1. General care:
Raise the head of a bed 15~30 degrees, in
order to facilitate intracranial venous reflux, reduce cerebral edema.
Oxygen supply: Intermittent or continuous
oxygen intake.
Maintain normal body temperature and
prevent infection.
Controlled inflow and outflow: the adult's
daily fluid infusion volume shall not exceed 2000ml and the daily urine volume
shall not be less than 600ml.
2. Prevent sudden increase of intracranial
pressure
Rest: Avoid increased intracranial pressure
caused by emotional excitement.
Maintain an open airway.
Avoid severe coughing and constipation.
Timely control of seizures.
3. Drug treatment and nursing
Nursing of dehydration treatment:
transfusion speed is fast, otherwise, increases the burden of the circulatory system.
Dehydrating drugs should be used to prevent the phenomenon of intracranial
pressure bounce alternately.
Nursing care of hormone therapy: observe
the adverse reactions such as stress ulcer bleeding and infection induced by
hormone without cause.
4. Hibernation treatment and nursing
Apply medicaments and physical method to
reduce body temperature, make the patient is in inferior hypothermia state, the purpose is to reduce cerebral oxygen consumption and cerebral metabolization
rate, reduce cerebral blood flow, increase cerebral to ischemia hypoxia
tolerance, reduce cerebral edema.
If did not enter hibernation state begins
to cool down, the patient's cold response will appear chill, make the body the metabolic rate increased, oxygen consumption increased, but increased
intracranial pressure.
The cooling rate should be 1℃ per hour,
and the temperature should be 32 ~ 34℃. Hypothermia can trigger
arrhythmias.
The time of hibernation hypothermia therapy
is generally 2 ~ 3 days. When the treatment is stopped, physical cooling is
stopped first, and then the hibernation drugs are gradually stopped. The
temperature is allowed to return spontaneously.
5. Nursing care of ventricular drainage:
The location of the drainage tube: sterile
drainage bag, proper fixation of the drainage tube and drainage bag, the
opening of the drainage tube should be 10-15cm higher than the lateral
ventricle plane to maintain normal intracranial pressure, the drainage tube
should be temporarily clipped when the patient is moved to prevent
cerebrospinal fluid reflux.
Drainage speed and volume: daily drainage
volume should not exceed 500ml.
Keep drainage clear.
Observe and record the color, quantity, and character of CSF.
Nursing care after cerebrospinal fluid
shunt: strictly observe the condition and judge the effect of the shunt.
6. Respiratory care
Keep respiratory tract unobstructed after
craniocerebral injury patients by fully to oxygen, the patient's breathing
difficulties, hypoxia symptoms not to improve or expectoration drainage is
difficult, should cooperate with the doctor early tracheotomy, keep clear of
respiratory secretions, relieve airway obstruction, make the intrathoracic
pressure and intracranial pressure drop, and reduce respiratory dead space,
increase the effective gas exchange, improve breathing and lack, relieve
cerebral edema and lower intracranial pressure. If the patient's breathing is
weakened and tidal volume is insufficient, use a ventilator to assist
breathing.
Oral care to prevent respiratory tract
infection 2 times a day, atomization inhalation 2 ~ 3 times a day, turn over,
pat back 2 ~ 3h once, turn over action should be light and steady. The dressings
at tracheotomy were changed daily to keep the dressings dry and clean, the endotracheal cannula was disinfected every 4h, the endotracheal drops were
added with 20ml normal saline and mucosolvan 15mg, 2ml per hour, and the outer
opening of the tracheotomy was covered with a single layer of sterile normal
saline gauze. Aseptic operation should be strictly observed when sputum
aspiration is carried out, the internal secretions should be inhaled first, and
then the nasal and mouth secretions should be inhaled. Each suction should not
exceed 15s, and the patient should not cough too much and increase the
intracranial pressure.