Ch 14 Head Injury

Question 1

What are head injuries classified as

Answer 1

Open or closed… They can be mild, moderate, or severe depending on the Glasgow coma scale

Question 2

What is a open head injury

Answer 2

Penetrating trauma, the skull integrity is compromised

Question 3

Open head injuries pose a high risk for what

Answer 3

Infection

Question 4

What are skull fractures often accompanied by

Answer 4

Brain injury…. Damage to the brain tissue may be the result of decreased oxygen supply, or the direct impact from the skull fracture, which caused the trauma. The glucose levels in the brain are negatively affected, resulting in alteration in neurological synaptic ability.

Question 5

What may head injuries be associated with

Answer 5

Hemmorhage ( epidural, subdural, amid intracerebral) or CSF leakage. Any collection of fluid or foreign objects that occupies the space within the skull poses a risk for cerebral edema, cerebral hypoxia, and brain herniation

Question 6

What should always be suspected when a head injury occurs

Answer 6

A cervical spine injury must be ruled out prior to removing any devices used to stabilize the cervical spine.

Question 7

What are manifestations of increased intracranial pressure

Answer 7

Severe headache
Deteriorating level of consciousness, restlessness, irritability
Dilated, pin point, or asymmetric pupils, slow to react or non reactive
Alteration in breathing pattern
Deterioration in motor function, abnormal posturing
Cushing reflex( which is a late finding characterized by severe hypertension with a widening pulse pressure and bradycardia
CSF leakage ( fluid will test positive for glucose)
Seizures

Question 8

What diagnostic is used to determine a cervical spine injury

Answer 8

Cervical spine films

Question 9

What is considered the golden window for head injuries

Answer 9

There is a 1 hour golden window for treatment of head injuries. Emergency treatment during this time frame decreases morbidity and mortality rates especially for epidural hematomas

Question 10

What is the brain dependent on

Answer 10

Oxygen to maintain function and it has little reserve available I’d oxygen is deprived. Brain function begins to diminish after 3 min of oxygen deprivation

Question 11

What provides the earliest indication of neurological deterioration

Answer 11

Glasgow coma scale

Question 12

What are 4 methods used to monitor ICP

Answer 12

1. A thin tube inserted into the lateral ventricle ( intraventricular)
2. Use a bolt or screw placed in the subarachnoid area ( subarachnoid)
3. Place a sensor in the epidural space ( epidural)
4. Place a fiber optic transducer tipped catheter into the subdural or subarachnoid space, ventricle or brain tissue.

Question 13

What is the expected reference range for ICP

Answer 13

10-15 mm Hg

Question 14

ICP may be increased by what

Answer 14

Hypercarbia which leads to cerebral vasodilation
Endotracheal or oral tracheal suctioning
Coughing, blowing the nose forcefully
Extreme neck or hip flexion/ extension
Maintains the HOB at angles less than 30 degrees
Increasing intra abdominal pressure ( restrictive clothing, valsalva maneuver)

Question 15

What are actions that can decrease ICP

Answer 15

Elevate HOB 30 degrees to reduce ICP and promote venous draining
Avoid extreme flexion, extension, or rotation of the head, maintain the body in a midline neutral position.
Hyperventilate clients on mechanical ventilation to keep PaCO2
between 35-38 mm Hg to reduce cerebral blood flow
Monitor fluid and electrolytes and osmolarity to detect changes in Na regulation, the onset of diabetes insipidus, or severe hypovolemia

Question 16

What is the last sense affected by a head injury

Answer 16

Hearing

Question 17

What can secondary brain injury result from

Answer 17

Hypotension, hypoxia, hyperglycemia, hypoglycemia, acidosis, hypercapnia….. MONITOR VITAL SIGNS, BLOOD GLUCOSE, O2 SATURATION, AND ABGs.

Question 18

What is mannitol

Answer 18

An osmotic diuretic used to treat cerebral edema
Administer IV to treat acute cerebral edema
Insert in dwelling catheter to monitor fluid and renal status. Monitor urine osmality daily
Monitor serum electrolytes and osmality Q 6 HR.

Question 19

Pentobarbital is used for what

Answer 19

Is used to induce a barbiturate coma to decrease cerebral metabolic demands

Question 20

When Is pentobarbital initiated

Answer 20

Treatment is performed when the ICP is refractory to treatment and has exceeded 25 mm Hg for 30 min, 30 mm Hg for 15 min or 40 mm Hg for 1 min

Question 21

What is a barbiturate coma and what is it used for

Answer 21

A barbiturate coma is a treatment of last resort and aims to decrease elevated ICP by inducing vasoconstriction and decreasing cerebral metabolic demands

Question 22

What are nursing considerations for pentobarbital

Answer 22

Medication is administered in bursts to decrease cerebral activity. Treatment continues until the ICP remains below 20 door 48 hours.
Medication is then slowly withdrawn

Question 23

What is phenytoin

Answer 23

Dilantin

Is used prophylactically to prevent or treat seizures

Question 24

Opioid use coupled with hypotension may cause what

Answer 24

Increased ICP

Question 25

What is a craniotomy

Answer 25

The removal of non viable brain tissue that allows for expansion and or removal of epidural or subdural hematomas. It involves drilling a burr hole or creating a bone flap to permit access to the affected area.

Question 26

Treatment of intracranial hemmorhages involves what

Answer 26

Surgical evacuation

Question 27

For supratentorial surgery how MUST the HOB be maintained

Answer 27

At least 30 degrees with body positioning to prevent increased ICP

Question 28

For a infratentorial craniotomy, how should the HOB be placed

Answer 28

KEEP THE CLIENT FLAT AND ON EITHER SIDE FOR 24-48 hour to prevent pressure on neck incision site. Monitor and maintain wound drain, documenting output Q 8 HR. Monitor wound dressing and mark drainage Q 1-2 hour

Question 29

What are nursing actions for the mechanically ventilated following a craniotomy

Answer 29

Hyperventilate for 24-48 hours as prescribed to maintain PaCo2 around 35 mm Hg

Question 30

What are complications of a craniotomy

Answer 30

Brain herniation

Question 31

What is a brain herniation

Answer 31

The downward shift of brain tissue due to cerebral edema. This can result from brain tissue moving downward through the foramen magnum.

Question 32

What are clinical findings of a brain herniation

Answer 32

Fixed dilated pupils
Deteriorating level of consciousness
Cheyne stokes respirations 
Hemodynamics instability
Abnormal posturing

Question 33

A intracranial hemmorhage is treated how

Answer 33

With osmotic diuretics

Question 34

What is treatment for a subdural and epidural hematoma

Answer 34

Surgery

Question 35

For a hematoma and intracranial hemmorhage what must the nurse monitor for

Answer 35

Severe headache
Rapid decline in level of consciousness
Worsening neurological function and herniation and changes in ICP

Question 36

What is neurogenic pulmonary edema

Answer 36

A life threatening emergency. Immediate aggressive treatment is used. Survival is rare.
Findings mimic acute pulmonary edema without cardiac involvement

Question 37

What is cerebral salt washing ( CSW)

Answer 37

Is causes decreased serum osmolality and hyponatremia. CSW is the primary cause of hyponatremia following neurosurgery. CSW causes hypovolemia, compared with increased extracellular fluid in clients with SIADH.

Question 38

What is CSW caused by

Answer 38

It is caused by the effects of atrial natriuretic factor ( ANF) located in the hypothalamus. Increase ANF production decreases Na retention in the kidneys. ANF may also prevent renin and aldosterone release.

Question 39

What are nursing interventions for CSW

Answer 39

Monitor serum electrolytes and osmality daily
Document strict I&O
Weigh daily
Treat electrolyte and fluid imbalance as prescribed
Monitor for dehydration or fluid overload during treatment.