Traumatic Brain Injury Flashcards
What is the definition of a head injury?
Includes injury to the scalp, the skull, or brain; any damage as a result of trauma
What is the most common cause of TBI in persons under 75 years of age?
motor vehicle crashes
What demographic has the highest risk for a TBI?
15-to 19-year age group. Males twice as likely as females to sustain a TBI.
A primary traumatic brain injury (select all that apply):
A) Is a result of the initial injury
B) Includes a contusion
C) Includes ischemia
D) Includes hypoxia
E) Includes a laceration
A, B,E
What are three primary mechanisms of injury associated with traumatic brain injury?
- acceleration and deceleration
- rotational
- penetrating
What is the most common mechanism of TBI?
acceleration and deceleration
What type of mechanism of injury occures when a moving blunt object strikes the head, involving transfer of energy along a linear path?
Acceleration injury (e.g., hit in head with bat, baseball or other moving object)
What type of mechanism of injury occurs when an individual’s head strikes an immovable object, such as a the dashboard of a car or the ground during a fall?
Deceleration injury
What mechanism of injury occurs when the force of impacting the head transfers energy to the brain in a non-linear fashion, whereby the head rotates on its axis, resulting in shearing forces being exerted throughout the brain and its axons.
rotational injury (e.g., in boxing)
What mechanism of injury occurs when a foreign object invades the brain?
penetrating injury
What is involved in primary injury in a TBI?
- Direct mechanical injury caused by the force of the imapct from the traumatic event
- Immediate and often causes irreversible damage
- May include laceration or shearing injury, contusion, swelling, hemorrhage
What is involved in secondary injury in a TBI?
- Occurs in response to the primary injury
- arises from local tissue and sustemic response to the primary injury
- Involves ischemia, neuronal death, inflammation, and cerebral swelling
- Secondary injury increases the severity of primary injury
- Minimizing secondary injury is a major focus of TBI management
On arrival to the emergency department, which nursing assessment has highest priority for the client with likely traumatic brain injury?
A) Testing for alcohol and drugs
B) Monitoring urine output
C) Assessing level of consciousness
D) Checking for pupil response to light
C) Assessing for level of consciousness
The GCS score for you client with a risk for increased intracranial pressure has been stable at 12 for the last 6 hours. This time you rate him at a 9. Which of the following have you noted and what does it mean?
A) He is less responsive, a sign that his intracranial pressure may be increasing
B) He is more responsive, a sign that he may be improving
C) His pupils are fixed and dilated, an ominous sign
D) He does not move or make sounds, which may mean he got too much pain medication
A
A 17-year-old man is admitted after sustaining a closed head injury in a gang related fight. The nurse in the ED reported that his VS before transfer were: BP 136/70, HR 92, RR 22. Your assessment indicates VS: BP 168/54, HR 50, RR 10 and irregular. Which of the following is the most appropriate response to this assessment data?
A) Inform the physician of the change in assessment
B) Give the client IV naloxone as ordered
C) Call the lab and request a stat blood draw for drug screen
D) Lower the head of the client’s bed flat immediately
A
What are the four different types of skull fractures?
- linear skull fractures
- depressed skull fracture
- open skull fracture
- impaled object
What is a basilar skull fracture and associated clinical findings?
Fractures of one or more bones that compose the base of the skull. Assessment findings include:
* presence of periorbital acchymosis “raccoon eyes”
* mastoid ecchymosis “Battle sign”
* otorrhea
* rhinorrhea
* facial nerve paralysis
In the case of drainage from from the nares or ear canals, what test can you perform to detect the presence of cerebrospinal drainage?
- Look for the halo sign
- Place a drop of drainage onto a sterile 2x2 gaunze; if it contains CSF, a yellowish-colored ring will form around the drop of fluid, suggesting the drainage contains CSF
- Also test with a glucose reagent strip for the presence of glucose; clear drainage that tests positive for glucose indicates the fluid is CSF
What are signs and symptoms of trauma to the head and resulting injury to the brain?
- Decreasing mental status from confusion to coma
- Deformity of skull
- Drainage of spinal fluid or blood from nose and ears
- Discoloration around the eyes (late)
- Unequal pupils or pupils that do not respond to light
- Respiratory changes
- Systolic blood pressure may increase
- Heart rate may decrease
- Abnormal posturing
- Sensory or motor deficits
- Sudden onset of neurologic deficits and neurologic changes; changes in sense, movement, and reflexes
- Changes in vital signs
- Headache
- Seizures
- Altered or absent gag reflex
The client has a traumatic brain injury from a MVA. Which sign does the nurse associate with increased intracranial pressure (ICP)?
A) Changes in breathing pattern
B) Dizziness when sitting up
C) Increasing level of consciousness
D) Equal and reactive pupils
A: Changes in breathing pattern
A client has fluid leaking from the nose after a basilar skull fracture. Which of the following would indicate that the fluid is cerebrospinal fluid?
A) It clumps together on the paper and has a pH of 7
B) It leaves a yellowish ring on the paper and tests positive for glucose
C) It is grossly bloody in appearance and has a pH of 6
D) It is clear in appearance and tests negative for glucose
B) It leaves a yellowish ring on the paper and tests positive for glucose
A client is admitted to the ICU after a craniotomy to remove a clot from the frontal lobe. How will the nurse position the client?
A) With flexed knees to decrease intra-abdominal pressure
B) On the right side to prevent bleeding at the incision site
C) With the head of bed elevated at least 30 degrees to promote venous drainage
D) Log rolled to bed and head of bed no more than 15 degrees elevation
C) With the head of bed elevated at least 30 degrees to promote venous drainage
