Head Injury Flashcards
1
Q
Concussion
A
a traumatic injury to the brain that alters the way the brain functions
2
Q
Contusion
A
brushing of the cerebral tissue
3
Q
Laceration
A
tearing of the cerebral tissue
4
Q
Fracturs
A
Linera, depredes, comminuted, basilar, open, or growing
5
Q
Health Promotion: Head Injury
A
- wear helmet when skateboarding, riding a bicycle or motorcycle, skiing, playing football, and participating in any other sport that might lead to head injury
- wear seat belts when driving or riding in a car
- avoid dangerous activities (riding a bicycle at night without a light, diving faster than the speed limit or while under the influence of alcohol or controlled substance)
- never shake a baby
6
Q
Risk Factors: Head injury
A
- lack of supervision
- inappropriate./ absent safety practices
- improper use of safety devices (helmet, seat belts)
7
Q
Expected Findings: head Injury
A
- history of events leading up to the injury, including any reports of dizziness, headache, diplopia, and/or vomiting
- amnesia (loss of memory) before and after injury
- alcohol or ingestions of controlled subtances
8
Q
Physical Assessment: head injury
A
Loss of consciousness: the length of time the client is unconscious is significant MINOR INJURY - possible LOC - temporary period of confusion - vomiting - pallor - irritability - lethargy - drowsiness PROGRESSION OF INJURY - marked changes in vital signs - altered mental status - social neurologic deficits - increase in agitation SEVERE INJURY - INFANTS: increased ICP - bulging fontanel, separation of cranial sutures. irritability, restlessness, increased sleeping, high-pitched cry, poor feeding, setting-sun sign, distended scalp veins. -CHILDREN: - nausea, headache, forceful vomiting, blurred vision, increased sleeping, inability to follow commands, decline in school performance, seizures -LATE SIGNS: - alterations in pupillary response, posturing (flexion and extension), bradycardia, decreased motor response, decreased response to painful stimuli, Cheyne-Stkes respirations, optic disc swelling , decreased consciousness
9
Q
Flexion
A
severe dysfunction of the cerebral cortex
demonstrates the arms, wrist, elbows, and fingers flexed and bent inward onto the chest and the legs extended and rotated internally
10
Q
Extension
A
Severe dysfunction at the level of the midbrain
demonstrates a backward arching of the legs and arms, flexed wrists and fingers, extended neck, clenched jaw, and possible an arched back.
11
Q
Lab Tests
A
- ABG
- blood alcohol and toxicology screening
- CBC with diff
- liver function tests
12
Q
Diagnostic Tests
A
- cervical spine x rays to rule out cervical spine injury
- computerized tomography and or MRI of head/neck might be performed with and without contrast if indicated
Measurement of ICP:
- the expected reference range is 1-10mmHg
- provide support to family and client
- a level greater than 15mmHg requires further assessment
13
Q
RN Care (PCC)
A
- care is determined by the extent of the brain trauma
- ensure the spine is stabilized until a spinal cord injury is ruled out
- monitor vital signs, LOC, pupils, ICP, motor activity, sensory perception, and verbal responses at frequent intervals (GCS as indicated)
- maintain patent airway. Provide mechanical ventilation as indicated
- administer oxygen as indicated to maintain an oxygen saturation level greater than 95%
- use padded restraints for clients who have agitation to prevent injury
- assess fro clear fluid drainage from ears or nose (CSF) and report to provider
- assess for bleeding from the ear (indicated basal skull fracture) and report to provider
- implement actions that will decrease ICP
- keep the head midline with the HOB elevated to 30 degrees which will also promote venous drainage
- avoid extreme flexion extension, or rotation of the head and maintain in midline neutral position
- keep the clients body in alignment, avoid hip flexion/extension
- minimize oral suctioning. Nasal suctioning is contraindicated
- instruct the client to avoid coughing and blowing of the nose, because they increase ICP
- implement measures to prevent complications of immobility ( turn q2h, maintain footboard and splints)
- insert and maintain and indwelling catheter
- administer stool softener to prevent straining
- provide a calm, restful environment (limit visitors, minimize noise)
- use energy- conserving measures, such as alternating activities with rest periods and cluster nursing care
- implement seizure precautions
- monitor fluid and electrolyte values and osmolarity to detect changes in sodium regulation, the onset of diabetes insidious, or sever hypovolemia
- provide adequate fluids to maintain cerebral perfusion. When large amounts of IV fluids are prescribed, monitor the client for excess fluid volume, which might increase ICP
- maintain the clients safety
- provide nutritional support (TPN or enteral nutrition)
- maintain ongoing communication with the client and family
- instruct the family on effective ways to communicate with the child (touching, cuddling, talking, assisting with care)
14
Q
Medications
A
Mannitol: osmotic diuretic used to treat cerebral edema
Anitepileptics: used to prevent or treat seizures that might occur
Antibiotics: in cases of CSF leakage, lacerations, or penetrating injuries
Analgesics (Acetaminophen): used for headache/pain management
15
Q
Therapeutic Procedures
A
- trainsfontanel percutaneous aspiration
- subdural drains
- placement of burr hole
- craniotomy: Involves removal of part of the skull. The bone is replaced once the edema has resolved
