Traumatic Brain Injury Flashcards
Traumatic Brain Injury could be described as…
Damage to the brain from an external mechanical force. Not caused by neurodegenerative changes or congenitial causes.
What is the most common CAUSE of TBI?
state population of people if applicable
- Falls: elderly, alcohol and drug influecned indiviuals
2. Motor Vehical Accidents
A patient arrives to the ED stating that he got into a fight in the park and got punched in the head. What type of scan is preferred to detect TBI?
CT Scan
A patient is diagnosed in the ED with a mild concussion. After patient education and final assessments are completed, what is the next step for the patients care?
Discharge home
A nursing student is learning about neurological disorders, what five disorders will he/she be learning about?
- Traumatic Brain Injury
- Neurodegenerative Conditions
- Stroke
- Brain Tumors
- Spinal Injury
A family member of a patient who had a traumatic brain injury asks the nurse how often do these patients have long term diabilities. What is an appropiate response of the nurse?
All patient prognosis is different; however, about 1/3 of people with TBI will have long term disability.
A patient in a recent AMA is brought to the Trauma ICU, upon arrival the nurses need to turn the patient to assess a gash coming from the back of the head. What is the safest way to turn the patient to prevent spinal injury?
Log Roll
How is the brain positioned in the skull?
Floating in cerebral spinal fluid
What are the meningeal layers that help protect the brain?
Dura Mater
Arachoid Mater
Pia Mater
A nursing student asks her professor what a head injury is, what is the best definition the professor will provide?
A broad term that is an injury to the scalp, skull, brain or blood vessels.
When is a head injury classified as a TBI?
When the head injury causes brain damage.
A 7 year old child comes to the Pediatric ED bleeding from his forehead. The patient says he feel on a pebble while at recess. When you assess the wound, a thick piece of skin is missing from the child’s forehead and the cut is deep. What type of head injury would you describe this as?
Scalp injury
A patient diagnosed with a linear skull fracture asks the nurse what that means and how to care for it, what is the best response from the nurse?
A linear skull fracture is a simple crack in the skull. It is non-depressed (meaning it doesn’t sink in) and usually is caused by low-impact forces. The staff will monitor for possible hematomas that can occur under the crack, which could cause temporary loss of consciousness. If not hematomas develop, the patient can go home.
What is an important education concept that nurses should teach their patients going home with mild head injuries?
If begin to be symptomatic, seek medical attention.
A patient arrives to your unit with am unopened depressed injury to his frontal bone. The report says the CT scan show multiple cracks in the skull. How would you as a nurse best decribe possible injury?
The frontal bone is more likely to crack. The patient most likely has a comminuted fracture, because of the depression and multiple cracks.
A 26 year old male patient who has a bullet wound to the head is rushed to the ED. Blood is everywhere and the patients fractured skull is exposed. How would you educate the family of this diagnosis?
The patient has a compound head fracture. There is a puncture wound through the skin and cracked bone is exposed.
A patient enters the ED anxious and paranoid. He yells that he has escaped from being murdered. Other than his behavior he seems medically fine, until he passes out, falling forward, and the nurse discoveres a large laceration and depression on the base of his skull. It looks as though the patient was attacked with an axe to the back of the head. What kind of fracture would the nurse determine the patient has? What will the nurse recognize as a common presentation with this diagnosis?
Basilar fracture!
The nurse would expect to see raccoon eyes and possible CSF leakage from the nose or ears.
A nursing student must understand that primary traumatic brain injuries are the result of…
Open head injuries: skull fracture usually from foreign object penetration causing laceration of brain tissue and vessels
Closed head injuries: no skull fracture and skin closed usually from concussion, brain contusion (bruising), diffuse axonal injury, or vessel tearing (resulting in hemmorage)
A 8 week old baby comes to the pediatric ED unconscious and the parents are saying that the child rolled off the couch. After assessing the patient and having a CT scan, it appears that the baby has suffered from contrecoup force to the head. The nurse should detect that the cause to this injury is what?
Shaken Baby Syndrome
This puts the baby at risk for brain contusion, which could result in swelling and possible TBI.
How would a nurse describe a diffue axonal injury to a nursing student?
Nerves are torn b/c of force injury to the head. This could lead to coma or slight vegetative state.
A football player lost consciousness after a play at a game 30 mins ago. The responders say that the patient was unconscious for 15 minutes. Why is the nurse suspecting a concussion?
Football players have the risk of getting hit in the head, with high intensity and force. When people get concussions they may or may not loss consciousness for 0 to 30 minutes.
A nurse has a patient that is diagnosed with traumatic brain injury r/t force. What should the nurse be most concerned about?
*Contusion (bruising, which could lead to swelling)
Intracranial hemorrhage
Diffuse axonal injury
A patient comes in after being in a motor vehical accident. In the accident, the patient felt her head go back and forth a couple times against the steering wheel and then the headrest. What type of brain injury would the nurse suspect?
Contrecoup: another example would be shaken baby syndrome
A patient who describes there injury as whiplash is most likely to have what kind of brain injury?
Acceleration
A patient comes to the ED after running into the newly cleaned glass sliding door. What type of brain injury would the nurse suspect?
Deceleration
Patients diagnosed with a mild TBI would be expected to have a GCS of what?
GCS 13-15
0-30mins loss of consciousness
A patient who got whiplash from a softball hitting him in the jaw without paying attention, passed out for 2 hours and has a GCS of 11. What level of TBI does the nurse believe the patient has? What is the patients plan of care?
Moderate TBI
Hospitalize for a minimum of a day; monitor for risk of hematoma, brain contusion or anxonal injury; really monitoring ICP
GCS 2-12
30mins-6hrs loss of consciousness
The nurse is taking an exam and there is a question on severe TBIs. The nurse understands that severe TBIs…
Have a GCS of 3-8
>6 hours loss of consciousness
Caused by a crushing blow or penetrating injury
Low chance of survival
How would a nurse define a secondary brain injury?
Any process that occurs after inital injury and worsens outcome
In secondary brain injuries intracranial hemmorage and edema both have the negative potential to cause?
Hypoxia: enough blood or edema builds up and compresses the vesses that are giving the brain oxygen
A patient comes to the ED with a head injury from a bar fight. The injury is under control, but a couple days later morning labs are drawn and show a WBC count of 14,000 and the patient has aa temperature of 101.3. The patient complains of a stiff neck and fatigue. What secondary brain injury does the nurse suspect?
Meningitis (infection)
The nurses patient has a fall at home and was diagnosed with an epidural hematoma. What information is important for the nurse to know about this specific intracranial hemorrhage?
Epidural hematoma is a secondary type of injury. When an artery has been torn or damaged and bleeding occurs between the skull and the dura mater. More life threatening becaue arterial blood has more pressue which increase the risk of more blood loss.
Where is a subdural hematoma located? What kind of blood is involved?
Between the dura and arachnoid space. The bleed consists of venous blood which allows the bleed to be slower and s/s may not present fast.
True or false. An intracerebral hematoma is bleeding within the brain. A patient would have s/s of severe headache, vomiting, one sided weakness and LOC changes.
True
What is a common phrase that is used to basically explain the clinical presentation of a patient with a epidural hematoma?
“Wake up and die”
B/c there is an initial loss of consciousness and then the patient regains lucidity and then start to decline again. Have the potential to die within mins to hours.
A patient presents to the ED complaing of headache and the patient appears slightly disoriented. The patient reportedly had a fall 6 days ago at home. The patient admits to a history of alcoholism. What brain injury should the nurse be on alert for?
Subacute Subdural Hematoma.
Alcholics who fall have a higher chance of developing a subdural hematoma b/c of cirrhosis and abnormal clotting factors in the damaged liver. This injury would be subacute because symptoms started to develop 6 days after the injury.
Acute Subdural Hematoma occurs within?
48 hours of injury
Subacute Subdural Hematoma occurs within?
48 hours to 2 weeks
Chronic Subdural Hematoma occurs within?
2 weeks to several months
What would as nurse identify as signs and symptoms of intraccerebral hematoma?
Severe headache
Vomiting
One sided weakness
LOC changes
A nursing student wants to know the biggest concern with increased intracranial pressure r/t brain contusions. What is the best answer?
Poor perfusion of the brain cells r/t swelling (b/t of contusion, normal inflammatory process), which results in a build up of blood and/or edema. The poor perfusion can lead to hypoxia.
A patient who has a ICP of 22 mmHg is admitted. The nurse knows that this ICP is?
Abnormally high. Anything over 20 causes brain cells to start to die.
What would be considered a normal ICP?
5 to 15 mmHg
What would be the primary intervention for a patient with a ICP of 24 mmHg?
Remove part of the skull, the blood or part of the brain in order to relieve the pressure
What is the earliest sign of increaed ICP?
Decreased LOC
What would the nurse be able to identify as two last signs of increased ICP?
- dilated and nonreactive pupils
2. Cushing’s Triad
A nursing student is taking an exam and the question is asking about key features of increased intracranial pressure. What would be the key s/s?
Decrease LOC (lethargy to coma) Behavioral changes C/O headache Recurrent N/V Change in speech pattern Aphasia Slurred Speech Change in Sensorimotor Pupillary changes Cranial nerve dysfunction Ataxia Seizures Cushing's Triad Abnormal posturing
Other than hypoxia, what is another complication to increase intracranial pressure?
Brain Herniation
A patient on your team was diagnosed with a brain contusion and has been declining in the past couple of days. You go into assess your patient and she is breathing deep and fast, with periods of apnea and has pinpoint nonreactive pupils, what would the nurse identify is going on with the patient?
Brain Herniation
w/ Cheyne-stokes respirations
What are the four criteria for brain death determination?
- Coma of known cause (has to be something we cannot fix)
- Normal or near normal core temperature (at least greater than 96.8, we warm them up)
- Systolic BP > or equal to 100mmHG
- At least one complete neurologic exam (sometimes 2)
A nurse is asked to assist the doctor in a complete neurologic exam. What might he/she anticipate?
Glasgow Coma Scale = 3
Apnea Test (stop vent, see if pt. picks up breathing)
No Pupillar Response (dilated and fixed)
No gag or cough reflex
No corneal reflex
No oculovestibular reflex
No oculocephalic reflex
A nursing student learns that a oculovestibular test uses what in the ear to determine nystagmus?
Cold water
A nursing student learns that an abnormal oculocephalic reflexes looks like what?
Doll’s Eye Movement
A nurse is assessing their patient using the GCS. When the nurse administers pain to the patient, the patient has a decerebrate response. What is this indicative of?
Brainstem dysfuntion
What is the issues with cerebral angiography, EEG, transcrainal dopple and cerebral scintigraphy when confirming brain death?
False positives and false negatives
True or false. Brain death is legal death.
True
After brain death is confrimed what are the next steps for the patient and their family?
Withdrawl of Life Support
Organ Donation
An ICU nurse is caring for a patient with traumatic brain injury, what interventions will the nurse do for this patient?
Neurological Assessment ABC & VS ICP Prevention/Treatment Nutrition Safety
During the nurses neurological assessment of their TBI patient, what 3 things are assessed?
LOC (prioirty) b/c first sign of deterioration
Pupillary Response
GCP
True or false. GCS includes pupillary reflex.
False. Pupillary reflex is assessed in neuro assesment, but is NOT part of GCS assessment.
How often should the ICU nurse perform a neuro assessment?
Every hour
An ICU nurse knows that a TBI patient with pinpoint/nonreactive pupils is because?
Brainstem dysfunction
An ICU nurse knows that a TBI patient with ovoid/nonreactive is indicitive of?
Development of increased ICP
An ICU nurse knows that a TBI patient with dilated/nonreactive pupils is indicitive of?
Poor prognosis, marked with increased ICP “blown”
A patient that is awake would what LOC?
Alert
A patient that is drowsy and needs a gentle verbal or touch stimulation would be what LOC?
Lethargic
A patient that responds slowly to external stimulation and needs repaeated stimulation to maintain attention and repsponse would be what LOC?
Obtunded
A patient that responds only minimally with vigorous stimulation and may only moan as a verbal response would be what LOC?
Stuporus
A patient that has no observable response to any external stimuli would be what LOC?
Comatose
What is the nurses highest priority for a patient with TBI?
Airway (ABC)
Finish this saying. “Less than 8…”
Intubate
For patients with TBI, nurses can help with respiratory management by?
Maintaining PaCO2 of 35-45 Preventing hypercarbia (which would cause vasodilation, increase ICP) Allow rest between suction, minimal suction if possible
A nurse has a patient with TBI on their team. The nurse is suspected of Cushing’s Triad. What s/s would the nurse see?
Hypertension
Widening pulse pressure
Bradycardia
A nurse knows to take vital signs on a TBi patient how often?
Every 1 to 2 hours
True or false. Fever is a common s/s of a TBI upon admission?
True – fever is a normal response to trauma
Why would the nurse want to control a fever for a TBI patient? What would the nurse give to help control the fever?
While it is a normal response, fever uses more oxygen, which could increase the risk of hypoxia. Nurses would give Tylenol.
How would a nurse prevent increased ICP?
Positioning
Avoid extreme flexion or extention of neck, maintain neutral midline positon, avoid hip flexion, HOB no more than 30 degrees
Monitor CSF leakage
Watch at ears and nose , halo sign
Nurses know that opioids, benzos and parlytics may mask neuro assessments and decrease BP. But why would they still give these to treat increased ICP?
To control agitation, which would worsen ICP
What drug is given to medically induce a coma?
Barbiturates (pentobarbital)
Why would a patient be put in a medically induced coma?
If increased ICP cannot be controlled. It slows down the central nervous system.
What are common complications of pentobarbital?
Decreased GI motility, dysrhythmias (decreased K+), decreased BP
What is the osmotic diuretic mannitol used for?
Decrease ICP and improve LOC, by pulling fluid off the brain and peeing it out.
What is important for the nurse to know when giving mannitol?
Given IV bolus via IVPB
Must use filtered needle or tubing
Furosemide as adjunctive therapy to prevent rebound edema
Monitor UO, serum and urine osmolatrity
SE: hyponatermia initillay and as urinitating continues, becomes hypernatremic
What is the goal for using mannitol?
LOC should improve
If mannitol is not effective, what could be given?
3% Saline (hypertonic fluid)
A nurse has a patient being admisitered 3% Saline. How often is the nurse going to check the sodium levels?
Every 6 hours
Patients with brain trauma to the pituitary or hypothalamus have a risk for these two fluid and electrolyte associated complications.
- Diabetes insipidus
2. SIADH
The nurse has a paitent with TBI and knows that fluid and electrolyte management is necessary for these patients. What must the nurse monitor the patient regarding F & E?
Monitor for fluid overload
Monitor urine specific gravity and osmolarity
Monitor electrolytes daily
Name the 4 different ICP monitoring devices.
Epidural
Subdural
Subarachnoid
Intraventricular
A patient has an intraventricular monitoring device. The nurse knows that this specific monitoring device is located where and has the ability to do what?
Located in the ventricles of the brain.
Has the ability to monitor ICP and drain CSF (ventriculostomy)
What is the biggest risk with intraventricular ICP monitoring devices?
Infection
What type of ICP monitoring device is the most accurate?
Intraventicular
When are craniotomy’s used?
When ICP cannot be controlled
What two things are commonly removed during a craniotomy?
Blood hematoma
Tumor
In a craniotomy what is being temporarily removed?
Skull
What are common nutritional changes that occur to patients with TBI?
Changes in smell, taste, swallowing
What is a safety concern for TBI patients when it comes to eating?
Decreased LOC and dysphasia RF aspiration
The nurse has a patient with a TBI and is considering her patients nutritional management, who might she consult?
Dietician
Occupational/Speech therapy
What might the nurse expect to see in her TBI patient regarding sensory/perceptual alterations?
Changes in vision & temp control Freq. reorientation Short term memory loss Cognitive impairment RF seizures
How will the nurse know if their patient is cognitively imparied after a TBI?
Once the patient improves their LOC
A nurse with a TBI patient is document safety precautions in place. What might she document as interventions for this patient?
Keep bed in low position Bed alarm Hand mittens to protect lines Restraints last resort Provide quiet environment (less stimuli better for patient)
