Ch. 56 Head Injury

Question 1

Define head injury

Answer 1

Any trauma to the skull, scalp, brain

Traumatic brain injury TBI- (serious HI)

High incidence 2% of Americans live with HI

Question 2

What are the causes for head injury? And are male or female more likely to sustain a HI?

Answer 2

1. Motor vehicle collisions
2. Falls
3. Firearm-related injuries
4. Assaults
5. Sports-related injuries
6. Recreational accidents
7. War-related injuries

Males

Question 3

Head injury outcome

And three points in time after injury

Answer 3

High potential for poor outcome.
Death occur at three points in time after injury
1. Immediately after the injury (majority of deaths) either from direct head trauma or from massive hemorrhage and shock.
2. within two hours after the injury (caused by progressive worsening of the head trauma or internal bleeding.
3. 3weeks after the injury (result from multisystem failure)

Question 4

Nursing interventions within a few hours of the trauma

Answer 4

That’s occurring within a few hours of the trauma are caused by progressive worsening of the head injury or internal bleeding. Immediately recognizing changes in your logic status in rapid surgical intervention or critical in the prevention of deaths.

Question 5

Nursing interventions 3 weeks after injury

Answer 5

Expert nursing care in the weeks following the injury is crucial in decreasing the mortality risk and in optimizing patient outcomes.

Question 6

Case Study: K. D. Is a 33-year-old woman, is brought by paramedics to emergency department following a motor vehicle collision. She has a laceration to her for head and bruises from her seatbelt.

What type of injury did K.D. incur?

Answer 6

Closed head injury (traumatic brain injury) secondary to trauma during motor vehicle crash.

Question 7

She is stuporous and does not answer questions. What is the most likely cause of her change in level of consciousness?

Answer 7

Closed head injury TBI, secondary trauma during motor vehicle crash.

Question 8

Types of head injuries and major complications of scalp lacerations:

Answer 8

Scalp lacerations
1. External head trauma

2. Scalp is highly vascular therefore profuse bleeding. Because the scalp contains many blood vessels with poor constructive abilities, most scalp lacerations are associated with profuse bleeding. Even relatively small wounds complete significantly. The major complications associated with scalp lacerations are 
3. Major complications—blood loss and infection.

Question 9

Types of head injuries

Hint: SF

Answer 9

Skull fractures frequently occur with head trauma

Question 10

Skull fractures—3 types

Linear or depressed

Answer 10

Linear fracture occurs when there is a break. It is associated With low velocity injuries. A depressed skull fracture is an inward indentation of school and is associated with a powerful blow.

Question 11

Skull fractures —3 types

Simple, comminuted, or compound

Answer 11

A simple linear or depressed skull fracture is without fragmentation or communicating lacerations. It is caused by low to moderate impact.

A comminuted fracture occurs when there are multiple linear fractures with fragmentation of bone into many pieces. It is associated with direct, high momentum impact. An example of a compound fracture is a depressed skull fracture and scalp laceration with communicating pathway to intracranial cavity. This is associated with severe head injury.

Question 12

Skull fractures—3 types

Closed or open

Answer 12

Fractures may be closed (skin is not open) or open, depending on the presence of a scalp laceration or extension of the fracture into the air sinuses or dura.

Question 13

Skull Fractures location and nursing interventions

Answer 13

Determines manifestations

Apply pressure

Question 14

Skull Fracture Complications hint: 3

Answer 14

Infections (intracranial)

Hematoma- collection of blood outside of a blood vessel (major bruising)

Tissue damage- meningeal and brain tissue damage
Brain coming out of skull is possible

Question 15

What else is important to note in cases where a basal skull fracture is suspected?

Answer 15

A nasogastric or oral tube should be inserted under flouroscopy.

Question 16

Signs of Basilar Skull Fracture

Manifestations

Answer 16

Periorbital Edema and ecchymosis “Racoon Eyes”

Battle signs is bruising around the ear

Leakage of CSF from the nose is called rhinorrhea

Otorrhea- leaking from the ear

When you collect the fluid on a gauze pad you may see a Halo sign, the red blood Accumulate in the middle and there’s a little yellow surrounding ring of CSF

Question 17

What are the risk factors for Head Injury?

Answer 17

The most common causes of head injury or falls and motor vehicle accidents. Other causes of head injury include firearms, assault, sports related trauma, recreational injuries, and war related injuries. Men are twice as likely lead to sustain a TBI as women.

Question 18

What are the prevention for head injury?

Answer 18

Always wear car seatbelts in motor vehicles.
Do not drive after using drugs or alcohol.
Do not text and drive or drive distracted.
Wear helmets while bicycling skating skateboarding skiing and things contact sports. Athletes should follow safe plan techniques and the rules of the game.
Assess the home safety and implement any corrective measures needed.
Older adults should continue to exercise regularly to improve strength and balance. Follow workplace safety precautions, including wearing helmet and protective gear.

Question 19

During admission of a patient with a severe head injury to the ED, the nurse places the highest priority on assessment for?

Answer 19

Patency of airway

Question 20

Assessment of the patient.

So one of the things that important when you’re an emergency room nurse for a head injury is what?

Answer 20

Getting a full history from paramedics when bringing patient into ER. Ask Questions like were they wearing a seatbelt?
Was the patient involved in a high velocity collision due to seatbelt injury?
As an ER nurse we want to assess for internal injuries.

Question 21

What else would we want to assess for if a patient is being brought to the emergency room after a vehicle accident?

Answer 21

Whether there was a fracture of the windshield. If that was broken during the accident then that means that the patient’s head flew forward and backward In such a force that it actually cracked windshield.

Question 22

Statistically speaking if a patient has a passenger that has died what does this mean?

Answer 22

It means that the patient is at a higher risk of a serious injury

Question 23

Check CSF fluid for? (In rhinorrhea)

Answer 23

Check the discharge for glucose

If it is sweet then it’s coming from the brain. Pt is leaking CSF

Question 24

What to look out for if patient suffers a basilar skull fracture which means a severe back of the head injury where the brain or CSF can be exposed?

Answer 24

Pt. May acquire an infection

Question 25

What are the types of head injuries? (5)

Answer 25

1. Diffuse (generalized) that is where damage cannot be localized to 1 particular area
2. Focal (localized) these are a contusion or hematoma That can be localized to one specific area.
3. Brain injury can be classified as minor of and that would be a Glasgow coma scale of 13 to 15
4. Or moderate and that would be 9 to 12 on the Glasgow coma scale
5. If a patient has a Glasgow coma scale of 3-8 which is severe that means that they’re in pretty serious shape and their chance of overcoming this is very very slim.

Question 26

Diffuse injury is what? And what symptoms would you see?

Answer 26

A concussion
The patient may have a brief description and their level of consciousness

They may have retrograde amnesia (Inability to recall events surrounding the accident)

They will complain of a headache and

most of the time this Is going to be a short duration

May result in post concussion syndrome (Their mentation is affected may take longer to come up with their thoughts, to understand concepts) Possible slight personality changes.

Question 27

Focal injury can occur through (4)

Answer 27

lacerations
contusions
hematomas and
cranial nerve injury’s

Question 28

Post concussion syndrome and symptoms

It occurs 2 from 2 months.

Answer 28

The patient will present with a persistent headache,
lethargy, (tired)
personality and behavior changes,
short attention span, decreased short-term memory, and
changes in intellectual ability and thinking

Question 29

Diffuse axonal injury and symptoms

Answer 29

Widespread accidental damage, 
decreased level of consciousness, 
increased ICP intracranial pressure, 
decortication, 
decerebration, 
global cerebral edema

Question 30

This is going to be how you as an RN doing your assessment are going to be able to identify patients who have increasing or severe intercranial pressure (ICP)
CUSHING’s Triad is?

Answer 30

For a decrease in respiratory rate your regular rest area and you’re going to look at a widening pulse pressure mean a large gap between the systolic and the diastolic numbers

For example: 149/68
RR: 12 irregular respirations caused by impaired brain stem fx
HR: 55 bradycardia

Question 31

Many times in the ICU you’re going to be getting a patient in order to calculate that cerebral perfusion pressure CPP. Why do we do this?

Answer 31

To adjust our medications

In order to provide just the right amount of pressure in the patient’s body To allow perfusion of the brain with blood

Question 32

And unconscious patient with a traumatic head injury has a blood pressure of 170/80 and an intracranial pressure (ICP) piece of 30. The nurse will calculate the cerebral perfusion pressure CPP as what?

Answer 32

First you are going to find a MAP (Mean arterial pressure)
And that is comprised of the diastolic BP x2 + The systolic blood pressure times 1 and divide by 3

80x2= 160+ 170=320/3=110
110-30 (ICP) = 80

Question 33

What measures the patients intercranial brain pressure?

Answer 33

A catheter that is inserted into the brain

Question 34

What is our gold standard study? And other diagnostic tests for HI.

Answer 34

Cat scan
Because that’s gonna tell us right away if there’s bleeding in the brain we’re gonna be able to see automatically white areas on the brain which are going to signify bleeding

Other test could be an MRI test NFL potential study which measures the brain activity we can get transcranial Doppler studies cervical spine x-ray why would we want to get those most patients with sustained head entry that severe enough are going to have add an impact on the cervical spine because of how our spine is holding our head upright so many times plus I had entry we always assume and trauma patients in the ER that they have sustained cervical injury so this is why your patients come in cervical spine precautions and we do not allow them to bend their neck until we’ve done sufficient studies that show there’s no fractures there were also going to want to do the Glasgow coma scale 
14-13 mild brain injury
12-9 moderate brain injury
8 or less a severe brain injury 
You can never get a 2 on GCS

Question 35

What is the prognosis for scores eight and under? (Glascow)

Answer 35

This signifies a severe brain injury.

Not good, Patient is probably not going to make it

Question 36

Contusion

Answer 36

Bruising of brain tissue
Association with closed head injury
Can cause hemorrhage, infarction, necrosis, edema

Question 37

If patient is on Coumadin, warfarin

Answer 37

Give Vit K (have antidote handy)

Question 38

Coup-countrecoup injury

Answer 38

Swing forward, hit steering wheel head flies backward

Question 39

Where are different areas brain can bleed?

Answer 39

Subdural, epidural

Question 40

Complications of epidural hematoma?

Answer 40

Bleeding between the dura and the inner surface of the skull

Neurologic emergency

Venous origin slow

Arterial origin rapid

Question 41

Epidural hematoma complications

Answer 41

Initial period of unconsciousness

Brief lucid

Question 42

Treatment for epidural hematoma?

Answer 42

Evacuation

Burr hole into the skull to alleviate inner cranial pressure

Question 43

Glasgow coma scale eye opening response

Answer 43

Spontaneously 4
To speech 3
To pain 2
No response 1

Question 44

GC Scale best verbal response

Answer 44

Oriented to time, place, and person

Question 45

GC Scale best motor response

Answer 45

Obeys Commands 6
Moves to localized pain 5
Flexion withdrawal from pain 4
Abnormal flexion (decorticate) 3
Abnormal extension (decerebrate) 2
No response 1

Question 46

How would you assess a patient using GCS Day 1?

Answer 46

2 Only opens eyes to sternal rub
2 Moans in comprehensible words
5 Pushes your hand out of the way with sternal rub
Total Score = 9

Question 47

Another example of GCS assessment

Answer 47

3 Eyes shut but opens eyes when you say “good morning” as you enter the room
4 Knows she is in the hospital, but cannot recall the date
6 Able to scoot herself up in bed
Score = 13

Question 48

What is a Subdural Hematoma?

What does it result from?

What is the source of most subdural hematomas?

Hematoma venous vs. arterial, which one develops slower/faster?

Subdural hematomas may be?

Answer 48

A subdural hematoma occurs from bleeding between the dura mater and the arachnoid layer of the meninges.

A subdural hematoma usually results from injury to the brain tissue and its blood vessels.

The veins that drain from the surface of the brain into the sagittal sinus are the source of most subdural hematomas.

Because a subdural hematoma is usually venous in origin, the hematoma may be slower to develop.

However, a subdural hematoma may be caused by an arterial hemorrhage, in which case it develops more rapidly.

Subdural hematomas may be acute, subacute, or chronic.

Question 49

Complications of Acute Subdural Hematoma

Answer 49

Acute Subdural Hematoma
Within 24 to 48 hours of the injury
Symptoms related to increased ICP
↓ LOC, headache
*Ipsilateral pupil dilated and fixed if severe
Ipsilateral = same side of body as injury

Question 50

Subacute vs. Chronic

Answer 50

Chronic Subdural Hematoma
Weeks or months after injury 
More common in older adults
Presents as focal symptoms
↑ Risk for misdiagnosis
ETHOers

Question 51

A subacute subdural hematoma usually occurs within 2 to 14 days of the injury.

Answer 51

2 to 14 days of the injury.

After the initial bleeding, a subdural hematoma may appear to enlarge over time, as the breakdown products of the blood draw fluid into the subdural space.

Question 52

A chronic subdural hematoma develops over weeks or months after a seemingly minor head injury.

Answer 52

Chronic subdural hematomas are more common in older adults due to a potentially larger subdural space as a result of brain atrophy. With atrophy, the brain remains attached to the supportive structures, but tension is increased, and it is subject to tearing. The larger size of the subdural space also accounts for the presenting complaint to be focal symptoms, rather than the signs of increased ICP. Chronic alcoholics are also prone to cerebral atrophy and subsequent development of subdural hematoma due to an increased incidence of falls.

Question 53

Delay in diagnosis of a subdural hematoma in the older adult can be attributed to

Answer 53

symptoms that mimic other health problems in persons of this age group, such as somnolence, confusion, lethargy, and memory loss. The manifestations of a subdural hematoma are often misinterpreted as vascular disease (stroke, transient ischemic attack [TIA]) and dementia.

Question 54

Intracerebral Hematoma

Answer 54

Bleeding within the brain tissue
Usually within frontal and temporal lobes
Size and location of hematoma determine patient outcome.

Intracerebral hematoma occurs from bleeding within the brain tissue and occurs in approximately 16% of head injuries.
It usually occurs within the frontal and temporal lobes, possibly from the rupture of intracerebral vessels at the time of injury.
The size and location of the hematoma is a key determinant of the patient’s outcome.

Question 55

ICP (intercranial pressure)

Answer 55

ICP = amount of pressure in the brain and spinal fluid

Question 56

CPP (cerebral perfusion pressure)

Answer 56

CPP = amount of pressure required to get a sufficient enough amount of blood to the brain.
Normal = 60 – 100 mg/hg

Question 57

Why Care About CCP?

Answer 57

In the past decade more emphasis has been directed towards optimizing cerebral perfusion pressure (CPP) in patients who have suffered TBI. Injured brain may show signs of ischemia if CPP remains below 50 mmHg and raising the CPP above 60 mmHg may avoid cerebral oxygen desaturation.
Though CPP above 70 mmHg is influential in achieving an improved patient outcome, maintenance of CPP higher than 70 mmHg was associated with greater risk of acute respiratory distress syndrome (ARDS). The target CPP has been laid within 50-70 mmHg.

Note: cerebral blood flow will decrease when there is ICP.

Question 58

Cushing’s Triad = Severe ?

If a patient presents with this, what does this indicate?

Answer 58

Severe ICP ***Cushing’s triadis
Irregular, decreased respirations (caused by impaired brainstem function)
Bradycardia
Systolic hypertension (widening pulse pressure)

Question 59

What else will you see with Cushing’s triad and when does it usually occur?

Answer 59

Confusion!! Level of consciousness, these are the key signs you’ll see with a head injury.

Cheyne-Stokes type of breathing

Bradycardia- trying to decrease blood flow to the brain

SH w/widening pulse pressure

Older adults lose elasticity of arteries therefore more of a widening pressure, can even be a normal finding minus 2 other signs, as long as no head injury

Occurs during end of life.

Question 60

Calculating CCP An unconscious patient with a traumatic head injury has a blood pressure of 170/80 mm Hg, and an intracranial pressure (ICP) of 30 mm Hg. The nurse will calculate the cerebral perfusion pressure (CPP) as ____ mm Hg.

Answer 60

CPP = mean arterial pressure [MAP] - ICP).

MAP = DBP x 2 + SBP divided by 3 =

170+160 = 320 divided by 3 = 110 minus ICP of 30 = 80 mmHg this is your cerebral perfusion pressure.

Meds MIGHT be ordered to lower the BP

Question 61

Diagnostic Studies for head trauma

What is the gold standard?

Answer 61

*CT scan

Best diagnostic test to determine initial extent craniocerebral trauma

Question 62

Other diagnostics for head trauma

Answer 62

MRI, PET
Evoked potential studies (measure brain activity)
Transcranial Doppler studies
Cervical spine x-ray
Glasgow Coma Scale (GCS)
to catch an occult (hidden) type of injury.
MRI, PET, and evoked potential studies may also be used in the diagnosis and differentiation of head injuries.
An MRI scan is more sensitive than the CT scan in detecting small lesions.
Transcranial Doppler studies allow for the measurement of CBF velocity.
A cervical spine x-ray series, CT scan, or MRI of the spine may also be indicated since cervical spine trauma often occurs at the same time as a head injury.
In general, the diagnostic studies are similar to those used for a patient with increased ICP.

Question 63

Anytime there is massive trauma What do you want protect

Answer 63

the cervical spine! Otherwise patient can become paralyzed!

When a patient has massive head injury they can also have other types of injuries.
Goal: is to get patient out of cervical spine device. Assess for skin damage.
It is very important to put your patient in cervical spine precautions. Make sure to DOCUMENT TO SUPPORT EVERYTHING THAT YOU DO!!
Older adults are more susceptible to osteoporosis! Easier to break their bones.
Also, brain shrinks as you get older (just a tad) meaning more room between skull, etc…

Question 64

What is the Glascow Coma Scale?

Can you ever get a 2 on GCS?

What is the prognosis for scores 8 and under?

Answer 64

14-13—mild brain injury
12-9—moderate brain injury
8 or less—a severe brain injury

No

> 8 not very good survival prognosis

Question 65

Limitations of GCS (how can these factors influence score)

Glucose?
Oxygenation?
ETOH?
Drugs?
Psychological?  
Age?

Answer 65

Low glucose- lethargic
High glucose- yes, bc can mimic strokes!

Oxygenation- confusion, issues with perfusion

ETOH- cannot comprehend, slurred speech, unresponsive maybe even to the sternal rub, vomiting

Drugs- Affect all CNS function, sedation, hallucinations, altered perception, disorientation, not feeling pain

Psychological- delusion, depressed, inappropriate responses, if they were combative and given meds, may not be able to identify where the pain is

Age – lower immune system, decreased sensation, issues with mobility, slower response time, decreased senses

Ask patient, Tell me about the feeling in your pain?

Question 66

NURSING CARE
Admission vital signs for KD were 
blood pressure 128/68,
pulse 110,
respirations 26

Answer 66

Normal BP

High tachycardic

High RR

Question 67

Which shows ICP?  Cushing’s Triad?
Which set of vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
BP 134/90, pulse 120, resps 20
BP 118/78, pulse 108, resps 27
BP 128/100, pulse 100, resps 18
BP 190/50, pulse 52, resps 12

Answer 67

BP 190/50, pulse 52, resps 12

Widened BP

Bradycardia

Lower resp.

Question 68

Case Study

What would be the initial priority care for K.D. upon admission to the ED?

Answer 68

Airway and cervical spine

Question 69

Collaborative Care Emergency Treatment

Answer 69

**Patent airway (ensure)
**Stabilize cervical spine.
Oxygen via non-rebreather mask
Establish IV access
Intubate if GCS <8.
Control external bleeding with sterile pressure dressing.
Remove patient’s clothing.

Question 70

Collaborative Care

Emergency Treatment

Answer 70

Maintain patient warmth.
Ongoing monitoring
Anticipate possible intubation.
Assume neck injury.
Administer fluids cautiously.
Ongoing Monitoring of a patient with a head injury during the emergency phase should include the following:
Maintain patient warmth using blankets, warm IV fluids, overhead warming lights, warm humidified O2.
Ongoing monitoring of
vital signs, level of consciousness, O2 saturation, cardiac rhythm, Glasgow Coma Scale score, pupil size and reactivity.
Assess for rhinorrhea, otorrhea, scalp wounds.
Anticipate need for intubation if gag reflex is impaired or absent.
Assume neck injury with head injury.
Administer fluids cautiously to prevent fluid overload and increasing ICP.

Blood bleeds more when it’s cold. So keep your patient warm. Document given patients warm blankets.

Question 71

Collaborative CareTreatment principles
Prevent secondary injury
Timely diagnosis
Surgery if necessary (i.e., craniotomy or burr holes). 
Concussion and contusion
Observation and management of ICP

Answer 71

Principles in caring for patients with a head injury include
measures to prevent secondary injury by treating cerebral edema and managing increased ICP,
timely diagnosis and
surgery (if necessary).

For the patient with concussion and contusion, observation and management of increased ICP are the primary management strategies.

The treatment of skull fractures is usually conservative.
For depressed fractures and fractures with loose fragments, a craniotomy is necessary to elevate the depressed bone and remove the free fragments. If large amounts of bone are destroyed, the bone may be removed (craniectomy), and a cranioplasty will be needed at a later time.

In cases of large acute subdural and epidural hematomas, or those associated with significant neurologic impairment,
primary management strategies. the blood must be removed through surgical evacuation.

A craniotomy is generally performed to visualize and allow control of the bleeding vessels.
Burr-hole openings may be used in an extreme emergency for a more rapid decompression, followed by a craniotomy.
A drain may be placed postoperatively for several days to prevent reaccumulation of blood.
In cases where extreme swelling is expected (e.g., DAI, hemorrhage), a craniectomy may be performed where a piece of the skull is removed to reduce the pressure inside the cranial vault, thus reducing the risk of herniation.

CAT scans put out a lot of radiation!! Cautious how many times you are doing CAT scans.

Question 72

Nursing Assessment Subjective Data

Answer 72

Mechanism of Injury 
Alcohol/drug use; risk-taking behaviors
Headache
Mentation changes; impaired judgment
Aphasia, dysphasia
Fear, denial, anger, aggression, depression
* Anticoagulants

Question 73

Obtain the following important health information related to pertinent functional health patterns:

Answer 73

Health perception–health management: Use of alcohol or recreational drugs; risk-taking behaviors
Cognitive-perceptual: Headache, mood or behavioral change, mentation changes, aphasia, dysphasia, impaired judgment
Coping–stress tolerance: Fear, denial, anger, aggression, depression

Question 74

Case Study
K.D.’s past medical history is negative except for the births of two children.
Her family denies any drug or alcohol use.
She was not taking any anticoagulant medications.

What objective data will you assess K.D. for when she is admitted to the ICU after surgery?

Answer 74

Temperature, (infection)
blood pressure,
mental status

Question 75

Nursing Assessment

Objective Data

Answer 75

Altered mental status
Lacerations, contusions, abrasions
Hematoma
Battle’s sign (basilar) 
Periorbital edema and ecchymosis "Racoon's eyes"
Otorrhea
Exposed brain

Possible focused assessment findings include
General
Altered mental status
Integumentary
Lacerations, contusions, abrasions, hematoma, Battle’s sign, periorbital edema and ecchymosis, otorrhea, exposed brain matter

Question 76

Nursing Assessment

Objective Data

Answer 76

Rhinorrhea
Impaired gag reflex
Altered/irregular respirations
Cushing’s triad
Vomiting
Bowel and bladder incontinence

Question 77

Possible focused assessment findings include

Answer 77

Respiratory
Rhinorrhea, impaired gag reflex, inability to maintain a patent airway. Impending herniation: altered/irregular respiratory rate and pattern
Cardiovascular
Impending herniation: Cushing’s triad (systolic hypertension with widening pulse pressure, bradycardia with full and bounding pulse, irregular respirations)
Gastrointestinal
Vomiting, projectile vomiting, bowel incontinence
Urinary
Bladder incontinence

No Gag reflex Yes intubate patient!

Question 78

Nursing Assessment

Objective Data

Answer 78

Uninhibited sexual expression
Altered LOC
Seizures
Pupil dysfunction
Cranial nerve deficit(s)

Question 79

Possible focused assessment findings include

Answer 79

Reproductive
Uninhibited sexual expression
Neurologic
Altered level of consciousness, seizure activity, pupil dysfunction, cranial nerve deficit(s)
Musculoskeletal
Motor deficit/impairment, weakness, palmar drift, paralysis, spasticity, decorticate or decerebrate posturing, muscular rigidity/increased tone, flaccidity, ataxia

Possible Diagnostic Findings
Location and type of hematoma, edema, skull fracture, and/or foreign body on CT scan and/or MRI; abnormal EEG; positive toxicology screen or alcohol level, ↓ or ↑ blood glucose level; ↑ ICP

Dilated pupil is a late sign

Question 80

Nursing Assessment

Objective Data

Answer 80

Motor deficit
Palmar drift
Paralysis
Spasticity
Posturing
Rigidity or flaccidity
Ataxia Possible focused assessment findings include
Musculoskeletal
Motor deficit/impairment, weakness, palmar drift, paralysis, spasticity, decorticate or decerebrate posturing, muscular rigidity/increased tone, flaccidity, ataxia

Palmar drift one of the arms lowers

Posturing - decorticate or decerebrate

Ataxia- altered gait

Question 81

Nursing Assessment
Objective Data
Abnormal CT scan or MRI 
Abnormal EEG
Positive toxicology screen or alcohol level
↑ or ↓Blood glucose level
↑ ICP

Answer 81

Possible Diagnostic Findings
Location and type of hematoma, edema, skull fracture, and/or foreign body on CT scan and/or MRI; abnormal EEG; positive toxicology screen or alcohol level, ↓ or ↑ blood glucose level; ↑ ICP

Question 82

Diuretics and Head Trauma***A nurse is evaluating K.D. and she has anisocoria. What medication will the nurse anticipate giving for this patient with ICP? Why?

Answer 82

Anisocoria – one big, one small pupils or different shapes of the pupils

Give Mannitol to pull fluid out of the body, decrease inflammation, along with giving steroids, remember this in an inflammatory

Also given in spinal cord injury to decrease the pressure

Question 83

Nursing Planning
Overall Goals
Cerebral oxygenation & perfusion

Answer 83

Cerebral oxygenation & perfusion
Normothermic
Control pain and discomfort
Free of infection
Adequate nutrition
Maximal cognitive, motor, and sensory function

Question 84

The overall goals are that the patient with an acute head injury will

Answer 84

The overall goals are that the patient with an acute head injury will
maintain adequate cerebral oxygenation and perfusion;
remain normothermic;
achieve control of pain and discomfort;
be free from infection;
have adequate nutrition; and
attain maximal cognitive, motor, and sensory function.

Question 85

Nursing Implementation

Health Promotion

Answer 85

Prevent car and motorcycle accidents.
Wear safety helmets.
Use seat belts and child car seats.
Home safety to prevent falls

Question 86

Nursing Implementation
Health Promotion

One of the best ways to prevent head injuries is

Answer 86

One of the best ways to prevent head injuries is to prevent car and motorcycle collisions.
The use of helmets by cyclists has led to fewer TBIs.
The use of car seat belts and the use of child car seats are also associated with reduced TBI mortality rates.
Be active in campaigns that promote driving safety and speak to driver education classes regarding the dangers of unsafe driving and of driving after drinking alcohol and using drugs. The use of seat belts in cars and the use of helmets for riding on motorcycles are the most effective measures for increasing survival after crashes. The wearing of protective helmets by lumberjacks, construction workers, miners, horseback riders, bicycle riders, snowboarders, and skydivers is also recommended.
Additionally, individuals who are at risk for falls (e.g., older adults) should be evaluated for safety in the home, as falls are the second leading cause of head injuries

Question 87

Nursing Planning

Overall Goals

Answer 87

Cerebral oxygenation & perfusion
Normothermic
Control pain and discomfort
Free of infection
Adequate nutrition
Maximal cognitive, motor, and sensory function

Question 88

You invite K.D.’s family into her room once you have her settled in.

What would be important to explain to the family at this point?

Answer 88

Prognosis: be realistic! Never lie about patient getting better. Devastating news doctor delivers. This is the doctor’s job to give prognosis.

Use: the patient died.

Question 89

Nursing Implementation

Acute Intervention

Answer 89

Maintain cerebral perfusion.
Prevent secondary cerebral ischemia.
Monitor for changes in neurologic status.
Patient and family teaching
Management at the injury scene can have a significant impact on the outcome of the head injury.

Question 90

The general goal of nursing management of the head-injured patient is to maintain

Answer 90

cerebral oxygenation and perfusion and prevent secondary cerebral ischemia.

Question 91

Surveillance or monitoring for changes in neurologic status is critically important because

Answer 91

the patient’s condition may deteriorate rapidly, necessitating emergency surgery.

Question 92

Because of the close association between hemodynamic status and cerebral perfusion, be aware of any

Answer 92

coexisting injuries or conditions.

Question 93

Perform neurologic assessments at intervals based on the patient’s condition.

Answer 93

he GCS is useful in assessing the LOC . Indications of a deteriorating neurologic state, no matter how subtle, such as a decreasing LOC or decreasing motor strength, should be reported to the health care provider. Monitor the patient’s condition closely.

Question 94

Explain the need for frequent neurologic assessments to both the patient and caregiver. Behavioral manifestations associated with head injury can result in

Answer 94

a frightened, disoriented patient who is combative and resists help. Your approach should be calm and gentle. A family member may be available to stay with the patient and thus prevent increasing anxiety and fear. One of the most important needs for the caregiver and family members in the acute injury phase is information about the patient’s diagnosis, treatment plan, and rationale for the interventions.

Question 95

Nursing Implementation

Answer 95

Acute Intervention
*Major focus of nursing care relates to increased ICP.
Eye problems
Eye drops, compresses, patch
Hyperthermia
Goal 36°to 37° C 
Prevent shivering

Question 96

The major focus of nursing care for the brain-injured patient relates to

Answer 96

increased ICP. However, there may be problems that require specific nursing intervention.

Question 97

Eye problems may include

Answer 97

loss of the corneal reflex, periorbital ecchymosis and edema, and diplopia. Loss of the corneal reflex may necessitate administering lubricating eye drops or taping the eyes shut to prevent abrasion. Periorbital ecchymosis and edema decrease with time, but cold and, later, warm compresses provide comfort and hasten the process. Diplopia can be relieved by use of an eye patch. A consult with an ophthalmologist should be considered.

Question 98

Hyperthermia may occur from injury to or inflammation of

Remember prevent shivering bc that can cause……

Answer 98

the hypothalamus.
Elevations in body temperature can result in increased CBF, cerebral blood volume, and ICP. Increased metabolism secondary to hyperthermia increases metabolic waste, which in turn produces further cerebral vasodilation. Avoid hyperthermia with a goal of 36°to 37°C as the standard of care. Use interventions to reduce temperature in conjunction with sedation as necessary to prevent shivering.

…can cause ICP

Question 99

Nursing Implementation

***Acute Intervention

Answer 99

If CSF rhinorrhea or otorrhea occurs, inform the physician immediately.
The head of the bed may be raised to decrease the CSF pressure so that a tear can seal.
A loose collection pad may be placed under the nose or over the ear. Do not place a dressing in the nasal or ear cavities.
Instruct the patient not to sneeze or blow the nose. Nasogastric tubes should not be used, and nasotracheal suctioning should not be performed on these patients due to the high risk of meningitis.

Question 100

Nursing Implementation

***Acute Intervention

Answer 100

Measures for patients leaking CSF
Head of bed elevated
Loose collection pad 
No sneezing or blowing nose
***No NG tube 
No nasotracheal suctioning

Question 101

NGT with basilar skull fracture:Lesson: Recommend

Answer 101

oral gastric tube or NGT under fluoroscopy.

Question 102

Nursing Implementation

Answer 102

Acute Intervention
Measures for immobilized patients
Antiemetics
Analgesics
Antibiotics
Diuretics 
Pre-op preparation, if needed

Question 103

Nursing measures specific to the care of the immobilized patient

Answer 103

such as those related to bladder and bowel function, skin care, and infection, are also indicated.
Nausea and vomiting may be a problem and can be alleviated by antiemetic drugs. Headache can usually be controlled with acetaminophen or small doses of codeine.
If the patient’s condition deteriorates, intracranial surgery may be necessary. A burr-hole opening or craniotomy may be indicated, depending on the underlying injury that is causing the symptoms. The emergency nature of the surgery may hasten the usual preoperative preparation. Consult with the neurosurgeon to determine specific preoperative nursing measures.
The patient is often unconscious before surgery, making it necessary for a family member to sign the consent form for surgery. This is a difficult and frightening time for the patient’s caregiver and family and requires sensitive nursing management. The suddenness of the situation makes it especially difficult for the family to cope.

Question 104

Case Study
KD is hemodynamically stable, extubated, and breathing .
She opens her eyes spontaneously and follow commands.
She needs help with ADLs
She is confused and restless
She has altered gait

The family asks what the next step in her care will be and if she will ever return to her ‘original self.’

How will you respond?

Answer 104

Time will tell. Doctor can give prognosis. But as a nurse do not advise them.

Question 105

Nursing ImplementationAmbulatory and Home Care

Acute rehabilitation

Answer 105

Motor and sensory deficits
Communication issues
Memory and intellectual functioning
Nutrition
Bowel and bladder management

Question 106

Seizure disorders are seen in approximately

Answer 106

5% of patients with a nonpenetrating head injury. Seizures are most likely to develop during the first week after the head injury. Some patients may not develop a seizure disorder until years after the initial injury. Antiseizure drugs may be used prophylactically to manage posttraumatic seizure activity.

Question 107

The mental and emotional sequelae of brain trauma are often the most incapacitating problems. One of the consequences of TBI is that

Answer 107

the person may not realize that a brain injury has occurred. Many of the patients with head injuries who have been comatose for more than 6 hours undergo some personality change. They may suffer loss of concentration and memory and defective memory processing. Personal drive may decrease. Apathy may increase. Euphoria and mood swings, along with a seeming lack of awareness of the seriousness of the injury, may occur. The patient’s behavior may indicate a loss of social restraint, judgment, tact, and emotional control.

Question 108

Progressive recovery may continue for

Answer 108

6 months or more before a plateau is reached, and a prognosis for recovery can be made. Specific nursing management in the posttraumatic phase depends on specific residual deficits.

Question 109

In all cases, the family must be given special consideration. They need to understand

Answer 109

what is happening and be taught appropriate interaction patterns. Provide guidance and referrals for financial aid, child care, and other personal needs. Assist the family in involving the patient in family activities whenever possible. Help the patient and family develop and maintain hope. The family often has unrealistic expectations of the patient as the coma begins to recede. The family expects full return to pretrauma status. In reality, the patient usually experiences a reduced awareness and ability to interpret environmental stimuli. Prepare the family for the emergence of the patient from coma and explain that the process of awakening often takes several weeks. Arrange for social work and chaplain consultations for the family in addition to providing open-visitation and frequent status updates.

Question 110

When it is the time for discharge planning,

Answer 110

the caregiver, family, and patient may benefit from specific posthospitalization instructions to avoid family-patient friction. Special “no” policies that may be appropriately suggested by the neurosurgeon, neuropsychologist, and nurse include no drinking of alcoholic beverages, no driving, no use of firearms, no work with hazardous implements and machinery, and no unsupervised smoking. Family members, particularly spouses, go through role transition as the role changes from that of spouse to that of caregiver.

Question 111

Positioning Patients With Head Trauma The nurse is caring for a patient after a head injury. How should the nurse position the patient in bed?

A. Prone with the head turned to the right side
B. High-Fowlers position with the legs elevated
C. Supine position with the head on two pillows
D. Side-lying with the head elevated 30 degrees

Answer 111

Answer: D
Rationale: To prevent increased intracranial pressure, the nurse should maintain the patient in the head-up position (no more than 30 degrees). Head elevation over 30 degrees may decrease cerebral perfusion pressure. Extreme neck flexion (head on two pillows) and hip flexion (high-Fowlers position) should be avoided. Head should remain midline.

Always check the physician orders for head trauma and positioning.

You want to put the patient in a position that will promote drainage.

B. Is not correct bc this will actually cause more ICP!!

Question 112

***What is the first and primary red flag assessment that occurs in head trauma indicative of a problem?

Answer 112

Confusion and altered mental status

Question 113

What 3 medicines in the patient’s list are most important to report to the doctor?
Atorvastatin
Furosemide
Aspirin
Diphenhydramine
Metoprolol
Coumadin
Rivaroxaban

Answer 113

Aspirin
Coumadin (anticoagulant)
Rivaroxaban (anticoagulant)

Question 114

The nurse is admitting a patient with a basal skull fracture. The nurse notes Battle’s sign behind both ears. Which admission order should the nurse question as being potentially unsafe?

A. Keep head of bed elevated
B. Oral care q 2 hours
C. Insert foley catheter
D. Insert Ngt

Answer 114

The NG tube! Because NG tube can accidentally be inserted to the brain.

Question 115

The nurse is admitting a patient with a basal skull fracture. The nurse notes Battle’s sign behind both ears. Which admission order should the nurse question as being potentially unsafe?

A. Keep head of bed elevated
B. Oral care q 2 hours
C. Insert foley catheter
D. Insert Ngt

Answer 115

D.

The NG tube! Because NG tube can accidentally be inserted to the brain.

Question 116

List 5 key assessments for your head injured patient

Answer 116

Vital, BP looking for cushing’s triad, airway, gag reflex, anticoagulants (risk of bleeding), does pt. have hemophilia?

Question 117

List 5 ominous assessments for your head injured patient

Answer 117

How do you know patient is going down hill?

Change in Glasgow, cushing’s triad is key!!, posturing,
decerebr ate worst than decorticate

Question 118

List 5 nursing interventions for your head injured patient

Answer 118

Interventions – follow doctor’s orders, spinal precautions, lay them on the side to promote drainage

Question 119

What med can quickly help to reduce ICP?

Answer 119

Mannitol is a osmotic diuretic
given IV provides reduction of ICP and treatment of cerebral edema.

Do not give to patient if they have hypovolemia

Monitor: CNS for coma
CV: transient volume expansion