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Med Surg 2 > head injuries > Flashcards

head injuries Flashcards

1
Q

open head injury

A

the integrity of the skull is compromised by either a penetrating object or blunt force trauma.

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2
Q

closed head injury

A

occurs from blunt trauma

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3
Q

head injuries classified as

A

mild, moderate, or severe, depending upon Glasgow Coma Scale ratings and the length of time the client was unconscious.

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4
Q

concussion

A

occurs after head trauma that result in a change in the client’s neurological function and usually resolves within 72 hr.

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5
Q

post concussion syndorme

A

includes persistence of cognitive and physical manifestations for an unknown period of time.

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6
Q

contusion

A

brain is bruised and the client has a period of unconsciousness associated with stupor and or confusion.

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7
Q

diffuse axonal injury

A

widespread injury to the brain that results in coma and is seen in severe head trauma.

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8
Q

head injuries clinical findings

A
  • Presence of alcohol or illicit drugs at time of injury.
  • Amnesia (loss of memory) before or after the injury.
  • Loss of consciousness: Length of time the client is unconscious is significant.
  • CSF leakage
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9
Q

cfk leakage from nose

A

can indicate a basilar skull fracture (“halo” sign: yellow stain surrounded by blood on a paper towel; fluid tests positive for glucose).

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10
Q

intracranial hemorrhage

A
  • can occur in the epidural, subdural, or intracerebral space.
  • It is a collection of blood following head trauma.
  • There can be a delay of weeks to months in presenting manifestations for a subacute or chronic subdural hematoma.
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11
Q

skull fractures: what should the nurse be alert for

A
  • can occur following forceful head injury.
  • The nurse should be alert for drainage from the ears or eyes (cerebral spinal fluid [CSF]).
  • A cervical spine injury must be ruled out prior to removing any devices used to stabilize the cervical spine.
  • Occur frequently with head trauma.
  • Location determines clinical manifestations.
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12
Q

epidural hematoma

A
  • Bleeding between the dura and skull.
  • Neurologic Emergency
  • Associated with a fracture crossing a major artery.
  • Needs Rapid Surgery bc artery bleeding
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13
Q

Subdural Hematoma

A
  • Bleeding between dura and arachnoid layer of meninges.
  • Venous bleed, slow to develop. (can take up to 2 days)
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14
Q

basilar skull fractures

A
  • Linear fx at base of skull
  • Battles Sign (Raccoon eyes)
  • Tear in the dura and CSF leakage from ear and nose.
  • Test drainage for glucose
  • DO NOT INTRODUCE NGTUBE IF BASILAR FX IS SUSPECTED!!!
  • Major complication is infection
  • Meningitis
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15
Q

Decerebrate posturing

A
  • Arms are stiffly extended, adducted, and hyperpronated. There is also hyperextension of the legs with plantar flexion of the feet.
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16
Q

Decorticate posturing (flexor)

A

internal rotation and adduction of the arms with flexion of the elbows, wrists, and fingers.

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17
Q

family care

A
  • Support of the family following head injury is of great importance.
  • The Brain Injury Association of America provides families and clients with information needed to cope with this potentially devastating injury.
  • The family can face difficult decisions following head injury.
  • If brain death has occurred, the family needs support when deciding whether to donate organ
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18
Q

care of a head injury

A

Respiratory status (the priority assessment):
- The brain is dependent upon oxygen to maintain function and has little reserve available if oxygen is deprived.

  • Untreated hypoxia leads to brain injury or death if the brain has been denied adequate oxygenation for 3 to 5 min.
  • Changes in level of consciousness, using the Glasgow Coma Scale (GCS), provide the earliest indication of neurological deterioration.
19
Q

cranial nerve function

A

Eye blink response, gag reflex, tongue and shoulder movement

20
Q

assess eyes for

A

pupils for size, equality, and reaction to light: Pupils that are equal, round, and react to light and accommodation (PERRLA) are a normal finding.

21
Q

factors that influnce intracranial pressure

A
  • Arterial pressure
  • Intraabdominal and intrathoracic pressure (venous congestion)
  • Posture
  • Temperature
  • Blood gases (CO2 levels)
22
Q

normal icp

A

5 to 15 mm Hg
Elevated if >20 mm Hg sustained

23
Q

normal compensation

A
  • Changes in CSF volume
  • Changes in intracranial blood volume
  • Changes in tissue brain volume
24
Q

Brain’s ability to compensate is limited If

A

volume increase continues, ICP rises → decompensation

25
Q

How do you know if your ICP is up?

A

CT scan
MRI
EEG
Cerebral angiography
NO lumbar puncture

26
Q

ventriculostomy

A

Catheter inserted into lateral ventricle
Coupled with an external transducer

27
Q

Manifestations of Increased Intracranial Pressure

A
  • Severe headache, nausea, vomiting
  • -Deteriorating level of consciousness, restlessness, irritability
  • Dilated or pinpoint nonreactive pupils
  • Cranial nerve dysfunction
  • Alteration in breathing pattern (Cheyne-Stokes respirations, central neurogenic hyperventilation, apnea)
  • Deterioration in motor function, abnormal posturing (decerebrate, decorticate, flaccidity)
    -Cushing’s triad
    Seizures
28
Q

cushings triad

A

a late finding characterized by severe
- hypertension with a widening pulse pressure (systolic – diastolic)
- bradycardia
- apnea.

29
Q

1’s sign of elevated icp

A
  • Change in level of consciousness
  • Change in vital signs
  • Cushing’s triad
  • Ocular signs (pupils abnormal, unequal, fixed, no movement)
30
Q

ocular sign ICP

A

Compression of oculomotor nerve
- Unequal pupil dilation (BAD)
- Sluggish or no response to light
- Inability to move eye upward
- Eyelid ptosis: eyelid droop down

31
Q

s/s of high icp

A

Headache
- Often continuous
- Worse in the morning

Vomiting
- Not preceded by nausea
- Projectile

32
Q

Herniation

A
  • Increased compression of brainstem and cranial nerves.
  • Forces Cerebellum and brainstem down.
  • If not resolved, respiratory arrest will occur.
  • bc of all pressure pushing on brain stem
33
Q

Collaborative Care: Increased ICP

A
  • Treat underlying cause.
  • Adequate oxygenation
    +PaO2 > 100 mm Hg
    +PaCO2 35-45 mm Hg
  • Intubation
  • Mechanical ventilation
  • Surgery
34
Q

Treating Elevated ICP: Medications

A

mannitol
hypertonic saline
corticosteroids

35
Q

mannitol

A

Plasma expansion
Osmotic effect: pull extracellular into cells

36
Q

Hypertonic saline

A
  • Moves water out of cells and into blood.
  • Monitor BP and serum sodium levels.
37
Q

Corticosteroids

A

Edema surrounding tumors, brain abscesses.

38
Q

pain and anxiety management

A
  • Opioids
    -Propofol (Diprivan)
  • Dexmedetomidine (Precedex)
  • Neuromuscular blocking agents
  • Benzodiazepines
39
Q

patient positoning

A
  • Elevate head at least 30 to reduce ICP and to promote venous drainage.
  • Avoid extreme flexion, extension, or rotation of the head, and maintain the body in a midline neutral position.
  • Maintain cervical spine stability until cleared by an x‑ray.
  • Implement measures to prevent complications of immobility (turn every 2 hr, footboard, and splints).
  • Specialty beds can be used.
40
Q

airway management

A
  • Maintain a patent airway.
  • Provide mechanical ventilation as indicated.
  • Administer oxygen as indicated to maintain PaO2
  • The client can be hyperventilated on mechanical ventilation to decrease ICP.
  • Brief periods of hyperventilation for the intubated client can be used after the first 24 hr following injury to help lower ICP.
  • Maintain safety and seizure precautions (side rails up, padded side rails, call light within the client’s reach).
41
Q

fluids high icp

A
  • Monitor fluid and electrolyte values and osmolality to detect changes in sodium regulation, onset of diabetes insipidus, or severe hypovolemia.
  • Provide adequate fluids to maintain cerebral perfusion and to minimize cerebral edema.
  • When a large amount of IV fluids are prescribed, monitor for excess fluid volume which could increase ICP.
  • The client should receive stool softeners and avoid the Valsalva maneuver
42
Q

craniotomy

A

Opening into skull by removal of bone flap and dura.
- Remove lesion/tumor
- Drain blood
- Relieve elevated ICP

43
Q

burr hole

A

Opening into skull with a drill.
Remove localized fluid and blood beneath top layer dura.

Med Surg 2 (35 decks)

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