Anoxic brain injury, sometimes confused as traumatic brain injury, occurs when the brain becomes deprived of oxygen for a prolonged period of time. The brain, just like every organ, requires a continuous flow of oxygen to function normally. Roughly after six minutes, neural cells begin to die, and normal brain function will begin to cease. The severity of harm and consequences are dependent on the damaged areas of the brain. According to Ramiro and Kumar (2015), “Anoxic brain injury is the leading cause of mortality and morbidity among cardiac arrest survivors.” Medical and nursing management can become challenging because of the unknown outcomes. And although nurses may have the skills required to improve one’s recovery, it is still vitally important to have evidence-based resources to help attain more successful results.
The main objective is to educate and to expand one’s knowledge on the subject of anoxic brain injury. In order to further educate others, nurses must know the physiology, pathophysiology, predisposing factors, and clinical manifestations involved. Understanding the affected organ and its function, along with the physiological process of the injury helps to better nursing management and care for those who may be affected.
Basic Conditioning Factors
B.S. is a 79-year-old married, Caucasian female patient who was medically diagnosed with anoxic brain injury. Her past medical history includes hypertension, hyperlipidemia, chronic obstructive pulmonary disease (COPD), lymphedema, congestive heart failure, a previous myocardial infarction (MI), and depression. The patient is 5’7”, weighs 105.5 kilograms (kg), and has a BMI of 36.41. B.S.’s attending physician was Dr. Christopher Yee, and the nurse providing care was Singrid.
B.S. was admitted to Long Beach Memorial Medical Center (LBMMC) originally as full code status patient but was changed to do not resuscitate (DNR) status by the durable power of attorney (DPOA), has allergies to macrodantin and sulfa, and eats nothing by mouth. The patient’s respiratory specimen resulted positive for metapneumovirus, and was placed on contact and droplet precautions. B.S. was not alert and oriented to person, place, time, and event. The patient was intubated and sedated. She was unresponsive to voice, physical stimulation, and pain, but opens eyes spontaneously.
Erik Erikson, a well-known American-German psychologist, believed that personality developed in a predetermined series of stages from infancy to adulthood. His theory of psychosocial development is centered on the impact of social experiences across the lifespan. According to Erikson’s theory, B.S.’s major developmental level is Integrity versus Despair. This final stage of Erikson’s theory is considered late adulthood; it begins at the age of 65 and ends with death. During this stage, one reflects on their life and all of what they may have accomplished and may feel a sense of satisfaction or failure. It is the reality that their life is coming to an end. Those who are proud of their accomplishments will have a feeling of integrity. On the contrary, those complaining about regrets, not having enough time, and not finding the meaning of life will have a sense of despair (Leifer and Fleck, 2013). As care was provided for B.S. and considering her past medical history of depression, despair was evident at this stage in her life.
Anatomy and Physiology of the Involved Organ
The lungs are a pair of organs that sit on the right and left of the chest and are divided into lobes. The right lung is composed of three lobes and the left is composed of two. The cardiac notch, which is located on the left lung, allows for space for the heart. The two lungs are connected to the trachea, also known as the windpipe, by the main bronchus that branches off into the right and left bronchi. Both the right and left bronchi branch off into smaller tubes called bronchioles. At the end of each bronchiole branch are little air sacs called alveoli. The alveoli is a very important structure of the lungs, because this is where gas exchange occurs. The base of the lungs is bordered by the diaphragm. As being the foundation of the respiratory system, the main function of the lungs is to perform gas exchange by way of the alveoli. Carbon dioxide and oxygen are exchanged to and from in the blood to perfuse tissue (Marieb, Hoehn, and Hutchinson, 2018).
The heart is an organ made up of four chambers and a few valves. It is located at the middle of the chest. The muscular organ is roughly the size of a clenched fist and weighs less than one pound. The four chambers include the following: right and left atrium and right and left ventricle. The heart is the center of the circulatory system with the primary responsibility of pumping blood and supplying the necessary nutrients and oxygen to the body. The right atrium receives deoxygenated blood from the superior and inferior vena cava, which then flows into the right ventricle and to be pumped to the lungs via the pulmonary artery. Once the blood reaches the lungs, gas exchange occurs and oxygenated blood is emptied to the left atrium through the pulmonary vein. The blood then moves into the left ventricle to be pumped through the aorta to be able to perfuse the body (Marieb, Hoehn and Hutchinson, 2018).
The brain has many functions, some of which include our senses, emotions, language, thinking and memory. The skull surrounds the brain and also protects it from injury. The cerebrum, cerebellum, pons, and medulla are the four structures that compose the brain. Each structure is significant in its own way and function. The cerebrum divides into two subparts: the right and left hemisphere. Its functions include the following but are not limited to: initiation and coordination of movement, temperature, touch, vision, hearing, problem solving, and learning. The cerebellum’s primary function is to regulate motor movements and control posture, balance, and speech. The pons and medulla make up the brainstem. The pons relays messages to the cerebellum, regulates breathing, and involved in sleeping, waking, and dreaming. The medulla regulates involuntary life sustaining functions such as breathing, swallowing, and heart rate. The medulla is the most important part of the brain. Without it, one would die (Marieb, Hoehn, and Hutchinson, 2018).
Unfortunately, one of the leading causes of mortality and neurologic disability after cardiac arrest is anoxic brain injury (Ramiro and Kumar, 2015). Predisposing factors include cardiac arrest, drowning, trauma, drug overdose, or poisoning. More than 356,000 people in the United States (US) annually suffer from cardiac arrest. Survival rates after hospital discharge is about 10% among adults and of that percentage, 9% survive with good neurological function (Newman, 2018). According to Paterson and Bruins research (2018), survival rates were poor for those aged 80 years or older. Of the 838 patients Paterson and Bruins studied, 285 were eighty years old or older. Of those 285 patients, 4.1% to 12.6% survived one year post cardiac arrest. Advancing age is associated with poor outcome and reduced survival rates following cardiac arrest (Paterson and Bruins, 2018).
The patient’s past medical history of hypertension, COPD, and CHF contributed to her event of respiratory failure, cardiac arrest, and ultimately anoxic brain injury. Hypertension is chronic elevation of blood pressure. When long-term, it can cause end-organ damage, which then results in increased mortality and morbidity rates. This can occur from increased tension on the arteries and heart related to the central nervous system, abnormal function of the renin-angiotensin-aldosterone system, endothelial dysfunction, genes, and environmental factors. COPD is a group of chronic lung conditions that progresses over time. It causes chronic inflammation and irritation to the small airways of the lungs, resulting in bronchoconstriction. Narrowing of these vessels will allow less air to flow in and out of the lungs. Because COPD includes emphysema, chronic bronchitis, and asthma, signs and symptoms will vary. CHF is the inability of the heart to efficiently pump blood forward to meet the demands of the body. Both hypertension and COPD contribute to the development of CHF by increasing systemic and pulmonary vascular resistance. The increased pressure on the vessels causes the heart to work harder. Overtime, the heart will thicken and increase in size, because of the increasing demands. Although the heart is still able to pump blood, it is not as effective (Hinkle and Cheever, 2018).
As previously mentioned, B.S,’s condition of COPD, resulting in increased pulmonary vascular resistance, contributed to her incident of respiratory failure. Failure for gas exchange to occur or having too much carbon dioxide results in respiratory failure. Being deprived of oxygen will cause shortness of breath and a feeling of not receiving enough air to breathe in. Skin, lips, and fingernails may become discolored due to the lack of oxygen. Increased carbon dioxide will cause rapid breathing and altered level of consciousness (Hinkle and Cheever, 2018).
Because the lack of tissue perfusion related to decreased oxygenation and the patient’s history of CHF, consequently, the heart’s electrical activity begins to malfunction. In a matter of time, the heart stops pumping, cessation of breathing occurs, and the patient becomes unconscious. If cardiac arrest is not treated almost immediately, death can follow (Hinkle and Cheever, 2018).
Anoxic brain injury is the primary outcome of cardiac arrest. If cells, specifically neural cells, are deprived of oxygen for more than six minutes, cell death occurs. Abrupt interruption of cerebral blood flow will cause brain injuries (Hinkle and Cheever, 2018). Such injuries are significantly linked to neurological disability ranging from mild deficits to vegetative states (Ramiro and Kumar, 2015).
B.S. was admitted to LBMMC Emergency Department (ED) on February 7, 2020, with a chief complaint of respiratory distress. The patient was found having shortness of breath, agonal breathing, and bradycardic at home by Emergency Medical Services (EMS). Per daughter, B.S. was sick with an upper respiratory infection (URI) for one week with the only signs and symptoms of a cough. On ED arrival, the patient went into pulseless electrical activity (PEA) arrest. Return of spontaneous circulation (ROSC) was achieved after cardiopulmonary resuscitation (CPR), two rounds of epinephrine, calcium gluconate, and bicarbonate. The patient was emergently intubated and hypothermia protocol was initiated. A computed tomography (CT) of the head and a computed tomography angiography (CTA) of the chest was ordered. CT of the head presented no abnormalities; however, the CTA of the chest was concerning for pneumonia. Empiric antibiotics with fluids were administered. Electrocardiogram (EKG) showed Sinus Rhythm with a Left Bundle Branch Block (LBBB) and discordant ST elevation.
On February 12, 2020, B.S. appeared intubated and sedated. The patient was unresponsive to voice, physical stimulation, and pain. Pupils were equal, round, and reactive to light; pupil size was 3 millimeters, sluggish to reaction, and moved spontaneously. According to the Richmond Agitation-Sedation Scale, the patient was categorized as (-4). On the Glasgow Coma Scale, B.S. scored 4:1:T. Upper and lower extremities were flaccid and generalized 3+ edema was present. A Foley catheter and orogastric tube were placed to help facilitate urination and feedings, respectively. Ventilator settings were as follows: assist-control, set respiratory rate of 24, set tidal volume of 450, FiO2 30%, and PEEP of 5. Teaching Plan
Although patient B.S. was intubated and sedated, teaching was still accomplished before every medication administration and procedure that was done. The content that was taught included what medications B.S. was administered and specifically why it was prescribed to her, why passive range of motion (PROM) was being performed, and why turning her every two hours was being done. The student nurse used verbal explanations as way of her teaching method. The medications that were taught were the following: heparin, white petrolatum, pantoprazole, furosemide, and piperacillin. The goal for B.S. was to be able to demonstrate knowledge as to why her medication was being administered, PROM, and turning every 2 hours was performed by way of explaining the concepts taught by the end of shift. The interventions to help achieve the patient’s goal include using slow and simple speech, therapeutic communication techniques, and a calm and quiet learning environment. Because the patient was not able to verbally communicate, the student nurse was not able to validate if learning had taken place.
The purpose of the nursing research article entitled, Communicating with Patients’ Families and Physicians About Prognosis and Goals of Care (Milic et al., 2015), was to improve the communication skill set among critical care nurses while speaking with physicians and patients’ families about prognosis. Statistics show that one-fifth of patients in America receiving care in the intensive care unit (ICU) die shortly after or have decreased functional outcomes. Implementing palliative care is an essential part of medical care in the ICU. To do so, the nurse must be actively involved in communicating such things to the patients’ family. It is part of the nurse’s responsibility to communicate effectively, and often times prognosis and goals of care are not discussed with the patient’s family members, leaving the family in psychological distress (Milic et al., 2015).
The method used to promote effective communication skills was that of an 8-hour-long educational workshop. Nurses from the University of California San Francisco Medical Center who provided care in the following units were encouraged to participate: medical-surgical, cardiac, neurological ICU, emergency department, and those on the rapid response team. Roles and communication techniques were outlined. All those who participated in the study practiced the various skills by way of role play sessions. The learning outcome for the workshop itself was to assess understanding of prognosis and goals of care by patients’ families; communicate the needs of patients’ fam¬ilies to physicians; advo¬cate for family members’ informational and emo¬tional needs; and develop skills for coping with stress, moral distress, and compassion fatigue (Milic et al., 2015).
The educational workshop was held from March of 2011 through April of 2013 with a total of 82 nurses participating. An increase in confidence and communication skills were reported by most, if not all of the participants through a follow-up survey. Of the total nurses who participated, 78 nurses reported a great increase of awareness of their roles and responsibility in ICU communication. Communication is an important aspect in all of health care, especially in critical care. To be more successful in promoting discussion of prognosis and care, nurses require an excellent communication skill set.