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Mgmt Neuro > Head Trauma/Spinal Cord Injury > Flashcards

Head Trauma/Spinal Cord Injury Flashcards

1
Q

history for head injury includes

A

how was the pt. injured - ask family

loss of consciousness?

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2
Q

knowing how the head injury occurred allows you to know

A

what to look for - whether you should call someone emergently

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3
Q

what is the most important assessment in Head injuries

A

LOC - awake then sleep - not okay

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4
Q

what type of pt. get head traumas

A

elderly - falls
young men - risky behaviors (trauma)
children - shaken baby - bike accidents(helmet wearing)
motorcycle accidents

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5
Q

what will complicate your head injury assessment

A

alcohol, drugs, low glucose, CO2, O2, anticoagulants

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6
Q

one of the 1st things you do w/trauma pt.

A

check blood sugar (low will decrease mental status)

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7
Q

anticoagulants and head injuries

A

did they bleed then fall or fall then bleed

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8
Q

S/S of basilar skull fracture

A

csf can leak - rhinorrhea and otorrhea

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9
Q

2 physical s/s w/basilar skull fractures

A 
battle sign (bruising on back of year unilateral)
raccoon eyes - bilateral
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10
Q

what don’t we do with basilar skull fractures

A

no NG Tube - could end up in brain/spine

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11
Q

what type of tubes do trauma pts. get

A

OG (orogastric) tubes - below the skull

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12
Q

how do you check CSF coming out of nose for glucose

A

halo test - halo sign - sent to lab - shine flashlight you see halo - see glucose

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13
Q

what type of injuries cause DAI - diffuse axonal injury

A

thrown out of car
rollover accident
fall from height

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14
Q

patho of DAI

A

white matter is torn - responsible for communication - axons tear, therefore communication problem

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15
Q

how do pt. with DAI present

A

present in coma - decreased LOC

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16
Q

GCS guidelines for mgmt. of severe brain injury (DAI)

A

GCS 8 or

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17
Q

traumatic brain injury with altered LOC presents, what is the first exam we do, and further exams in the ER

A

non contrast head CT - looking for blood

cervical spine x-ray - can have injury to spine as well with force of traumatic brain injury

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18
Q

what is a GCS - Glasgow Coma Scale

A

standardized measure of how awake a person is - designed for head traumas

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19
Q

the way a pt. is managed with a head injury is based on preventing what

A

secondary injuries - make timely dx to manage

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20
Q

Leakage of spinal fluid is a potential neurosurgical complication. How should a
nurse assess for this complication?

A

C. Test all nasal and ear drainage for glucose.

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21
Q

how do we prevent secondary injuries in head trauma pt.

A

make sure pt. has adequate oxy - no hypoxia or hypotensive

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22
Q

what is the rule of thumb for preventing secondary injury

A

everything is over a 100 - O2 over a 100, systolic BP over a 100

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23
Q

rules for body temperature with head injury

A

keep 97 - don’t let them get a fever

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24
Q

what is the most life threatening head injury

A

epidural hematoma

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25
Q

what type of injuries result in epidural hematomas

A

injuries to the SIDE of the head (hit with a bat, fall off of something)

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26
Q

patho of epidural hematoma

A

artery (meningeal) tears - acute bleed in head - compression - herniation through foramen magnum - injury to brain stem - death

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27
Q

s/s of epidural hematoma

A

ipsilateral (same side of injury) pupil dilation
rapid chg. in neuro status (awake then unresponsive)
death

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28
Q

what can we do to help ICP

A

craniotomy - window

hemi-craniotomy - half of the skull

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29
Q

state of conscious is defined by

A

behavioral changes

pattern of brain activity of EEG

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30
Q

a coma is defined as

A

GCS of 8 or

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31
Q

GCS is based on what 3 criteria

A

eye opening, verbal and motor response

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32
Q

IICP and pupils

A

oculomotor (cranial nerve 3) compression

causes both pupils to dilate

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33
Q

if 1 pupil dilates with IICP what is it a sign of

A

neurologic emergency

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34
Q

is pupil dilation in IICP an early or late sign

A

late sign - epidural hematoma is the exception

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35
Q

if you have a high suspicion your pt. is brain dead what 2 eye tests will you do

A 
Doll’s Eyes Reflex (Oculocephalic) 
Caloric Stimulation (Oculovestibular)
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36
Q

what do you do in dolls eyes reflex (oculocephalic)

A

move head side to side

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37
Q

what do you do in oculovestibular (caloric stimulation) eye test

A

cold water flush in the ears

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38
Q

motor function assessment with IICP

A

normal - pt withdraws from painful stimuli

abnormal - noxious stimuli - decorticate/decereberate

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39
Q

types of posturing

A

decorticate OR decereberate

mixed (decorticate/decereberate) - give better score - document in notes

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40
Q

headaches r/t IICP will present like this

A

continuous -
pressure headaches are more common/worse in the am
vascular headaches are more common in the afternoon

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41
Q

type of vomiting r/t IICP

A

projectile vomiting NOT r/t nausea

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42
Q

a change in VS is a late sign of IICP, t or f

A

true

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43
Q

ominous sign of IICP

A

Cushings Triad - Brady, widened pulse pressure (high systolic lower diastolic) low respiration’s

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44
Q

temp r/t IICP

A

no control, pressure is effecting hypothalamus - temp can be very high or very low

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45
Q

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.

A

C.Hypo-tension
D.Bradycardia
E.Hypertension
F.Bradypnea

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46
Q

Which respiratory change would a nurse see most often in a patient with IICP?

A

B.Slow, irregular respiration’s.

47
Q

ICP of 8 or less on GCS get what

A

intubated - need airway

ICP monitor

48
Q

normal ICP range

A

0-15

49
Q

what is the procedure called for ICP monitoring

A

ventriculostomy - risk of infection

50
Q

what increases ICP

A

valsalva maneuver, seizures, fever, position, straining

51
Q

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

A.Hyperventilation per mechanical ventilation (constricts cerebral blood vessels, creating more room in brain)

52
Q

should you use steroids with TBI pt?

A

no

53
Q

drugs used to trt IICP

A

mannitol

54
Q

an increased need for this w/IICP pt

A

glucose (fuel for the brain) - feed the pt.

55
Q

A patient has developed diabetes insipidus after TBI. Which finding would the nurse expect?

A

A.Polyuria.

56
Q

Which findings should indicate to a nurse that a TBI has resulted in brain death? Select all that apply.

A

A.No response to the cold caloric test.
C.EEG tracing is flat.
E.No spontaneous respiration’s

57
Q

Following a head injury, a patient has no cough or gag reflex. The correct nursing action for feeding this patient is to

A

D.use a feeding tube

58
Q

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

A.Notify the physician.

59
Q

The nurse is taking the VS of a moribund patient when the patient suddenly grabs the nurse’s hand. The nurse should

A

C.talk calmly to the patient while continuing to take the VS.

60
Q

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

A

B.“Tell me what it is that worries you.”

61
Q

Assessing the SCI - first steps

A

find out what happened

stabilize

62
Q

what is a SCI

A

trauma causing compression, ischemia, edema or transection of spinal cord

63
Q

types of spinal cord injuries

A

permanent, partial

64
Q

severity of spinal cord injury depends on

A

where the injury occurred
higher injury the more serious SCI - less rehab potential
lower injury more mobility/function

65
Q

an injury above c4 (where diaphragm is) pt.. will have

A

respiratory compromise - may be perm. or temp.

watch pt. very carefully

66
Q

an injury above t6 pt. will have

A

cardiovascular compromise

67
Q

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

A

B. push-ups to strengthen her arm muscles.

68
Q

problems post SCI include

A

airway, ventilation, circ. blood vol., secondary damage to cord (extension of cord damage)

69
Q

planning/goals for SCI pt.

A

maint. neurologic fxn, immobility (pressure ulcers/contractures/skin breakdown), how are they going to take care of themselves

70
Q

when suctioning a pt. with an SCI be cautious to avoid

A

pneumonia - sterile procedure*

71
Q

when treating a SCI pt. be careful to avoid

A

pulmonary edema - too much fluids

72
Q

within the first 48 hrs. of SCI pt. is at risk for

A

edema - assessment is so important muscle check

73
Q

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

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.

74
Q

max suction times for adult and children

A

5 sec for child/10 sec for adult

75
Q

Your patient with SCI has just been extubated. Which assessment would indicate signs of laryngeal edema?

A

D. High pitched crowing sounds on inspiration.

76
Q

a spinal cord above t6 will present with this type of problem

A

cardiovascular (decreased cardiac output/venous return)no vasoconstriction - everything is dilated out - problems with sympathetic nervous system-

77
Q

s/s of t6

A

bradycardia (

78
Q

what is the first thing we do w/SCI pt.

A

IV fluids - vasopressor drugs (levophed)

79
Q

any increase in vagal stimulation (turning/suctioning) w/SCI pt. can cause

A

cardiac arrest

80
Q

prior to suctioning SCI pt. what should we do

A

hyperventilate

81
Q

what is an SCI pt. at high risk for

A

DVT due to vasodilation (pooling of blood), immobile

82
Q

what can we do to prevent DVT in SCI pt

A

compression boots - make sure on all the time

lovenox

83
Q

Identify the appropriate actions in the prevention of thrombophlebitis in a patient on bed rest. Select all that apply.

A

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.

84
Q

A nurse should evaluate the effects of Coumadin, used in the treatment of DVT, by looking at the results of which laboratory test?

A

A. Prothrombin time (PT).

85
Q

drug therapy for SCI pt.

A

solumedrol

hyperbaric oxygen therapy

86
Q

if SCI pt. is on methylprednisone what are they at risk for

A

infection - diabetes - stress ulcers (watch for GI bleed in stool/OG tube)

87
Q

GI problems assoc with SCI pt.

A

gastric distention
paralytic ileus
stress ulcer - increased acid in stomach

88
Q

fluid and nutrition r/t SCI

A

feed as soon as possible provided they have good bowel sounds - don’t have paralytic ileus/distention

89
Q

The doctor has ordered NG feedings for a patient following SCI. Prior to administering a tube feeding, the nurse should

A

B. check for tube placement by checking the pH of the aspirant.

90
Q

an injury below t12 r/t GI

A

bowel is areflexic - decreased sphincter tone

91
Q

what is spinal shock

A

immediate loss of all reflexes following SCI - no tone

92
Q

is spinal shock temporary

A

yes - few weeks - after return of reflexes begin bowel program (great implications on rehab programs)

93
Q

trt for constipation in SCI pt.

A

daily suppository

94
Q

immediately after SCI urine is retained, t or f

A

true - initial indwelling Foley catheter then intermittent

95
Q

skin integrity w/SCI pt.

A

turn frequently to avoid pressure ulcers - can lead to infection/sepsis

96
Q

temp control w/SCI pt.

A

no temp control below level of lesion - monitor environment - dress approp.

97
Q

dx studies for SCI

A

cervical spine x-ray
CAT scan of head if injury to neck
comprehensive neuro exam

98
Q

stabilization of SCI pt. can be

A

surgical or non-surgical

focused on stabilization of injured segment

99
Q

when turning a SCI pt do so this way

A

min 3 people - log roll

100
Q

Which of the following pieces of equipment should be kept at the bedside of a patient immobilized with Crutchfield tongs?

A

A. Wire cutters.
B. Torque wrench.
C. Pliers.
D. Flat-head screwdriver.

101
Q

SCI immobilization devices

A

tongs - crutchfield
brace - before and/or after surgery
thoracolumbar orthosis (“body jacket”) skin care

102
Q

surgical therapy guidelines for SCI

A

taken very early - evidence suggests that early cord decompression may result in ↓ secondary injury

103
Q

surgical interventions for SCI include

A

stabilizing rods

104
Q

if SCI pt. cannot go to surgery right away what intervention is used

A

kinetic therapy - rotate side-to-side to keep pt. safe

105
Q

return of reflexes in SCI pt. occur

A

after spinal shock and may be hyperactive

106
Q

autonomic dysreflexia happens in an injury at

A

t6 or above - sympathetic response - visceral overstimulation

107
Q

s/s of autonomic dysreflexia

A

hypertensive crises
bradycardia - due to full bladder/bowel irritation
**flushed/sweaty above the lesion
**pale/cool below the lesion

108
Q

if you don’t find cause of autonomic dysreflexia and correct it pt can have

A

hypertensive stroke

MI

109
Q

autonomic dysreflexia is life threatening, t or f

A

true

110
Q

most common cause of autonomic dysreflexia

A

distended bladder/rectum

Foley catheter kinked?

111
Q

if you cant find cause of autonomic dysreflexia trt symptoms, t or f

A

true - notify physician - educate family may happen again

112
Q

rehab/home care responsibilities/goals of the nurse

A

educate what they can expect

encourage independence

113
Q

grief/depression r/t SCI pt.

A

let pt. talk - let pt. discuss what they want to discuss

Mgmt Neuro (5 decks)

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