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Nur 471 Exam 2-Utica University > Neurological Trauma > Flashcards

Neurological Trauma Flashcards

1
Q

Head Injury Pathophysiology-
Primary Injury

A
  • Contusions
  • Lacerations
  • External hematomas
  • Skull fractures
  • Subdural hematomas
  • Concussion
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2
Q

Head Injury Pathophysiology-
Secondary Injury

A
  • Cerebral edema
  • Ischemia
  • Chemical changes
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3
Q

Head Injury Pathophysiology-
Monro–Kellie doctrine

A

The cranial vault is a closed system, and if one of the three components increases in volume, at least one of the other two must decrease in volume or the pressure will increase.

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4
Q

Head Injury -Assessment

A

*MRI
*CT SCAT

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5
Q

Skull Fractures- Types
Linear

A

Break in the continuity of the bone.

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6
Q

Skull Fractures- Types
Comminuted

A

A splintered or multiple fracture line

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7
Q

Skull Fractures- Types
Depressed

A

Occurs when the bones of the skull are forcefully displaced downward and can vary from a slight depression to bones of the skull being splintered and embedded within brain tissue

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8
Q

Skull Fracture-
Clinical Manifestations

A
  • Depends on the severity and anatomic location of the underlying brain injury
  • Persistent, localized pain
  • Bleeding from the nose, pharynx, or ears
  • Blood under the conjunctiva
  • Battle sign (Bruising over the mastoid process)
  • Cerebrospinal fluid otorrhea
  • Cerebrospinal fluid rhinorrhea
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9
Q

Skull Fracture- Assessment

A

*MRI
*CT Scan

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10
Q

Traumatic Brain Injury
Assessment

A

*Ask questions that establish the nature of the injury and the patient’s condition immediately after the injury.

*This assessment includes determining the patient’s LOC using the Glasgow Coma Scale (GCS) and assessing the patient’s response to tactile stimuli.

*Monitoring of ICP is crucial to decision making for patients with neurologic injuries

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11
Q

Traumatic Brain Injury
Nursing Interventions

A

*MAINTAINING THE AIRWAY
*MONITORING NEUROLOGIC FUNCTION
*MONITORING FLUID AND ELECTROLYTE BALANCE
*PROMOTING ADEQUATE NUTRITION
*PREVENTING INJURY (Fall Risk)
*MAINTAINING THERMOREGULATION
*MAINTAINING SKIN INTEGRITY
*IMPROVING COPING
*PREVENTING SLEEP PATTERN DISTURBANCE
*SUPPORTING FAMILY COPING

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12
Q

Subdural Hematoma (SDH)
Acute

A

Symptoms develop over 24 to 48 hours

Clinical Manifestations:
*Changes in the level of consciousness (LOC)
*Pupillary signs
*Hemiparesis (One-sided muscle weakness)
*Bradycardia
*slowing RR
*Increasing BP

Treatment:
* Craniotomy to control intracranial pressure

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13
Q

Subdural Hematoma (SDH)
Chronic

A
  • Develops over weeks to months
  • Causative injury may be minor and forgotten
  • Clinical manifestations may fluctuate
    Symptoms include severe headache, which tends to come and go; alternating focal neurologic signs; personality changes; mental deterioration; and focal seizures.
  • Treatment is evacuation of clot
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14
Q

Epidural Hematoma

A

After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura mater.

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15
Q

Epidural Hematoma
Nursing Management

A

Monitor for signs of increased ICP.
Respiratory support
Vital function support

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16
Q

Brain Death Criteria

A

*Coma
*The absence of brain stem reflexes.
*Apnea
* 3 on Glascows Coma Scale

17
Q

Glascows Coma Scale

A

Measure of Consciousness
The Glasgow Coma Scale is a tool for assessing a patient’s response to stimuli. Scores range from 3 (deep coma) to 15 (normal).
GCS Score
* 15 = Highest Score
* 8 = intubate
* 3 = lowest score
REPORT Decreasing GCS score!
*Eye-opening response (1-4)
*Best verbal response (1-5)
*Best motor response (1-6)

18
Q

Intracranial Pressure-
Normal Range

A

7-15 mm Hg

19
Q

Intracranial Pressure-
Prevention of Increase

A
  • Maintain adequate oxygenation
  • Elevate the head of the bed
  • Maintain normal blood volume

S/S:
Altered LOC/mental status
Vomitting
Bradycardia
Widening Pulse Pressure
Headache

20
Q

Spinal Cord Injury

A
21
Q

Spinal Cord Injury
Common Causes

A
  • Motor vehicle accident (MVA)
  • Falls
  • Violence
  • Sports-related injury
22
Q

Spinal Cord Injury
Assessment/ Diagnostic

A

*Neurological Assessment
* Diagnostic x-rays (lateral cervical spine x-rays)
*CT Scan
*MRI

23
Q

Spinal Cord Injury- C4
Clinical Manifestation

A

LEVELS OF INJURY:
Paralysis in arms, hands, trunk and legs
* Cervical Injury: paralysis below neck (level of injury)
* Quadriplegia: 4 limbs paralyzed
diplegia= sounds like paralyzed
* BREATHING impaired - Life threatening
er

24
Q

Spinal Cord Injury-C6
Clinical Manifestation

A

C6 SCI does not have the ability to move their trunk or legs. They have limited movement of the arms and should be able to move their shoulders, bend their elbows, and extend their wrists.

25
Q

Spinal Cord Injury- T6
Clinical Manifestation

A

Significant leg weakness or loss of sensation. Loss of feeling in genitals or rectal region. No control of urine or stool. Fever and lower back pain.

Complication: Autonomic Dysreflexia

26
Q

Spinal Cord Injury- L1
Clinical Manifestation

A

Legs may be completely paralyzed or lack sensation.
Bladder and Bowel Dysfunction

27
Q

HALO Traction Mgt

A

Key priority is Infection risk!!!
- NO showers - ONLY sponge bath
- Assess pin sites for infection
- Red, warm, smelly drainage

28
Q

Autonomic Dysreflexia
Clinical Manifestations

A

Acute emergency!
Clinical manifestations:
* Severe, pounding headache
* Sudden increase in blood pressure/ Hypertension
* Profuse diaphoresis (Sweating)
* Piloerection (Goosebumps)
* Nausea
* Nasal congestion
* Bradycardia
OCCURS IN PATIENTS WITH A LESION ABOVE T6

29
Q

Autonomic Dysreflexia
Management

A
  • Place patient in a seated position
    Rapid assessment to identify and eliminate the cause:
  • Check BP q 5 minutes
  • Empty the bladder
  • Irrigate or change an indwelling catheter
  • Examine rectum
  • Examine skin
  • Examine for any other stimulus
  • Administer intravenous ganglionic blocking agent
  • Notify healthcare team
  • Patient education
30
Q

Neurogenic Shock

A

S/S:
*Hypotension
*Bradycardia
*Flushed/ warm skin
TX:
*IV Fluids
*Vasopressors
*Atropine

31
Q

Spinal Cord Shock
Managment

A

Hypotension and shock can further damage the spinal cord; therefore, the mean arterial pressure (MAP) should be maintained at 85 mm Hg or higher during the hyperacute phase.
Nursing mgt:
Immobilize Spine
Monitor and Prevent VTE
Monitor for S/S of internal bleeding
Passive ROM of immobilized extremities
Elevate HOB 30

32
Q

Paraplegic/Tetraplegic-
Rehabilitation

A

Increasing mobility
* Exercise programs
* Mobilization
*Preventing disuse syndrome
* Promoting skin integrity
* Improving bladder management
* Establishing bowel control
* Counseling on sexual expression
* Enhancing coping mechanisms

Monitoring and managing potential complications
* Spasticity
* Infection
* Sepsis

Nur 471 Exam 2-Utica University (3 decks)

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