TBI/Head trauma/SCI Flashcards
1
Q
What is the triad portrayed in increased intracranial pressure? What are the symptoms? When is this seen?
A
- Cushings Triad*
- Increased Systolic BP (Widened pulse pressure)
- Decreased HR
- Decreased Respirations
- VERY LATE STAGE OF increased ICP
2
Q
The Monro-Kellie Doctrine states?
A
- Cranial vault is closed system
- If 1 of 3 components increases (brain tissue, blood, csf) and the other 2 do not decrease, ICP will increase.
3
Q
3 components of the cranial vault?
A
- Brain tissue- 80%
- Blood - 10%
- CSF - 10%
4
Q
A _____ fracture is a break in the continuity of the skull bone. (Bone is not moved at all)
A
Linear/simple
5
Q
A ______fracture refers to a splintered or multiple fracture line.
A
comminuted
Note: can involve bone fragments and sharp pieces - displaced
6
Q
A_____fracture refers to when the bones of the skull are forcefully displaced downward.
A
Depressed
7
Q
If ICP remains elevated it can decrease ____? What is this?
A
- cerebral perfusion pressure
* Net pressure gradient that drives oxygen delivery to the cerebral tissue
8
Q
What does the GCS measure?
What are the 3 criteria?
What is the range indicating a severe head injury?
A
- Measures LOC
- Eye opening, Verbal, Motor responses
- 3-8 (scale ranges from 3 to 15)
9
Q
4 Positioning points for a client with increased ICP?
A
- Elevated 30-45 degrees or as prescribed (Decreases intracranial pressure by promoting venous drainage)
- Head in neutral position
- avoid excessive neck and hip flexion
- Prevent valsalva maneuver
10
Q
What happens to the pulse pressure with increasing ICP?
A
*Widens
11
Q
A unilaterally dilated and poorly responding pupil may indicate a developing _______. With pressure on the _____ cranial nerve due to _______.
A
- Hematoma
- 3rd cranial nerve
- shifting of brain
12
Q
Enlarged ventricles with sometimes little or no increase in intracranial pressure is called?
A
Normal pressure hydrocephalus
13
Q
Triad of symptoms seen in normal pressure hydrocephalus?
A
- Gait disturbances - Wide stance, slow steps
- Cognitive impairments
- Impaired bladder control
14
Q
Describe shunt system used for NPH.
A
- Burr hole in skull
- Catheter is threaded into ventricle
- Other tip of cath is placed where CSF can be drained (Abdomen/peritoneum).
15
Q
Complications of ventricular shunt system?
A
- Symptoms of NPH - gait, cognitive, bladder
* Infection, redness, swelling, fever
16
Q
Primary vs Secondary brain injury
A
Primary - initial injury occurring after direct contact to head/brain (contusion, fracture)
Secondary - Evolves hours/days after initial injury as result of inadequate nutrients/o2 to cells (cerebral edema, Seizures)
17
Q
Difference between open and closed head injuries?
A
Open = Tear in dura Closed = Dura intact
18
Q
What are some common clinical manifestations of a Basal skull fracture?
A
- Raccoon eyes
- Bruising over mastoid (Battle sign)
- CSF otorrhea and rhinorrhea
19
Q
How can you determine if rhinorrhea/otorrhea contains csf? When is this contradicted?
A
*Test for presence of glucose, indicating CSF. If there is blood present then Halo test can be done (Yellow ring around blood is csf)
20
Q
What type of herniation is associated with EDH? What is this considered?
A
- Uncal herniation (from pressure on midbrain)(decerebrate)
* Extreme emergency - respiratory arrest can occur
21
Q
What are the symptoms that characterize EDH?
A
1st - Brief loss of consciousness
2nd - Lucid interval (awake and conversing)- due to compensatory mechanisms where CSF is absorbed.
3rd - Becomes restless and confused, eventually leading to coma, rapidly deteriorating (Compensatory mechanisms fail and slight increase in volume of blood clot cause increase in ICP).
22
Q
Where does blood collect in an EDH? Where does this blood usually come from? Expansion speed?
A
- Space between skull and dura mater
- Middle meningeal artery (Arterial blood)
- Rapidly expanding
23
Q
Where does blood collect in an SDH? Where does this blood usually come from? Expansion speed?
A
- Space between Dura mater and brain
- Venous from small vessels
- Slow expansion speed (can be acute or chronic)
24
Q
Prognosis for subarachnoid hemorrhage in clients with TBI? What complication can occur and how is it treated? Causes?
A
- Poor prognosis
- Vasospasm - decreasing blood flow - treated with CCB nimodipine
- Cerebral aneurysm and head trauma
25
S+S of Arterial dissection of carotid and vertebral arteries in neck?
* Sudden focal neurologic changes
* Neck pain
* Horners Sign
26
3 characteristics of horners sign?
* Ipsilateral miosis - Pupil constricted on one side
* Ptosis- Drooping of upper eyelid
* Anhidrosis - abscence of facial sweating
27
Describe diffuse axonal injury?
* Damage (Tearing) to the axon of the nerve cell
* Immediate and proglonged coma, decorticate/decerebrate posturing, cerebral edema
* Poor prognosis depending on severity
28
Describe a concussion? How are they graded? What are some long term effects?
* Confusion or loss of consciousness for a short period of time
* graded by duration of mental status abnormalities/loss of consciousness
* Lack of concentration and personality changes
29
Degenerative brain disease found in individuals with repetitive brain trauma.
Chronic Traumatic encephalopathy
30
In chronic traumatic encephalopathy, A protein called _____ forms clumps that spread throughout the brain, doing what?
* Tau
| * Killing brain cells
31
Early Signs of chronic traumatic encephalopathy? Late signs?
* Early - Mood and behaviors changes (atrophy of the frontal lobe)
* Late - Cognitive, dementia (atrophy of the temporal lobe)
32
How often do you wake a child with a closed head injury?
Every 2 hours.
33
What are 4 complications of TBI to monitor for?
* Increased intracranial pressure
* Decreased cerebral perfusion pressure
* Cerebral edema and herniation
* Posttraumatic seizures
34
How do you calculate MAP?
Double the dystolic pressure and add that number to systolic pressure. Divide total by 3 to get MAP.
35
Equation to calculate CPP?
CPP=MAP-ICP
36
Normal ICP range? Goal is to keep ICP below what in a pt with TBI?
* 0-10 mmHG, with the upper limit being 15.
| * Goal is to keep below 20
37
MAP must exceed___ in order for what to occur?
* 65
| * Cells to receive adequate o2/nutrients to metabolize energy in sufficient amounts.
38
Goal is to maintain CPP in what range with a TBI? What happens if it goes too low?
* 70-100 mmHG
* Maintain between 50-70, but generally above 60
* CPP below 50 causes vasodilation and blood volume increase in brain, causing an increase in ICP. Cerebral perfusion is hindered causing hypoxia and ischemia, which leads to brain damage.
39
3 cardinal signs of brain death on clinical examination?
* Coma
* Absence of brain stem reflexes
* Apnea
40
What occurs when CPP threshold is reached?
Vasoconstriction of blood vessels and ICP decrease
41
What should the patients temp be maintained at? How often is this checked? What is done if there is an increase? What should be used with caution and why?
* promote normothermia or mild hypothermia (33-34 degrees C)
* checked every 2 to 4 hours
* If increases, figure out cause. Can be maintained with acetaminophen and cooling devices
* Be cautious using Cooling devices, shivering may occur which can increase ICP.
42
List the GCS eye opening response scores from greatest to least.
4 - spontaneous
3- to speech
2 - to pain
1 - no response
43
List the GCS Verbal response from greatest to least.
```
5 - oriented to time, person, place
4 - confused
3 - inappropriate words
2 - incomprehensible sounds
1 - no response
```
44
List the GCS Motor response from greatest to least.
```
6 - obeys commands
5 - moves towards localized pain
4- flexion withdrawal from pain
3 - abnormal flexion/decorticate
2- abnormal extension/decerebrate
1- no response
```
45
What are some causes of fever in TBI?
* Inflammatory respnse
* Infection
* Central Fever (hypothalamic damage)
46
Two types of herniation that can result from ICP with grave outcomes?
* Central- downward herniation
| * Uncal - downward herniation (compresses midbrain)
47
TBIS can often be associated with what type of injuries? What should be assessed as a result.
* Cervical spine injuries (C1 and C2)
| * Assess for indicators of this, such as changes in breathing pattern/need for intubation/mechanical ventilation
48
Early signs of increased ICP?
*Behavioral/mental changes - restless, irritable, disoriented
49
late signs of increased ICP?
* Cushings *Cushings Triad
* Severe H/A
* Projectile vomitting/nausea
* Seizures
* Papilledema
50
______ and _____pupils are a poor prognostic sign of______.
* Fixed/dilated
| * Herniation
51
what is preferred for ICP monitoring? When is this used? What is a benefit of this?
* Ventriculostomy catheter
* Used in people with GCS < *
* Allows drainage of CSF to decrease ICP
52
When using a ventriculostomy catheter what are 3 important things to remember?
* Sterile technique is critical
* Transducer must be level with patients ear
* Keep ICP below 20mmHg
53
in a patient with increased ICP the PCO2 should be kept at _____ and the PO2 should be kept at _____ in order to prevent _____. This is done using ________.
* 30-35 mmHG
* 90- 100 mmHG
* Vasodilation
* Mechanical ventilation
54
When should suctioning be done in ICP patient and why? What should be done prior?
* Suction only when needed, to prevent excessive coughing (increases ICP).
* Hyperoxygenate w/ 100% O2 prior to suctioning.
55
What can be used to decrease cough reflex in ICP patient?
*Lidocaine or sedation
56
What class of medication is mannitol? How does it assist with increased ICP? How is it administered? What lab should be monitored?
* Osmotic Diuretic
* Pulls water out of edematous tissue and back into circulation, decreasing ICP.
* Administer with filtered needle
* Keep serum osmolality between 310-320
57
In addition to mannitol, what other medication may need to be used and why?
* Furosemide (loop diuretic)
| * prevents systemic fluid overload
58
What are some sedatives used to help treat increased ICP and why? What is the downside?
* Phenobarbitol/thipentone (barbiturates) are drug of choice. Opioids and propofol used as well.
* Decreases metabolic demands of body and pain, resulting in decrease in cerebral blood flow and edema, and aggregation.
* Can't perform neuro assessments while on these medications.
59
Positioning for Post op craniotomy? How often are clients turned? What medication is given to decrease post op edema?
* Supratentorial craniotomy - HOB 30 degrees
Infratentorial craniotomy - flat (Prevents brain from pressing down on excision site)
*Turn every 2 hours
*Dexamethasone
60
ABNORMAL POSTURING - flexion of the upper extremities, internal rotation of the lower extremities, and plantar flexion of the feet
Decorticate
61
ABNORMAL POSTURING - extension and outward rotation of upper extremities and plantar flexion of the feet.
Decerebrate (More serious and poorer prognosis)
62
what happens if ICP is equal to MAP?
cerebral circulation ceases
63
Risk factors for Spinal chord injury
* Male
* 15 to 35
* Alcohol and drug use
64
The initial mechanical disruption of axons as a result of stretch or laceration is referred to as?
Primary injury
65
Signifies Loss of sensory and voluntary motor communication from the brain to the periphery, resulting in paraplegia or tertraplegia.
Complete spinal chord injury
66
Signs of ability of spinal cord to relay messages to and from brain are not completely absent and sensory/motor fibers below injury are preserved.
incomplete spinal chord injury
67
paralysis of lower body
paraplegia
68
Paralysis of all four extremities
tetraplegia (incomplete tetraplegia is most frequent injury)
69
An SCI injury that takes place at what level will require ventilator support. Why?
*C4 ( minimal) and above (full)
*Paralysis of the diaphragm
(acute respiratory failure is leading cause of death)
70
What can cause cord compression in primary spinal cord injury?
* Bone displacement
* Interrupted Blood spply
* Traction from pulling on cord
71
What can cause tearing and transection of the spinal cord in a primary injury?
*Penetrating trauma (gunshot or stab wounds)
72
Within 24 hours of SCI, permanent damage may occur because of ______?
Edema
73
secondary injury progresses over time, the extent of the injury and prognosis for recovery are most accurately determined when?
At least 72 hours after injury
74
Important signs of improvement following SCI include what? When does greatest improvement occur?
* Muscular strength and pinprick sensation BELOW level of injury.
* Greatest imporvement occurs 3 to 6 months following injury.
75
what causes vasospasms and hypoxia with subsequent necrosis in secondary spinal injury?
High levels of vasoactive substances (noerepi, serotonin, dopaine) are released as a result of reduced oxygen levels from primary injury.
76
Four types of incomplete injuries? Which is the most common?
* Central cord syndrome (Most common)
* Posterior/Anterior cord syndrome
* Brown-Sequard syndrome
77
At which of the spinal cord injury levels does the patient have full head and neck control?
C5
78
Asymmetric injury with ipsilateral loss of motor function and sensation and contralateral loss of pain and temperature.
Brown-sequard syndrome
79
An initial incomplete spinal cord injury often results in complete cord damage because of
infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
80
Even if the injury is below C4, spinal cord edema and hemorrhage can affect the function of ______ nerve and cause ______,
Phrenic Nerve
| Respiratory insufficiency
81
In cervical and thoracic injuries, Paralysis of abdominal and intercostal muscles cause what? This increases risk for? What can the nurse do to prevent this?
* Ineffective cough
* Risk for aspiration, atelectasis, pmeumonia
* Deep breathing, incentive spirometry, maintain airway
82
Injury above T6 leads to dysfuntion of what system? What happens as a result? Symptoms? What is it important to identify?
* Sympathetic nervous system
* Neurogenic shock - Bradycardia, Vasodilation, Hypotenstion, Hypovolemia, Decreased CO
* Causes of hypotension
83
C3 and Above
Functional Ability: Inability to control ______
Self-care capability: Unable to ____. What is essential?
* Muscles of breathing
* Unable to care for self
* Life sustaining ventilatory support is essential
84
C4
Functional ability: Movement of ___ and ____ muscles. No function of what muscles?
Self- care capability: Unable to_____. able to do what with assistance of ___?
* Movement of Trapezius and Sternocleidomastoid muscles
* No function of upper extremity muscles
* Unable to care for self
* May self feed with powered devices
85
C5
Functional ability: _____ movement. Possible partial strength of ____ and ____.
Self-care capability: Able to drive____. Feeding?
* Neck movement
* Shoulder and biceps
* Drive electric wheelchair
* Feed self with powered devices
86
C6
Functional ability: Muscle function in ___. Partial strength in which muscles?
Self-Care ability: Can do what for self? May self propel a _____. Transferring?
* Muscle function in C5 level.
* Partial strength of pectoralis major.
* Can care for self
* Self propels lightweight wheelchair
* Transfers self from chair to bed.
87
C7
Functional ability: Muscle function in___. Lacking ____ muscle power.
Self-Care ability: Can dress ____. level of assistance needed? Transportation?
* Muscle function in C6 level.
* Lacking finger muscle power
* Dresses lower extremities
* minimal assistance needed
* Can use wheelchair and car w/ hand controls
88
C8
Functional ability: Muscle function in___.
Has_____Muscle power.
Self-Care ability: Can dress ____. level of assistance needed? Transportation?
* Muscle function in C7 level.
* Finger muscle power
* Dresses lower extremities
* minimal assistance needed
* Can use wheelchair and car w/ hand controls
89
T!-T4
Functional ability: Good _____ muscle strength
Self-Care ability:some independence from ____. requires ____ for standing exercises.
* upper extremity
* Wheelchair
* Long leg braces
90
T5-L2
Functional ability:_____ difficulties
Self-Care ability: Still requires___. Limited ambulation with ___ and ____
* balance
* Wheelchair
* Long leg braces and crutches
91
L3-L5
functional ability:______-_____ muscle function intact
Self-care ability: Uses ___ or ___ for ambulation.
* Trunk-Pelvis
| * Crutches or canes
92
L5-S3
Functional ability: ____ gait
Self-care capability: Able to do what?
* Waddling gait
| * Ambulation
93
describes any type of bladder dysfunction related to abnormal or absent bladder innervation
Neurogenic bladder
94
Common problems with a neurogenic bladder include what?
* urgency to void
* Increased Voiding frequency
* Incontinence
* Inability to void
* Urine reflux into kidneys from high bladder pressure.
95
Decreased GI motor activity in client with SCI contributes to _____ and development of______.
* gastric distention
| * paralytic ileus
96
Why are SCI clients more prone to stress ulcers?
*Excessive release of HCl acid in stomach
97
Why are intra-abdominal bleeds more difficult to diagnose in clients with SCI? What are 3 signs and symptoms to look for?
* May not experience pain/tenderness
| * Continued hypotension, Decreased H&H, Epanding girth of abdomen
98
______is the adjustment of the body temperature to the room temperature. Why does this happen? What type of injury is associated with this? What else contributes to this?
* Poikilothermism
* Interruption of sympathetic nervous system prevents temperature sensations from reaching hypothalamus.
* High cervical injuries
* decreased ability to sweat below injury
99
What can Ng suctioning lead to? It is importan to monitor what?
* metabolic alkalosis
| * Monitor F&E - especially sodium and potassium
100
SCI patients have a _____ in nutritional needs. What 3 things does adequate nutrition help with.
* Increase
| * Prevents skin breakdown, reduces infection, decreases muscle atrophy
101
What is one of the leading causes of death in patients with SCI?
Pulmonary Embolism. (DVT prevention is crucial since this is difficult to detect in SCI client)
102
Preferred diagnostic test for SCI?
CT scan
103
Nonoperative treatments involve ______of the injured spinal segment and ______, either through _____ or ______.
* Stabilization
* Decompression
* Traction (craniocervical)
* realignment
104
Immediate post SCI injury goals include what? 4 things
* Patent airway
* Adequate ventilation
* Adequate circulating blood volume
* Prevention of extended spinal cord damage (secondary injury)
105
Surgery within______ is associated with improved neurologic outcome
First 24 hours
106
involves attaching metal screws, plates, or other devices to the bones of the spine to help keep them aligned
Fusion
107
How often is traction maintained? What needs to be done if displacement occurs? Which device has possibility of displacement?
* maintained at all times
* Hold head in neutral position and get help.
* Gardner-wells/crutchfield tongs
108
What is kinetic therapy? What does this help prevent?
* continuous side to side rotation to 40 degrees or more using special bed.
* Helps prevent pulmonary complications and pressure ulcers
109
What is a profound effect of immobility in SCI patients? What can the nurse do?
* Skin breakdown due to decreased sensation and circulation
| * Meticulous skin care, remove backboard ASAP, assess areas under immobilization devices.
110
When is the need for spinal surgery determined?
After the spine is reduced
111
What may the patient wear after fusion or other stabilization surgery?
* Cervical collar
| * Sternal occipital mandibular immobilizer brace (SOMI BRACE)
112
IV fluid management for SCI?
*Crystalloids
*Colloids
*Blood products
(combo of all)
113
Disturbances that interrupt sympathetic nerve impulses result in vasodilation.. This is known as?
neurogenic shock
114
5 Clinical manifistations of neurogenic shock?
* vasodilation
* bradycardia
* Hypotension
* dry skin
* Temp instability (takes temp of room)
115
What is the main focus of treament for neurogenic shock? What is used?
* Maintaining blood pressure
| * Vasopressors, Fluid, atropine
116
Clinical manifistations of spinal shock?
* Flaccid paralysis
* Hypotension
* Anhidrosis below lesion
* urinary and fecal retention
* Abscence of deep tendon reflexes
* Impaired proprioception
* Decreased visceral and somatic sensations
* Paralytic illeus (muscles used for digestion stop working)
117
_____, the return of reflexes, is a sign of resolving ______.
* Spasticity
| * spinal shock
118
Pathophysiology of Autonomic dysreflexia?
* Stimulus below level of injury (distended blowel or bladder, skin)
* Mass sympathetic response causing vasoconstriction, leading to hypertension
* Baroreceptors signal cranial nerves 9 and 10 (glasso and vagus), and vagus nerve slows heartrate.
119
3 aspects of GRADE 1 (mild) concussion
* Short period of confusion
* No loss of consciousness
* Mental status abnormalities resolve in less than 15 minutes
120
3 Aspects of GRADE 2 (moderate) concussion
* Short periods of confusion
* No loss of consciousness
* Concussive symptoms/mental status abnormalities last more than 15 minutes
121
Aspect of GRADE 3 (severe) concussion
*Any loss of consciousness lasting from minutes to seconds.
122
how can the nurse facilitate cough effectiveness in SCI?
* chest physiotherapy and assisted coughing
| * Deep breathing, Incentive spirometry
123
When does AD occur?
*In clients with injury of T6 only after spinal shock has subsided
124
5 clinical manifestations of Autonomic dysreflexia?
* SEVERE headache
* HYPERtension
* Flushing/Sweating ABOVE injury site
* Pallor BELOW injury site
* Bradycardia
125
Interventions for AD?
* immediately Raise head of bed to 45-90 degrees (lowers BP)
* Rapid assessment to identify cause/ check BP every 5 min
* Check for bladder and bowel distention, and advise
* Check for stimuli of skin such as tight clothing/pressure areas
* If still isnt resolved, contact prescriber for antihypertensives (watch for rebound hypotenstion)
126
Pharmacological intervention for pain in SCI?
* NSAIDS
* Anticonvulsants
* Antidepressants
* Opioids
* Muscle relaxants
127
Deep rapid breathing. Seen in what?
Hyperventilation - midbrain lesion
128
Increasing/Decreasing depth, followed by periods of apnea. Seen in what?
Cheyne-Stokes - diffuse cerebral injury
129
prolonged pause at end of inspiration. Seen in what?
Apneutistic - seen in lesion proximal to cranial nerve V in pons.
130
Breathing in short bursts. Seen in what?
Cluster/Biots - seen in pontine (pons) lesion
131
Irregular Breathing. Seen in what?
Ataxic - Seen in medula lesion
132
Which type of hematoma has the higher mortality rate?
Subdural hematoma
