PLAN OF THEORETICAL LESSON

Date: according to the calendar-thematic plan

Number of hours: 4

Subject: VI/VII-3 CLOSED CRANIO-BRAIN INJURY. FRACTURE OF THE CAPITAL AND BASE OF THE SKULL

Lesson type: lesson learning new educational material

Type of training session: lecture, conversation, story

The goals of training, development and education:

Formation: knowledge on a given topic.

Questions:

- Anatomical and physiological features of the head.

TBI. Causes. Classification, general symptoms.

- Closed TBI: concussion, bruise, compression of the brain; clinic, principles of diagnosis, provision of PHC at the prehospital stage, principles of treatment, care. Organization of the nursing process.

- Bruising of the soft tissues of the head. Fracture and dislocation of the lower jaw. Fractures of the bones of the vault and base of the skull. Causes, clinic, principles of diagnosis, provision of PHC at the prehospital stage, principles of treatment, care. Organization of the nursing process.

Development: consciousness, thinking, memory, speech, emotions, will, attention, abilities, creativity.

Upbringing: feelings and personality traits (ideological, mental, aesthetic, labor).

As a result of mastering the educational material, students should: gain theoretical knowledge on a given topic.

Logistics support of the training session: presentation, tables 118-123

Interdisciplinary and intradisciplinary links: anatomy, physiology, traumatology, pharmacology.

Update the following concepts and definitions: Traumatic brain injury. Brain concussion. Intracranial hematoma. craniotomy.

STUDY PROCESS

1. Organizational and educational moment: checking attendance for classes, appearance, protective equipment, clothing, familiarization with the lesson plan - 5 minutes .

2. Survey of students - 10 minutes .

3. Familiarization with the topic, questions, setting educational goals and objectives - 5 minutes:

4. Presentation of new material (conversation) - 50 minutes

5. Fixing the material - 5 minutes :

6. Reflection - 10 minutes.

7. Homework - 5 minutes . Total: 90 minutes.

Homework:, pp. 19-22; , pp. 517-523; ,

Literature:

1. L.I. Kolb et al. Textbook: "Private Surgery".

5. I.R. Gritsuk "Surgery"

2. L.I. Kolb et al. Textbook: "Nursing in surgery".

4. Workshop: "Surgery in tests and tasks"

6. Website: www.site

7. Teacher's personal website: www.moy-vrach.ru

VI/VII-3 CRANIO-BRAIN INJURY

ANATOMICAL AND PHYSIOLOGICAL FEATURES OF THE SKULL STRUCTURE

The main anatomical feature of the skull is a closed cavity with rigid walls. Because of this, the usual reaction to damage to soft tissues - swelling leads to compression of the brain, which requires urgent surgical intervention.

I. Cerebral skull

1. Foundation The skull on the inside is represented by 3 cranial fossae:

Anterior cranial fossa

Middle cranial fossa (the following openings open: optic canal, inferior orbital fissure, round, oval and spinous openings. Through these openings, the cranial cavity communicates with the environment.)

Posterior cranial fossa (cerebellum, medulla oblongata)

If the brain is damaged, as a result of edema, the medulla oblongata can be wedged into the foramen magnum, which can lead to death, because all the vital centers are in the medulla oblongata.

2. The upper jaw, sphenoid bone, frontal bone, ethmoid bone contain air sinuses, lined with a mucous membrane. If the air sinuses are damaged through a hole in the base of the skull, infection of the meninges, medulla with subsequent development of meningitis or brain abscesses is possible.

3. In the brain, the dura mater forms the venous cerebral sinuses (the cavernous sinus and sagittal sinus are of greatest importance)

4. The presence in the brain of the meninges (hard, arachnoid, soft, which are involved in metabolism and are part of the blood-brain barrier - a complex immunological protection of the brain from toxic substances, bacteria and viruses.

5. The presence of an aponeurotic helmet on the skull, which leads to the possibility of scalping wounds.

6. Rich innervation and blood supply to the head lead to a discrepancy between the appearance of the wound and the patient's condition.

7. The presence of facial muscles leads to gaping wounds on the face.

8. The presence of anastomoses of the venous bed of the face and brain can lead to thrombosis of the cerebral sinuses and death.

Base of the skull, inside view:

1. Anterior cranial fossa

23. Middle cranial fossa

20. Posterior cranial fossa

18. Foramen magnum

11. Pyramid of the temporal bone

II. facial skull- a container for the senses: vision, smell, the initial section of the digestive and respiratory systems.

Educated unpaired bones:

Lower jaw

Vomer (bone part of the nasal septum)

Hyoid bone

Paired:

upper jaw

palatine bone

Inferior turbinate

nasal bone

lacrimal bone

Cheekbone

The main anatomical feature of the brain, affecting the occurrence, course and outcome of his injury, the nature of the provision of medical care, as well as its consequences, is that the brain is located in a rigid (bone) cranium, which does not allow its volume to change during edema due to injury.

CAUSES OF CRANIO-BRAIN INJURY

Such reasons are obvious. This is a blow with a heavy blunt object on the brain (mostly) or on the facial (less often) skull. Origin: Accident, fall from a height onto a hard surface, aggression.
CLASSIFICATION

According to the condition of the skin:

Closed TBI

Open TBI

According to the state of the meninges:

Penetrating

Non penetrating

Closed TBI - concussion, bruise, compression. This is damage to the head without violating the integrity of the skin or damage to the soft tissues of the head without damaging the aponeurosis.

Open TBI - concussion, contusion, compression, soft tissue wounds, fracture of the cranial vault, fracture of the base of the skull. This is damage to the soft tissues of the head, aponeurosis, fracture of the base of the skull, accompanied by damage to the airways.

With open, especially penetrating TBI, there are conditions for infection of the brain and its membranes.
Open TBI:

1. non-penetrating - without damaging the dura mater.

2. penetrating - with damage to the dura mater.
Clinical forms of TBI:

1. Concussion

2. Brain injury

3. Compression of the brain
Classification according to the severity of TBI:

Mild head injury: concussion, mild contusion

Moderate TBI: moderate brain contusion, chronic and subacute cerebral compression

Severe TBI: severe brain contusion, acute compression of the brain due to intracranial hematoma.

General view of a patient with TBI

CLINICAL SYMPTOMS

Shake brain - traumatic brain injury without obvious anatomical damage.

Refers to mild TBI. It is believed that during a concussion there is no damage to the anatomical structures of the brain, but only functional disorders of the brain. But this is only about anatomical damage. There are damages at the cellular and molecular level. This indicates the relativity of such a division. Characterized cerebral symptoms, the main ones that make it possible to establish a diagnosis are:
1. short-term loss of consciousness from a few seconds to 20 minutes;
2. retrograde amnesia - loss of consciousness due to events preceding the moment of injury;
3. nausea, single vomiting;
In addition, headache, dizziness, tinnitus, drowsiness, pain when moving the eyeballs, from vegetative reactions - sweating, nystagmus is possible.

Diagnostics:

1. Clinical examination + examination by an oculist (fundus) and a neuropathologist (topical neurological diagnostics)

2. Additional examination methods:

X-ray of the skull in 2 projections

Echoencephalography (to rule out brain compression)

Treatment:

Although a concussion is a mild head injury, it is necessary to hospitalize the patient, because sometimes under the guise of a concussion, compression of the brain occurs. Further behavior and condition of the patient is simply unpredictable. A mild TBI may well become severe over time. Treatment is carried out in the neurosurgical or in the department of pure surgery.

Appointments:

Strict bed rest

Non-narcotic analgesics intravenously

Antihistamines

Dehydration therapy

B vitamins

If necessary, sedatives (sedatives)

Injury

A brain contusion is a traumatic injury to the brain substance from minor (small hemorrhages, swelling) to severe (contusion, crushing of tissues) already accompanied by anatomical changes in the brain tissue. Hence - focal neurological symptoms.

There are 3 degrees of severity:

- easy: loss of consciousness up to 1 hour, moderately pronounced cerebral symptoms (amnesia, nausea, vomiting, headache, dizziness). Focal symptoms appear: impaired movement, sensitivity). Characteristic disorder of speech, vision, paresis of facial muscles, language, nystagmus, anisocoria. The pressure of the cerebrospinal fluid increases.

- average degree: loss of consciousness up to several hours, headache, repeated vomiting, mental disorder, bradycardia, increased blood pressure, subfebrile body temperature, tachypnea, focal symptoms - nystagmus, anisocoria, oculomotor disorders, limb paresis, sensitivity disorder, increased pressure of cerebrospinal fluid. Moderate bruises are often accompanied by fractures of the base and calvaria, as well as subarachnoid hemorrhage.

- severe degree: loss of consciousness from several hours to several weeks, focal symptoms are pronounced (nystagmus, anisocoria, paresis, oculomotor disorders), stem symptoms are pronounced - hyperthermia, floating eyeballs, tonic large-scale nystagmus, respiratory rhythm disorders, bradycardia, increased blood pressure, impaired pupillary response to light, absence or decrease in the swallowing reflex. Significantly increases the pressure of the cerebrospinal fluid flowing out (instead of a frequency of 1 drop per second) during lumbar puncture, a general state of extreme severity, convulsions, involuntary urination, involuntary defecation are possible, a fatal outcome is possible.

Diagnostics:

1. Clinical examination

2. Additional diagnostic methods:

Lumbar puncture

Echoencephalography

X-ray of the skull in 3 projections (especially when there is a suspicion of a fracture of the base of the skull)

3. examination by an oculist (fundus), a neuropathologist (topical neurological diagnostics)

Treatment:

Mild degree (see treatment of concussion) + drugs that improve microcirculation and cerebral circulation (trental, caventon, aminofillin). Dehydration therapy (20% glucose - 400 ml, magnesium sulfate 25% - 5 ml, insulin 24 units _- all administered intravenously).

For moderate to severe brain injury:

1. the introduction of drugs that improve the rheological properties of blood (rheopolyglucin, chimes, ascorbic acid, heparin).

2. antihypoxic drugs (sodium oxybutyrate, seduxen)

3. antispasmodics (papaverine 2%, nosh-pa 2%)

4. drugs that improve cerebral circulation (caventon, trental, aminofillin).

5. protease inhibitors (kontrykal)

6. nootropic drugs (nootropil, aminalon)

7. prophylactic antibiotics (ceftriaxone, thienam)

8. lytic mixtures (diphenhydramine + pipalfen + chlorpromazine)

9. dehydration therapy (40% glucose 40-60 ml, 30% urea 100 ml, 20% mannitol 30-40 ml, lasix)

10. cardiac glycosides (strophanthin and corglicon not more than 1 ml per 5% glucose with ascorbic acid and insulin).

Fracture of the base of the skull

When present, there is almost always a brain injury. If the fracture line passes through one of the air sinuses, then such a fracture is considered open.

Open fractures are the most dangerous, because it is possible to infect the brain and meninges through a hole in the middle cranial fossa.

Clinic of fracture of the base of the skull (photo):

Outflow of cerebrospinal fluid with an admixture of blood from the nose or ear canal (rhinorrhea - outflow of cerebrospinal fluid from the nose, otorrhea - from the ear).

To determine liquorrhea, a DOUBLE SPOT TEST is performed (in the center of the gauze napkin is a yellow spot of cerebrospinal fluid, and along the periphery of the gauze napkin is a brown halo of expired blood).

In case of a fracture of the pyramid of the temporal bone or the body of the bone, hidden liquorrhea is possible: the flow of cerebrospinal fluid into the nasopharynx and swallowing it, a symptom of glasses (paraorbital hematomas), a symptom of Bethel (hemorrhage in the mastoid process) - occurs when the body of the main bone or pyramid of the temporal bone is fractured.

Spectacle sign and Bell's sign do not appear immediately, but often 6-24 hours from the moment of injury.

Injury to the cranial nerves - most often damaged auditory, facial, glossopharyngeal nerves.

Diagnosis of a fracture of the base of the skull:

1. Clinical examination

2. Additional examination methods:

Radiography in 3 projections

Echoencephalography

CT scan

Nuclear magnetic resonance imaging (NMRI)

Treatment depends on whether the injury is mild or severe.

compression

Compression of the brain - traumatic damage to the medulla with gross anatomical changes in it, combined with its compression (hypertension).
P reasons:

Depressed skull fractures

Foci of crushing of the brain with bruises of the brain and, as a result, inflammatory edema in these foci;
- intracerebral hematomas

Subdural hydromas (accumulation of CSF under the dura mater)

Pneumoencephaly

Tumors, abscesses of the brain.

Acute compression of the brain - no more than 24 hours passed from the moment of injury to the examination.

Subacute compression - no more than 14 days passed from the moment of injury to the examination.

The most common causes of compression aresevere TBI and intracerebral hematoma

Triad of symptoms characteristic of intracranial hematomas:

1. The presence of a light interval (after 1 loss of consciousness, there is a period of time before a second loss of consciousness, and this interval can last from several hours to 14 days, more often 2 days.

2.Homolateral hemiparesis is the expansion of the pupil on the side of compression.

3. Contralateral hemiparesis is a paresis of a limb on the side opposite to the focus of compression.

Other symptoms of brain compression:

psychomotor agitation

repeated vomiting

Large-scale nystagmus

Psychomotor agitation is gradually replaced by lethargy, drowsiness, coma

Stem disorders: bradycardia, hypertension, convulsions, respiratory rhythm disturbance, sometimes blood pressure decreases.

Treatment brain compression:

See treatment of severe brain contusions + surgical craniotomy.

characteristic a feature of the clinical course of brain injury in childhood often the absence of pronounced neurological symptoms at the time of examination is already a few hours after a mild brain injury. In clinical manifestation, traumatic brain injury in children has a number of significant differences from those in adults. They are primarily due to the anatomical and physiological characteristics of childhood, such as:

The incompleteness of the process of ossification of the skull,

Immaturity of brain tissue

Lability of the vascular system.

All of these facts affect the clinical picture of trauma in children, which is manifested in the following:

The relative value of anamnestic information,

Loss of consciousness at the time of injury is very rare in young children, and in older children it occurs in 57% of cases,

Indistinctness and therefore subjectivism in the interpretation of the neurological picture,

Rapidity of neurological symptoms

The predominance of cerebral symptoms over focal,

Absence of meningeal symptoms in young children with subarachnoid hemorrhage,

The relative rarity of intracranial hematomas,

More often than in adults there is cerebral edema,

Good regression of neurological symptoms.

At the suggestion of M.M. It is expedient for Sumerkina to divide children into three age groups, in each of which the symptoms and course of the injury are more or less similar. The first - from 0 to 3 years old, the second - 4-6 years old, in the third are children of school age.

EXAMINATION METHODS

Clinical Methods studies in TBI:

1. Anamnesis (if the victim is unconscious, then the anamnesis is collected from a medical worker, eyewitnesses, police officers).

2. Determination of the state of vital functions (airway patency, level of consciousness, the state of the respiratory system, skin, cardiovascular activity, temperature)

3. Inspection, palpation (when examining the head, we pay attention to the integrity of the skin, the presence of deformities, paraorbital hematomas in the mastoid process. On palpation, the presence of local pain, crepitus of bone fragments, subcutaneous crepitus in the upper eyelid and forehead).

4. Assessment of neurological status:

Assessment of consciousness according to the Glasgow scale, the study of the functions of 12 pairs of cranial nerves.

Determination of the volume of active and passive movements in the limbs.

Determination of strength and muscle tone of the limbs.

Presence of nystagmus and anisocoria.

5. Consultation of an oculist (fundus) and a neuropathologist (topical neurological diagnostics)

Additional Methods research:

X-ray of the skull bones in 2 projections, with a suspected fracture of the base of the skull in 3 projections.

Lumbar (spinal tap) with laboratory examination of cerebrospinal fluid

Echoencephalography - to determine the absence or presence of displacement of the median structures of the brain

Electroencephalography helps to determine the level of brain viability.

Rheoencephalography - determination of the function of cerebral vessels.

CT scan of the brain - determination of crush injuries and the presence of hematomas.

NMRI - more accurate localization of hematomas, abscesses, crush injuries.

To assess the condition of a patient with TBI, it is necessary to know some neurological concepts:

1. Amnesia - loss of memory.

Retrograde - loss of memory for previous trauma events.

Antegrade - loss of memory for trauma and the events following it.

2. Cerebral symptoms:

Memory loss

Loss of consciousness

Dizziness

Nausea

Vomit

Photophobia

Pain in the area of ​​the eyeballs

3. Meningeal symptoms:

Neck stiffness

Kernig's symptom- a symptom that is one of the important and early signs of irritation of the meninges with meningitis, hemorrhages under the membranes and some other conditions.This symptom is checked as follows: the leg of the patient lying on his back is passively flexed at an angle of 90 ° in the hip and knee joints (the first phase of the study), after which the examiner makes an attempt to straighten this leg in the knee joint (second phase). If a patient has meningeal syndrome, it is impossible to straighten his leg in the knee joint due to a reflex increase in the tone of the leg flexor muscles; in meningitis this symptom is equally positive on both sides. At the same time, it must be borne in mind that if a patient has hemiparesis on the side of paresis due to a change in muscle tone, Kernig's symptom may be negative.

Brudzinsky's symptoms- a group of symptoms that occur due to irritation of the meninges. They are one of the meningeal symptoms and can occur with a number of diseases.

Allocate:

Upper Brudzinsky's symptom - involuntary bending of the legs and pulling them to the stomach when trying to passively bend the head. First described in 1909.

Average(pubic) symptom of Brudzinsky - with pressure on the pubis, the legs bend at the hip and knee joints. Described in 1916.

Lower Brudzinski's symptom - when checking on one side of Kernig's symptom, the other leg, bending at the knee and hip joints, is pulled up to the stomach. Described in 1908.

buccal Brudzinsky's symptom - when pressing on the cheek below the zygomatic arch, the shoulders reflexively rise and the patient's arms bend at the elbow joints.

Increased sensitivity to visual and auditory stimuli.

GLASGOW SCALE

Opened and e eye	1. Spontaneous
	2. To addressed speech
	3. To a painful stimulus
	4. Missing
Speech reaction	1. Correct speech
	2. Confused speech
	3. Incomprehensible words
	4. Inarticulate sounds
	5. Missing
motor response	1. Executes commands
	2. Repels pain stimulus
	3. Withdraws a limb
	4. Flexion to a painful stimulus
	5. Extension to a painful stimulus
	6. Missing

Sum of points:

15 - clear consciousness

13-14 - stupor (stun)

9-12 - stupor (cloudiness)

Less than 9 - coma (lack of consciousness)

stem symptoms:

Floating eyeballs, multiple tonic nystagmus, impaired breathing, swallowing, thermoregulation.

Focal symptoms:

Paresis, paralysis, impaired sensitivity, loss of vision, hearing, motor and sensory aphasia.

An epidural hematoma is a collection of blood between the bones of the skull and the dura mater.

A subdural hematoma is an accumulation of blood under the dura mater.

Subarachnoid hematoma is an accumulation of blood between the arachnoid and pia maters, due to damage to the pia mater and brain substance.

DIFFERENTIAL DIAGNOSISof various types of TBI is extremely important for determining the timing of inpatient and outpatient treatment, the time of disability, predicting the outcomes of each specific injury, preventing late consequences of TBI, and identifying a group of patients in need of surgical treatment.

Taking into account the fact that the vast majority of traumatic hematomas are formed against the background of a brain contusion, the main rule for the differential diagnosis of various types of TBI should be the following: every time when diagnosing a concussion of the brain, it is necessary to exclude its contusion, and every time when diagnosing a brain contusion, it is necessary rule out intracranial hematoma.

The diagnosis of cerebral contusion in the absence of focal symptoms of cortical damage should be made whenever the loss of consciousness was prolonged, the cerebral symptoms are significantly pronounced and prolonged, there is repeated vomiting, amnesia, meningeal symptoms, a fracture of the calvarium is visible on the x-ray, with a lumbar puncture in the cerebrospinal fluid blood. Blood in the cerebrospinal fluid and the presence of a skull fracture are undoubted symptoms of a brain contusion. That is why an x-ray of the skull in two projections must be done for each patient and a lumbar puncture must be done at the slightest suspicion of a brain injury.

It is very important in each case of brain contusion to exclude the possibility of compression of the brain by an intracranial hematoma. A hematoma is characterized by a "light gap" (two-stage loss of consciousness), increasing bradycardia, pupil dilation on the side of the hematoma, increased pressure and blood in the cerebrospinal fluid, congestion in the fundus. It should be noted that the "light gap", slowing of the pulse and pupil dilation on the side of the hematoma (classic Cushing's triad of intracranial hematoma) occur collectively in only 15% of patients with intracranial hematomas. Therefore, even if there is at least one of these symptoms, then it is necessary to carefully examine the patient, resorting to special methods to exclude the possibility of brain compression. But even if there are none of these three classic symptoms of a hematoma, there are no focal symptoms of cortical damage, but there is evidence for a brain contusion, then in each such case it is still necessary to assume the possibility of an intracranial hematoma. Therefore, when a patient is hospitalized with a brain contusion, after formulating the diagnosis of a contusion, it is necessary to write the words from a new line: “There are currently no data for intracranial hematoma.” And by all means, in the appointments you should write: "Hourly measurement of the pulse, registration of consciousness." The nurse on duty of the department where the patient is hospitalized should know that the deterioration or disappearance of consciousness (“light gap”) and increasing bradycardia are characteristic symptoms of brain compression by a hematoma. She should paste a separate sheet of observation of the pulse and the safety of consciousness into the medical history and note every hour or every two hours on this sheet the safety of consciousness and the pulse rate. With a deterioration in consciousness and a decrease in the pulse, she should call the doctor on duty to the patient, without waiting for the morning round.

And of course, in large hospitals where there is computed tomography, every patient with a brain contusion needs to have echolocation of the brain (every district hospital now has echolocators) and computed tomography.

Osteoplastic trepanation of the skull (photo of the surgical wound)

BASIC PRINCIPLES OF TREATMENT OF CRANIO-BRAIN INJURY

The first measures in providing first aid to patients with traumatic brain injury at the accident site should be aimed at normalizing breathing and preventing aspiration of vomit and blood, which usually occurs in patients who are unconscious. To do this, put the victim on his side or linden down.

The task of the ambulance service is to clear the airways of mucus, blood, vomit, if necessary, intubate, and in case of respiratory failure, ensure adequate ventilation of the lungs. At the same time, measures are taken to stop bleeding (if any) and maintain cardiovascular activity.

^ TOPIC: NURSING PROCESS IN CEREBROVASCULAR

DISEASES

Stroke

Stroke(since late Tinsky - an attack) - states that are different in etiology and pathogenesis, the realizing link of which is a vascular catastrophe of both the arterial and venous bed. The stroke is acute disorders of cerebral circulation (ACV) characterized by a sudden (within minutes, less often hours) development of focal neurological symptoms (motor, sensory, speech, visual, coordinating) or cerebral disorders (disorders of consciousness, headache, vomiting), which persist for more than 24 hours or lead to the death of the patient in more a short period of time due to cerebrovascular causes. Poor circulation may be in the brain (cerebral stroke) or in the spinal cord (spinal stroke).

Undoubtedly, it is clear to everyone that it is almost impossible to completely cure an already developed stroke, and therefore the activity of medical workers aimed at preventing cerebrovascular diseases is so important. Middle managers should play the most active role in this, as they are the closest to the patient. The above data oblige nursing staff to have good knowledge in this area, and to know not only the etiology, the clinic of strokes and the main problems of patients, but also ways to solve these problems, rehabilitation features, and ergonomic techniques. In the work of a nurse, special importance is attached to the organization of the nursing process and nursing of patients. It is very important to involve the patient's relatives in the organization of care, to teach them the techniques and methods of care at home.

The main causes leading to the development of strokes

1. Atherosclerosis, arterial hypertension, diseases of the heart and blood vessels (cardiac arrhythmias that occur during myocardial infarction, coronary heart disease, rheumatism and a number of other pathological conditions are considered especially unfavorable. Cardiac pathology contributes to the formation of blood clots in the heart cavities, and cardiac arrhythmias create conditions their entry into the arteries of the brain.

2. Blood diseases (leukemia, anemia, coagulopathy).

3. Anomalies in the development of cerebral vessels (aneurysms, arteriovenous malformations, stenoses).

4. Brain injury.

5. Cervical osteochondrosis, especially in combination with atherosclerosis.

Risk factors for stroke

There are two types of stroke risk factors: uncontrolled (unmanaged) and controlled (managed).

Uncontrolled (unmanaged) risk factors:

– in age (over 65 years);

- gender (men are somewhat more likely to have a stroke, but women have more severe consequences, especially after the involutionary period);

- race (persons of the black race are affected more often than whites).

Controlled (managed) risk factors:

- arterial hypertension, especially if DBP is greater than or equal to 100 mmHg;

- the presence of coronary artery disease, constant or paroxysmal atrial fibrillation, mitral valve prolapse;

- history of stroke;

- heredity: coronary artery disease or stroke in relatives under the age of 60;

- diseases of the heart and blood vessels (especially unfavorable are cardiac arrhythmias arising from myocardial infarction, coronary heart disease, rheumatism and a number of other pathological conditions). Cardiac pathology contributes to the formation of blood clots in the cavities of the heart, and cardiac arrhythmias create conditions for their drift into the arteries of the brain);

- blood diseases (leukemia, anemia, coagulopathy);

- anomalies in the development of cerebral vessels (aneurysms, arteriovenous malformations, stenoses);

– brain injury;

- cervical osteochondrosis, especially in combination with atherosclerosis.

Acute cerebrovascular accident (ACC) can be of two types:

1. Transient (dynamic) disorders of cerebral circulation, in which neurological symptoms persist for no more than 24 hours. These include:

- transient ischemic attack (TIA) - manifested focal neurological insufficiency, which completely disappears within 24 hours;

- hypertensive crises the second type, accompanied by the developmentcerebral symptoms and / or convulsive syndrome;

Diagnosis usually put retrospectively.

2. Persistent disorders of cerebral circulation - stroke .

There are two types of stroke: ischemic stroke or cerebral infarction (occurs in 80-85% of cases) and hemorrhagic stroke or hemorrhage (in 15-20%).

Ischemic stroke (cerebral infarction) according to the mechanism of development is divided into thrombotic, embolic and non-thrombotic:

– thrombotic and embolic stroke arise due to occlusion of an extra- or intracranial vessel of the head due to thrombosis, embolism, complete occlusion of the vessel by an atherosclerotic plaque, etc. The lumen of the vessel closes completely or partially when an atherosclerotic plaque or thrombus forms at the site of this plaque. This mechanism is more common in a large vessel (aorta, carotid arteries). The lumen of smaller vessels closes, usually, a detached piece of a thrombus from the site of a vascular atherosclerotic plaque or from an intracardiac thrombus (for example, in violation of the heart rhythm). Blood clots, thrombi, develop in the area of ​​atherosclerotic plaques that form on the inner walls of the vessel. Thrombi can completely block even large vessels, causing serious cerebrovascular accidents.

– non-thrombotic (hemodynamic) stroke develops more often as a result of a combination of factors such as atherosclerotic vascular damage, angiospasm, arterial hypotension, pathological tortuosity of the vessel, chronic cerebrovascular insufficiency.

A cerebrovascular accident in which neurological symptoms persist for less than 21 days is calledsmall stroke.

Hemorrhagic stroke occurs due to a violation of the integrity (rupture) of the vascular wall with the penetration of blood into the tissue of the brain, its ventricles or under the membranes. In most patients, rupture of the vessel wall occurs at high blood pressure figures or against the background of an anomaly in the form of a protrusion of the vascular wall (aneurysm), or due to trauma.

According to localization, the following hemorrhages are distinguished:

- parenchymatous (intracerebral);

- with ubarachnoid (subarachnoid);

- p arenchymal-subarachnoid (mixed);

- intraventricular;

subdural and epidural hematoma.

CVA occur suddenly (minutes, less often hours) and are characterized by the appearance of focal and/or cerebral and meningeal neurological symptoms. With hemorrhages or extensive ischemic strokes, violations of vital functions develop. With subarachnoid hemorrhage and cerebral edema, the development of a convulsive syndrome is possible.

Clinicalsyndromes characteristic of stroke:

Cerebral symptoms :

- a decrease in the level of wakefulness from subjective sensations of "uncertainty, cloudiness in the head" and a slight stupor to a deep coma;

– headache;

– pain along the spinal roots;

- t nausea, vomiting.

Focal neurological symptoms :

– d movement disorders (hemiparesis, hyperkinesis, etc.);

- R speech disorders (sensory, motor aphasia, dysarthria);

– sensory disorders (hypesthesia, violation of deep, complex types of sensitivity);

– coordination disorders (vestibular, cerebellar ataxia);

- h serious disorders (loss of visual fields, double vision);

– n disturbances of cortical functions (apraxia, alexia, etc.);

- a mnesia, disorientation in time, etc.;

– b ulnar syndrome.

Meningeal symptoms :

– n tension of the posterior cervical muscles;

- P positive symptoms of Kernig, Brudzinsky (upper, middle, lower);

- on increased sensitivity to external stimuli;

- X typical posture of the patient.

Brief clinical characteristics of stroke

Hemorrhagic stroke (GI) develops as a result of rupture of the vessel (the most common localization of cerebral aneurysms is shown in Fig. 4). Hemorrhage causes destruction of brain tissue in the hematoma area, as well as compression and displacement of surrounding intracranial formations. Violated venous and liquor outflow, develops cerebral edema, rises intracranial pressure, which leads to events dislocation of the brain , compression of the brain stem. All this explains the particular severity of the clinical picture of HI, the appearance of formidable, often incompatible with life, stem symptoms, disorders of respiratory functions and the activity of the cardiovascular system. HI usually develops suddenly, during the day, at the moment of physical or emotional stress. There is a sudden headache, the patient loses consciousness, falls. Vomiting, psychomotor agitation are noted. The early appearance of pronounced vegetative disorders is characteristic: flushing of the face, sweating, fluctuations in body temperature. Blood pressure, as a rule, is elevated, the pulse is tense. Breathing is disturbed: may be frequent, snoring, stridor, or intermittent Cheyne type - Stokes. At the same time with pronounced cerebral, vegetative and, often, shell symptoms, focal symptoms are observed, the features of which are determined by the localization of the hemorrhage (the presence of focal symptoms can be determined by the following signs: drooping of the corner of the mouth and puffing out the cheek during breathing (sail symptom), symptoms of hemiplegia (the foot on the side of paralysis is rotated outward , the passively raised arm falls like a lash, pronounced muscle hypotonia, a decrease in tendon and skin reflexes, the appearance of pathological protective and pyramidal reflexes) A ​​breakthrough of blood into the ventricles of the brain is accompanied by a sharp deterioration in the patient's condition: consciousness disorders increase, vital functions are impaired, vegetative functions are aggravated symptoms (chill-like tremor and hyperthermia occur, cold sweat appears), death occurs.

subarachnoid hemorrhage often occurs at a young age, sometimes even in children. The most common cause of SAH is a ruptured aneurysm. Its development is facilitated by physical and emotional overstrain, traumatic brain injury. As a rule, the disease develops without precursors: blood poured into the intrathecal space irritates the meninges, there is a sharp headache, nausea, then vomiting, an increase in body temperature to 38-39.5 °, psychomotor agitation, sometimes loss of consciousness, which can be short-term or long-term. development of meningeal syndrome(general hyperesthesia, photophobia, neck stiffness, symptoms of Kernig, Brudzinsky). Epileptic seizures are often observed.

Figure 4. Most common aneurysm location(rupture of these vessels is the most common cause of intracerebral hemorrhage in arterial hypertension).

^ Picture. 5. Ischemic stroke. The infarction zone is marked in purple. The arrow shows the displacement of the median structures of the brain.

Ischemic stroke (IS) - develops as a result of impaired blood supply to a part of the brain, followed by necrosis (infarction) of the brain (see Fig. 5).

IS is most commonly seen in the elderly (50 to 60 years of age and older), but sometimes also at a younger age. The development of IS is often preceded by transient cerebrovascular accidents. A harbinger of AI can be feelings of general discomfort, headache, short-term disorder of consciousness. AI can develop at any time, but more often at night and in the morning, immediately after sleep. Sometimes IS occurs after myocardial infarction or SAH. IS is characterized by a gradual increase in neurological symptoms over several hours, rarely days. Unlike GI, in cerebral infarction, focal neurological symptoms prevail over cerebral ones, which may sometimes be absent. The disturbance of consciousness in most cases is manifested by a slight stupor, increased drowsiness, and some disorientation. Vegetative disorders are less pronounced than with cerebral hemorrhage. BP is often reduced or normal; pulse is quickened, low filling. Body temperature is usually not elevated. The nature of focal neurological symptoms is determined by the localization of the infarction. Most often, IS develops in the basin of the middle cerebral artery, which is manifested by the development of hemiplegia (hemiparesis) on the contralateral, opposite side of the localization of the lesion. There are violations of sensitivity opposite to the focus according to the hemitype, head and eye rotation towards the pathological focus, cortical speech disorders (aphasia, "cortical" dysarthria) apraxia , violation of stereognosis, body scheme; anosognosia. When the lesion is localized in the brain stem, along with conduction motor and sensory disorders, damage to the nuclei of the cranial nerves and cerebellar disorders are observed. Often there are alternating syndromes.

The course of IS is determined by many factors: the mechanism of its development, the characteristics of the affected vessel, the possibilities for the development of collateral circulation and the safety of capillary blood flow, the localization of the lesion, the age and individual characteristics of the patient's brain metabolism, the severity of concomitant pathology (cardiac, vascular, etc.). With IS, the greatest severity of the condition is usually observed in the first days of the disease. Then comes a period of improvement, which is manifested by the stabilization of symptoms or a decrease in their severity. In severe hemispheric IS, accompanied by cerebral edema and secondary stem syndrome, with extensive infarction in the brain stem, death is possible (in about 20% of cases).

spinal stroke usually develops as a result of degenerative-dystrophic changes in the spine, as a result of which compression of the arteries that supply the brain with blood occurs. The main cause of hemorrhagic spinal stroke is aneurysm rupture. Spinal stroke is quite rare. The most common localization of spinal stroke is cervical and lumbar thickening of the spinal cord. With a stroke, tetraparesis develops in the region of the cervical thickening: flaccid peripheral paresis of the arms and spastic paresis of the legs. With a stroke in the region of the lumbar thickening, peripheral paresis of the legs and dysfunction of the pelvic organs occur.

Diagnostics of stroke

On an outpatient basis, stroke is diagnosed on the basis of anamnesis and clinical picture. To clarify the diagnosis, the patient is hospitalized. In the hospital, a clinical and biochemical blood test, a study of cerebrospinal fluid, echoencephalography, electroencephalography, and angiography are carried out.

The highest diagnostic capabilities have X-ray computed or magnetic resonance imaging of the head, which allows in the acute period of stroke to recognize cerebral infarction on average in 75% of cases, cerebral hemorrhages - in almost 100%, hemispheric infarcts - in 80%, stem - a little more than 30% of the time. With the help of Doppler ultrasound, occlusions and stenoses of the carotid and vertebral arteries, as well as their branches, are detected.

Treatment of stroke (strokes)

Treatment of stroke (strokes) includes the prehospital stage, the stage of intensive care in the conditions of the intensive care unit or intensive care unit, the stage of treatment in the conditions of the neurological department, and then the out-of-town or rehabilitation polyclinic department, as well as the dispensary stage.

^ At the prehospital stage the patient needs to ensure complete rest, lay him on his back, remove tight clothes, if possible without moving his head. The severity of the patient's condition should be assessed and early hospitalization should be ensured in a specialized neurological department or in a hospital with a ward or intensive care unit.

^ Intensive care in the hospital is aimed at eliminating vital disorders, regardless of the nature of the stroke (the so-called undifferentiated or basic therapy). Indications for basic therapy are impaired consciousness, the presence of epileptic seizures, a combination of stroke with myocardial infarction, cardiac arrhythmias, etc. Basic therapy includes measures aimed at eliminating respiratory disorders, acute cardiovascular disorders, changes in homeostasis, combating cerebral edema, eliminating hyperthermia . The first priority is to maintain airway patency. Treatment of acute cardiovascular disorders aims to keep systemic BP at 5 - 10 mmHg Art. above the usual level for the patient: to normalize the heart rhythm and eliminate signs of cardiovascular insufficiency.

^ Patient care is of great importance. Patients who are conscious and whose swallowing is not disturbed, from the first day of the disease, are fed fruit juices, broth, infant formula. From the 2-3rd day they give easily digestible products. Patients in a coma, in the first two days, are injected parenterally with fluids containing electrolytes, 5% glucose solution, plasma-substituting solutions, and later through a nasogastric tube - nutrient mixtures.

^ Prevention of complications includes the prevention of hypostatic pneumonia, cystitis and ascending urinary tract infection, bedsores, contractures in paralyzed limbs.

^ Treatment of hemorrhagic stroke has features and is aimed primarily at eliminating cerebral edema and reducing intracranial pressure, lowering blood pressure (with its increase), normalizing vital and autonomic functions, increasing blood coagulation properties and reducing vascular permeability. In case of GI, the indications for surgical treatment are a progressive deterioration in the condition of patients with the onset of symptoms. dislocation of the brain. In addition, an indication for surgical treatment is the rupture of arterial and arteriovenous aneurysms, which is clinically manifested by subarachnoid or intracerebral hemorrhage. In this case, surgery is aimed at turning off the aneurysm from the blood circulation of the brain.

^ Ischemic stroke treatment It is aimed at improving the blood supply to the brain, increasing the resistance of brain tissue to hypoxia and improving its metabolism. Since IS usually develops against the background of an increase in the coagulating properties of the blood and a decrease in the activity of its fibrinolytic system, anticoagulants and antiaggregants are prescribed.

Rehabilitation of patients with stroke

Rehabilitation of patients with stroke is aimed at functional recovery or compensation of a neurological defect, social, household and professional rehabilitation. It should be started already in the acute period of a stroke and carried out gradually, systematically, for a long time. Drug correction of movement disorders is effective only in combination with physical therapy (early preventive laying of paralyzed limbs, passive and active gymnastics), massage, physiotherapy, reflexology. The success of rehabilitation treatment largely depends on the involvement of the patient in active participation in it. Correction of speech disorders is carried out by speech therapy methods, the effectiveness of which is also determined by the activity of the patient's independent studies.

Prognosis for stroke

The prognosis for stroke (strokes) depends on the nature and course of the stroke, the location and extent of the lesion, and the presence of complications. Prognostically unfavorable signs are profound impairment of consciousness, the development of cerebral edema and secondary stem syndrome, and impaired vital functions. Mortality in cerebral hemorrhages averages 60-90%. The cause of death is often edema and dislocation of the brain. The prognosis for IS is more favorable. Death occurs in approximately 20% of cases with extensive infarcts of the cerebral hemispheres.

Prevention of stroke

Primary prevention includes the identification of patients with initial manifestations of insufficiency of blood supply to the brain, with dyscirculatory encephalopathy (DE), with transient cerebrovascular accidents (TIMC); special attention should be paid to monitoring patients with severe arterial hypertension, coronary heart disease, diabetes mellitus, rheumatism. Systematic drug therapy of the underlying disease, adherence to the correct regime of work and rest with dosed physical activity, the organization of a rational diet with the restriction of fatty, sweet, starchy foods, the exclusion of bad habits (smoking, drinking alcohol) are necessary.

^ Secondary prevention (prevention of the occurrence of repeated disorders of cerebral circulation) is carried out with the help of dispensary observation of patients.

^ BACKGROUND SUMMARY No. 4

NURSING PROCESS FOR INJURIES AND MASSIVE DISEASES OF THE NERVOUS SYSTEM

Brain Injury - Traumatic Brain Injury (TBI)- one of the most common types of damage. In adults, the main causes of TBI are car accidents, accidents at home and at work, in children - games and falls. Despite the improvement of methods for diagnosing and treating TBI, the consequences of injuries often lead to neurological and mental complications that reduce the quality of life of patients.

^ TBI classification

TBI can be closed, open and penetrating.

Closed TBI - damage that is not accompanied by a violation of the integrity of the soft tissues of the head and meninges (even with fractures of the skull bones).

Open TBI - any damage with violation of the integrity of the aponeurosis of the head, but without damage to the meninges and the formation of cerebrospinal fluid fistulas. Open TBI should be distinguished from soft tissue injury to the head (eg, incised wounds), in which there is no evidence of brain damage.

Penetrating TBI - trauma with fracture of the skull bones, damage to the meninges, outflow of cerebrospinal fluid (liquorrhea) through cerebrospinal fluid fistulas. With such TBI, the integrity of the integument of the skull is sometimes preserved, but there are fractures of the bones of the base of the skull, ruptures of the meninges and cerebrospinal fluid fistulas with liquorrhea into the nasopharynx.

Both with closed and open TBI, brain damage can be of varying severity.

According to the modern classification, brain damage in TBI is divided into concussion, bruise and compression. The main criteria for the severity of TBI are the duration and depth of loss of consciousness, the presence of focal and cerebral symptoms, data from additional research methods.

Brain concussion is the most common form of TBI. It occurs in 70% of victims when exposed to a small traumatic force. With a concussion, the loss of consciousness is either absent or does not exceed 15 minutes. Victims complain of headache, weakness, dizziness, nausea and single vomiting. Some people have retrograde amnesia (memory loss for events preceding the trauma). Anterograde amnesia (for events after trauma) does not occur. On examination, pallor of the skin, tachycardia, sweating, fluctuations in blood pressure are determined. Clinical manifestations of concussion are associated with functional disorders and within 2-3 weeks. completely pass.

brain contusion - heavier TBI, because it is associated not only with functional changes, but also with damage to the substance of the brain at the time of injury. Depending on the severity of the damage and the clinical symptoms, mild, moderate and severe bruises are distinguished.

Mild brain injury manifested by loss of consciousness for 30-40 minutes, retrograde amnesia up to 30 minutes, sometimes short-term anterograde amnesia. The victims complain of headache, nausea, repeated vomiting, dizziness, general weakness, decreased attention, slight weakness in the limbs.

On examination, exhaustion, drowsiness, and less often arousal are determined. The skin is pale, brady- or tachycardia, increased blood pressure. In the neurological status - horizontal nystagmus, mild hemiparesis, meningeal syndrome. However, in some patients, there are no clinical signs of focal brain damage, which makes it difficult to differentiate mild brain contusion from brain concussion. Therefore, in TBI, CT scan of the brain is very important, which makes it possible to detect the presence of foci of damage to the brain tissue.

In the case of mild brain contusion, neurological manifestations are usually mild and regress completely within 2-3 weeks after the injury.

Moderate brain injury severity is characterized by a longer loss of consciousness, on average up to 2-4 hours. Patients complain of severe headache, accompanied by nausea and repeated vomiting. During the examination, stupor is determined, which, after the restoration of consciousness, can persist for up to a day, retro- and anterograde amnesia. Patients with moderate brain contusion are often disoriented, agitated, they experience epileptic seizures. The neurological status revealed meningeal syndrome and signs of focal brain damage in the form of moderate hemiparesis, sensory disturbances, oculomotor and other disorders. Restoration of functions in such patients occurs in longer periods (from 1 to 3 months) and is not always complete.

At severe brain injury clinical manifestations are even more severe: loss of consciousness for a period of several hours to several days. Perhaps the development of stupor or coma. At the beginning, there may be psychomotor agitation, followed by the development of atony. In the neurological status, pronounced cerebral and meningeal symptoms, signs of damage to the cerebral hemispheres (paralysis of the limbs) and the trunk (floating movements of the eyeballs, anisocoria) are determined. There are violations of swallowing and breathing, instability of blood pressure with a tendency to decrease, a disorder of cardiac activity. Victims with a severe degree of brain contusion need constant monitoring and treatment in intensive care units.

Brain compression - damage that develops with a decrease in the intracranial space due to the ingress of foreign bodies into the skull, bone fragments, the formation of intracranial hematomas. The severity of clinical manifestations during compression depends on the degree and rate of reduction of the intracranial space. The clinical picture is characterized by the presence of a "light interval", which is 12-36 hours after the injury, when there are no clinical manifestations of gross brain damage, but then a severe headache, repeated vomiting, meningeal syndrome, convulsions, paralysis, repeated impairment of consciousness develop. In the acute stage of TBI, it is necessary to perform computed tomography of the brain (Fig. 6), which allows diagnosing traumatic hemorrhages, skull fractures, and focal injuries in such patients, complications are likely that require neurosurgical intervention.

^ Figure 6. Computed tomography of the brain.

TBI treatment

First aid is provided to victims on the spot and during transportation to a medical facility. Let's name the priority actions:

1. Ensuring the patency of the airways: free the airways from foreign bodies, if indicated, intubate.

2. Normalization of blood pressure indicators: perform venipuncture, start infusion therapy. As prescribed by the doctor, introduce drugs that increase blood pressure (cordiamin, mezaton, etc.).

3. Replenishment of circulating blood volume - intravenous administration of blood-substituting fluids or blood according to indications.

4 . With pain shock – painkillers and sedatives.

When monitoring a victim in a hospital, constant monitoring of vital indicators is necessary. (number of heartbeats, blood pressure, number of respiratory movements, body temperature) and changes in neurological status . The increase in neurological disorders in the first days after TBI may be associated with the development of intracranial complications requiring surgical intervention. Therefore, the role of the nurse in providing care and monitoring of patients on the first day after TBI is especially important.

Symptoms to be followed notenurse and immediately report to the doctor:

- deepening disturbance of consciousness;

- increase in movement disorders;

- dilation of the pupil of one eye;

- increase in blood pressure;

- violation of the rhythm of breathing;

- bradycardia;

- epileptic seizure.

If these or other new symptoms appear, you should immediately report them to your doctor.

Further treatment of the victims depends on the severity of the condition and is aimed at restoring the vital functions of the body, combating cerebral edema, oxidative stress, normalizing cerebral circulation and metabolism.

^ Complications of TBI

A frequent complication of TBI in the acute period, especially in children in the first decade of life, is epileptic seizures. . In most cases, a single attack does not recur in the future, and special treatment is not required.

In the acute period of TBI, complications associated with infection of the wound may occur. : purulent meningitis, meningoencephalitis, brain abscesses. Early complications require additional antibiotic therapy, careful clinical observation, and re-examination using computed tomography of the brain and lumbar puncture.

^ TBI outcome- either a complete recovery or the development of late post-traumatic dysfunction of the nervous system.

The most common late complications of TBI are::

1. Vegetative-vascular dystonia, manifested mainly by headaches.

2. Hypertensive syndrome (increased intracranial pressure), which is characterized by morning headaches with nausea and vomiting.

3. Symptomatic epilepsy, in which, after an injury, the victim develops epileptic seizures.

Patients with late complications of TBI need regular follow-up with a neurologist and complex treatment according to indications:

- sedative and neurometabolic therapy for vegetative-vascular dystonia;

- dehydration, vasoactive and neurometabolic therapy for hypertension syndrome;

- selection of antiepileptic drugs for epilepsy.

^ Spinal cord injury

Spinal cord injuries are less common than TBI. The causes of spinal injury are road accidents, falls from a height, gunshot wounds.

The most mobile parts of the spine - the cervical and lumbar - are most often traumatized. There are primary injuries, in which the traumatic force acts directly on the spinal cord, and secondary ones, caused by compression of the spinal cord by fragments of the spine.

The main mechanisms of spinal cord injury in trauma:

- compression by bones, ligaments, hematoma;

- stretching with strong bending;

- swelling of the spinal cord, which develops immediately after the injury and aggravates other pathological processes in it;

- circulatory disorders due to compression of the spinal vessels by bone fragments or foreign bodies.

According to the severity of clinical manifestations, spinal injury is divided into concussion, bruise and compression.

^ it has no structural damage. The clinical picture is dominated by transient disorders in the form of flaccid paralysis of the lower extremities, which completely disappears within 48 hours.

^ For spinal cord injuries structural disturbances occur; their consequence is persistent neurological disorders (paresis and paralysis of the limbs), which do not recover after 48 hours.

^ Spinal cord compression hematoma or damaged tissue occurs some time after the injury. The compression is characterized by the presence of a “light interval”, during which there are no signs of focal damage, and only after a few hours paralysis and other dysfunctions of the spinal cord develop.

All patients with spinal injury have transient or persistent disorders of the spinal cord function, requiring special treatment and ongoing nursing care.:

1. Violation of urination immediately after an injury by the type of delay requires regular emptying of the bladder using a catheter. Subsequently, urinary incontinence may develop, in which particularly careful treatment of the skin is necessary to prevent the formation of bedsores.

2. Violation of defecation after trauma is associated with intestinal atony and requires mechanical emptying of the intestine using a siphon enema. When intestinal motility is restored, it is necessary to monitor its filling and cause reflex emptying with the help of rectal suppositories.

3. Trophic skin disorders in spinal injury may appear within a few days and lead to the development of bedsores. Therefore, patients with spinal injury need careful skin care and regular measures to prevent bedsores.

^ Spinal Injury Treatment

Emergency care for spinal injury aims to prevent additional damage to the spinal cord. Awkward handling of the patient during first aid aggravates the severity of the injury:

- if a spinal injury is suspected, the patient should be moved carefully. Victims cannot be put on their feet, planted and lifted;

– Transportation should be carried out on a hard, level surface with immobilization of the head. To prevent the patient from moving during transportation, it must be fixed from the sides with folded pillows or sandbags. The best way to transport a spinal injury is with a vacuum stretcher;

- in order to avoid hypothermia, the patient is covered with a warm blanket;

- patients with spinal injury are hospitalized in specialized institutions, where an additional examination is carried out and the question of the use of conservative or surgical treatment is decided.

With concussion of the spinal cord recommend conservative treatment that helps restore spinal cord function: rest, strict bed rest, normalization of basic physiological parameters (hemodynamics, circulating blood volume), control of spinal cord edema (diuretics, mannitol), control of urination and defecation, prevention of bedsores.

With bruises and compression of the spinal cord complex treatment is prescribed: surgical and conservative. The latter (after surgery) corresponds to that in concussion of the spinal cord in the acute stage.

Outcomes of spinal injury : with concussion of the spinal cord - full restoration of functions, recovery. With bruising and compression, some patients have neurological disorders for months and years, people need rehabilitation.

Care of patients with traumatic injury of the nervous system

From the first hours after the injury, the victims must be provided with peace and careful skin care to prevent bedsores. With urinary retention, bladder catheterization is indicated, followed by washing with antiseptic solutions. With intestinal atony, a siphon enema is made, and then, when peristalsis is restored, reflex emptying of the intestine is caused with the help of rectal suppositories.

Tumors of the nervous system

Brain tumors are classified according to two main features.:

- topographic-anatomical, i.e. according to the localization of the neoplasm in the cranial cavity and the brain;

– histological structure and biological properties of tumors.

^ Topographic and anatomical classification tumors is based on dividing them into two main groups:

Supratentorial tumors , located above the cerebellar mantle. These include tumors cerebral hemispheres(tumors of the frontal, parietal, temporal and occipital lobes, lateral and III ventricles, corpus callosum, basal ganglia, diencephalon and midbrain with pineal gland) and tumors pituitary region.

subtentorial, located under the cerebellar plaque (or tumors of the posterior cranial fossa).

Metastatic tumors . Most often, cancer of the lung, breast, kidney, melanoma metastasizes to the brain, somewhat less often - cancer of the bladder, prostate, gastrointestinal tract, ovaries, placental tumors. Metastases of sarcomas are extremely rare.

Clinic of brain tumors

The clinical picture of brain tumors is expressed by the progressive development of the disease and the steady increase in cerebral, focal and general somatic symptoms.

Cerebral symptoms in brain tumors, they arise due to an increase in intracranial pressure and a violation of the neurodynamics of nervous processes. Increased pressure is due to the fact that a neoplasm growing in a closed space of the skull causes compression of blood vessels (veins), disrupts free blood circulation and impedes the outflow of cerebrospinal fluid from the ventricles of the brain. Venous plethora of vascular plexuses and irritation of the nerves innervating them are fraught with hypersecretion of cerebrospinal fluid and an even greater increase in intracranial pressure.

The most common, early and characteristic symptom is headaches. The head hurts more often and worse in the middle of the night or in the morning, less or not at all in the afternoon or in the evening. Pain is aggravated by excitement, physical exertion, sometimes with a change in the position of the head and torso in space, which is most characteristic of brain ventricular tumors, especially the IV ventricle (Bruns syndrome).

Vomit - one of the most frequent and early symptoms of brain tumors; it is distinguished by its sudden, reflex, gushing character. Occurs regardless of food intake, often on an empty stomach, without prior nausea, belching and abdominal pain, in most cases - at the height of a headache at night or in the morning, often with a change in the position of the head and torso.

Dizziness- a symptom that occurs in half of the patients.

Mental disorders - one of the manifestations of brain tumors. Most often develops "tumor psyche" , manifested by the deafness of patients. It is expressed in a weakening of attention, a dulling of perception and memory, a slowdown in associative processes, a decrease in a critical attitude towards oneself, towards one's illness, towards others, in the development of general lethargy, indifference, lack of initiative. The question addressed to the patient has to be repeated several times before a slow monosyllabic answer follows. The patient gives the impression of a person deeply immersed in his thoughts, intensely pondering some problems. Therefore, some doctors use the term “workload” to characterize such patients.».

The defeat of various parts of the brain is characterized by special disorders with certain focal symptoms. .

Yes, with tumors frontal lobes , playing an important role in mental activity, along with general lethargy, inertia, lack of initiative, apathy, decreased intelligence (apatic-abulic syndrome), patients often have a special, disinhibited euphoria

Chesky state in the form of mental excitement, aggressiveness, replaced by complacency, euphoria. The perception of the surrounding life is narrowed and flattened. Patients are frivolous, uncritical, exhibit strange behavior, are prone to flat witticisms and jokes, are foolish (Moriya), cynical, sexually disinhibited, gluttonous. They are often slovenly and untidy, commit absurd acts. For example, the patient may get out of bed and urinate in the middle of the room on the floor, etc. Patients have impaired coordination of movements and balance.

Tumors occipital lobe : a local symptom of prolapse is visual field defects in the form of homonymous hemianopsia or scotoma. In some cases, visual hallucinations are noted, often in the form of sparks or glowing cattle, various forms of optical agnosia, object agnosia, alexia, metamorphopsia. Among the early signs of the localization of the tumor in this area are epileptic seizures, often starting with the visual aura.

For temporal lobe tumor , containing the cortical endings of the olfactory, gustatory, auditory and vestibular analyzers, irritation of these centers is often observed, expressed in stereotypical olfactory, gustatory, auditory hallucinations. With a tumor of the left temporal lobe, the most important symptom is sensory aphasia. Sometimes, especially in the initial period of the disease, only paraphasias are noted. In the early stages, with tumors of this localization, vestibular symptoms are significantly pronounced. They are very diverse (feeling of instability and rotation of surrounding objects, dizziness, combined with vivid visual, auditory and gustatory hallucinations).

For tumors of the parietal lobe disturbances of sensitivity on all opposite half of a body are noted. Foci in this area cause peculiar symptoms of agnosia - a violation of orientation in space, body patterns. The patient is not able to distinguish right from left, does not notice, ignores his paretic limb, or it seems to him that he has three or four arms or legs. The patient sees and feels these non-existent limbs and disposes of them. Hand movements that are not controlled by the eye become uncertain, awkward, lose their smoothness and purposefulness due to impaired afferentation, which leads to loss of control over the volume and direction of movements, dosage of muscle efforts. The most pronounced form of the above is “postural apraxia”, the inability to give the limb the desired position.

Tumors of the cerebellum usually have severe symptoms. The most common are ataxia, asynergia, and dysmetria. With damage to the cerebellar vermis, static ataxia is more pronounced, with damage to the hemispheres - dynamic ataxia. There is a violation of gait, patients sway when walking, fall to the sides, legs wide apart. There is instability in the Romberg position (the patient is unsteady with his eyes closed, his arms extended in front of him), asynergy (torso lag when walking, raising legs when rising from a horizontal position), and in addition, speech impairment (scanned speech, intentional trembling).

Tumors of the pituitary gland and pituitary region . Symptomatology of tumors of the lower appendage of the brain consists of slowly developing endocrine disorders, progressive destruction of the sella turcica, visual disturbances and brain symptoms that occur after a breakthrough of an overgrown adenoma through the saddle diaphragm into the cranial cavity. Endocrine disorders are diverse: obesity, the development of sexual weakness in men and amenorrhea in women, the disappearance of secondary sexual characteristics, thinning of the skin and hair on the head or sudden weight loss (cachexia). acromegaly, a gradual increase in the size of the distal extremities, nose, zygomatic arches, parietal and frontal tubercles, lower jaw with a rarefaction of the dentition.

^ Diagnosis of brain tumors

The main method of establishing a clinical diagnosis of a brain tumor is clinical neurological examination. A comprehensive examination includes:

– carefully collected anamnesis of the disease;

– general somatic and detailed neurological examination of the patient;

– study of survey data from related specialists and laboratory tests;

- additional diagnostic methods.

The most valuable objective symptoms of venous stasis and increased intracranial pressure in brain tumors include ophthalmic research ania, namely, the detection of congestive optic discs.

craniography in two main projections allows you to detect destructive changes in the bones of the skull, the most demonstrative in benign brain tumors that have been growing for years, accompanied by a long-term increase in intracranial pressure.

In case of brain tumors, in the cerebrospinal fluid obtained during the lumbar puncture, larger or smaller deviations from the normal indicators of cerebrospinal fluid pressure, protein content, and less often cellular elements are usually found. If a tumor of the posterior cranial fossa or the temporal lobe is suspected with a pronounced hypertensive syndrome and congestive optic discs during ophthalmoscopy, lumbar puncture is contraindicated due to the high risk of complications - dislocation of the brain substance and herniation.

X-ray computed tomography (CT) and Magnetic resonance imaging (MRI) is the most informative method for diagnosing brain tumors. The resulting images, three-dimensional visualization, make it possible to judge the localization of the tumor, its relationship to adjacent structures, blood supply, and histology with a fairly high degree of certainty.

Rarely used now cerebral angiography in the diagnosis of brain tumors. The presence of a tumor is judged by the dislocation of the brain vessels, the identification of its vascular network. They also evaluate its blood supply, relation to large vessels.

^ Tumors of the spinal cord

By location relative to the cross section of the spinal cord and dura mater, all tumors are divided into intramedullary, located in the thickness of the spinal cord, growing from its substance, and extramedullary, located outward from the spinal cord, growing from its nerve roots, meninges, vessels and other mesodermal elements of the spinal canal.

Extramedullary tumors make up the largest group of neoplasms:

- primary, arising from the spinal roots (neurinoma), meninges, blood vessels;

- secondary, arising from the spine (osteochondroma, osteosarcoma);

- metastatic - most often metastases of cancer of the breast, thyroid and prostate glands, esophagus, kidney cancer, etc.

intramedullary tumors meet much less often extramedullary. They are considered the least amenable to surgical treatment. Quite often observed in children and adolescents (up to 15 years). Intramedullary tumors are most often located in the cervical and cervicothoracic spinal cord, differing in considerable length (from 3 to 10 segments), while extramedullary tumors are located mainly in the thoracic spinal cord and cauda equina.

Spinal Tumor Clinic

The clinical picture of the disease consists of local, focal symptoms indicating the level of compression of the spinal cord by the tumor, and symptoms of progressive transverse compression of the brain substance and mechanical blockade of the subarachnoid space. Thus, the clinical picture of this pathology is made up of radicular, segmental and conduction symptoms.

Root membrane symptoms - one of the earliest, local character:

- pain during percussion of the spinous process of the vertebra, corresponding to the localization of the tumor;

- sensitivity disorders (hyperalgesia, paresthesia, hypesthesia) in the zone of innervation of the corresponding root or segment of the spinal cord;

- atrophy of the muscles innervated by the corresponding root;

- trophic disorders (anhidrosis, hyperhidrosis, hyperemia, dry skin, maceration, etc.) in the area of ​​the corresponding root or segment of the spinal cord;

Conduction violations are observed when the tumor compresses or destroys the pathways of the spinal cord and manifests itself with varying degrees of motor and sensory defects below the level of the lesion.

Diagnosis of spinal cord tumors

At the first stage, in addition to a thorough neurological examination, it is necessary to conduct X-ray examination of the spine – spondylography .

Study of the cerebrospinal fluid. Normally, cerebrospinal fluid is clear and colorless. An increased protein content in the analysis of cerebrospinal fluid is one of the signs of a tumor lesion. With tumors of the cauda equina, the so-called dry puncture is possible. During a puncture, if a tumor of the spinal cord is suspected, cerebrospinal fluid tests are required to detect the patency of the cerebrospinal fluid spaces. In addition, myelography with the use of water-soluble contrast agents is still an important diagnostic method.

Most reliable in the diagnosis of spinal cord tumors to date Magnetic resonance imaging, allowing with a high degree of probability to detect almost all tumors of the spinal cord, to judge their localization, histological structure, blood supply.

Treatment of tumors of the central nervous system

Surgery

In most brain tumors, indications for surgery prevail over indications for other methods of treatment. The indications for emergency surgery are the presence of an increasing hypertension syndrome with symptoms of dislocation and herniation of the brain. The choice of the type of intervention depends on a number of factors: the location and histology of the tumor, the severity of the patient's condition, age, and the presence of concomitant diseases.

However, in some cases, the operation is not performed even with an immediate threat to the life of the patient: mainly for inoperable deep-seated malignant tumors, especially with a relapse of the process, in elderly patients in a terminal state, and also in cases where the tumor is not available for direct surgery, and palliative intervention is impossible or will not give a positive effect.

For tumors of the spinal cord, surgery is considered indicated for almost any tumor that manifests symptoms of spinal cord compression. However, in patients with metastatic lesions in the presence of paraplegia, surgery is not justified due to the low probability of restoration of functions, and in the case of multiple metastases, it is contraindicated.

^ Radiotherapy

Refers to radiotherapy treatments. In the management of patients with brain tumors, external beam radiation therapy is used. Irradiation with wide beams (X-ray and gamma therapy) and precision irradiation with narrow beams (a beam of protons or other heavy accelerated particles, gamma therapy) are used. In neurosurgical treatment, radiation therapy is most often used as part of a combined treatment after removal of brain tumors. As an independent method, radiation therapy is used for pituitary adenomas.

^ Medical treatment

The possibilities of medical treatment in neurosurgery are limited.

The complex treatment of brain tumors includes chemotherapy (procarbazine, lomustine, vincristine, carmustine).

Most brain tumors, especially after surgery, require symptomatic drug therapy: anticonvulsant, hormone replacement, vasoactive.

Nursing issues in tumors of the central nervous system

Unlike colleagues in hospitals of other profiles, a nurse in the neurological and neurosurgical departments is faced with the widest range of medical issues: from catheterization of the bladder, preparing the patient for surgical treatment to providing assistance in emergency situations (epileptic attack, hypertensive-hydrocephalic crisis, etc.). .). Working with patients with tumors of the brain and spinal cord has a number of features.

When determining the state of consciousness, attention is paid even to slightly pronounced signs of stupor, light drowsiness. The patient's response to questions and commands is assessed.

The nurse should be aware of the possibility of developing mental changes in patients with brain tumors (from decreased mood to twilight disorders, suicidal attempts).

Constant vigilance, attention, the ability to monitor the behavior of patients with this diagnosis, “keep everything in sight” is the key to the patient’s safety, his protection from mental decompensation and severe breakdown.

^ BACKGROUND STRATEGY No. 5

18. Nursing process in closed traumatic brain injury: concussion. Real patient problems, dependent and independent nursing interventions.

Brain concussion- this is the most common form of brain damage, relatively mild in course and outcome; at the same time, functional disorders are observed without damage to the substance of the brain.

Symptoms. Cerebral symptoms predominate: short-term (from several seconds to 15-20 minutes) loss of consciousness, retro- or anterograde amnesia, nausea, single vomiting. Typical patient complaints: headache, dizziness, tinnitus, pain when moving the eyeballs, sweating. The patient is pale, breathing is frequent, superficial, tachycardia is observed; body temperature and blood pressure are unchanged. The bones of the skull were not damaged. CSF pressure is normal. Functional disorders of the central nervous system persist for 10-12 days. Some patients have a post-concussion syndrome - insomnia, dizziness, easy fatigue, lethargy, sweating.

Treatment conservative with mandatory hospitalization in the neurosurgical or trauma department. Patients must comply with strict bed rest for 10-14 days; they are provided with complete physical and mental rest. Dehydration therapy is carried out: intravenous (in / in) injections of glucose, ascorbic acid, subcutaneous injections of diphenhydramine, vitamins of group B; oral analgesic tablets are prescribed.

With a brain injury

19. Nursing process in closed traumatic brain injury: brain contusion Real problems of the patient, dependent and independent nursing interventions.

brain contusion- this is a local damage to the brain substance from minor (small hemorrhages in the affected area and swelling) to severe (rupture and crushing of the brain tissue). Fractures of the skull bones, the presence of blood in the CSF confirm the diagnosis. In the clinical picture, in addition to general cerebral symptoms, focal symptoms characteristic of the affected area of ​​the brain are clearly visible. There are 3 degrees of brain injury: mild, moderate, severe.

Symptoms. With mild degree consciousness turns off from several tens of minutes to several hours (1-3 hours). Cerebral symptoms are moderately expressed: amnesia, nausea, vomiting. The patient is worried about headache, dizziness. Focal symptoms appear: impaired movement and sensitivity on the side of the body opposite to the site of the brain injury; disorders of speech, vision; paresis of the mimic muscles of the face and muscles of the tongue; mild anisocoria; nystagmus. CSF pressure is slightly increased. Morphological changes are manifested by subarachnoid hemorrhages, which are accompanied by vasospasm. Therefore, after the elimination of vascular spasm, the symptoms of mild cerebral contusion regress within 2-3 weeks, the general condition of the patient returns to normal.

With an average degree consciousness turns off from several tens of minutes to a day. Patients have expressed amnesia, there is a mental disorder, anxiety, repeated vomiting. The pulse rate changes (bradycardia or tachycardia), blood pressure and body temperature rise (subfebrile), breathing quickens without rhythm disturbance. Focal symptoms are pronounced: impaired pupillary reaction, oculomotor disorders, nystagmus, paresis of the extremities, sensitivity disorder. Gradually over 3-5 weeks. focal symptoms subside. A sharp increase in intracranial pressure causes a breakdown in the functions of the central nervous system.

Severe injury It is characterized by turning off consciousness from several hours to several weeks. Focal symptoms are pronounced and persist for a long time due to damage to the brain stem: hyperthermia (up to 39-40 ° C), respiratory rhythm disorder, bradycardia or tachycardia, arterial hypertension. Neurological symptoms dominate: violation of the diameter and reaction of pupils to light, oculomotor disorders, inhibition of corneal reflexes and swallowing, etc. CSF pressure is sharply increased. The general condition remains extremely difficult for many days and often ends in death.

With positive dynamics, cerebral and focal symptoms disappear slowly, and motor and mental disorders remain for life.

Treatment brain bruises is carried out in a medical facility, the main treatment is aimed at combating acute respiratory failure - restoring airway patency (insertion of an air duct, intubation, mechanical ventilation, oxygen inhalation). To combat increased intracranial pressure, glucose, urea, manitol, lasix, novocaine are injected intravenously. To reduce body temperature in / m appoint amidopyrine and analgin 3-4 times a day. In a severe form of brain contusion, combined lytic mixtures (diphenhydramine, pipolfen, chlorpromazine, tizercin, pentamine) are administered. Transfusion therapy is carried out up to 3-4 liters per day. To improve the supply of oxygen to the brain, a 20% solution of sodium oxybutyrate (GHB) is injected intravenously at a dose of 40-80 ml per day.

1. Traumatic brain injury (TBI), definition, classification.
2. TBI clinic (closed TBI and open TBI)
3. Complications and consequences of TBI.
4. Emergency care and transportation of patients with TBI.
5. Spinal cord injury (clinic, emergency care, transportation of patients).
6. The principle of antishock therapy for TBI and spinal cord injury (SC).
7. Peculiarities of care for patients with TBI and SC injuries.

TBI - the most common type of injury and accounts for about 40% of all injuries.

TBI classification

1. Closed- CBI - an injury in which there is no damage to the soft tissues of the head, or there are damage to them up to the aponeurosis, as well as fractures of the cranial vault without damage to the adjacent soft tissues.
2. open TBI - includes damage to the soft tissues of the head and aponeurosis, as well as a fracture of the base of the skull. A) penetrating - with damage to the dura mater. B) non-penetrating - without any damage.

In the TBI clinic, there are: Concussion, Bruising, Compression.

Brain concussion - this is a mild TBI, in which there are no gross lesions of the National Assembly, but there are reflex disorders of blood circulation, liquorodynamics and neurodynamics. In the clinic, there is: a short-term loss of consciousness for several minutes, then a diffuse headache, vomiting, memory impairment in the form of retrograde amnesia (for events preceding the injury), autonomic disorders in the form of: pallor of the face, hyperhidrosis, tachycardia. On examination also revealed: nystagmus, pain when moving the eyeballs.

brain contusion more severe injury. Bruises occur with CTBI and TBI, may be accompanied by hemorrhages in the substance of the brain or subarachnoid. When bruised at the moment of impact, the base and poles of the frontal and temporal lobes are more often damaged. Depending on the severity, there are three degrees of brain injury.

• Mild injury - impaired consciousness in the form of stunning or stupor up to 2 hours. In addition to the cerebral syndrome (headache, vomiting) and vegetative syndrome, non-rough focal symptoms are detected - mild paresis, mild sensory disturbances. These symptoms regress after 2-3 weeks.
• Medium bruise - impaired consciousness up to 4-6 hours. The cerebral syndrome is more pronounced, more severe focal: hemiparesis, hemianesthesia, aphasia, amblyopathy, hypoacusia. Often there are fractures of the cranial vault.
• Severe injury - impaired consciousness from several hours to several weeks. Possible psychomotor agitation. Violation of the rhythm of breathing and cardiac activity. Floating movements of the eyeballs, decreased pupillary response to light, severe paresis, sometimes convulsions. A severe contusion, as a rule, is accompanied by a fracture of the vault and base of the skull, massive subarachnoid hemorrhages. The regression of symptoms is slow, gross residual phenomena are characteristic - motor and mental.

Brain compression - it can be caused by hematomas (epidural, subdural, intracerebral), depressed skull fractures. The presence of a light interval (a period of imaginary well-being) after an injury is characteristic. Depending on the severity of the injury, this interval can be long, erased or absent, on average it is 12-36 hours. After this time, headache, vomiting suddenly increase, meningeal syndrome appears, impaired consciousness progresses, bradycardia, convulsions, hemiparesis on the opposite side, anisocoria (pupil dilation on the side of the hematoma).

OCMT. Includes a fracture of the calvarium and base of the skull. With a fracture of the cranial vault, bone fragments damage the dura mater and the substance of the brain.

Fracture of the base of the skull - in the clinic, symptoms of a concussion or bruise, bleeding from the nose and ears, a symptom of "glasses" - due to the penetration of blood into the periorbital tissue, liquorrhea - the outflow of cerebrospinal fluid from the nose and ears. Damage to FMN is characteristic: visual, facial, vestibulocochlear in the form of amblyopia, hypoacusia, facial asymmetry. The condition of patients is severe, complications are possible: meningitis, meningoencephalitis, brain abscess.

Additional examinations for TBI.

1. Skull x-ray
2. Fundus examination
3. CT and MRI
4. ECHO-EG

Complications and consequences of TBI:

Early (up to 3 months) - meningitis, meningoencephalitis, brain abscess, osteomyelitis.

Late. 1) Post-traumatic epilepsy- the nature of the attacks depends on the location of the focus, and it is based on the formation of a connective tissue scar. 2) Post-traumatic cysts- formed at the site of hemorrhage. It is manifested by convulsions, progressive mental disorders, paresis of the muscles of the limbs. 3) Hypertension-hydrocephalic syndrome- are formed against the background of the adhesive process in the shells. It is manifested by dull, arching headaches, aggravated by tilting and turning the head, nausea and vomiting. 4) Cerebrosthenic syndrome. Manifested by fatigue, sleep disturbance, headache, autonomic disorders.

Providing emergency care

1. Call a doctor, an ambulance.
2. Carefully remove the victim.
3. Get rid of tight clothing.
4. Put something soft under your head. Cold on the head.
5. Control of blood pressure, pulse, respiration.
6. When vomiting, turn your head to the side.
7. To prevent retraction of the tongue, clean the oral cavity from saliva.
8. With bleeding from the nose and ears - the toilet of the nose, ears, tamponade with a sterile napkin.
9. With an open wound, apply an aseptic bandage.
10. In case of respiratory failure - IVL.

Patients are transported on a stretcher, putting something soft under their heads, fixing them on the sides with rollers.

Patients are hospitalized in the neurosurgical department, with severe TBI in intensive care. Drug treatment includes dehydration agents (furasemide, mannitol) that improve cerebral circulation (cavinton, vinpocetine), nootropics (nootropil, piracetam), analgesics, normalization of hemodynamics (polyglucin, rheopolyglucin). With TBI from the first day - antibiotics. no later than 12 hours after the injury, tetanus toxoid is administered.

Spinal Cord Injuries.

As a rule, they are combined with a spinal injury. The spinal cord suffers from a fracture of the vertebrae (compression, comminuted). Morphologically, this is manifested by edema of the roots, membranes, brain substance, foci of hemorrhages and necrosis. The forms of SM injuries are the same as GM: concussion, contusion, compression. Hematomyelia - hemorrhage in the substance of the SM. Hematocharis - hemorrhage in the membranes of the SM.

Concussion of the spinal cord - mild form, manifested by parasthesia, hypoesthesia, slight weakness in the legs, pelvic disorders (urinary retention, constipation), pain at the site of injury. These disturbances are short-term, functions are restored in 2-3 weeks.

spinal cord injury - usually combined with a fracture of the vertebral arch and its displacement to the spinal canal. Clinically, this is manifested by radicular pains (shooting, jerking), sensory disturbances from the level of the lesion, flaccid paresis and plegia, and pelvic disorders.

The type of urinary disorder depends on the level of injury: Injuries of the lumbosacral spine gives true urinary incontinence (discharge of it drop by drop), or false excretion of it as the sphincter is stretched. Injuries above the lumbosacral level gives urinary retention, and then it is replaced by periodic incontinence.

Spinal cord compression - occurs when the vertebral bodies are displaced, with the formation of hematomas. In the clinic observed: pain, paresthesia, flaccid muscle paresis, trophic disorders, - below the level of damage. In the first hours after the injury, due to spinal shock, it is difficult to determine the severity of the lesion.

spinal shock- this is the inhibition of the reflex activity of the SM, manifested by the syndrome of its complete break - these are plegia, anesthesia, pelvic and trophic disorders. Lasts up to 2-3 days. Patients with SC injury should be urgently hospitalized in a neurosurgical or intensive care unit by a SP machine.

Urgent care

1. Call a doctor, SP.
2. Lay the victim very carefully on the shield, fix the limbs. The position should be strictly horizontal.
3. In case of injury of the cervical spine - transportation on the back, fix the neck with a cotton-gauze collar of Shants. To prevent bedsores, put rollers under the back of the head, shoulder blades, sacrum, and heels.
4. In case of injury of the thoracic region - on the stomach - turn the head on its side, fix the limbs.
5. Measure blood pressure, pulse, respiratory rate.
6. With an open wound, aseptic dressing.

Principles of antishock therapy for TBI and spinal cord injury:

1. Painkillers: Analgin 4 ml IV together with Relanium 1-2 ml, in severe cases - narcotic analgesics.
2. Prednisolone 60-90 ml.
3. 40% glucose solution 10-20 ml IV.
4. For the normalization of cardiac activity - strophanthin, corglicon.

In a medical institution, an examination is carried out: X-ray, CT, ECHO-EG, MRI, after which the question of the need for surgical treatment is decided. Of the medications used: antibiotics, B vitamins, nootropics, biostimulants, anticholinesterase agents, exercise therapy, massage, physiotherapy.

Features of caring for patients with TBI and spinal cord injuries:

1. Observe the sanitary and hygienic regime.
2. All hygiene measures should be carried out lying down.
3. Prevention of congestive pneumonia: change of body position every 2-3 hours; vibration massage of the back, chest; do breathing exercises; put jars, mustards (as directed by a doctor).
4. Prevention of contractures - laying paralyzed limbs.
5. Control over the functions of the pelvic organs. The most dangerous are urinary and fecal retention.

Nursing interventions for urinary retention: reflex provocations, in order to prevent urosepsis, bladder catheterization is performed 2 times a day, after removal it is washed with a solution of furacilin. With urinary incontinence, an inflammatory process can develop, so the bladder is also washed by installing a permanent catheter.

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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 of first aid in emergency conditions in neurology
• findings
• 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 outside 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. In the surgical treatment of cerebral injuries and their consequences, minimally invasive techniques, reconstructive interventions, microneurosurgery, new equipment and new medical technologies have become widely used. We received confirmation and recognition of the concept of focal and diffuse lesions, primary and secondary lesions of the brain, phases of the clinical course of various forms of 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 injury 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 executing 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, moderate injuries - moderate brain contusions, 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 impact, 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 of water column) are 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 CGM, is short-term, but retrograde amnesia is more pronounced, neurological symptoms are more stable.

It should be noted that in recent years the number of chronic hematomas after the so-called mild craniocerebral 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 the vascular department with a diagnosis of 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. Subsequently, the rapid regression of 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 stupor (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 numbers. 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 the diagnosis of intracranial hematoma requiring emergency intervention should be as precise as possible, and this time is 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 apply burr holes under local anesthesia, followed, if necessary, by 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 care should own. 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 with a positive symptom of "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 the provision of first aid: underestimation of respiratory disorders, improper manipulation of medications, insufficient anesthesia (a 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 "congestive" nipples of the 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.) with preservation of 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. Tachycardia, normal or low blood pressure, and varying degrees of anemia predominated in almost everyone in this group. 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, vasoactive drugs, proteolysis inhibitors, antihistamines, psychotropic drugs, drugs that improve the metabolism of neurotransmitters, and a properly balanced diet were prescribed. 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. The introduction of drugs into 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 of the carotid artery, five methods can be used: direct catheterization of the artery, passing the catheter through the seddinger through the femoral artery, through one of the branches of the carotid artery in the neck, through the internal thoracic artery. The simplest, most affordable and safest way is to insert 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 preventing 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 the 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

Over the years, nurses in different countries have sought to achieve recognition 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.

Starting from the 50s in the USA, and later in Europe, scientific theories of nursing began to appear, 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 the nursing process in professional activities.

Withnursing 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 the necessary care for 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, morbidity rates, provision of the population with doctors and nursing staff joined the examination of the classifier. 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.

Based on this, 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 the general principles for classifying 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 non-compliance with 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 in various areas, impaired mobility (arms, legs), speech impairment, 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, in severe forms of ischemic attack, consciousness may be disturbed up to 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 WITH).

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, peace

- 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 due to 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 of internal organs, diseases of the endocrine glands, organic brain lesions, 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 arising doubts, fears, ideas, thoughts, memories, aspirations, desires, movements and actions that are alien to the patient's personality, 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 throughout the 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. The nurse of the neurological department should know the behavioral features, course and complications of the disease in 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 a 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 remedy 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 in 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 has poor vision or hand tremor).

2. 3 Ethical and deontological foundations of nursing

Nursing deontology - the science of duty to the patient and society, the professional behavior of a medical worker, is part of nursing ethics. A nurse should have professional observation skills that allow her to see, remember and evaluate the smallest changes in the patient's physical and psychological state in a nursing manner. 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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