Acute Intracranial Conditions Flashcards

1
Q

Describe different types of head injury

A

Time periods of death from head trauma:
-Immediately after the injury
-Within 2 hrs after the injury
-Approx. 3 weeks post injury – multi system failure

types of head injury:

Scalp lacerations (most common)
-Scalp is highly vascular _ profuse bleeding.
-Major complications are blood loss and infection.

Skull fractures
-Linear or depressed
-Simple, comminuted, or compound
-Closed or open

Clinical Manifestations:
-basilar skull fracture’s manifestations:
Battle sign - bruising behind ears
-Battle sign (postauricular ecchymosis) with otorrhea
(-Racoon eyes & rhinorrhea- CSF leak from nose)
-Halo or ring sign- Yellowish ring encircles blood if CSF is present

basliar skull fracture: CSF leak from the meninges
CSF leak ↑ risk for meningitis
———————————–

Head Trauma:

Brain injuries are categorized as:
-focal (localized) ex contusion, hematoma
-diffuse-Damage to brain cannot be localized ex concussion

FOCAL
Focal injury
-Consists of laceration, contusions, hematomas, and cranial nerve injury

Laceration:
-tearing of brain tissue
-Often associated with penetrating injuries
-Severe tissue damage

Contusion
-Bruising of brain tissue within a local area
-Coup → contusions or lacerations occur both at the site of direct impact of brain on the skull
-contrecoup → at a secondary area of damage on opposite side away from injury, leading to multiple contused areas

Coup-countercoup ex: hit head hard on forehead which whips head back, causing damage to front and back (primary and secondary impact)

DIFFUSE injuries:

Concussion: a sudden transient mechanical head injury with disruption of neural activity and a change in LOC
-Signs of concussion
Brief disruption in LOC
Amnesia
Headache
Short duration

Postconcussion syndrome: seen 2 weeks to 2 months post-concussion
Symptoms
Persistent headache
Lethargy
Personality & behavioral changes
_ short-term memory, _ attention span
Changes in intellectual ability

Chronic traumatic encephalopathy (CTE)
-Degeneration in brain from repeated concussions

Diffuse axonal injury (DAI)
-Widespread axonal damage that occurs following mild, moderate, or severe traumatic brain injury (TBI)
-Trauma changes the function of axon → results in axon swelling
-Clinical signs & symptoms
decrease LOC
increase ICP
Decortication, decerebration
Global cerebral edema
90% of pts with severe DAI remain in persistent vegetative state

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2
Q

Complications of Head Injury

A

Complications of Head Injury

-Epidural hematoma
-Subdural hematoma
Acute subdural hematoma
Subacute subdural hematoma
Chronic subdural hematoma
-Intraparenchymal hematoma
-Traumatic subarachnoid hemorrhage

Epidural hematoma:
-From bleeding between dura & inner surface of skull
-Often result of torn artery
Symptoms:
unconsciousness at the scene
A brief lucid interval followed by ↓ LOC
Headache, N/V

*Artery bleeds rapidly = neurological EMERGENCY

Subdural hematoma:
-From bleeding between dura matter & arachnoid layer of brain
-Usually venous in origin, thus, slower to develop
-Acute subdural hematoma
signs within 48 hrs of injury
↑ ICP; ↓ LOC, headache

Subacute subdural hematoma
Occur within 2- 14 days of injury
Subdural hematoma may appear to enlarge over time

Chronic subdural hematoma
Develops over weeks or months after a seemingly minor injury
Peak incidence in 50s and 60s
-chronic alcoholics

Classic signs in kids: Vomiting, sick, sleepy. Watch for 24-48 hours. Don’t let them fall sleep. ICP = take to ER

Intraparenchymal hematoma:
aka intracerebral hematoma
Collection of blood within parenchyma, from bleeding within brain tissue itself
In 16% of head injuries
Usually occurs in the __FRONTAL_______and ___TEMPORAL________ lobes

Traumatic subarachnoid hemorrhage:
Result of traumatic forces damaging the superficial vascular structures in subarachnoid space
May dispose pts to cerebral vasospasm & ↓CBF
Vasospasm: brain blood vessels narrow and block blood flow. Fever, stiff neck, paralysis one sided, decreased LOC

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3
Q

Explain the nursing care of patients with head injury.

A
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4
Q

Explain the types, clinical manifestations and interprofessional care of brain tumours.

A

Brain Tumours

-Primary- arising from tissues in the brain
-(majority) Secondary- resulting from a malignant neoplasm located somewhere else in the body

Unless treated all will eventually cause death by tumour volume leading to increased ICP, brain will herniate, death.

Clinical Manifestations:
-Depend on location, rate of growth and size.
-(common) headache, worse at night. Trouble sleeping, dull constant pain, occasional throbbing
-__nausea_____ and _vomiting______ from increased ICP
-Seizures especially in gliomas and brain metastases.
Gliomas: glipma cells
Glioglastoma is very aggressive, will die

Interprofessional Care
Identify the tumour
Remove or decrease tumour mass.
Prevent or manage increased ICP

Medication
-common med for brain tumour to decrease swelling: prednisone (steroids), dexamethasone, methylprednisone. Can make you crazy

Sx
-is preferred tx to remove tumour

Ventricular Shunts
-fluid in ventricles so put catheter in to drain fluid.
-Risk of draining too much fluid, too quickly (hypotension shock), infection, misplacement

Radiation
-seeds implanted in brain and slowly release small amounts of radiation. Not systemic. BBB. Only certain meds are effective or brain

Chemotherapy and Targeted Therapy
-systemic tx (affects whole body)
-difficult because of BBB

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5
Q

Describe the nursing management of someone undergoing cranial surgery.

A

Neurosurgery

-Reasons
-The removal or repair of brain tissue to prevent more harm
-To give palliative relief of distressing symptoms when the cause cannot be removed

Trauma
-Fractured skull
-Traumatic brain injury

Infection
- Cerebral and spinal abscesses

Vascular disorders
-Cerebral aneurysm
-Arteriovenous malformation

Spinal disorders
- Tumors of the spine

Congenial abnormalities
- hydrocephalus

Cerebral & spinal tumors
- glioma

Degenerative disorders
- Arthritic changes in the spine
—————————————————————————–
Surgical approaches:

Burr Holes:
-Holes drilled into skull and is used for insertion of brain needles to remove tissue for biopsy, or subdural hematoma
-To insert Gigli’s saw to create a bone flap in a craniotomy

Craniotomy
-skull piece removed, returned later

Decompressive craniectomy
-Remove flap and leave off, allowing brain to expand so doesn’t put pressure

Hypophysectomy
-Remove the pituitary gland. Go up the nose. For cancer or if pit gland is overactive

Post craniotomy nursing care

-Principles of care:
Safe recovery from anesthesia
Monitoring for signs of ICP & its clinical management
Provide nursing care based on pt’s degree of dependency
Promote rehabilitation

1) Management of ICP
-neuro vs
Glasgow Coma Scale q1h
hand grips (equal)
pronator drift and close eyes -drop is bad and indicated opposite sides injury)
feet (pedal, toes to nose) bilat,
-if one side is weaker than the other – bleed is the opposite side.
-Pupils are on same side as injury

-VS per protocol, e.g., q1h
-Full neurological assessment
-Report any change in pt’s condition immediately
-Admin ordered meds to decrease ICP

ICP likely caused by hemorrhage into wound site, cerebral edema, or hydrocephalus
-HOB to 30-40 degrees
-Chin and sternum should be aligned
-Pace nursing activities to decrease frequency of stimulation
-Prevent constipation
-Pain control
-Require good oxygen supply and sufficient CO2 to stimulate respiration
-If cerebral edema is causing deterioration of neurological status =May need to administer Mannitol

2) Wound care

-Inspect incision to ensure edges remain well approximated and staples/sutures intact
-Monitor for redness, discharge, signs of infection
-Incision usually left open to air
-Removal of sutures, usually in 2 wks
-Cover incision when going outside

3) Safety considerations

-Support positioning with towels and pillows to prevent pressure on surgical site
-Sign at bedside e.g, “No right bone flap”
-Keep bed at lowest level – risk of falling

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6
Q

Know the Glasgow Coma Scale scores that indicate the level of brain injury.

A

Classification of brain injury: (GCS score)
Mild 13-15
Moderate 9-12
Severe 3-8

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7
Q

Describe the primary causes and clinical manifestations of bacterial meningitis and encephalitis.

A

Bacterial meningitis-Acute inflammation of meningeal tissues surrounding brain & spinal cord

-If untreated, mortality rate near 100% =emergency

Leading causal agents:
-Streptococcus pneumoniae
-Neisseria meningitidis

Clinical manifestations:
-Fever, severe headache
-n/v
-Nuchal rigidity (resistance to flexion of the neck)
-positive Kernig sign (pain when hip flexed to 90º and extension of the knee)

Complications
↑ ICP (major cause of altered mental status)
—————————————————————————–

Encephalitis:

-Acute inflammation of brain
-Usually caused by a virus

Clinical manifestations:
-Onset is typically nonspecific
-Fever, headache, N/V
-Signs appear on day 2 or 3
-Signs may vary from min. to coma
-Hemiparesis
-seizures, tremors,
-cranial nerve palsies
-personality changes
-memory impairment, amnesia

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