Nursing care of head injury, surgery, ICO, seizures, spinal cord injury

Question 1

What is the most common cause of traumatic brain injury

Answer 1

Falls

Question 2

What happens to the symtoms of a hemmorage

Answer 2

They are delayed until hematoma is large enough to increase ICP

Question 3

What are the different types of TBI?

Answer 3

open, closed, diffuse, focal.

Question 4

What is the usual cause of an epidural hemmorage?

Answer 4

rupture of middle meningeal artery it’s a MEDICAL EMERGENCY and can cause herniation.

Question 5

Signs of brain herniation

Answer 5

Loss of consciousness, pupil dilation, paralysis of extremity.

Question 6

What is an epidural hemmorage?

Answer 6

above the dura under the skull, caused by rupture of middle meningeal artery.

Question 7

What is a subdural hemmorage?

Answer 7

below dura, between dura and brain

Question 8

What is the nature of a subdural hemmorage

Answer 8

usual venous in nature, can be acute, sub acute, and chronic

Question 9

who is more prone to a subdural hemmorage

Answer 9

elderly on anti-coagulants.

Question 10

Intracerebral hemmorage

Answer 10

within the brain tissue, CVA,HTN

Question 11

traits of a contusion

Answer 11

localized, cells die, effects peak 18-36 after injury, coup-contracoup, can cause ICP increase from bleeding.

Question 12

S&S of concussion

Answer 12

irritability, confusion, disorientation, headache

Question 13

S&S of contusion

Answer 13

blurred vision, disorientation, unsteady gait, vomiting, slurred speech, coma.

Question 14

Diagnosis of coup contra coup

Answer 14

CT, MRI, skull xray, angiography

Question 15

medical care of coup contracoup - contusion

Answer 15

control ICP, intracranial bolt, mechanical ventilation, prevent hypoxemia and increase in lactic acidosis, vaso dilation, leading to an increase in ICP. reduce metabolic demands by putting into a coma, minimize secondary injury.

Question 16

Nursing care of head injury - goal

Answer 16

address acute injuries (respirations, cerebral circulation, safety. Prevent secondary complications (infections, skin integrity, safety positing. Prevent and treat consequences with PT OT education.

Question 17

First level of nursing care following a head injury

Answer 17

assess all systems for direct impact and primary compromise, patent airway, optimal breathing pattern, optimal cerebral perfusion, appropriate fluid balance.mentation, H&H, lytes

Question 18

second level of nursing care following a head injury

Answer 18

assess for secondary compromise S&S of infection, complications, consequences.

Question 19

what should be told to the patient for eduation

Answer 19

headache, dizzyness, lethargy, irritability, emotional, fatigue, poor concentration, decreased attention span.

Question 20

following a head injury, when should a patient notify an MD?

Answer 20

Difficulty in waking and speaking, confusion, severe headache, vomiting, unilateral weakness.

Question 21

What does the frontal lobe do

Answer 21

behavior, intelligence, memory, movement

Question 22

what does the temporal lobe do

Answer 22

behavior, hearing, memory, speech, vision.

Question 23

What does the parietal lobe do

Answer 23

intelligence, lanquage, sensation, reading.

Question 24

What does the brain stem control?

Answer 24

BP, HR, breathing, consciousness, swallowing

Question 25

Why would they preform intracranial surgery

Answer 25

reduce ICP, remove tumor, ecacuate a blood clot, removal of skull to allow room for swelling, repair of skull

Question 26

What is supratentoria?

Answer 26

brain surgery above the tenrotum (eye) most of brain above cerebellum.

Question 27

What is infratentorial

Answer 27

below tentorum (eyeline) cerebellum).

Question 28

Nursing care pre brain surgery

Answer 28

document baseling neurological status, routine pre-op care and education, continuation of care. admin meds as prescribed.

Question 29

Nursing care post brain surgery

Answer 29

asses hourly, neuro with glasgow or four score, respiratory, ABG, labs, ICP monitor readings). Proper positioning depends on surgical approach. monitor OUT and IN, dressing changes.

Question 30

Glasgow

Answer 30

Eyes,verbal, motor, not good for patients on ventilators

Question 31

FOUR

Answer 31

Full Outline of Unresponsiveness - good for patients on venilator, lower score worse situation same with glasgow.

Question 32

Potential post op brain surgery complications

Answer 32

bleeding and hypovolemic shock, fluid and electrolyte disturbances, infection, increased ICP, seizures, diabetes insipidus, SIADH

Question 33

What does the monroe Kelly doctrine state?

Answer 33

increase in one component of brain, blood, and csf will lead to compensatory changes in others.

Question 34

early human responses to increase in ICP

Answer 34

Change in LOC, pupillary changes, impaired occular movement, weakness on one side, constant headache,

Question 35

Late responses to increase ICP

Answer 35

LOC, respiratory pattern alterations, loss of brainstem reflexes, cushings triad, hemiplegia, decorticate, decerebrate posturing.

Question 36

What is cushings triad?

Answer 36

Hypertension with widening pulse pressure, bradycardia, bradypnea

Question 37

Human respions to I-C-P

Answer 37

Increase in pulse pressure, Changes in LOC, Pupils, Puking, Pain, Posturing

Question 38

Decorticate

Answer 38

turn inwards damage to corticospinal tracts

Question 39

Decerebrate

Answer 39

turning outwar