Neurologic Trauma - prep U Flashcards
Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)?
change in LOC (level of consciousness)
what is it called when blood collects between the dura mater and the arachnoid membrane?
** this space normally contains a thin layer/ cushion of fluid**
Subdural hematoma
An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An epidural hematoma is AKA _______ ________.
extradural hematoma
A patient coming into the ER is reported to have a “Battle Sign,” what is this referring to?
bruising behind the ear, specifically to the mastoid process
A client sustained a head trauma and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?
intracerebral hematoma
The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
cerebral spinal fluid (CSF) leaking from the ear
-periorbital ecchymosis (raccoon’s eyes)
-post-mastoid ecchymosis (Battle sign)
-otorrhea
-rhinorrhea
-loss of cranial nerve I (olfactory nerve) function
After assessing these findings what trauma would be suspected?
basilar skull fracture - is a break in one or more bones at the base of the skull
When caring for a client who is post–intracranial surgery what is the most important parameter to monitor?
body temperature
What are the clinical manifestations of CUSHINGS TRIAD?
-hypertension
-bradycardia
-bradypnea
Signs of INCREASING ICP are called the CUSHING REFLEX. what 3 signs does this consist of?
-increase on systolic BP
-widened pulse pressure
-bradycardia
In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find?
-hypotension
-venous pooling
-tachypnea
-hypothermia
-decreased cardiac output
what are the 3 cardinal signs of brain death?
-apnea
-absence of brainstem reflexes
-coma
Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. (IE. full bladder, constipation, tight clothing, ingrown toenail) - What manifestations occur?
-increased BP
-bradycardia
-bad headache
-skin above injured area turns red/ blotchy
-diaphoresis
-anxious
-stuffy nose
-blurred vision
if a patient is experiencing autonomic dysreflexia due to a SCI, what should you do right away?
sit the patient up/ raise their upper body to bring their BP down
IE.
-if bladder is full - empty
-if constipated - stool softener
-clothes too tight - loosen clothes
what are early and late signs of a UTI in a patient with a spinal cord injury?
early = fever + changes in urine clarity
late = fever
___________ ___________ is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. (severe hypertension, slow heart rate, pounding headache, sweating)
autonomic dysreflexia
When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor?
body temperature
what are S/S of a rapidly expanding acute subdural hematoma?
-hemiparesis
-decreased pupil reactivity
-bradycardia
-coma
-change in LOC
-hypertension
-bradypnea
or there may be minor or no symptoms at all with small collections of blood
Neurological level of spinal cord injury refers to which of the following?
refers to the lowest level at which sensory and motor functions are normal.
