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ATI Pediatrics-MJ > Ch. 14: Head Injury > Flashcards

Ch. 14: Head Injury Flashcards

1
Q

An injury to the brain that alters the way the brain functions

A

Concussion

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2
Q

Bruising of the cerebral tissue

A

Contusion

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3
Q

Tearing of the cerebral tissue

A

Laceration

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4
Q

How can fractures be?

A 
Linear
Depressed
Comminuted
Basilar 
Open
or 
Growing
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5
Q

Loss of consciousness–what is significant about this?

A

The length of time the client is unconscious

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6
Q

What are signs of minor head injuries?

A
  • Possible loss of consciousness
  • Confusion
  • Vomiting
  • Pallor
  • Irritability
  • Drowsiness
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7
Q

Signs of severe injury?

A

ICP increased

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8
Q

Sings if increased ICP in infants?

A
  • Bulging fontanel
  • Separation of cranial sutures
  • Irriability
  • Increased sleeping
  • High pitched cry
  • Poor feeding
  • Setting sun sign
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9
Q

Signs of increased ICP in children?

A
  • N, V
  • Headache
  • Blurred vision
  • Increased sleeping
  • Inability to follow simple commands
  • Seizures
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10
Q

What are late signs of increased ICP?

A
  • Alterations in pupillary response
  • Decorticate or decerebate positioning
  • BRADYcardia
  • Decreased motor and sensory response
  • Cheyne-stokes
  • Coma
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11
Q

Demonstrates the arms, wrists, and fingers flexed and bent inward not the chest and the legs extended and adducted

A

Decorticate

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12
Q

Demonstrates a backward arching of the head and arms with legs rigidly extended and toes pointing downward

A

Decerebrate

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13
Q

Dysfunction at the midbrain

A

Decerebrate

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14
Q

Dysfunction of the cerebral cortex

A

Decorticate

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15
Q

What is the expected reference range of ICP?

A

10-15 mmHg

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16
Q

Why would a cervical spine x-ray be done for a head injury?

A

To rule out cervical spine injury

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17
Q

Nursing care: Why do we ensure spine is stabilized?

A

This is done until spinal cord injury is ruled out

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18
Q

For head injury, we need to maintain patent airway. We also administer oxygen as indicated to maintain an oxygen sat. level greater than ____

A

95%

19
Q

Where would we assess for clear fluid drainage. What happens if we find it?

A

Ears or nose (clear fluid=CSF)

Report to provider!!

20
Q

What are some actions that would decrease ICP (5)?

A
  1. HOB elevated to 30 degress (promotes venous drainage)
  2. Maintain head in midline neutral postiion (avoid extreme flexion, extension, and rotation)
  3. Keep body in alignment (avoid hip flexion/extension)
  4. Minimize suctioning
  5. Tell client to avoid coughing or blowing nose–these can increase ICP
21
Q

Why would we administer a stool softener for a head injury?

A

To prevent straining (Valsalva maneuver)

22
Q

Seizure precautions with head injuries?

A

Yes

23
Q

What meds are used to decrease cerebral edema?

A

Corticosteroids (dexamethasone and methylprednisolone)

24
Q

What mesa are used to treat cerebral edema?

A

Mannitol (osmotic diuretic)

25
Q

What meds are used to prevent or treat seizures?

A

Antiepileptics

26
Q

What meds are used in cases of CSF leakage, lacerations, or penetrating injuries?

A

Antibiotics

27
Q

What meds are used for headache/pain management?

A

Analgesics like acetaminophen

28
Q

Talk about surgical intervention of craniotomy.

A

Involves removal of part of skull

Bone is replaced once edema has resolved

29
Q

What are 4 complications of head injury?

A
  1. Epidural hemmorrhage
  2. Subdural hemorrhage
  3. Cerebral edema
  4. Brain herniation
30
Q

What complication: bleeding between the dura and skull

A

Epidural hemorrhage

31
Q

What are clinical manifestations of epidural hemorrhage?

A

Short period of unconsciousness followed by a normal period leading to herniation, coma, and death

32
Q

What complication: bleeding between the dura and the arachnoid membrane

A

Subdural hemorrhage

33
Q

What can a subdural hemorrhage be a result of?

A

Birth injury
Fall
Violent shaking

34
Q

Clinical manifestation of subdural hemorrhage?

A

Irritability
Vomiting
Seizures

35
Q

When would cerebral edema develop?

A

24-72 hours post op

36
Q

What are clinical manifestations of cerebral edema?

A

Increased ICP

37
Q

What complication: Downward shift of brain tissue

A

Brain herniation

38
Q

What are clinical manifestation of brain herniation?

A 
Loss of blinking
Loss of gag reflex
Pupils dont react to light
Coma
Resp. arrest
39
Q

A nurse is caring for a child who was admitted to ED after a MVA. The child is unresponsive, spontaneous respirations 22/min, and has laceration on forehead that is bleeding. What is priority intervention at this time?

A. Keep neck stabilized
B. Insert NG tube
C. Obtain VS
D. Establish IV

A

A

40
Q

A nurse is caring for an adolescent who has sustained a closed head injury. Which of the following are clinical manifestations of increased ICP. (SATA)

A. Report of headache
B. Alteration in pupillary response
C. Increased motor response
D. Increased sleeping
E. Increased sensory response
A

A, B, D

41
Q

A nurse is caring for a child who has increased ICP. Which of the following are appropriate actions by the nurse? (SATA)

A. Suction the endotracheal tube q2h
B. Maintain quiet environment
C. Use 2 pillows to elevate the head
D. Administer a stool softener
E. Maintain body alignment
A

B, D, E

42
Q

A nurse is assessing a child who has a concussion. Which of the following are clinical manifestations of a minor head injury. (SATA)

A. Vomiting
B. Delayed pupillary response
C. Drowsiness
D. Pallor
E. Confusion
A

A, C, D, E

43
Q

A nurse is teaching a parent about dexamethasone to treat head injury. Which of the following should be included in teaching?

A. It decreased cerebral edema
B. It promotes control of seizures
C. It promotes improved pain management
D. It is used to treat an infection

A

A

ATI Pediatrics-MJ (41 decks)

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