common problems encountered in rehabilitation treatment patients with a neurological profile. Most often, bedsores occur in the region of the sacrum, ischial tuberosity, greater trochanter of the femur, and heel region. In patients lying on their back for a long time, bedsores can occur in the back of the head, and in cases of kyphosis thoracic spine - above the spinous processes of the vertebrae. For the prevention of bedsores All linens must be dry and without wrinkles. All abrasions on the skin are washed with a 3% solution of hydrogen peroxide and smeared with a 1% solution of brilliant green (on the face) or a 3% solution of iodine tincture (on the trunk and limbs). The skin of the trunk is regularly wiped with a 3% solution of camphor alcohol. Every 2-3 hours change the position of the patient. Rubber circles are placed under the heels, sacrum, shoulder blades and other bony protrusions. A bedsore is an area of ​​ischemia and tissue necrosis that occurs in an area of ​​constant pressure on tissues (usually over bony prominences).

To prevent thromboembolism the legs are laid so that there is no compression of the veins, the legs are bandaged with elastic bandages. Ensuring proper nutrition, monitoring the normal function of the intestines and excretion of urine is also included in the set of measures aimed at maintaining the normal functioning of the body and the speedy restoration of impaired functions.

See Surgical Diseases and Head Injuries

Saenko I. A.

Sources:

1. Barykina N.V. Nursing in surgery: textbook. allowance / N. V. Barykina, V. G. Zaryanskaya.- Ed. 14th. - Rostov n/a: Phoenix, 2013.
2. Barykina N. V. Surgery / N. V. Barykina.- Rostov n / D: Phoenix, 2007.

Introduction

1. Closed craniocerebral injury

1 Closed craniocerebral injury

2 Etiology of closed craniocerebral injury

3 Classification of closed craniocerebral injuries

4 Clinic of closed craniocerebral injury

5 Methods for diagnosing a closed craniocerebral injury

6 Treatment of closed craniocerebral injury

1.7 Classification of the consequences of TBI (according to Likhterman L.B., 1994)

2. Features of nursing care for a patient with a closed craniocerebral injury

Conclusion

Bibliography

Note

Introduction

Traumatic brain injury is a global problem in neurosurgery. Every year, statistics record 200 cases of TBI per 10,000 population. Half of all head injuries are due to road traffic accidents. According to the World Health Organization (WHO), over the past 10-15 years, the number of cases of TBI has increased by an average of 2% annually. In the structure of traumatism, TBI accounts for 2/3 of deaths.

In recent decades, there has been an increase not only in the number of craniocerebral injuries, but also in their more severe course. This is due to an increase in the number Vehicle, rapid urbanization, insufficient compliance with traffic rules by individual drivers and pedestrians, especially in a state of intoxication, and poor road conditions. As a rule, people of young and middle age, that is, of the most able-bodied age, are injured, which gives the problem not only medical, but also important social significance. To date, the problem of the late period of post-traumatic brain injury, in particular, such issues as predicting the course of the process, adequate clinical, pathophysiological and expert assessment, and, especially, secondary prevention of complications, are of great socio-economic and general medical importance. Meanwhile, many issues of this problem have not been studied enough, some of them remain debatable. According to the statistics of the World Health Organization, the frequency of closed craniocerebral injuries (TBI) increases by an average of 2% per year and, according to various authors, ranges from 50 to 70% in the overall structure of injuries. The medical and social significance of CBI is due to the predominant lesion of people of working age. In the Russian Federation, 1 million people receive brain damage annually. 200 thousand people, of which 100 thousand are recognized as disabled, and 40-60% of them are of the second and first groups. Relevance of Exploring Opportunities effective treatment consequences of a closed craniocerebral injury (CTBI) is due to the fact that psychoneurological disorders that occur in the early or late post-traumatic period can also cause serious disorders in the human body, up to complete disability. In 44-62% of cases, traumatic brain injury occurs as a result of alcohol intoxication, which greatly complicates the early diagnosis of damage. With a traumatic brain injury, in addition to the cerebral hemispheres, the stem part of the brain suffers, in which centers are located that regulate the functioning of vital organs and systems, as well as metabolic processes. All these circumstances make the correct timely diagnosis extremely important, determine the tactics of the ambulance doctor and the amount of necessary therapeutic measures.

Purpose of the study: to identify the features of nursing care for patients with closed craniocerebral injuries.

Research objectives:

-analyze literary sources on the topic;

-analysis of an inpatient card;

-to analyze the principles of nursing care for patients with closed craniocerebral injuries;

Object of study: patient, inpatient card.

Research methods: observation of the patient, analysis of literary sources.

1. Closed craniocerebral injury

1.1Definition of CTBI

Closed craniocerebral injury - damage to the skull and brain, which is not accompanied by a violation of the integrity of the soft tissues of the head and / or aponeurotic stretching of the skull.

1.2Etiology of TBI

Craniocerebral injuries occur from the shock wave of an explosion, a blow to the head with a hard object, or a blow to the head on a hard object. The brain reacts to trauma with the development of edema followed by rapid swelling of the brain substance, which leads to increased intracranial pressure and serious disorders of brain function, and, consequently, of the whole organism as a whole.

1.3CTCI classification

-concussion,

-mild brain injury

-moderate brain injury

-severe brain injury

-compression of the brain on the background of a bruise,

-compression of the brain without injury.

1.4Clinical manifestations of CTBI

Concussion is the mildest form of injury, characterized by the development of functionally reversible damage and short-term loss of consciousness (within a few seconds to 30 minutes). After the restoration of consciousness, patients may experience retrograde amnesia, nausea, vomiting, dizziness, and headaches. Sometimes it is possible to register asymmetry of deep reflexes, decrease in abdominal reflexes, paresis of mimic muscles.

A brain contusion is a combination of cerebral symptoms and local, focal symptoms, depending on the location of the injury. With a mild bruise, loss of consciousness (from several minutes to 1-2 hours) by the type of stunning or stupor. Brief speech impairment. With a moderate bruise, loss of consciousness up to several hours, a decrease in the reaction of the pupil to light, corneal reflexes, nystagmus may be recorded. With a severe bruise, loss of consciousness by the type of stupor or coma. (during many days) a picture of diencephalic-catabolic or mesencephalobulbar syndromes develops.

Brain compression occurs against the background of a severe bruise (in 60% of cases). Most often, compression of the brain is due to the development of intracranial hematoma (64% of cases), fragments of the bones of the cranial vault (11%), cerebral edema (11%), or a combination of these causes (11%). Most early symptoms development of intracranial hematoma are hemolateral anisocoria (55-75%), contralateral hemiparesis (15-35%), asymmetry of deep reflexes (42%), epileptic seizures (8-16%), bradycardia (38%).

One of the leading symptoms of a growing intracranial hematoma is the presence of a light interval (a period of complete or relatively clinical well-being between the moment of injury and the onset of cerebral and focal symptoms). Tragic errors in the diagnosis of intracranial hematomas at the pre-hospital level arise from ignorance or underestimation of this symptom. Post-traumatic intracranial hematoma can also develop without a primary disorder of consciousness or against the background of clinical forms of contusion. The duration of the light interval, the intensity of the development of clinical symptoms of cerebral compression depend on the rate of compression, otherwise, on the source of bleeding. With an arterial source of bleeding, the light interval can be calculated in minutes, and with a venous source, hours. The defining symptoms of cerebral compression are the appearance of anisocoria, an increase in the depth of disorders of consciousness, respiration, and blood circulation. Other significant symptoms of cerebral compression are psychomotor agitation, if it is preceded by a satisfactory condition of the patient, an increase in headache, focal or generalized convulsive seizures, the appearance of extensor convulsions. Attachment to the indicated symptoms of bradycardia and arterial hypertension enhances confidence in the increase in intracranial pressure. The shorter the luminous interval and the more intense the increase in focal and cerebral symptoms, the more acutely the patient needs neurosurgical care.

Traumatic brain injury, as a rule, is complicated by the development of intracranial hypertension, which may be due to cerebral edema. It is usually formed after an injury due to hypoxia and hypercapnia, which entails an increase in cerebral blood flow, an increase in the permeability of the blood-brain barrier and fluid fixation in the brain tissue. Intracranial hypertension not associated with trauma is manifested by the development of headache, nausea, vomiting, arterial hypertension, bradycardia, mental disorders, and in severe cases - respiratory and circulatory disorders.

During TBI, periods are distinguished:

)Acute - the interaction of the traumatic substrate, the reaction of damage and the reaction of protection.

)Intermediate - resorption and organization of damaged areas and deployment of compensatory - adaptive mechanisms.

)Remote - completion or coexistence of local and distal degenerative and reparative processes:

-with a favorable course - complete or almost complete clinical balancing,

-if unfavorable - a clinical manifestation launched by trauma (adhesive, cicatricial, atrophic, hemolytic circulatory, vegetovisceral, autoimmune and others) processes.

Their selection in traumatic brain disease is based on the sum of clinical, pathophysiological, pathomorphological criteria.

The temporal and syndromological characteristics of the periods are determined by the clinical form of TBI, its nature, type, as well as the quality of treatment, age, premorbid and individual features the victim. The length of the periods depends on the clinical form: acute - from 2 to 10 weeks, intermediate - from 2 to 6 months, remote - with clinical recovery - up to 2 years, with a progressive course - not limited.

There is also a direct dependence of the severity and duration of impaired consciousness on the severity of TBI. At present, a single gradation of impaired consciousness has been adopted in Russia:

-Clear - the safety of all mental functions, wakefulness, complete orientation, adequate reactions, quick reaction to any stimulus, maintaining speech contact.

-Stunning (moderate and deep) - depression of consciousness while maintaining limited verbal contact, moderate drowsiness, not gross errors of orientation, the execution of only simple commands.

-Sopor - deep depression of consciousness with the preservation of coordinated defensive reactions and opening of the eyes in response to pain and other stimuli.

-Moderate coma - lack of consciousness with a complete loss of perception of the surrounding world, non-awakening, not opening the eyes, not coordinated protective movements without localization to a painful stimulus.

-Deep coma - lack of protective movements for pain. The absence of any reaction to pain, only to a strong painful stimulus, extensor movements in the limbs may occur.

-Coma transcendental - muscle atony, bilateral fixed mydriasis

5 Methods for diagnosing CTBI

To tentatively determine the degree of loss of consciousness, you can use the most common Glasgow Coma Scale (GCS) in the world. Radiation diagnostic methods are an integral part of the general clinical examination and are of decisive importance for determining the nature of the damage and developing further tactics for managing the patient. Broad prospects in neurotraumatology are associated with the introduction of computer (CT) and magnetic resonance (MRI) tomography into clinical practice. These research methods significantly increased the accuracy of diagnostics and made it possible to non-invasively and quickly determine the state of the medulla, detect intracranial hematomas, and assess the state of the ventricular system of the brain. The volume and choice of methods of X-ray examination of patients with TBI depends on the severity and rate of focal, cerebral, stem symptoms. The main methods radiodiagnosis craniocerebral injuries are:

-Survey craniography

-CT

-Cerebral angiography

Under additional or partial indications, radioisotope studies may be performed. Also, all the victims undergo an x-ray of the skull.

It is especially difficult to diagnose TBI on the background of alcohol intoxication, which can obscure the clinical manifestations of injury, or aggravate them. Accurate diagnosis is possible with dynamic observation after the elimination of alcohol intoxication. For decreasing possible errors in doubtful cases, the diagnosis should be tilted in favor of TBI. as a rule, a combination of 3-4 clinical symptoms gives grounds to diagnose intracranial hematoma in 90% of cases. The most informative way to identify it is the echoencephalography technique, which makes it possible to make the correct diagnosis in 95-99% of cases.

1.6 Treatment of PTBI

Prevention of intracranial hypertension and its brain-damaging consequences at the pre-hospital stage can be implemented using glucocorticoid hormones and saluretics. It is also advisable to intravenously or intramuscularly administer prednisolone at a dose of 30 mg, dexamethasone at a dose of 4-8 mg, which is practically devoid of mineralocorticoid properties. In the absence of circulatory disturbances, simultaneously with glucocorticoid hormones, for dehydration of the brain, it is possible to use fast-acting saluretics - 20-40 mg, lasix (2-4 ml of 1% solution). In a hospital, therapy aimed at the prevention and elimination of intracranial hypertension - cerebral edema, can be extended by the use of inhibitors of protiolytic enzymes, neurovegetative blockade, and artificial lung hyperventilation. to reduce intracranial pressure, both at the pre-hospital stage and in the hospital, osmotically active substances (mannitol) should not be used, since if the blood-brain barrier is damaged, the patient's condition may worsen due to the rapid development of a secondary increase in intracranial pressure. An exception may be glucose, which in acute situations can be administered intravenously in a 40% solution of 1-2 ml / kg of body weight, it is advisable to combine it with the appointment of glucocorticoid hormones and saluretics.

Development of an integrated pathogenetic treatment of victims with TBI is based on the study of the mechanisms of its pathogenesis and the results of conservative therapy. in concussion (CGM), the pathogenesis is based on temporary functional disorders of the central nervous system, in particular, its autonomic centers. victims with a concussion are placed on bed rest for 1-3 days, which is then extended to 2-5 days. Discharge from the hospital is carried out on the 10th day. Drug therapy should not be aggressive and is mainly aimed at normalizing the functional state of the brain, relieving headaches, dizziness, anxiety, insomnia and other complaints. In the early period, sedatives are prescribed, prolonging physiological sleep in the afternoon and at night until bed rest is canceled (valerian, motherwort, corvalol, valocordin), as well as tranquilizers (elenium, sibazon, phenazipam, nozepam, rudotel, etc.). To eliminate insomnia at night, phenobarbital or reladorm is prescribed. Painkillers - analgin, pentalgin, baralgin, sedalgin, maxigan and others. They do the same with dizziness, choosing one of the available medicines(betaserg, belloite, bellaspon, platifillin with popaverine, tanakan, microzero, etc.) It is also advisable to conduct a course of vascular and metabolic therapy for faster and more complete recovery and impaired brain functions. Preferably a combination of vasoactive (cavinton, stugeron, sermion, teonicol etc.) and nootropic (nootropil, incefobol, aminolone, picamelon) drugs. There is no need to use anticonvulsants.

1.7 Classification of the consequences of TBI (according to Likhterman L.B., 1994)

Often there is a combination of different effects. Progressive and non-progressive variants of consequences are largely determined by the type (open, closed) and severity of TBI.

.Mostly non-progressive: local or diffuse atrophy brain, meningeal scars, subarachnoid and intracerebral cysts, aneurysms; bone defects of the skull, intracranial foreign bodies, cranial nerve damage, etc.

Table 1 Glasgow Outcome Scale

Traumatic Brain Injury Outcome Definitions Recovery Return to the previous level of employment Moderate disability Neurological or psychiatric disorders that prevent the return to the previous job with the ability to serve oneself Severe disability Inability to self-care Vegetative state Spontaneous opening of the eyes and maintenance of the sleep-wake cycle in the absence of response to external stimuli, inability to follow commands and utter sounds Death Cessation of breathing , heartbeat and electrical activity of the brain

We can talk about outcomes 1 year after the traumatic brain injury, since there are no significant changes in the patient's condition in the future. Rehabilitation activities include physiotherapy exercises, physiotherapy, taking nootropic, vascular and anticonvulsant drugs, vitamin therapy. The results of treatment largely depend on the timeliness of assistance at the scene and upon admission to the hospital.

The consequences of a traumatic brain injury may be associated with damage to a specific area of ​​the brain or be the result of a general brain damage due to edema and increased pressure.

Possible consequences of traumatic brain injury:

-epilepsy,

-a decrease in a certain degree of mental or physical abilities,

-depression,

-memory loss,

-personality changes

closed cranial brain injury

2. Features of nursing care for a patient with a closed craniocerebral injury

Due to an accident, in the MOKB them. Boyandin, a patient was admitted to the OAR 3 department:

Statuspresents: The condition is serious, due to the severity of the injury, shock. The skin and visible mucous membranes are pale. BP 90/60 mmHg PS - 110 per minute, rhythmic. Heart sounds are muffled. Both half of the chest are symmetrical, participate in the act of breathing. NPV 24 per minute. Breathing is carried out in all departments, there are no wheezing. The abdomen is soft, does not respond to palpation. Urine is light.

Conducted research:

)May 1, 2011 MSCT of the brain and bones of the brain skull.

)05/3/2011 MSCT of the brain and bones of the brain skull.

Conclusion: hemorrhagic foci of contusion in both frontal lobes, more on the right. SAK. Edema of the fronto-parietal - occipital regions of both hemispheres.

)May 3, 2011 X-ray on an open (paid) device.

Conclusion: C7 vertebra "not broken", its assessment is impossible. Violation of the integrity of bodies C2-6 was not revealed.

)05/03/2011 ECG in intensive care.

Conclusion: PQ = 0.18" RR = 0.72" HR = 83 per minute, sinus rhythm. Violations of the processes of repolarization in the myocardium.

)05/10/2011 MSCT of the brain and bones of the brain skull.

Conclusion: In comparison with the results of the study dated May 3, 2011, hemorrhagic foci of contusion in the media-basal parts of the frontal lobes of both hemispheres of the brain decreased in size, their cavity characteristics decreased due to reblooming and blood resorption. The degree of perifocal edema slightly decreased.

)05/1/2011 (67002) Blood test on a hematological analyzer - 1- indicators - semi-automatic.

)(67097) Calcium - automatic.

)Conclusion: calcium, mmol/l - 2.38.

)(67120) Coagulogram in the OAR laboratory.

)(67203) acid-base balance, blood gases, electrolytes, hemoglobin and hematocrit, glucose.

)(67215) Comprehensive biochemical study No. 2 (glucose, urea, bilirubin, creatinine, protein, ALT, AST, alpha-amylase) automatic.

)(83008) Urinalysis in the laboratory on duty - protein quality.

)(67004) KLA (clinical) - 12 impressions Blood analysis on a gem.analyzer + leukoformula + ESR.

Consultations:

-Urologist from 05.05.2011.

-Neurosurgeon dated May 25, 2011.

-Neurologist 1 time in 6 months.

Patient monitoring

Disturbed Needs:

-Breathe

-Eat, drink

-sleep, rest

-Move

-To be healthy

-Communicate

Problems:

-Headaches due to closed craniocerebral injury.

-Discomfort associated with restriction of movement, violation of the integrity of the skin, changes in blood pressure.

-Restricted mobility due to connected ventilators, feeding tube, urinal.

Psychological problems:

-Loss of consciousness, delirium due to trauma

-Lack of knowledge about disease and condition

Priority issues:

-Discomfort associated with movement restriction

Potential issues:

-Risk of complications

Goals of nursing care:

-The patient will feel satisfactorily by the time of discharge.

-The patient will not experience complications after the nursing interventions

-Prevention of possible complications, prevention of bedsores

-(meningeal scars, subarachnoid and intracerebral cysts, aneurysms, cranial nerve lesions)

Patient care

)Informing relatives about the disease.

)Ensuring the mode of motor activity - strict bed rest. Creating a comfortable position in bed - with a raised head end, on an anti-decubitus mattress.

)Ensuring the sanitary and epidemiological regime in the ward.

)Aerotherapy - airing 1-2 times a day

)Control of wet cleaning in the ward

)Compliance with asepsis and antisepsis

)Ensuring sanitary and hygienic regime

)Nail cutting, bed linen change, hygienic treatment of the body and mucous membranes, care of the subclavian and intravenous catheter, insertion and care of the urinary catheter.

)Condition control: blood pressure, respiratory rate, pulse, body temperature, consciousness, condition of the skin and visible mucous membranes, daily diuresis, localization and nature of pain, volume and composition of the fluid received per day, body weight.

)Refuses to eat on his own, switched to tube feeding. Receives meat meat broths, milk mixtures (through a probe).

)Preparation of the patient for instrumental and laboratory examinations is not required due to the patient's condition. All procedures are carried out in the ward.

)Fulfillment of medical prescriptions (drugs administered in case of illness), control of possible side effects.

)Documenting the activities of a nurse:

)Filling out the appointment sheet

)Filling out the temperature sheet

)Registration of applications to the pharmacy for medicines

)Registration of directions

Conclusion

After analyzing the literature sources on the topic of closed craniocerebral injuries, it was found that this injury is quite severe, especially in patients with brain compression due to a severe contusion. Such injuries are difficult to diagnose and treatment in such patients is longer and these patients need long-term care due to being in a coma.

After analyzing the card of an inpatient, it was found that the patient's condition is severe, due to the severity of the injury, shock, as a result of which there is long time on the ventilator. The patient is unable to eat on his own and is fed through a nasogastric tube. Forced to be on strict bed rest, which increases the risk of developing bedsores.

Based on this, the features of nursing care for such patients will be aimed at the exact implementation of medical prescriptions, monitoring the patient's condition and possible side effects from administered drugs. Carrying out the prevention of possible complications, such as the risk of developing bedsores, congestive pneumonia. Competent diagnostic studies, as well as tell the patient's relatives about his disease, possible consequences and treatment. Assist patients with body hygiene. Monitor inserted catheters. If the patient is on a ventilator, then they should be able to sanitize the upper and lower respiratory tract. Place a nasogastric tube.

Based on this, we found that the nurse is very important for the care of patients.

Bibliography

) Sitel A. B., Teterina E. B., Avanesova T. S. Magazines" traditional medicine" 2007 #"justify">Note

1)Diencephalic-catabolic syndrome is a type of course after the surgical period that develops as a result of surgical manipulations in the area of ​​the bottom of the third ventricle during the removal of medial-basal meningiomas, ependiomas of the third ventricle, pharyngiomas and pituitary adenomas with retro- and suprasellar growth.

)Mesencephalobulbar syndrome is a severe degree of contusion of the brain stem. Characterized by bradycardia, hypothermia, hypotension, bradypnea against the background of oppressed conscious activity.

)Homolateral anisocoria is pupil dilation on the same side of the body as the affected hemisphere of the brain.

)Anisocoria is a symptom characterized by the size of the pupils of the right or left eye. As a rule, one pupil behaves normally, and the second is in a fixed position.

)Focal seizure - localized (focal) (partial) idiopathic epilepsy and epileptic syndromes with seizures with focal onset

)Extensor spasticity is due to increased muscle tone in the extensor muscles. The limbs are extended, retracted from the human body.

)The blood-brain barrier is a physiological barrier between circulatory system and CNS. Main function: maintaining brain homeostasis. It protects the nervous tissue from microorganisms circulating in the blood, toxins, cellular and humoral factors. immune system that perceive brain tissue as foreign. The BBB acts as a highly selective filter through which nutrients enter the brain from the bloodstream, and waste products of the nervous tissue are excreted in the opposite direction.

)Progressive - gradually increasing changes (progressive)

)Extensor movements - limb extension

)Mydriasis - pupil dilation.

)The Glasgow Coma Scale is a scale for assessing the degree of impaired consciousness and coma in children over 4 years of age and adults.

)Radiation diagnostic methods are methods based on the results of MRI, CT and radiography indications.

)Echoencephalography is a method of studying the brain using ultrasound.

)Bedsore care:

-Wash and dry hands, put on gloves.

-The patient is turned to the side.

-Treat the skin of the back with a napkin moistened with warm water.

-Dry the skin with a dry towel.

-They massage places where bedsores often form.

-Lubricate the skin with sterile vaseline or boiled vegetable oil.

-The resulting bedsores are treated with quartz treatment, starting from 1-2 minutes and gradually increasing the exposure time to 5-7 minutes.

-Under the places of formation of bedsores, cotton-gauze circles or rubber circles in a pillowcase are placed.

-Examine the patient's bed, remove the crumbs after eating.

-Wet and soiled bedding and underwear are changed immediately.

-When changing bed and underwear, make sure that there are no seams, patches, or folds on them in places where pressure sores form.

-Places of reddening of the skin are treated with a weak solution of potassium permanganate.

-Antidecubital mattresses are used in the department for the best prevention.

)The department is supplied with:

-Anti-decubitus mattresses

-Press massagers for patients with stroke

-Standing table for patients with stroke

-Patient heating and cooling system

-New ventilators

-Dräger anesthesia machines with patient monitors and gas analyzer

-Ultrasound machine for placing subclavian, jugular, femoral and other catheters

-New ECG machine with cardioversion

)Feeding patients through a tube

Purpose: the introduction of the probe and feeding the patient.

Indications: injury, damage and swelling of the tongue, pharynx, larynx, esophagus, swallowing and speech disorders, unconsciousness, refusal of food in mental illness, non-scarring stomach ulcer.

Contraindications: peptic ulcer stomach in the acute stage.

Equipment: sterile: probe 8 - 10 ml in diameter, funnel 200 ml or Janet syringe, glycerin, wipes, furacillin solution 1:2000, clamp, phonendoscope, 3-4 cups of warm food.

A mark is made on the probe: the entrance to the esophagus is 30 - 35 cm, the stomach is 40 - 45 cm, the duodenum is 50 - 55 cm. The patient sits down if there are no contraindications. The course of probing: examination of the nasal passages, the probe is lubricated with petroleum jelly and injected. If the patient is unconscious: lying position, head turned to the side. The probe is left for the entire period of artificial nutrition, but not more than 2 - 3 weeks. Carry out the prevention of bedsores of the mucosa.

Table 2 Tube feeding of patients

STAGESNOTE PREPARATION FOR THE PROCEDURE1. Establish a trusting relationship with the patient (or with his relatives). 2. Explain the purpose of the procedure, obtain his (their) consent, explain the sequence of actions 15 minutes before feeding. Tell the patient what he will be fed. Ventilate the room before feeding.3. Wash hands, dry. 4. Give the patient a high Fowler position and determine the length of the probe being inserted by measuring the distance from the mouth to the stomach (or in another way, for example, height in cm - 100), put a mark.5. Pour a solution of furacillin 1:2000 into the tray and immerse the probe into it to the mark. Wetting the probe facilitates its introduction into the stomach.6. Lay the patient on his back, placing a pillow under his head and neck, placing a napkin on his chest. The head is slightly tilted forward. Conditions are created to ensure the free passage of the probe in the nasopharynx. PERFORMING THE PROCEDURE1. Put on gloves. 2. Insert a thin gastric tube through the nasal passage to a depth of 15 - 18 cm, then give the patient a Fowler's position (half-sitting) and offer to swallow the probe to the mark. The probe is freely advanced into the stomach.3. Draw 30-40 ml of air into Janet's syringe and attach it to the probe. 4. Introduce air through the probe into the stomach under the control of a phonendoscope. Characteristic sounds are heard, indicating that the probe is in the stomach.5. Disconnect the syringe and clamp the probe by placing the outer end of the probe in the tray. Prevents leakage of stomach contents.6. Fix the probe with a piece of bandage and tie it around the patient's face and head. Fixation of the probe is provided.7. Remove the clamp from the probe, connect a funnel or use Janet's syringe without a piston and lower it to the level of the stomach. Air exits the stomach.8. Tilt the funnel slightly and pour prepared food into it, heated in a water bath to 38 - 40 ° C, gradually raise the funnel until the food remains only at the mouth of the funnel. Preventing air from entering the stomach.9. Lower the funnel to the level of the stomach and repeat the introduction of food into the stomach. 10. Rinse the probe with tea or boiled water after feeding. END OF THE PROCEDURE1. Place a clamp on the end of the probe, remove the funnel and wrap the end of the probe with a sterile cloth, fix it. 2. Place the end of the probe with a clip in the tray, or fix it with a loop of bandage around the patient's neck until the next feeding. 3. Remove gloves, disinfect. 4. Wash hands, dry 5. Place the patient in a comfortable position, create complete rest, observation.

)Conducted procedures:

Blood sampling for analysis from a peripheral vein

1. Preparation for the procedure:

1.1. Ensure that the patient has informed consent for the procedure to be performed. In the absence of such, check with your doctor for further actions.

1.2. Wash and dry hands.

1.3. Prepare the necessary equipment.

1.4. Invite the patient to take a comfortable position: sitting or lying down.

1.5. Select and examine / palpate the area of ​​​​the proposed venipuncture in order to avoid possible complications.

1.6. When performing venipuncture in the region of the cubital fossa, offer the patient to extend the arm as much as possible in the elbow joint, for which purpose place an oilcloth pad under the elbow.

1.7. Apply a tourniquet (on a shirt or diaper) so that at the same time the pulse on the nearest artery is palpable, ask the patient to squeeze the hand into a fist several times and unclench, then squeeze the hand into a fist.

1.8. When performing venipuncture in the region of the cubital fossa, apply a tourniquet in the middle third of the shoulder, check the pulse on the ulnar artery. 1.9. Wear gloves (non-sterile).

2.1. Consistently treat the skin with two alcohol balls: the first is a large area and throw it into the disinfectant, the second is the immediate puncture site and dump it, the third is clamped by the fifth finger of the left hand.

2.2. Take the syringe, fixing the cannula of the needle with the index finger. The remaining fingers cover the syringe barrel from above.

2.3. Stretch the skin in the venipuncture area, fixing the vein. Hold the needle with the cut up, parallel to the skin, pierce it, then insert the needle into the vein (no more than ½ needles). When the needle enters the vein, there is a "hit in the void"

2.4. Make sure that the needle is in the vein: pull the plunger towards you, while blood should flow into the syringe. Warn the patient not to open his fist.

2.5. Draw the required amount of blood into the syringe.

2.6. Untie / loosen the tourniquet and ask the patient to open his fist.

3. End of the procedure.

3.1. Press a napkin / cotton ball with a skin antiseptic to the venipuncture site. Remove the needle, ask the patient to hold the tissue / cotton ball at the venipuncture site for 5-7 minutes, pressing the thumb of the other hand. The time that the patient holds the tissue/cotton ball at the venipuncture site (5-7 minutes) is recommended.

3.2. Make sure that there is no external bleeding in the venipuncture area.

3.3. Release the blood into the test tube along the wall without touching its outer edges.

3.4. Dispose of the syringe and used material in a container for disinfection.

3.5. After 5-7 minutes, drop the patient balloon into the disinfectant.

3.6. Remove gloves, place them in a container for disinfection.

3.7. Wash and dry hands (using soap or antiseptic).

3.8. Make an appropriate record of the results of the execution in medical documentation or arrange execution.

3.9. Arrange delivery to the laboratory.

Urine collection for analysis from a urinal

)Injected drugs:

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COURSEWORK

« Traumatic brain injury. Features of the nursing process»

Introduction

2.2 Brain contusion

2.3 Brain pressure

Conclusion

skull fracture nursing craniocerebral

Introduction

It would seem that little threatens our brain. After all, he is protected by full program. It is washed by a special liquid, which not only provides the brain with additional nutrition, but also serves as a kind of shock absorber. The brain is covered with several layers of membranes. After all, it's just safely hidden in the skull. However, head injuries very often result in serious brain problems for a person. Traumatic brain injury is one of the most significant in public health.

In the world, traumatic brain injury ranks third as the cause of death of the population, second only to cardiovascular and oncological diseases. However, among children, people of young and younger middle age, it leaves its “competitors” far behind, exceeding mortality due to cardiovascular diseases by 10, and cancer by 20 times. At the same time, brain damage is the cause of death due to injuries in almost 50% of cases. Traumatic brain injury is one of the leading causes of disability in the population.

In Russia, such an injury as the cause of death comes in second place, second only to cardiovascular diseases. Every year, about 600,000 people get traumatic brain injury, 50,000 of them die, and another 50,000 become disabled. The incidence of traumatic brain injury in men is two times higher than that in women, with the preservation of this dependence in all age groups. The most common causes are car accidents and household injuries.

Closed craniocerebral injury is much more common than open, and accounts for about 90% of all traumatic brain lesions. Concussion ranks first among all head injuries.

1. Traumatic brain injury: a general concept

Traumatic brain injury (TBI) is mechanical damage to the skull, brain and its membranes. When the brain is damaged, there are disorders of cerebral circulation, liquor circulation, and permeability of the blood-brain barrier. Cerebral edema develops, which, together with other pathological reactions, causes an increase in intracranial pressure.

Displacement and pressure of the brain can lead to wedging of the brain stem into the opening of the cerebellar tenon or into the foramen magnum. This, in turn, causes further deterioration of blood circulation, metabolism and functional activity of the brain.

An unfavorable factor in brain damage is hypoxia due to respiratory failure or a drop in systemic arterial pressure.

There are closed craniocerebral injury, in which there are no conditions for infection of the brain and its membranes, and open, which often leads to the development of infectious complications from the meninges (meningitis) and the brain (abscess, encephalitis). To closed injury include all types of craniocerebral injuries, in which the integrity is not violated skin head, and soft tissue injuries that are not accompanied by damage to the aponeurosis.

An open craniocerebral injury is characterized by simultaneous damage to the soft integument of the head and cranial bones. If it is accompanied by a violation of the integrity of the dura mater, it is called penetrating, in which case the danger of infection of the brain is especially great.

Damage to the skull can be in the form of cracks, perforated and depressed fractures, fractures of the bones of the base of the skull.

External signs of a fracture of the base of the skull are bruising around the eyes in the form of glasses, bleeding and leakage of cerebrospinal fluid from the nose and ear.

The clinical symptoms of traumatic injuries consist of general cerebral symptoms and local disorders caused by damage to certain areas of the brain.

First aid is primarily to prevent the ingress of blood, cerebrospinal fluid or vomit into the respiratory tract.

The diagnosis of traumatic brain injury is made on the basis of anamnesis and clinical signs damage to the brain and all its integuments. To clarify the diagnosis, instrumental research methods are used.

All victims with a traumatic brain injury are given X-rays of the skull (craniography), usually in 2 projections - lateral and direct. They allow you to identify (or exclude) cracks and fractures of the bones of the cranial vault.

Recognition of fractures of the bones of the base of the skull often requires special styling for the image, however, the presence of bleeding or especially cerebrospinal fluid from the nose or ear makes it possible to determine them clinically. Echoencephalography reveals compression of the brain due to intracranial hematoma, hygroma, or brain crush.

The most informative method for diagnosing craniocerebral injury is computed X-ray tomography, which gives an idea of ​​violations of the anatomical and topographic relationships in the cranial cavity. By changing the density of tissues, it is possible to establish the location, nature and degree of brain contusions, to identify meningeal and intracerebral hematomas and hygromas, subarachnoid and intraventricular hemorrhages, cerebral edema, as well as expansion or pressure of the ventricular system and cisterns of the base of the brain.

Less commonly, cerebral angiography is used to detect meningeal hematomas, which, when a displacement of the great vessels is detected, and especially characteristic of these hematomas without a vascular zone on the angiogram, makes it possible to recognize not only their presence, but also their localization.

The volume and nature of treatment measures are determined by the severity and type of traumatic brain injury, the severity of cerebral edema and intracranial hypertension, disorders of cerebral circulation, liquor circulation, brain metabolism and its functional activity, as well as complications and vegetative-visceral reactions, the age of the victim and other factors.

2. Closed craniocerebral injury

The main clinical forms of traumatic brain injury are concussion, brain contusions (mild, moderate and severe), pressure of the brain, fractures of the bones of the vault or base of the skull.

2.1 Concussion

A concussion is a functionally reversible brain injury with a short-term loss of consciousness. Pathological changes can be detected only at the cellular and subcellular levels.

A concussion is usually manifested by loss of consciousness of varying duration (from a few moments to several minutes).

After leaving the unconscious state, headache, nausea, and sometimes vomiting are noted, the patient almost always does not remember the circumstances that preceded the injury, and the very moment of it (retrograde amnesia), hardly recognizes the people around him. Memory loss is important sign, by which one can judge the severity of brain damage: whether a person remembers the moment of injury, and if not, how much time before the injury fell out of his memory. The greater the memory lapse, the more serious the injury!

Prolonged (over 1-2 hours) unconsciousness usually indicates more serious damage, bruising or pressure on the brain. However, a short loss of consciousness does not exclude the possibility of a combination of brain contusion with its pressure. This happens in those cases when, during a bruise, a rupture of blood vessels occurs in the membranes or substance of the brain and forms intracranial hemorrhage, which gradually increases and causes pressure on the brain.

Characterized by blanching or redness of the face, increased heart rate, general weakness, excessive sweating. Vital functions are not impaired, focal neurological symptoms are absent. All these symptoms gradually disappear, usually in 1-2 weeks. But this does not mean that the concussion passed without a trace. In some patients, general weakness, headaches, instability of the vascular system, increased emotionality, and decreased ability to work persist for a long time.

In the first hours after a concussion, the victim's pupils are dilated or constricted - a traumatic brain injury of any severity leads to disruption of the nerve pathways responsible for the work of the eyes. With a mild concussion, the pupils react to light, but sluggishly, and with a severe concussion, there is no reaction at all. At the same time, the expansion of only one of the pupils and the absence of a reaction in the second is a formidable symptom and may indicate a severe brain injury.

Hospitalization is essential because the initial symptoms of concussion and more severe brain injuries (eg, brain contusion or intracranial hemorrhage) may be identical. Only a doctor can determine what kind of injury was received. It is possible that an x-ray examination (image of the bones of the skull) may be required to rule out a fracture of the skull bones. Continuous observation for at least 24 hours after injury in order to timely diagnose cerebral pressure.

In case of concussion, conservative treatment is carried out: non-narcotic analgesics are prescribed for pain, antibacterial agents in the presence of soft tissue wounds, sedatives and hypnotics, bed rest for 7-10 days.

Patients with a concussion need to observe bed rest, while reading, listening to music and even watching TV are not allowed. It should be remembered that a person who has suffered even a mild concussion may develop post-traumatic neurosis or other, more serious complications such as epilepsy. Therefore, some time after recovery, you should definitely undergo an electroencephalography and visit a neuropathologist.

2.2 Brain contusion

A brain contusion is a craniocerebral injury characterized by focal macrostructural damage to the medulla of varying severity. This is any local damage to the brain substance - from minor, causing only minor hemorrhages and swelling in the affected area, to the most severe, with rupture and crushing of the brain tissue. A bruise is possible with a closed and open craniocerebral injury.

Pathomorphology: changes in the focus of contusion, destruction (crushing) of the brain substance, punctate hemorrhages (due to rupture of blood vessels under the influence of a mechanical factor) in the brain parenchyma, perifocal cerebral edema, traumatic subarachnoid hemorrhage as a result of ruptured vessels of the pia mater, skull fractures, bone fractures of the cranial vault without pressure (linear and comminuted), fractures of the bones of the skull base (with rupture of the membranes) - CSF leakage through the nose (rhinorrhea) or external auditory canal (otorrhea), depressed fractures - compression of the brain, fractures of the bones of the cranial vault - the formation of intracranial hematomas , brain pressure.

Mild brain injury. It is characterized by loss of consciousness up to 1 hour after the injury, complaints of headache, nausea, and vomiting. In the neurological status, rhythmic twitching of the eyes when looking to the sides (nystagmus), meningeal signs, asymmetry of reflexes are noted. Roentgenograms may show skull fractures. In the cerebrospinal fluid - an admixture of blood (subarachnoid hemorrhage).

Moderate brain injury. Consciousness is switched off for several hours. Loss of memory (amnesia) for the events preceding the trauma, the trauma itself and the events after it is expressed. Complaints of headache, repeated vomiting. Short-term respiratory disorders, heart rate, blood pressure are detected. There may be mental disorders. Meningeal signs are noted. Focal symptoms manifest themselves in the form of uneven pupil size, speech disorders, weakness in the limbs, etc. Craniography often reveals fractures of the vault and base of the skull. Lumbar puncture showed significant subarachnoid hemorrhage.

Severe brain injury. It is characterized by a prolonged shutdown of consciousness (lasting up to 1-2 weeks). Gross violations of vital functions are revealed (changes in pulse rate, pressure level, frequency and rhythm of breathing, temperature).

In the neurological status, there are signs of damage to the brain stem - floating movements of the eyeballs, swallowing disorders, changes in muscle tone, etc. There may be weakness in the arms and legs up to paralysis, as well as convulsive seizures. A severe contusion is usually accompanied by fractures of the vault and base of the skull and intracranial hemorrhages.

The final diagnosis is made according to the results of X-ray of the skull in frontal and lateral projections (presence of bone damage), CT and MRI.

The main method of treatment is conservative: hospitalization is mandatory, bed rest, maintenance of vital functions, if necessary, resuscitation; brain edema therapy; analgesics if necessary; with convulsions - anticonvulsants; funds that improve cerebral circulation and metabolism, nootropics.

The duration of bed rest with a mild bruise is 10-14 days, with a moderate bruise from 2 to 3 weeks, depending on the clinical course and results instrumental research. With subarachnoid hemorrhage, hemostatic therapy is carried out. Spinal puncture for therapeutic and diagnostic purposes is performed in the absence of signs of pressure and dislocation of the brain. Surgical treatment is indicated for brain contusion with crushing of its tissue (most often occurs in the region of the poles of the frontal and temporal lobes).

With mild brain contusions, motor, sensory and other disorders usually completely disappear within 2-3 weeks. With more severe bruises, as a rule, persistent consequences remain: paresis and paralysis, sensory disturbances, speech disorders, and epileptic seizures may occur.

2.3 Brain pressure

Cerebral pressure is a progressive pathological process in the cranial cavity that causes compression of the brain resulting from trauma. With any morphological substrate, depletion of compensatory mechanisms can occur, which leads to pressure, dislocation, herniation of the brain stem and the development of a life-threatening condition. Depressed fractures of the cranial vault are the cause of local compression of the brain.

The main cause of brain pressure in traumatic brain injury is the accumulation of blood in a closed intracranial space. Depending on the relationship to the membranes and the substance of the brain, there are: epidural (located above the dura mater, in 20% of cases), subdural (between the dura mater and the arachnoid, 70-80%), intracerebral (in the white matter of the brain and inside the ventricular (in the cavity of the ventricles of the brain) hematomas; then depressed fractures of the bones of the cranial vault (especially the penetration of bone fragments to a depth of more than 1 cm); foci of crushing of the brain; space according to the valve mechanism) and extremely rarely pneumocephalus (accumulation of air in the cranial cavity).

The first signs of the onset of cerebral pressure with increasing hemorrhage are increased headaches, anxiety of the patient or, conversely, drowsiness, focal disorders appear and gradually increase, the same as with a brain injury.

Signs of herniation: increased severity of the general cerebral syndrome, the appearance or increase in focal hemispheric and stem symptoms, depression of consciousness. Contralateral hemiplegia (on the side opposite to the focus of pressure), mydriasis, lack of response to light, irregular breathing, coma. Loss of consciousness occurs, life-threatening disorders of cardiac activity, respiration occur, and if appropriate assistance is not provided, death will occur.

With a depressed fracture, the brain is subjected to both pressure and contusion, and cerebral edema develops rapidly. With pressure from the brain by a hematoma, a rupture of a blood vessel, especially in the meninges of the brain, can occur with craniocerebral injuries without gross damage to the brain tissue, which caused only a slight contusion of the brain.

In most cases, there is loss of consciousness at the time of injury. Subsequently, consciousness can be restored. The period of restoration of consciousness is called the light interval. After a few hours or days, the patient may again fall into an unconscious state, which, as a rule, is accompanied by an increase neurological disorders in the form of the appearance or deepening of paresis of the limbs, epileptic seizures, pupil dilation on one side, slowing of the pulse (frequency less than 60 per minute), etc.

According to the rate of development, acute intracranial hematomas are distinguished, which appear in the first 3 days from the moment of injury, acute - clinically manifested in the first 2 weeks after injury and chronic, which are diagnosed after 2 weeks from the moment of injury.

Diagnostics. If the patient is conscious, careful identification of the circumstances and mechanism of injury is necessary, since a stroke or an epileptic seizure may be the cause of a fall and head injury. Often the patient cannot remember the events that preceded the injury (retrograde amnesia), immediately following the injury (anterograde amnesia), and the moment of injury itself (cograde amnesia).

It is necessary to carefully examine the head for signs of injury. Hemorrhages over the mastoid often indicate a fracture of the pyramid temporal bone. Bilateral hemorrhages in the fiber of the orbit (the so-called "glass symptom") may indicate a fracture of the base of the skull. This is also indicated by bleeding and liquorrhea from the external ear canal and nose. With fractures of the cranial vault, a characteristic rattling sound is heard during percussion - “a symptom of a cracked pot”.

The main method of treatment is surgical. Emergency surgery: osteoplastic or resection trepanation, decompression (removal of blood, clots, depressed bone fragments) - elimination of the cause of pressure in the brain, stopping bleeding. Evacuation of intracranial hematomas should be performed within the first 4 hours after injury.

Possible complications: brain abscess, subdural empyema, meningitis, re-formation of hematoma, post-traumatic epilepsy.

2.4 Fractures of the base (vault) of the skull

Fractures of the base of the skull - damage to the bones of the specified area (in most cases, the continuation of fractures of the bones of the cranial vault), extending to the bone base of the anterior, middle and posterior cranial fossae.

With fractures of the cranial vault, symptoms of concussion or brain contusion are observed, combined with hemorrhages from the meningeal vessels. special attention require depressed fractures of the cranial vault, the removal of which prevents the development of severe complications (traumatic epilepsy).

The main causes of these injuries are a fall from a height onto the head and a direct blow to the midline of the face, especially in the bridge of the nose.

Fractures of the base of the skull are usually accompanied by a rupture of the dura mater, a communication with the external environment is formed through the nasal, oral cavities, middle ear cavity, orbit, or paranasal sinuses nose, which causes the appearance of nasal, ear liquorrhea and post-traumatic pneumocephalus

Clinical picture: general brain disorders, symptoms of damage to the brain stem and cranial nerves, often facial with a picture of unilateral paresis of the muscles of the face or auditory with hearing loss, bleeding and liquorrhea from the nose, ear or orbit. Loss of consciousness reaches deep stupor or coma and often lasts several hours. Generalized convulsions with a clear tonic component are possible. In connection with liquorrhea, intracranial hypotension is observed. Signs of damage to the brain stem are noted: bulbar or pseudobulbar syndrome, respiratory arrhythmia, tachycardia, and a drop in blood pressure. Of the cranial nerves, the facial, vestibulocochlear, and efferent nerves are most often affected. The presence of liquorrhea creates a constant threat of purulent meningitis. It may appear in another period, its relapses are possible.

A skull base fracture can be confirmed by a Stinvers or Schüller craniogram. However, giving the head of the victim a special position in the acute period of injury is not always possible. Also, small fractures may not show up on these scans. The most common sign of a skull base fracture is shading of the cells of the mastoid process or pterygoid sinus.

Treatment is conservative - if a crack or fracture of the base of the skull is suspected, treatment is performed auricle(or nose) with an antiseptic solution with the imposition of an aseptic dressing, the appointment of massive doses of antibiotics and sulfonamides, tk. the likelihood of infection of the cranial cavity is very high.

From the first minutes after a traumatic brain injury, the patient should be on strict bed rest. He needs to provide free access to air. In case of loss of consciousness, aspiration of vomit and saliva should be prevented. It is advisable to prescribe cold on the head. Anti-shock measures are needed: the introduction of plasma and plasma substitutes, analgesics, sedatives, and vascular agents. To improve cerebral circulation, it is advisable to prescribe cinnarizine (stugeron) or cavinton. Sermion improves hemodynamics and activates the metabolism of the brain - these drugs are used for all traumatic brain injuries, not only in the acute period, but also for the next 3-4 weeks. In addition to pathogenetic therapy, symptomatic agents are used. Also shown are vitamins, tonics.

3. Open traumatic brain injury

With an open craniocerebral injury, the cranial cavity communicates with the external environment and, therefore, there is a high probability of infectious complications (meningitis, brain abscess, osteomyelitis). In turn, the open is divided into penetrating, in which there is damage to the dura mater and non-penetrating.

In addition to fractures of the base of the skull, accompanied by nose or ear bleeding and the outflow of cerebrospinal fluid, lacerations of the head with fractures of the underlying bones of the skull are most common. Cut, chopped and stab wounds are also not uncommon. Particularly dangerous are penetrating wounds with damage to the dura mater and brain matter.

The main clinical factors that determine the severity of traumatic brain injury are: the duration of loss of consciousness and amnesia (sometimes occurs without primary loss of consciousness, and the slow development of coma indicates intracranial bleeding or progressive cerebral edema); the degree of depression of consciousness at the time of hospitalization; the presence of brain stem neurological symptoms.

Resuscitation measures for severe traumatic brain injury (foci of crushing, diffuse axonal damage) begin at the pre-hospital stage. In order to normalize breathing, the upper respiratory tract is provided with free patency (their release from blood, mucus, vomit, the introduction of an air duct, tracheal intubation, tracheostomy), inhalation of an oxygen-air mixture is used, and, if necessary, artificial ventilation of the lungs is carried out. Further treatment is carried out in a hospital. The victim must be urgently taken to the hospital, always lying down, even with the shortest loss of consciousness. At the scene of the incident, no manipulations are carried out on the brain wound; sterile dressing, when the medulla bulges, the bandage should not squeeze it; it is impossible to introduce gauze or cotton wool into the nostrils, it is impossible to bleed from them into the ear, this can complicate the course of the wound process.

The treatment of victims with open and closed injuries of the skull and brain has much in common, since they almost always have a concussion or contusion of the brain, which requires protective therapy, rest, the use of sedatives, and careful monitoring of patients.

4. Features of the nursing process

Nursing process - a scientific method of nursing practice, based on the standards of nursing interventions and directed to the individualization and systematization of patient care, a dynamic process, the last link of which is closely intertwined with the first.

Nursing care is planned based on the failure to meet the patient's needs, and not on the basis of a medical diagnosis.

The goal of the nursing process is to maintain and restore the patient's independence in meeting the basic needs of the body.

TBI is one of the most serious injuries requiring a special attitude of medical personnel towards the victim at all stages of treatment, from the scene of the accident to the restoration of working capacity.

Care of patients with TBI is determined by the regimen prescribed by the doctor. Careful skin care and feeding of patients are components of rational care for them.

Nurses must be proficient in special manipulations and methods of preparing patients for examinations.

For wounds, wounds, first aid and care for the victim consists in stopping bleeding, protecting wounds from infection and pain relief, as well as in the toilet of the skin around the wound: the hair is shaved away from the wound, dirt and dried blood are removed, and the surrounding skin is washed. Compliance with asepsis is also necessary for a purulent wound. The skin around the wound is protected with a layer of fat, ointment or paste. The dried bandage is pre-moistened with hydrogen peroxide; remove dressings, tampons and drains carefully, with sterile instruments.

At conservative treatment TBI, especially if the patient is unconscious, the nurse has a special responsibility to prevent the most common complications.

Prevention of pneumonia begins from the very first hours. It includes: prevention of aspiration of liquid media entering the mouth, and maintenance of the drainage function of the tracheobronchial tree. From oral cavity liquid media (saliva, drain) are removed by wiping the mouth with napkins or using an electric suction. The drainage function of the trachea and bronchi is supported by a cough reflex or passive removal of mucus with an electric suction. To facilitate suction of sputum, solutions of sodium bicarbonate, proteolytic enzymes are introduced into the trachea, inhalation is carried out with aerosols. To improve drainage, effleurage and vibration massage of the chest, breathing exercises, alternating elevation of the head and foot ends of the bed are performed. With aspiration of a large amount of vomit, lavage of the tracheobronchial tree is done (airway lavage). During endotracheal anesthesia, the patient is injected into the trachea with 50 ml of sterile isotonic sodium chloride solution, in which antibiotics are diluted, then it is immediately sucked off.

To prevent secondary infection of the lungs, the nurse must strictly follow the rules of asepsis when working with catheters, instruments, solutions introduced into the trachea. All of them must be sterile and individual.

Prevention of mumps and partly pneumonia includes a thorough toilet behind the oral cavity, nasopharynx, which is carried out several times a day.

The nurse is feeding the patient: parenteral - intravenous administration liquids (protein hydrolysates, protein, lipofundia, glucose, etc.) or enteral - through a nasogastric tube until the swallowing reflex is restored.

For the prevention of bedsores, anti-decubitus mattresses, rubber circles, "bagels" are used; skin care is provided. An important point in the care of any patient, including those with TBI, is the control of urination and timely bowel movements. Change of linen, performance of procedures requires special care, since disturbance of rest for these patients is fraught with possible complications.

Conclusion

As a conclusion, it is necessary to say about the prognosis and consequences of traumatic brain injury.

The prognosis for mild traumatic brain injury (concussion, mild brain contusion) is usually favorable and the vast majority of patients recover completely if the victim complies with the recommended treatment and behavior regimen.

With a craniocerebral injury of moderate severity (medium brain contusion), it is often possible to restore the labor and social activity of patients. A number of victims develop arachnoiditis and hydrocephalus, causing asthenia, headaches, vegetovascular dystonia, arterial hypertension, disturbances of statics and coordination and other neurological symptoms.

In severe traumatic brain injury (severe brain contusion, brain pressure, open skull injuries), mortality reaches 45-60%. Timely removal of the hematoma saves the patient's life, but the survivors often remain disabled. They are observed mental disorders, epileptic seizures, gross motor disorders.

Care of patients with severe traumatic brain injury is to prevent bedsores and hypostatic pneumonia (turning the patient in bed, massage, skin toilet, banks, mustard plasters, suction of saliva and mucus from the oral cavity, sanitation of the trachea).

Even with mild and moderate traumatic brain injury, the consequences make themselves felt within months or years. The so-called "post-traumatic syndrome" is characterized by headache, dizziness, increased fatigue, decreased mood, memory impairment.

We can talk about outcomes 1 year after the traumatic brain injury, since there are no significant changes in the patient's condition in the future. Rehabilitation measures include physiotherapy exercises, physiotherapy, taking nootropic, vascular and anticonvulsant drugs, vitamin therapy.

With recovering patients, relatives, the nurse should conduct conversations on the prevention of TBI. In the prevention of these injuries and their complications, an important role is played by the observance of safety regulations, traffic rules by drivers and pedestrians, and the ability to competently provide first aid to the victim. In addition to general measures to prevent TBI, attention should be paid to personal protective equipment - the use of helmets that protect the head during construction work, riding a motorcycle, playing hockey, etc.

List of used literature

1. Dralyuk M.G. Traumatic brain injury. Tutorial/ M.G. Dralyuk, N.S. Dralyuk, N.V. Isaeva. - Rostov-on-Don: Phoenix, 2006. - 192 p.

2. Kondakov E.N. Traumatic brain injury: A guide for doctors of non-specialized hospitals / E.N. Kondakov, V.V. Krivetsky. - M.: Medicine, 2002.

3. Latysheva V.Ya. Traumatic brain injury: classification, clinical picture, diagnosis and treatment. Textbook / V.Ya.Latysheva, M.V.Olizarovich, V.L.Sachkovsky. - Minsk: Higher School, 2005.

4. Dreval O.N. Traumatic brain injury: Textbook / Shaginyan G.G. Dreval O.N. Zaitsev. - GEOTAR - Media, 2010

5. Gusev E.I. Neurology: National leadership / E.I. Guseva, A.N. Konovalova, V.I. Skvortsova, A.B. Hecht. - GEOTAR - Media, 2009

6. Lebedev N.V. Emergency surgery of traumatic brain injury: For neurosurgeons, traumatologists, surgeons, neurologists, physicians / Lebedev N.V., Lebedev V.V. - MIA, 2008

7. Nikiforov A.S., Clinical Neurology: Textbook / Nikiforov A.S. Konovalov A.N. Gusev E.I. - Medicine, 2004

8. Kondratiev A.N. Emergency Neurotraumatology: Textbook / Kondratiev A.N. - GEOTAR - Media, 2009

9. Sumin S.A., Surgical diseases and injuries in general medical practice: Textbook / Sumin S.A., Belikov L.N., Sukhovatykh B.S., Gorshunova N.K. - GEOTAR - Media, 2008

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