Head Injury Assessment Flashcards
1
Q
General
A
Rule out cervical injury/determine symptoms
Check LOC (Glasgow Coma Scale)
Ask “Did u black out?”
2
Q
Eye opening Response (Are you ok?):
A
4 - Purposeful and spontaneous
3 - to verbal command
2 - to painful stimuli
1 - no response
3
Q
Best Verbal Response (What happened?):
A
5 - oriented and converses 4 - disoriented and converses 3 - inappropriate words 2 - incomplete sounds 1 - no response
4
Q
Best Motor Response (Where does it hurt?):
A
6 - obeys verbal commands 5 - localizes pain 4 - withdrawls from pain 3 - decorticate (arms flexed) rigidity 2 - decerebrate (arms extended) rigidity 1 - no response
5
Q
Memory/Amnesia (Atleast 1)
A
What is your name? Do you know where you are? What day is it? What month? Remember 3 things (ask to recall in 10 min) ABCs backwards, count by 3s etc.
6
Q
Head
A
Signs of Skull Fracture -Battle's sign (behind ear bruise) -Raccoon Eyes Does your head hurt? Where? Is the headache moving?
7
Q
Eyes
A
Do you have blurred/double vision? Is it hard to focus? How many fingers am I holding up? What does the scoreboard/sign say? What does the scoreboard/sign say? Check for unequal pupils (internal bleeding) Check PEARL Check tracking & peripheral vision
8
Q
Face & Neck
A
Familiar smell (icy hot) Facial Expressions Facial Sensations (bi-lateral comparison) Stick out tounge (hypoglossal) Shoulder shrug (accessory nerve #5)
9
Q
Coordination & Balance
A
Dizzy or nauseous Is there ringing in ears (tinitis)? Romberg's sign (close eyes>sway) -modified = arms out, head back Stork stand (one legs, hands on hips, lean backwards) -Rub fingers together (adds difficulty)
10
Q
Cranial Nerves
A
#1. Olfactory (smell>bengay) #2. Optic (fingers/scoreboard) #3. Oculomotor (PEARL-finger up & in) #4. Trochlear (Finger down & out) #5. Trigeminal (touch face & bite) #6. Abducens (peripheral vision) #7. Facial (smile, wrinkle forehead) #8. Vestibulocochlear/Acoustic (Rhomberg) #9. Glossopharyngeal (Swallow, gag, taste) #10. Vagus (talking/breathing) #11. Accessory (resist shoulder shrug) #12. Hypoglossal (stick out tounge)
11
Q
When to refer (know 5)
A
Signs of skull fx Rapid LOC Abnormal breathing patterns Slowing heart rate Increasing BP Prolonged mental confusion Prolonged amnesia Increasing headache Unequal or fixed pupils Uncoordinated/involuntary eye movements Positive test for any cranial nerves that doesn't improve in few hrs
12
Q
Head Injury Instruction Sheet includes:
A
Periodic reevaluation of symptoms
Instructions if symptoms worsen
Emergency numbers - hospital, AT staff, physician
