Nursing care of head injury, surgery, ICO, seizures, spinal cord injury Flashcards
What is the most common cause of traumatic brain injury
Falls
What happens to the symtoms of a hemmorage
They are delayed until hematoma is large enough to increase ICP
What are the different types of TBI?
open, closed, diffuse, focal.
What is the usual cause of an epidural hemmorage?
rupture of middle meningeal artery it’s a MEDICAL EMERGENCY and can cause herniation.
Signs of brain herniation
Loss of consciousness, pupil dilation, paralysis of extremity.
What is an epidural hemmorage?
above the dura under the skull, caused by rupture of middle meningeal artery.
What is a subdural hemmorage?
below dura, between dura and brain
What is the nature of a subdural hemmorage
usual venous in nature, can be acute, sub acute, and chronic
who is more prone to a subdural hemmorage
elderly on anti-coagulants.
Intracerebral hemmorage
within the brain tissue, CVA,HTN
traits of a contusion
localized, cells die, effects peak 18-36 after injury, coup-contracoup, can cause ICP increase from bleeding.
S&S of concussion
irritability, confusion, disorientation, headache
S&S of contusion
blurred vision, disorientation, unsteady gait, vomiting, slurred speech, coma.
Diagnosis of coup contra coup
CT, MRI, skull xray, angiography
medical care of coup contracoup - contusion
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.
Nursing care of head injury - goal
address acute injuries (respirations, cerebral circulation, safety. Prevent secondary complications (infections, skin integrity, safety positing. Prevent and treat consequences with PT OT education.
First level of nursing care following a head injury
assess all systems for direct impact and primary compromise, patent airway, optimal breathing pattern, optimal cerebral perfusion, appropriate fluid balance.mentation, H&H, lytes
second level of nursing care following a head injury
assess for secondary compromise S&S of infection, complications, consequences.
what should be told to the patient for eduation
headache, dizzyness, lethargy, irritability, emotional, fatigue, poor concentration, decreased attention span.
following a head injury, when should a patient notify an MD?
Difficulty in waking and speaking, confusion, severe headache, vomiting, unilateral weakness.
What does the frontal lobe do
behavior, intelligence, memory, movement
what does the temporal lobe do
behavior, hearing, memory, speech, vision.
What does the parietal lobe do
intelligence, lanquage, sensation, reading.
What does the brain stem control?
BP, HR, breathing, consciousness, swallowing
Why would they preform intracranial surgery
reduce ICP, remove tumor, ecacuate a blood clot, removal of skull to allow room for swelling, repair of skull
What is supratentoria?
brain surgery above the tenrotum (eye) most of brain above cerebellum.
What is infratentorial
below tentorum (eyeline) cerebellum).
Nursing care pre brain surgery
document baseling neurological status, routine pre-op care and education, continuation of care. admin meds as prescribed.
Nursing care post brain surgery
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.
Glasgow
Eyes,verbal, motor, not good for patients on ventilators
FOUR
Full Outline of Unresponsiveness - good for patients on venilator, lower score worse situation same with glasgow.
Potential post op brain surgery complications
bleeding and hypovolemic shock, fluid and electrolyte disturbances, infection, increased ICP, seizures, diabetes insipidus, SIADH
What does the monroe Kelly doctrine state?
increase in one component of brain, blood, and csf will lead to compensatory changes in others.
early human responses to increase in ICP
Change in LOC, pupillary changes, impaired occular movement, weakness on one side, constant headache,
Late responses to increase ICP
LOC, respiratory pattern alterations, loss of brainstem reflexes, cushings triad, hemiplegia, decorticate, decerebrate posturing.
What is cushings triad?
Hypertension with widening pulse pressure, bradycardia, bradypnea
Human respions to I-C-P
Increase in pulse pressure, Changes in LOC, Pupils, Puking, Pain, Posturing
Decorticate
turn inwards damage to corticospinal tracts
Decerebrate
turning outwar
