Head Trauma/Spinal Cord Injury Flashcards
history for head injury includes
how was the pt. injured - ask family
loss of consciousness?
knowing how the head injury occurred allows you to know
what to look for - whether you should call someone emergently
what is the most important assessment in Head injuries
LOC - awake then sleep - not okay
what type of pt. get head traumas
elderly - falls
young men - risky behaviors (trauma)
children - shaken baby - bike accidents(helmet wearing)
motorcycle accidents
what will complicate your head injury assessment
alcohol, drugs, low glucose, CO2, O2, anticoagulants
one of the 1st things you do w/trauma pt.
check blood sugar (low will decrease mental status)
anticoagulants and head injuries
did they bleed then fall or fall then bleed
S/S of basilar skull fracture
csf can leak - rhinorrhea and otorrhea
2 physical s/s w/basilar skull fractures
battle sign (bruising on back of year unilateral) raccoon eyes - bilateral
what don’t we do with basilar skull fractures
no NG Tube - could end up in brain/spine
what type of tubes do trauma pts. get
OG (orogastric) tubes - below the skull
how do you check CSF coming out of nose for glucose
halo test - halo sign - sent to lab - shine flashlight you see halo - see glucose
what type of injuries cause DAI - diffuse axonal injury
thrown out of car
rollover accident
fall from height
patho of DAI
white matter is torn - responsible for communication - axons tear, therefore communication problem
how do pt. with DAI present
present in coma - decreased LOC
GCS guidelines for mgmt. of severe brain injury (DAI)
GCS 8 or
traumatic brain injury with altered LOC presents, what is the first exam we do, and further exams in the ER
non contrast head CT - looking for blood
cervical spine x-ray - can have injury to spine as well with force of traumatic brain injury
what is a GCS - Glasgow Coma Scale
standardized measure of how awake a person is - designed for head traumas
the way a pt. is managed with a head injury is based on preventing what
secondary injuries - make timely dx to manage
Leakage of spinal fluid is a potential neurosurgical complication. How should a
nurse assess for this complication?
C. Test all nasal and ear drainage for glucose.
how do we prevent secondary injuries in head trauma pt.
make sure pt. has adequate oxy - no hypoxia or hypotensive
what is the rule of thumb for preventing secondary injury
everything is over a 100 - O2 over a 100, systolic BP over a 100
rules for body temperature with head injury
keep 97 - don’t let them get a fever
what is the most life threatening head injury
epidural hematoma
what type of injuries result in epidural hematomas
injuries to the SIDE of the head (hit with a bat, fall off of something)
patho of epidural hematoma
artery (meningeal) tears - acute bleed in head - compression - herniation through foramen magnum - injury to brain stem - death
s/s of epidural hematoma
ipsilateral (same side of injury) pupil dilation
rapid chg. in neuro status (awake then unresponsive)
death
what can we do to help ICP
craniotomy - window
hemi-craniotomy - half of the skull
state of conscious is defined by
behavioral changes
pattern of brain activity of EEG
a coma is defined as
GCS of 8 or
GCS is based on what 3 criteria
eye opening, verbal and motor response
IICP and pupils
oculomotor (cranial nerve 3) compression
causes both pupils to dilate
if 1 pupil dilates with IICP what is it a sign of
neurologic emergency
is pupil dilation in IICP an early or late sign
late sign - epidural hematoma is the exception
if you have a high suspicion your pt. is brain dead what 2 eye tests will you do
Doll’s Eyes Reflex (Oculocephalic) Caloric Stimulation (Oculovestibular)
what do you do in dolls eyes reflex (oculocephalic)
move head side to side
what do you do in oculovestibular (caloric stimulation) eye test
cold water flush in the ears
motor function assessment with IICP
normal - pt withdraws from painful stimuli
abnormal - noxious stimuli - decorticate/decereberate
types of posturing
decorticate OR decereberate
mixed (decorticate/decereberate) - give better score - document in notes
headaches r/t IICP will present like this
continuous -
pressure headaches are more common/worse in the am
vascular headaches are more common in the afternoon
type of vomiting r/t IICP
projectile vomiting NOT r/t nausea
a change in VS is a late sign of IICP, t or f
true
ominous sign of IICP
Cushings Triad - Brady, widened pulse pressure (high systolic lower diastolic) low respiration’s
temp r/t IICP
no control, pressure is effecting hypothalamus - temp can be very high or very low
The care of a patient post TBI includes monitoring for signs of brain-stem herniation and occlusion of cerebral blood flow. A nurse should recognize a deterioration in the patient if which VS changes occurred? Select all that apply.
C.Hypo-tension
D.Bradycardia
E.Hypertension
F.Bradypnea
Which respiratory change would a nurse see most often in a patient with IICP?
B.Slow, irregular respiration’s.
ICP of 8 or less on GCS get what
intubated - need airway
ICP monitor
normal ICP range
0-15
what is the procedure called for ICP monitoring
ventriculostomy - risk of infection
what increases ICP
valsalva maneuver, seizures, fever, position, straining
The nurse is caring for a patient with TBI who has IICP. The physician plans to reduce the cerebral edema by reversing dilation of cerebral blood vessels. Which physician prescription would the nurse expect to accomplish this?
A.Hyperventilation per mechanical ventilation (constricts cerebral blood vessels, creating more room in brain)
should you use steroids with TBI pt?
no
drugs used to trt IICP
mannitol
an increased need for this w/IICP pt
glucose (fuel for the brain) - feed the pt.
A patient has developed diabetes insipidus after TBI. Which finding would the nurse expect?
A.Polyuria.
Which findings should indicate to a nurse that a TBI has resulted in brain death? Select all that apply.
A.No response to the cold caloric test.
C.EEG tracing is flat.
E.No spontaneous respiration’s
Following a head injury, a patient has no cough or gag reflex. The correct nursing action for feeding this patient is to
D.use a feeding tube
The nurse is caring for a patient with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse’s best action?
A.Notify the physician.
The nurse is taking the VS of a moribund patient when the patient suddenly grabs the nurse’s hand. The nurse should
C.talk calmly to the patient while continuing to take the VS.
Following visitation on the TBI unit, the nurse observes a patient’s wife sitting alone crying. When approached, the wife states, I’m so worried about him.” Your best response is
B.“Tell me what it is that worries you.”
Assessing the SCI - first steps
find out what happened
stabilize
what is a SCI
trauma causing compression, ischemia, edema or transection of spinal cord
types of spinal cord injuries
permanent, partial
severity of spinal cord injury depends on
where the injury occurred
higher injury the more serious SCI - less rehab potential
lower injury more mobility/function
an injury above c4 (where diaphragm is) pt.. will have
respiratory compromise - may be perm. or temp.
watch pt. very carefully
an injury above t6 pt. will have
cardiovascular compromise
A patient recuperating from a T4 SCI wants to learn to use a wheelchair.To prepare the patient for use of a wheelchair, the nurse should teach her to do
B. push-ups to strengthen her arm muscles.
problems post SCI include
airway, ventilation, circ. blood vol., secondary damage to cord (extension of cord damage)
planning/goals for SCI pt.
maint. neurologic fxn, immobility (pressure ulcers/contractures/skin breakdown), how are they going to take care of themselves
when suctioning a pt. with an SCI be cautious to avoid
pneumonia - sterile procedure*
when treating a SCI pt. be careful to avoid
pulmonary edema - too much fluids
within the first 48 hrs. of SCI pt. is at risk for
edema - assessment is so important muscle check
A nurse prepares to suction the trach of a 15 month old child. What steps should the nurse take in completing this procedure? Select all that apply.
A. Select vacuum pressure between 60-100 mm Hg.
D. Wash hands.
E. Hyperventilate the child with 100% oxygen via resuscitation bag.
F. Remove sterile 8- or 10-French suction catheter from package.
max suction times for adult and children
5 sec for child/10 sec for adult
Your patient with SCI has just been extubated. Which assessment would indicate signs of laryngeal edema?
D. High pitched crowing sounds on inspiration.
a spinal cord above t6 will present with this type of problem
cardiovascular (decreased cardiac output/venous return)no vasoconstriction - everything is dilated out - problems with sympathetic nervous system-
s/s of t6
bradycardia (
what is the first thing we do w/SCI pt.
IV fluids - vasopressor drugs (levophed)
any increase in vagal stimulation (turning/suctioning) w/SCI pt. can cause
cardiac arrest
prior to suctioning SCI pt. what should we do
hyperventilate
what is an SCI pt. at high risk for
DVT due to vasodilation (pooling of blood), immobile
what can we do to prevent DVT in SCI pt
compression boots - make sure on all the time
lovenox
Identify the appropriate actions in the prevention of thrombophlebitis in a patient on bed rest. Select all that apply.
B. Encourage exercises that dorsiflex and plantar flex the ankle.
C. Apply sequential compression devices bilaterally.
D. Prevent dehydration.
E. Periodically elevate the feet and lower legs above level of heart.
A nurse should evaluate the effects of Coumadin, used in the treatment of DVT, by looking at the results of which laboratory test?
A. Prothrombin time (PT).
drug therapy for SCI pt.
solumedrol
hyperbaric oxygen therapy
if SCI pt. is on methylprednisone what are they at risk for
infection - diabetes - stress ulcers (watch for GI bleed in stool/OG tube)
GI problems assoc with SCI pt.
gastric distention
paralytic ileus
stress ulcer - increased acid in stomach
fluid and nutrition r/t SCI
feed as soon as possible provided they have good bowel sounds - don’t have paralytic ileus/distention
The doctor has ordered NG feedings for a patient following SCI. Prior to administering a tube feeding, the nurse should
B. check for tube placement by checking the pH of the aspirant.
an injury below t12 r/t GI
bowel is areflexic - decreased sphincter tone
what is spinal shock
immediate loss of all reflexes following SCI - no tone
is spinal shock temporary
yes - few weeks - after return of reflexes begin bowel program (great implications on rehab programs)
trt for constipation in SCI pt.
daily suppository
immediately after SCI urine is retained, t or f
true - initial indwelling Foley catheter then intermittent
skin integrity w/SCI pt.
turn frequently to avoid pressure ulcers - can lead to infection/sepsis
temp control w/SCI pt.
no temp control below level of lesion - monitor environment - dress approp.
dx studies for SCI
cervical spine x-ray
CAT scan of head if injury to neck
comprehensive neuro exam
stabilization of SCI pt. can be
surgical or non-surgical
focused on stabilization of injured segment
when turning a SCI pt do so this way
min 3 people - log roll
Which of the following pieces of equipment should be kept at the bedside of a patient immobilized with Crutchfield tongs?
A. Wire cutters.
B. Torque wrench.
C. Pliers.
D. Flat-head screwdriver.
SCI immobilization devices
tongs - crutchfield
brace - before and/or after surgery
thoracolumbar orthosis (“body jacket”) skin care
surgical therapy guidelines for SCI
taken very early - evidence suggests that early cord decompression may result in ↓ secondary injury
surgical interventions for SCI include
stabilizing rods
if SCI pt. cannot go to surgery right away what intervention is used
kinetic therapy - rotate side-to-side to keep pt. safe
return of reflexes in SCI pt. occur
after spinal shock and may be hyperactive
autonomic dysreflexia happens in an injury at
t6 or above - sympathetic response - visceral overstimulation
s/s of autonomic dysreflexia
hypertensive crises
bradycardia - due to full bladder/bowel irritation
**flushed/sweaty above the lesion
**pale/cool below the lesion
if you don’t find cause of autonomic dysreflexia and correct it pt can have
hypertensive stroke
MI
autonomic dysreflexia is life threatening, t or f
true
most common cause of autonomic dysreflexia
distended bladder/rectum
Foley catheter kinked?
if you cant find cause of autonomic dysreflexia trt symptoms, t or f
true - notify physician - educate family may happen again
rehab/home care responsibilities/goals of the nurse
educate what they can expect
encourage independence
grief/depression r/t SCI pt.
let pt. talk - let pt. discuss what they want to discuss
