Beth - Week 3 - Exam 1 Flashcards
what are the different types of head trauma?
- Skull fractures
- Concussion
- Contusion
- Penetrating Trauma Foreign Object
- Epidural Hematoma
- Subdural Hematoma
- Intracerebral Hematoma
- Increased ICP
- Alteration in Cerebral perfusion
____ people die from TBI daily, making up ___% of all deaths
153; 30
what are the causes of TBIs?
Falls 40.5%, Unknown 19%, Struck by objects 15.5% MVA 14.3% Assaults 10.7%
55% age 0-14 d/t _____
81% age 65 and older d/t ____
75% age 15-44 d/t ______
26% age 5-24 d/t _____
falls
falls
assaults
MVA
what are open head injuries?
injuries that penetrate the skull - brain tissue open
what are the different types of skull fractures?
- linear/simple
- depressed
- basilar skull fracture
what are normal findings of a skull fracture?
- CSF leak (otorrhea/rhinorrhea - ear/nose drainage)
- raccoon/battle signs
- cranial nerve injuries
what should you check nasal drainage for?
glucose
T/F: you can see if it’s an open fracture by CT scan
TRUE DAT
T/F: you should palpate the whole skull to see if there is blood for a depressed fracture?
TRUE
For a penetrating fracture, the degree of injury depends on what three characteristics?
- velocity (bullet)
- mass/shape (steak knife vs gun)
- direction of impact (mouth/chin - can still miss the brain and live)
T/F closed head injuries are the most dangerous d/t pressure
TRUE
what are the 2 closed head injuries from blunt trauma?
- concussion and contusion
what is a concussion?
- jarring of the brain/soft tissue
- *any pt that falls/hits head**
- make sure pt doesn’t slide into a lower state of awakeness
what are the 2 characteristics of a concussion?
- may (< 5min) or may not lose consciousness
- can be transient (short period)
what is found in a nursing assessment when assessing a concussion?
- GCS 14 - 15
- headache
- nausea
- negative CT/ MRI
what is a coup contra coup?
hit something hard (concrete/car) and the brain hits the back on the skull and the front of the skull
what is a contusion?
brain with bruising/petechial hemorrhages
- long term (up to 3 - 6 months)
- can involve the brain stem
- pts can be awake then slide into a coma & can herniate
what is found in a nursing assessment in regards to a contusion?
- GCS 10 - 15
- stupor/confusion
- headache
- n + v
- residual headache/vertigo
- **herniation is possible - symptoms depend on severity
what is a secondary injury and what are they?
complications of the initial injury
- subdural hematoma
- epidural hematoma
- intracerebral hematoma
what is a SDH?
- below the epidural space
- subdural space has blood from impact
what is EDH?
- above the subdural space
- epidural space has blood from impact or shirring
what is ICH?
blood in the brain tissue itself like a hematoma
A subdural hematoma can be from what?
a fall, MVA, hard hit to the head
Subdural hematomas are usually _____ bleed.
venous
what are the 3 classifications of subdural hematomas?
• Acute 24-48 hours
• Subacute > 2days < 2 wks
• Chronic > 2 wks or months
** presentation is about the same **
what are common s/sx of SDH?
n + v, confusion
what are acute SDH nursing assessment findings?
can be rapid deterioration with change in LOC
what are subacute and chronic SDH nursing assessment findings?
- Family reports subtle personality changes
- intermittent HA
- Subtle mental deterioration:
- drowsy; confused
what is the way to phrase how an injury occurred for someone > 65? 15 - 44?
“have you fallen?”
“is this an athletic injury?”
it’s important to assess if a patient with a SDH is on what type of medication?
anticoagulants
- aspirin
- ibuprofen
- coumadin (warfarin)
a intracerebral hematoma can be from what?
- uncontrolled HTN
- fall from high
- MVA
- very hard hit to the head
- *will never be recoverable→ prevent further damage**
T/F: bleeding into the brain occurs like a hematoma (anywhere)
YAS MA’AM
what is the surgical tx for ICH?
Craniotomy or Craniectomy if possible depending on location
- tx NOT a cure
- remove part of skull so brain can swell
what is the medical tx for ICH?
- medications
- time for the brain to heal as the blood resolves
what are the 5 nursing assessment findings for ICH?
- pt is usually semi-comatose to comatose
- pupils sluggish
- pt can be very agitated then deteriorates to coma
- high potential for seizures (so high potential for herniation)
- loss of air to breath (will need intubation; ABCs)
EXAM: a EDH can be from a ?
fall, MVA. hard hit to the head
EDH are _____ bleeds
arterial; middle meningeal a. or v.
rapid collection of blood
what is the KEY progression of a EDH?
rapid deterioration with a period of lucid at first then then deteriorates loss
example: MVA → loss consciousness → HA; 3 hr later → coma
what is happening during a EDH to fix the problem?
compensation by the brain (absorption of CSF and decrease in production of CSF)
what is found in a EDH nursing assessment? (6)
- H/A, confused or drowsy
- Rapid change in LOC from agitation to coma
- Contralateral hemiplegia or paresis
- One pupil dilatation- ipsilateral
- MUST have rapid surgical intervention
- Burr holes, craniotomy, bone flap
If a patient has an ICP bolt, the RN should ____ and ____.
- monitor for ↑ ICP w/ any stimulation
- calculate CPP
what are the goals for altered cerebral perfusion?
- Normal ICP
- Normal CPP
- Improve Tissue Perfusion
- Normal V/S
- Improvement of LOC
what are the medical/surgical intervention for excessive cerebral edema?
- CSF removal
- surgical decompression
how is CSF removal achieved?
- ventriculostomy
- VP shunt
how is surgical decompression achieved?
- bone flap allowing brain to expand
- craniotomy (hematoma evacuation; tumor removal)
- burr holes (drill 3 holes in pt skull; blood drains out; hematoma evacuation)
any drains in the brain → ↑ risk for ______.
INFECTION
***pt will be on prophylactic ATBs
T/F bloody CSF = bad; should be clear and odorlesss
T
what does old blood look like draining out?
jelly/dark with a yellow fluid
what is a bone flap?
tx for cerebral edema and CPP; usually one side
- explanted to the abdomen
- responsible for assessing portion of abdomen
what are the NI for a pt with a bone flap?
- Keep the head in alignment; HOB 30 degrees
- Do not allow head to turn toward the bone flap side—
towels/sand bags - Assess for softness, hydration status (concave - neuro pts are dehydrated; ↑ fluid → ↑ cerebral edema)
- Make a sign and hang over bed
- pt can’t get out of bed without special helmet
don’t turn had onto operative side
what is a VP shunt?
permanent shunt that drains CSF fluid into the peritoneal cavity
- can have a bulb control center → controls how much CSF comes out
what are the goals and expected outcomes of someone with a TBI?
- goal is to reduce long term injury to the brain (ICP in control)
- preserve as much of the brain as possible
- prevent more brain damage
what are the characteristics of a TBI frequent assessment?
- Monitor changes in LOC (GCS; pupils; sensory; motor function)
- Frequent Vital Signs q 15
- Give IV–isotonic solutions
- Keep dry (skin integ; ↑ temp; ↑ metabolism)
- I&O (Fluid overload Leads to cerebral edema)
- Oral care (bacteria → pneumonia)
- Give pain medications
- Give coma inducing drugs if required
EXAM: what should you never give to a patient with a TBI?
DO NOT GIVE ENEMA FOR SOMEONE WITH A BRAIN INJURY!
what are the 10 interventions to prevent further brain injury?
•Prevent hypotension (keep MAP 70-90) •Start pressure agents if needed •No IVF bolus •Keep CPP normal •Keep ICP normal •Keep HOB at 30 degrees •Prevent skin breakdown •Prevent respiratory complication •Keep Normothermic •No Enemas
what do we do in order to rest the brain?
coma is induced
what is the goal of induced coma and what is required?
goal is to reduce cerebral metabolic demand thus ↓ ICP and a ventilator is required
what are the two coma inducing drugs?
- propofol (diprivan) - non barbiturate; easy to assess; short acting
- pentobarbital - barbiturates (unable to neurologically assess; longer acting drug)
- *good neuro; assess with neurosurgeon
what drug therapies are used to decrease ICP?
- steroids, diuretic/hyperosmolar agents, opioid agonist analgesic agents, and anti-convulsants/seizure agents
what two steroid drugs are used to decrease ICP? how does it ↓ ICP? what is a major side effect of steroids?
• Dexamethasone (Decadron)-long acting glucocorticoid
- passes through BBB
•Methylprednisone (Solu-Medrol)-intermediate acting glucocorticoid
- Reduces Cerebral edema due to anti-inflammatory effects
- Major side effect is hyperglycemia (monitor glucose); ↑ infection; poor healing
what 3 diuretic/hyperosmolar agents are used to decrease ICP? how do they work? what are the side effects?
- Mannitol -Hyperosmolar/Osmotic diuretics-creates osmotic gradient that draws cerebral edema fluid from brain tissue into the circulation
- Hypertonic Saline (3%) Hyperosmolar-Same as above
- Furosemide(Lasix)-Loop diuretics
- Major side effects of both agents; hyponatremia; K + (watch I&O and Sodium and potassium; VS q 4hr)
what opioid is used to decrease ICP?
• Morphine (watch for sedation)
- pain level
what 2 anti-convulsants/seizure agents are used to decrease ICP? how does it work?
• Fosphenytoin(Cerebyx)-Prodrug for Phenytoin, modulates sodium and calcium channels to decrease seizure threshold
• Phenytoin(Dilantin)-Same
- don’t get too much → rash on torso
what is the NI and POC for these patients?
- fluid volume excess or deficit
- monitor strict I + O
- monitor serum and urine osmolarity
- maintain isotonic solutions
what are the NI for fluid volume excess or deficit ?
- Keep patient dry
- Monitor electrolytes
- Caution with Sodium increases and decreases
what are the NI for monitor strict I + O?
- They should be equal or slightly dry
- Hourly urine output
what are the NI for monitor serum and urine osmolarity? where do we want the serum osmolarity?
- high and dry (serum) —low and dry (urine)
- low and wet (serum) —high and wet (urine)
´ want serum osmo 280-300 mOsm/L
what are the NI for maintain isotonic solutions
- .9%NS or LR, D5NS
- can call pharm to change concentration for a ATB
what are electrolyte complications r/t cerebral edema?
- Diabetes insipidus
- Syndrome of Inappropriate ADH (SIADH)
what is Diabetes insipidus?
deficient in ADH - nothing to do with BG
- dehydration/diuresis >300ml/hr
- check sp. gr. (<1.005)
- serum osmo high (check serum & urine Na)
- tx. DDAV
what is SIADH?
excessive ADH
- hyponatremia (diluted); overhydrated
- u/o < 20ml/hr
- serum osmo low (check serum & urine Na)
- tx. fluid restriction and diuretics
what are the NIs to prevent skin breakdown?
• Turn every 2 hrs as tolerated
• Alignment limbs, neck, head
• Multi podus boots to prevent foot
drop
• Passive range of motion (if ICP remains normal; have family straighten fingers)
• DVT prophylaxis (lovenox - talk to N.S.)
• Oral care every 2 hours & PRN
- oral suction
- assess for opportunistic infection (swish and swallow - thrush)
what are the NIs in regards to nutrition?
- address nutritional support
- malnutrition → promotes cerebral swelling
- monitor albumin levels → adequate protein
- insert NG tube with NS approval
- soft feeding q 2 - 4 hr
- PEG/G tube q 2 - 4 hr
- ↓ peristalsis → potential ileus
what are characteristic of therapeutic communication for the family and patient?
- Establish trust
- Keep family informed
- Open communication-non- judgmental
- Participation in decision- making
- Allow family to visit frequently
- Emphasize positive abilities
- Allow for privacy– balance this with social interaction
what are teaching points for the family?
- Expectations
- Post-Traumatic Syndrome
- Plan for Respite
- Plan for the Future
