Ch 14 Head Injury Flashcards
What are head injuries classified as
Open or closed… They can be mild, moderate, or severe depending on the Glasgow coma scale
What is a open head injury
Penetrating trauma, the skull integrity is compromised
Open head injuries pose a high risk for what
Infection
What are skull fractures often accompanied by
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.
What may head injuries be associated with
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
What should always be suspected when a head injury occurs
A cervical spine injury must be ruled out prior to removing any devices used to stabilize the cervical spine.
What are manifestations of increased intracranial pressure
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
What diagnostic is used to determine a cervical spine injury
Cervical spine films
What is considered the golden window for head injuries
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
What is the brain dependent on
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
What provides the earliest indication of neurological deterioration
Glasgow coma scale
What are 4 methods used to monitor ICP
- A thin tube inserted into the lateral ventricle ( intraventricular)
- Use a bolt or screw placed in the subarachnoid area ( subarachnoid)
- Place a sensor in the epidural space ( epidural)
- Place a fiber optic transducer tipped catheter into the subdural or subarachnoid space, ventricle or brain tissue.
What is the expected reference range for ICP
10-15 mm Hg
ICP may be increased by what
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)
What are actions that can decrease ICP
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
What is the last sense affected by a head injury
Hearing
What can secondary brain injury result from
Hypotension, hypoxia, hyperglycemia, hypoglycemia, acidosis, hypercapnia….. MONITOR VITAL SIGNS, BLOOD GLUCOSE, O2 SATURATION, AND ABGs.
What is mannitol
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.
Pentobarbital is used for what
Is used to induce a barbiturate coma to decrease cerebral metabolic demands
When Is pentobarbital initiated
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
What is a barbiturate coma and what is it used for
A barbiturate coma is a treatment of last resort and aims to decrease elevated ICP by inducing vasoconstriction and decreasing cerebral metabolic demands
What are nursing considerations for pentobarbital
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
What is phenytoin
Dilantin
Is used prophylactically to prevent or treat seizures
Opioid use coupled with hypotension may cause what
Increased ICP
What is a craniotomy
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.
Treatment of intracranial hemmorhages involves what
Surgical evacuation
For supratentorial surgery how MUST the HOB be maintained
At least 30 degrees with body positioning to prevent increased ICP
For a infratentorial craniotomy, how should the HOB be placed
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
What are nursing actions for the mechanically ventilated following a craniotomy
Hyperventilate for 24-48 hours as prescribed to maintain PaCo2 around 35 mm Hg
What are complications of a craniotomy
Brain herniation
What is a brain herniation
The downward shift of brain tissue due to cerebral edema. This can result from brain tissue moving downward through the foramen magnum.
What are clinical findings of a brain herniation
Fixed dilated pupils Deteriorating level of consciousness Cheyne stokes respirations Hemodynamics instability Abnormal posturing
A intracranial hemmorhage is treated how
With osmotic diuretics
What is treatment for a subdural and epidural hematoma
Surgery
For a hematoma and intracranial hemmorhage what must the nurse monitor for
Severe headache
Rapid decline in level of consciousness
Worsening neurological function and herniation and changes in ICP
What is neurogenic pulmonary edema
A life threatening emergency. Immediate aggressive treatment is used. Survival is rare.
Findings mimic acute pulmonary edema without cardiac involvement
What is cerebral salt washing ( CSW)
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.
What is CSW caused by
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.
What are nursing interventions for CSW
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.
