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Nursing Theory IV A- Cindy'S Class > Head Injury > Flashcards

Head Injury Flashcards

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1
Q

What is intracranial pressure?(ICP)

A

state of equilibrium and maintain a normal ICP of 10 to 20 mm Hg.
-pressure within the craniospinal compartment
- With disease or injury, ICP may increase
- ↑ ICP decreases cerebral perfusion, causes ischemia, cell death, and (further) edema
- Brain tissues may shift through the dura and result in herniation
- CO2 plays a role:
↓ CO2 = vasoconstriction
↑ CO2 = vasodilatation and ↑ ICP

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2
Q

How is LOC important when it comes to head injuries and increased ICP?

A
  • Level of responsiveness and consciousness is the most important indicator of the patient’s condition
  • LOC is a continuum from normal alertness and full cognition (consciousness) to coma
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3
Q

What is akinetic mutism?

A

unresponsiveness to the environment; the patient makes no movement or sound but sometimes opens eyes

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4
Q

What is persistent vegetative state?

A

patient is devoid of cognitive function but has sleep–wake cycles

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5
Q

What is locked-in syndrome?

A

patient is unable to move or respond except for eye movements owing to a lesion affecting the pons

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6
Q

What are early S&S of ICP?

A
  • changes is LOC
    -Restlessness, confusion, increasing drowsiness, increased respiratory effort, and purposeless movements
  • Pupillary changes
    -Weakness in one extremity or one side
  • headache
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7
Q

What are late S&S of ICP?

A

-Projectile vomiting
-Further deterioration of LOC; stupor to coma
- Hemiplegia, decortication, decerebration, or flaccidity
- Respiratory pattern alterations including Cheyne-Stokes breathing and arrest
- Loss of brain stem reflexes: pupil, gag, corneal, and swallowing

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8
Q

What do we do when increased intracranial pressure happens?

A
  • Detect the underlying cause of increased ICP
  • MRI, CT, MRA, CT angiography
  • Taking a careful history is important
  • Ensure adequate oxygenation
  • Drug therapy
  • Hyperventilation therapy
  • Nutritional therapy
  • maintenance of patent airway
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9
Q

How do we assess eye signs and motor function for increased ICP?

A

Eye: perrla (pupils, equal, round, reactive to light, and accommodation)
motor function: observe spontaneous movements, hand strength, response to painful stimuli , speech

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10
Q

What are interventions for increased ICP?

A
  • Avoid hip flexion, Valsalva maneuver, abdominal distention, or other stimuli that may increase ICP
  • HOB elevation 30 degrees
    -Frequent monitoring of respiratory status and lung sounds and measure to maintain a patent airway
  • Maintain a calm, quiet atmosphere and protect patient from stress
  • Use strict aseptic technique for management of ICP monitoring system
  • monitor fluid status
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11
Q

What is a head injury?

A

A broad classification that includes injury to the scalp, skull, or brain
-Head trauma includes an alteration in consciousness, no matter how brief.

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12
Q

What is the two types of a brain injury?

A
  1. closed brain injury (blunt trauma)
  2. open brain injury
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13
Q

What is a closed brain injury?

A

acceleration or deceleration injury occurs when the head accelerates then rapidly decelerates, damaging brain tissue

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14
Q

What is an open brain injury?

A

object penetrates the brain or trauma is so severe that the scalp and skull are opened

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15
Q

What is the three points in time after an injury where death can occur?

A
  1. primary injury: initial/immediate damage resulting from the traumatic event.
  2. within 2 hours after the injury
  3. secondary injury
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16
Q

What is secondary injury?

A
  • Damage evolves after the initial insult
  • 3 weeks after the injury
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17
Q

What is the cause and S&S of a secondary injury?

A
  • Caused by cerebral edema, ischemia, or chemical changes associated with the trauma
  • Includes a series of complications that lead to a poorer prognosis or even death

Symptoms: depend on the severity and location of injury, persistent, localized pain, stiff neck, nasal discharge, swelling, bruising, LOC

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18
Q

What is a scalp laceration?

A
  • The most minor type of head trauma
  • Scalp is highly vascular → profuse bleeding
    —> Because tend to bleed heavily; scalp wounds are also portals for infection
  • Major complication is infection.
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19
Q

What is a skull fracture?

A

fracture in the skull

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20
Q

What is the S&S of a skull fracture?

A
  • Usually have localized, persistent pain
  • Facial paralysis
  • Battle’s sign: ecchymosis behind the ear
  • Conjugate deviation of gaze
  • Rhinorrhea or otorrhea indicates that a fracture has traversed the dura.

halo sign: ring of csf leak around the blood stain from drainage

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21
Q

What are the 7 classified types of a skull fracture?

A
  1. linear
  2. depressed
  3. comminuted
  4. compound
  5. basilar
  6. closed (dura is not torn)
  7. open (dura is torn)
22
Q

What is a linear fracture? Care?

A

Greatest number, Single crack in skull. Simple, clean break
care: bedrest, close observation of behaviours of brain injury

23
Q

What is a depressed fracture?

A
  • Bone pressed inward into brain tissue to at least the thickness of the skull
  • Requires surgery to elevate bone and debride body fragments from underlying tissue
24
Q

What is a comminuted fracture?

A
  • Bone is fragmented into many pieces
  • Requires craniectomy of fragments
25
Q

What is a compound or perforated fracture?

A
  • Depressed fracture with added problems of hemorrhage from scalp lacerations and an entry for intracranial infections
  • Debris includes impact object, hair, dirt, and tissue
    –> Surgically removed to decrease risk of abscess
26
Q

What is a basal skull fracture?

A
  • Involves base of skull
  • Most often results from extension of linear fracture into base of skull
  • Majority involve temporal bone (hearing) and frontal lobe
  • Results in CSF leak through dural tear from nose or ear Will produce halo sign on bed linen
    -Fractures of the base of the skull frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva, battles sign, serious infection
  • does not need surgery if dura repairs on its own
27
Q

What is the medical management for a skull fracture?

A
  • Non-depressed skull fractures do not require surgical treatment but require close observation
  • Depressed skull fractures may be managed conservatively
  • Contaminated or deforming fractures require surgery
  • Antibiotic treatment and blood component therapy if indicated
28
Q

When is surgery necessary for a skull fracture?

A
  • If necessary: scalp is shaved and cleansed with copious amounts of saline to remove debris.
  • Fracture is exposed
  • Skull fragments are elevated and the area is debrided.
  • Immediate bone or artificial grafts
  • Repair can be delayed 3 to 6 months if there is significant edema.
29
Q

What is minor head trauma?

A
  1. concussion: A temporary loss of consciousness with no apparent structural damage, amnesia, headache
  2. post-concussion syndrome: persistent headache, lethargy, personality and behavioural changes. short term memory loss, changes in intellectual ability
  3. diffuse axonal injury: Widespread axonal damage following mild, moderate, or severe traumatic brain injury (TBI), decrease LOC; patient experiences immediate coma, increased ICP, Decortication, decerebration, Global cerebral edema
30
Q

What is major head trauma?

A
  • Includes cerebral contusions and lacerations
  • Both injuries represent severe trauma to the brain.
31
Q

What is a coup-countercoup injury?

A

coup: primary impact where brain strikes part of skull
contrecoup: secondary impact when brain strikes the skull in a second location

32
Q

What is an intracranial hemorrhage?

A
  • Hematomas that develop within the cranial vault are the most serious results of brain injury
  • A hematoma may be epidural, subdural, or intracerebral depending on the location
  • Interval between bleeding and appearance of symptoms may be minutes or weeks
  • Its main effects are frequently delayed until the hematoma is large enough to cause distortion, increased ICP, and herniation of the brain
33
Q

what are the three types of intracranial hemorrhage?

A
  1. subdural
  2. intracerebral
  3. epidural
34
Q

What is an epidural hematoma?

A
  • atrial bleed
    Blood collects in the epidural space between the skull and dura mater
35
Q

What are the signs of an epidural hematoma?

A
  • Initial period of unconsciousness
  • Brief lucid interval followed by decrease in LOC
  • Headache
  • Nausea, vomiting
  • Focal findings
  • positive babinski
  • pt will deteriorate quickly when the is no possible side signs of compression (deterioration of LOC, IICP, Positive babinski)
36
Q

What is the medical management for an epidural hematoma?

A
  • Extreme emergency!!!
  • Respiratory arrest may occur within minutes
  • Burr holes are made to remove the clots, and the bleeding point is controlled
37
Q

What is a subdural hematoma?

A
  • venous bleeding, slower to develop
  • Blood collects between the dura and the underlying brain (arachnoid)
  • Creates direct pressure on brain
  • Most common cause is trauma
  • May be associated with various bleeding tendencies ie. Rupture of an aneurysm
38
Q

What are the three types of subdural hematoma?

A
  1. acute
  2. subacute
  3. chronic
39
Q

What is an acute subdural hematoma?

A
  • (major head injury)-within 2 days
    -Signs within 24 to 48 hours of the injury
  • Similar signs and symptoms to brain tissue compression in increased ICP
  • Patient appears drowsy and confused.
  • Ipsilateral pupil dilates and becomes fixed.
40
Q

What is an subacute subdural hematoma?

A
  • Occurs within 2 to 14 days of the injury
  • After initial bleeding, subdural hematoma may appear to enlarge over time.
41
Q

What is an chronic subdural hematoma?

A
  • chronic (more than 2 weeks)
  • Develops over weeks or months after a seemingly minor head injury
  • Peak incidence in sixth and seventh decades of life
42
Q

What are the symptoms of a subdural hematoma?

A
  • Much slower to develop into a mass large enough to produce symptoms
  • Nuchal rigidity (neck stiffness)
  • Severe headache
  • Decreased LOC
  • Contralateral hemiparesis (stroke)
  • Dilated pupil
43
Q

What is the diagnostic studies for intracranial hemorrhage?

A
  • CT scan: Best diagnostic test to determine craniocerebral trauma
  • MRI
  • PET
  • Transcranial Doppler studies
  • Cervical spine x-ray
  • Glasgow Coma Scale (GCS)
    ** Bloody spinal fluid suggests brain laceration or contusion**
44
Q

What is the nursing management for an intracranial hemorrhage?

A
  • glasgow coma scale score
  • neuro status
  • presence of CSF leak
  • health promotion
  • monitor ICP, maintain body temperature and away
45
Q

What are some supportive measures for an intracranial hemorrhage?

A
  • Seizure precautions and prevention
  • NG to manage reduced gastric motility and prevent aspiration
  • Fluid and electrolyte maintenance
    –> Monitor blood and urine electrolytes, osmolality, and blood glucose, Monitor I&O and daily weights
  • Pain and anxiety management
  • Nutrition
    –> Implement measures to promote adequate nutrition
46
Q

What is decorticate posturing?

A

extension posturing (decerebrate rigidity)

47
Q

What is decerebrate posturing?

A

Abnormal flexion (decorticare rigidity)

48
Q

What is decerebrate posturing?

A

Abnormal flexion (decorticare rigidity)

49
Q

What is a contusion?

A
  • more severe injury with possible surface hemorrhage
  • Usually associated with closed head injury
  • Prognosis is dependent on amount of bleeding around the contusion site.
  • Symptoms and recovery depend on the amount of damage and associated cerebral edema
  • Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vital signs
  • Coup-contrecoup injury
49
Q

What is a laceration?

A
  • Involve actual tearing of the brain tissue
  • Often occur in association with depressed and open fractures and penetrating injuries
  • Intracerebral hemorrhage is generally associated with cerebral laceration.
  • Surgical repair of laceration is impossible.
  • Prognosis is poor with large intracerebral lacerations.
50
Q

What are some interventions to prevent further injury in patients with intracerebral hematoma?

A
  • Reduce environmental stimuli
  • Use adequate lighting to reduce visual hallucinations
  • Implement measures to minimize disruption of sleep–wake cycles
  • Provide skin care
  • Implement measures to prevent infection ie. Posey Mitt

Nursing Theory IV A- Cindy'S Class (17 decks)

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