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Nursing Semester 3 > Beth - Week 3 - Exam 1 > Flashcards

Beth - Week 3 - Exam 1 Flashcards

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1
Q

what are the different types of head trauma?

A
  • Skull fractures
  • Concussion
  • Contusion
  • Penetrating Trauma Foreign Object
  • Epidural Hematoma
  • Subdural Hematoma
  • Intracerebral Hematoma
  • Increased ICP
  • Alteration in Cerebral perfusion
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2
Q

____ people die from TBI daily, making up ___% of all deaths

A

153; 30

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3
Q

what are the causes of TBIs?

A 
Falls 40.5%, 
Unknown 19%, 
Struck by objects 15.5%
MVA 14.3%
Assaults 10.7%
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4
Q

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 _____

A

falls
falls
assaults
MVA

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5
Q

what are open head injuries?

A

injuries that penetrate the skull - brain tissue open

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6
Q

what are the different types of skull fractures?

A
  • linear/simple
  • depressed
  • basilar skull fracture
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7
Q

what are normal findings of a skull fracture?

A
  • CSF leak (otorrhea/rhinorrhea - ear/nose drainage)
  • raccoon/battle signs
  • cranial nerve injuries
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8
Q

what should you check nasal drainage for?

A

glucose

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9
Q

T/F: you can see if it’s an open fracture by CT scan

A

TRUE DAT

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10
Q

T/F: you should palpate the whole skull to see if there is blood for a depressed fracture?

A

TRUE

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11
Q

For a penetrating fracture, the degree of injury depends on what three characteristics?

A
  • velocity (bullet)
  • mass/shape (steak knife vs gun)
  • direction of impact (mouth/chin - can still miss the brain and live)
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12
Q

T/F closed head injuries are the most dangerous d/t pressure

A

TRUE

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13
Q

what are the 2 closed head injuries from blunt trauma?

A
  • concussion and contusion
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14
Q

what is a concussion?

A
  • jarring of the brain/soft tissue
  • *any pt that falls/hits head**
  • make sure pt doesn’t slide into a lower state of awakeness
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15
Q

what are the 2 characteristics of a concussion?

A
  • may (< 5min) or may not lose consciousness

- can be transient (short period)

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16
Q

what is found in a nursing assessment when assessing a concussion?

A
  • GCS 14 - 15
  • headache
  • nausea
  • negative CT/ MRI
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17
Q

what is a coup contra coup?

A

hit something hard (concrete/car) and the brain hits the back on the skull and the front of the skull

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18
Q

what is a contusion?

A

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
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19
Q

what is found in a nursing assessment in regards to a contusion?

A
  • GCS 10 - 15
  • stupor/confusion
  • headache
  • n + v
  • residual headache/vertigo
  • **herniation is possible - symptoms depend on severity
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20
Q

what is a secondary injury and what are they?

A

complications of the initial injury

  • subdural hematoma
  • epidural hematoma
  • intracerebral hematoma
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21
Q

what is a SDH?

A
  • below the epidural space

- subdural space has blood from impact

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22
Q

what is EDH?

A
  • above the subdural space

- epidural space has blood from impact or shirring

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23
Q

what is ICH?

A

blood in the brain tissue itself like a hematoma

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24
Q

A subdural hematoma can be from what?

A

a fall, MVA, hard hit to the head

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25
Q

Subdural hematomas are usually _____ bleed.

A

venous

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26
Q

what are the 3 classifications of subdural hematomas?

A

• Acute 24-48 hours
• Subacute > 2days < 2 wks
• Chronic > 2 wks or months
** presentation is about the same **

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27
Q

what are common s/sx of SDH?

A

n + v, confusion

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28
Q

what are acute SDH nursing assessment findings?

A

can be rapid deterioration with change in LOC

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29
Q

what are subacute and chronic SDH nursing assessment findings?

A
  • Family reports subtle personality changes
  • intermittent HA
  • Subtle mental deterioration:
  • drowsy; confused
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30
Q

what is the way to phrase how an injury occurred for someone > 65? 15 - 44?

A

“have you fallen?”

“is this an athletic injury?”

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31
Q

it’s important to assess if a patient with a SDH is on what type of medication?

A

anticoagulants

  • aspirin
  • ibuprofen
  • coumadin (warfarin)
32
Q

a intracerebral hematoma can be from what?

A
  • uncontrolled HTN
  • fall from high
  • MVA
  • very hard hit to the head
  • *will never be recoverable→ prevent further damage**
33
Q

T/F: bleeding into the brain occurs like a hematoma (anywhere)

A

YAS MA’AM

34
Q

what is the surgical tx for ICH?

A

Craniotomy or Craniectomy if possible depending on location

  • tx NOT a cure
  • remove part of skull so brain can swell
35
Q

what is the medical tx for ICH?

A
  • medications

- time for the brain to heal as the blood resolves

36
Q

what are the 5 nursing assessment findings for ICH?

A
  • 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)
37
Q

EXAM: a EDH can be from a ?

A

fall, MVA. hard hit to the head

38
Q

EDH are _____ bleeds

A

arterial; middle meningeal a. or v.

rapid collection of blood

39
Q

what is the KEY progression of a EDH?

A

rapid deterioration with a period of lucid at first then then deteriorates loss
example: MVA → loss consciousness → HA; 3 hr later → coma

40
Q

what is happening during a EDH to fix the problem?

A

compensation by the brain (absorption of CSF and decrease in production of CSF)

41
Q

what is found in a EDH nursing assessment? (6)

A
  • 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
42
Q

If a patient has an ICP bolt, the RN should ____ and ____.

A
  • monitor for ↑ ICP w/ any stimulation

- calculate CPP

43
Q

what are the goals for altered cerebral perfusion?

A
  • Normal ICP
  • Normal CPP
  • Improve Tissue Perfusion
  • Normal V/S
  • Improvement of LOC
44
Q

what are the medical/surgical intervention for excessive cerebral edema?

A
  • CSF removal

- surgical decompression

45
Q

how is CSF removal achieved?

A
  • ventriculostomy

- VP shunt

46
Q

how is surgical decompression achieved?

A
  • bone flap allowing brain to expand
  • craniotomy (hematoma evacuation; tumor removal)
  • burr holes (drill 3 holes in pt skull; blood drains out; hematoma evacuation)
47
Q

any drains in the brain → ↑ risk for ______.

A

INFECTION

***pt will be on prophylactic ATBs

48
Q

T/F bloody CSF = bad; should be clear and odorlesss

A

T

49
Q

what does old blood look like draining out?

A

jelly/dark with a yellow fluid

50
Q

what is a bone flap?

A

tx for cerebral edema and CPP; usually one side

  • explanted to the abdomen
  • responsible for assessing portion of abdomen
51
Q

what are the NI for a pt with a bone flap?

A
  • 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
52
Q

what is a VP shunt?

A

permanent shunt that drains CSF fluid into the peritoneal cavity
- can have a bulb control center → controls how much CSF comes out

53
Q

what are the goals and expected outcomes of someone with a TBI?

A
  • 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
54
Q

what are the characteristics of a TBI frequent assessment?

A
  • 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
55
Q

EXAM: what should you never give to a patient with a TBI?

A

DO NOT GIVE ENEMA FOR SOMEONE WITH A BRAIN INJURY!

56
Q

what are the 10 interventions to prevent further brain injury?

A 
•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
57
Q

what do we do in order to rest the brain?

A

coma is induced

58
Q

what is the goal of induced coma and what is required?

A

goal is to reduce cerebral metabolic demand thus ↓ ICP and a ventilator is required

59
Q

what are the two coma inducing drugs?

A
  • propofol (diprivan) - non barbiturate; easy to assess; short acting
  • pentobarbital - barbiturates (unable to neurologically assess; longer acting drug)
  • *good neuro; assess with neurosurgeon
60
Q

what drug therapies are used to decrease ICP?

A
  • steroids, diuretic/hyperosmolar agents, opioid agonist analgesic agents, and anti-convulsants/seizure agents
61
Q

what two steroid drugs are used to decrease ICP? how does it ↓ ICP? what is a major side effect of steroids?

A

• 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

62
Q

what 3 diuretic/hyperosmolar agents are used to decrease ICP? how do they work? what are the side effects?

A
  • 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)
63
Q

what opioid is used to decrease ICP?

A

• Morphine (watch for sedation)

- pain level

64
Q

what 2 anti-convulsants/seizure agents are used to decrease ICP? how does it work?

A

• 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

65
Q

what is the NI and POC for these patients?

A
  • fluid volume excess or deficit
  • monitor strict I + O
  • monitor serum and urine osmolarity
  • maintain isotonic solutions
66
Q

what are the NI for fluid volume excess or deficit ?

A
  • Keep patient dry
  • Monitor electrolytes
  • Caution with Sodium increases and decreases
67
Q

what are the NI for monitor strict I + O?

A
  • They should be equal or slightly dry

- Hourly urine output

68
Q

what are the NI for monitor serum and urine osmolarity? where do we want the serum osmolarity?

A
  • high and dry (serum) —low and dry (urine)
  • low and wet (serum) —high and wet (urine)
    ´ want serum osmo 280-300 mOsm/L
69
Q

what are the NI for maintain isotonic solutions

A
  • .9%NS or LR, D5NS

- can call pharm to change concentration for a ATB

70
Q

what are electrolyte complications r/t cerebral edema?

A
  • Diabetes insipidus

- Syndrome of Inappropriate ADH (SIADH)

71
Q

what is Diabetes insipidus?

A

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
72
Q

what is SIADH?

A

excessive ADH

  • hyponatremia (diluted); overhydrated
  • u/o < 20ml/hr
  • serum osmo low (check serum & urine Na)
  • tx. fluid restriction and diuretics
73
Q

what are the NIs to prevent skin breakdown?

A

• 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)

74
Q

what are the NIs in regards to nutrition?

A
  • 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
75
Q

what are characteristic of therapeutic communication for the family and patient?

A
  • 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
76
Q

what are teaching points for the family?

A
  • Expectations
  • Post-Traumatic Syndrome
  • Plan for Respite
  • Plan for the Future

Nursing Semester 3 (29 decks)

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