TBISC Flashcards
what are the 3 components of the head
brain tissue
blood
CSF
*monroe kelly hypothesis is if the volume of one of the 3 increases then the volume of the other two must decrease
when ICP is increases what is the first thing that displaces in the head
cerebral spinal fluid
*next thing to go is blood volume then brain tissue herniates into the foreman of monroe because it has no where else to go
what is an ominous sign of potential brainstem herniation and impending death
cushings triad
*systolic hypertension with widening pulse pressure
what is a sign of increased ICP
when pt is talking and all a sudden vomits or has posturing
why do cranial nerves matter
can be compressed as the brainstem is compressed, and warn of impending herniation
what cranial nerve is olfactory (smell)
cranial 1
what cranial nerve is vision
cranial 2
what cranial nerve is pupillary reaction
cranial 3
if patient has vision problems what can you do to help them
show them around the room, show them always, leave call light with them, when they are eating describe their plate like a clock
what are the 3 points in time death can occur after a head injury
immediately after the injury (massive head injury)
within 2 hours after injury (increase in bleeding or swelling)
3 weeks after injury
(ischemia, been in hospital long enough to become septic)
where is a basilar skull fracture and what are symptoms
at the base of skull
CSF leaks from ears, nose, or both
*dont pack ears or nose to stop it, don’t use NG tube either
how long does a mild concussion last
30 minutes
how long does a classic concussion last
unconscious lasting less than 6hrs
moving force that hits stationary head
acceleration injury
*gunshot to stationary head
moving head hits stationary object
deceleration injury
*fall and hits ground
moving head hits a moving object
acceleration/deceleration injury
*car crash head on
what is coup-contrecoup
brain hits skull surface (coupe) brain hits the skull surface opposite of first hit (contrecoup)
tearing twisting of the brain
diffuse axonal injury
*know it happens because pt comes in unconscious and stays unconscious
clinical signs of diffuse axonal injury
decrease LOC
increased ICP
decerebrate or decorticate
global cerebral edema
results from bleeding between the dura and the inner surface of the skull
epidural hematoma
*walking dead man because knocked out at the scene but regains consciousness at some point and becomes unconscious again
occurs from bleeding between the dura mater and arachnoid ayer of the meningeal covering of the brain
subdural hematoma
*a tear in the small bridging veins is the most common source
slower than an epidural bleed
after initial bleeding, subdural hematoma may appear to enlarge over time, rebelled, or never really stop is called…
subacute subdural hematoma
*can happen to children
subdural that you can’t see any changes due to big amount of space in the head
seen in chronic alcoholics from cerebral atrophy
chronic subdural hematoma
*peak incidence in sixth and seventh decade of life as we get older brain shrinks
occurs from bleeding within the parenchyma
intracerebral hematoma
*usually occurs within the frontal and temporal lobes
can not evacuate this hematoma but you can open up a skull flap to let swelling go out
intracerebral hematoma
bleeding into the subarachnoid space
subarachnoid hematoma
a pt with a subarachnoid hematoma will say they have…
migraine, light sensitive, nuchal rigidity, nausea and really high BP
what is important to know about a berry aneurysm
if we don’t control HTN it will blow
*prevent vasospasm by giving calcium channel blocker nimodipine (give on time every day)
what is the nursing assessment of a head injury
airway
glasglow coma scale
neuro check
presence of CSF leak
what is the best position to have injured head at
pt semifowlers (30 degrees) and head midline so they can drain from both sides
how do we treat brain injuries
maintain airway breathing circulation start fluids raise HOB near check
bruising marks behind ear indicate
basilar fraction
“raccoon eyes” indicate
coup-contrecoup
chronic subdural hematoma are seen in
alcoholics and elderly
temporary neurologic syndrome which is decrease of reflexes, loss of sensation, placid paralysis below injury site
spinal shock
*these symptoms may last weeks to months, but can resolve from time of injury to when they arrive at hospital
loss of vaso motor tone which is venous pooling of blood, decrease CO
neurogenic shock
*careful use of IV fluids and use pressors
liters of fluid will do NOTHING for them so we use pressor to constrict
hyperflexion occurs from _______ and the head bends _______
compression; forward
where is the high priority place for hyperflexion
cervical neck and below ribs (lower lumbar)
hyperextension occurs when the head ______ and _______
accelerates and decelerates
*vertebrae may fracture or subluxate
axial loading is a ______ force
vertical force
*vertebrae shatter into little pieces in spinal cord
rotational injury is _______ of the spinal column
displacement (rotation)
what level of injury is the vertebral level where there is most damage to vertebral BONES and LIGAMENTS
skeletal level
what level of injury is the LOWEST SEGMENT OF SPINAL CORD with normal sensory and motor function on both sides of the body
neurologic level
what level of injury is it where there is no or decreased sensation below and normal sensation above
sensory level
results in total loss of sensory and motor function below level of injury
complete cord involvement
results in a mixed loss of voluntary motor activity and sensation and leaves some tracts intact
incomplete (partial) cord involvement
what is the central cord syndrome
the central of the central cord is damaged
- occurs most common in cervical cord region
- motor weakness and sensory loss are present in both upper and lower extremities
in a patient with central cord syndrome is the loss greater in the arms or legs
arms
*will still be able to move the legs in bed… eventually may be able to walk again but way later
result of damage to one half of spinal cord
brown-sequard syndrome
- loss of motor function and position and vibration sense on same side of injury (paralysis on same side as lesion)
- the opposite side has loss of pain and temp sensation below level of lesion
what makes the vertebral injuries unstable
if there is a ligament and tendon damage
*get MRI if not done in first 72hrs you won’t see it because edema will cover it up
an atlanto-occupital injury is
internal decapitation
a C1-jefferson fracture is known as the
hang man
a C2 odontoid fracture is most common in
old people
a cervical injury above ___ is almost always going to be on a ventilator
C3
C3-C5 cervical injury is loss of _____ nerve function
phrenic
*phrenic nerve and intercostals are what help us breath
C6-T8 injury is loss of _______
intercostals
- these patients will be see saw breathing, using everything they have left to breathe, rocking back and forth
- make sure they get oxygen, stays sitting up
T7-T12 injury is loss of
abdominal muscles
*very hard for them to cough
in patients with spinal injury urinary retention is
common
*make sure they are emptying at regular tines and bowels move at regular times to prevent UTI
if cord injury is above T5 GI problems will be related to ______ and injury at T12 or below is decreased _______ tone
hypomotility; sphincter
*may need to give enemas to stimulate it to move along
in a spinal cord injury they have decreased ability to ____ and ____ below the lesions
sweat and shiver
- lose ability to regulate their body temp
- make sure temp is suitable for pt because they take on temp of the room
what is the BIGGEST complication of cord injuries
autonomic dysreflexia *hypertension blurred vision throbbing headache marked diaphoresis above lesion level
if pt has autonomic dysreflexia what interventions should be done
elevate HOB 45 degrees or sit upright
notify physician
immediate catheterization
*major cause of this is full bladder or bowel
