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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
How do you know if your ICP is up?
CT scan MRI EEG Cerebral angiography NO lumbar puncture
26
ventriculostomy
Catheter inserted into lateral ventricle Coupled with an external transducer
27
Manifestations of Increased Intracranial Pressure
- 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
cushings triad
a late finding characterized by severe - hypertension with a widening pulse pressure (systolic – diastolic) - bradycardia - apnea.
29
#1's sign of elevated icp
- Change in level of consciousness - Change in vital signs - Cushing’s triad - Ocular signs (pupils abnormal, unequal, fixed, no movement)
30
ocular sign ICP
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
s/s of high icp
Headache - Often continuous - Worse in the morning Vomiting - Not preceded by nausea - Projectile
32
Herniation
- 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
Collaborative Care: Increased ICP
- Treat underlying cause. - Adequate oxygenation +PaO2 > 100 mm Hg +PaCO2 35-45 mm Hg - Intubation - Mechanical ventilation - Surgery
34
Treating Elevated ICP: Medications
mannitol hypertonic saline corticosteroids
35
mannitol
Plasma expansion Osmotic effect: pull extracellular into cells
36
Hypertonic saline
- Moves water out of cells and into blood. - Monitor BP and serum sodium levels.
37
Corticosteroids
Edema surrounding tumors, brain abscesses.
38
pain and anxiety management
- Opioids -Propofol (Diprivan) - Dexmedetomidine (Precedex) - Neuromuscular blocking agents - Benzodiazepines
39
patient positoning
- 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
airway management
- 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
fluids high icp
- 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
craniotomy
Opening into skull by removal of bone flap and dura. - Remove lesion/tumor - Drain blood - Relieve elevated ICP
43
burr hole
Opening into skull with a drill. Remove localized fluid and blood beneath top layer dura.

Med Surg 2 (35 decks)

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