If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. J Spec Pediatr Nurs. TBI can result in physical, cognitive, behavioral, or emotional difficulties. A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The care of the pediatric patient with a severe traumatic brain injury (TBI) is an all-encompassing nursing challenge. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage. A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Acute pain related to altered brain or skull tissue. Therefore, the dose can’t be repeated in 30 to 45 seconds because the first dose wouldn’t have been administered completely by that time. Paraplegia occurs as a result of injury to the thoracic cord and below. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Start studying Hesi Case Study Traumatic Brain Injury. Please visit using a browser with javascript enabled. Traumatic brain injury (TBI) presents in various forms ranging from mild alterations of consciousness to an unrelenting comatose state and death. The complex nature of traumatic brain injury outcomes and possible accompanying injuries might require the neurological physiotherapist to use core skills like facilitation, therapeutic exercises or physical activity prescription, but also to clinically reason and apply the knowledge of therapeutic interventions and strategies from other specialities, eg. “Expect profuse vomiting for 24 hours after the injury.”, “Notify the physician immediately if he has a headache.”, “Watch him for keyhole pupil the next 24 hours.”, “Wake him every hour and assess his orientation to person, time, and place.”. Epub 2019 Sep 3. Editor(s): Bender Pape, Theresa Dr.PH. Rhinorrhea indicating anterior fossa skul fracture. Traumatic Brain Injury EBP Systematic Reviews & Research Evidence-based practice (EBP) is based on the integration of critically appraised research results with the clinical expertise, and the client’s preferences, beliefs and values. The indwelling urinary catheter should be assessed immediately after the HOB is raised. You have not finished your quiz. These head injuries can be classified as either penetrating or non-penetrating. Neurosurgical intervention to preserve life has long standing impacts on patients and their families, which gives importance to pre-operative considerations on prospectively estimated quality of life with subsequent issues of ethics, and socio-economic burdens. A client is admitted with a spinal cord injury at the level of T12. Neuroscience intensive care unit (ICU) nurses deliver a number of interventions when caring for critically ill traumatic brain injury (TBI) patients. Caring for families: double binds in neuroscience nursing. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn’t exceed 100 mg in 24 hours. (3)College of Nursing, University of Cincinnati, Cincinnati, Ohio, United States. The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. If this activity does not load, try refreshing your browser. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn’t be suspected without an injury. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems.