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NUR 265 ADVANCED MED SURG > Unit 7 Chapter 41 Traumatic Head Injury: Concussion,Contusion, Skull fracture, > Flashcards

Unit 7 Chapter 41 Traumatic Head Injury: Concussion,Contusion, Skull fracture, Flashcards

1
Q

What is Traumatic Brain Injury?
A. occlusion of carotid artey
B. decreased intracranial pressure
C. embolism in left coronary artery
D. external mechanical force to the head

A

D. external mechanical force to the head

Traumatic brain injury (TBI) is damage to the brain from an external mechanical force and not caused by neurodegenerative or congenital conditions. TBI can lead to temporary and permanent impairment in cognition, mobility, sensory perception, and/or psychosocial function.

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2
Q

Early assessment of deterioration includes

A

assessing level on conconusness

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3
Q

Basillar skull fracture, behavior that would warrant attention

A

change in behavior and level on consciousness, irritable , disoriented , aggressive

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4
Q

Are patient with Neurodisorders at risk for seizures?
A. YES
b. Yes

A

**A. YES **

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5
Q

What can lead TBI to?

A

TBI can lead to… temporary and permanent impairment in cognition, mobility, sensory perception, and/or psychosocial function.
-HIT TO HEAD- MTV ACCIDENT- HUGE FALL
-CONTRA COUP BRAIN IS HIT FORWARD AND BACK

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6
Q

What is. the typical plan of care for a client with Traumatic Head Injury?
A. Monior client for the first 24 hours
B. Keep light bright
C. Administer Morphine for pain
D. Assess abdomen for peritinitis

A

A. Monior client for the first 24 hours

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7
Q

Why is it important to monitor clients with TBI?

A
  • Death usually occurs at 3 points:
  • Immediately with injury
  • Within 2 hours after injury
  • 3 weeks after injury
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8
Q

What does the degree of brain injury depend on select all that apply?
A. open or closed
B. Force
C. Location
D. Patient reports
E. Medication administered
F. Health History

A

A. open or closed
B. Force
C. Location

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9
Q

Which of the following locations of TBI are alcholic prone to being diagnosed with after external force to the head?
A. subdural hematoma
B. Intracerebral hemorrhage
C. Epidural hematoma
D. Petechia

A

A. subdural hematoma

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10
Q

What drug is contraindicated for a client who has just sustained a Traumatic Brain Injury?
A. Methyphenidate
B. Acetominophen
C. Morphine
D. Mannitol

A

C. Morphine
Morphine sedates and can induce confusion in your patient, while obtaining history we do not want to induce sleep

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11
Q

are motor vehicle accidents the leading cause of head injuries?
A. Yes
B. No

A

A. Yes

MVC’s (motor vehicle crashes OR MVA’s motor
vehicle accidents) and falls are the leading
cause of head injuries

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12
Q

Your client reports havinga throbbing headache , what medication would you administer if they sustained a fall?
A. Methyphenidate
B. Acetominophen
C. Morphine
D. Mannitol

A

B. Acetominophen

Morphine sedates and can induce confusion in your patient, while obtaining history we do not want to induce sleep

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13
Q

When it comes to a patient with a neurological disorder. They is a a rise and fall of the upper chest. What should be the next basis of your assessment?
A. Gatrointestinal assessment
B. Skin assessment
C. Respiratory assessment
D. Level of consciousness

A

D. Level of consciousness

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14
Q

After a patient falls what is the best diagnostic tool?

A

CT SCAN

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15
Q

What scale is best used to determine your patients neurological status?

A. Glascow Coma Scale
B. Wond Baker Faces scale
C. PQRST Scale
D. NIPS Scale

A

A. Glascow Coma Scale

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16
Q

Criteria of Glascow Coma Scale

A

EYE OPENING
Spontaneous= 4
To Voice= 3
To Pain= 2
None=1

BEST VERBAL RESPONSE
Oriented=5
Confused=4
Inappropriate words=3
Incomprehensible sounds=2
None=1

BEST MOTOR RESPONSE
Obeys commands=6
Localizes pain=5
Withdrawns=4
Flexion=3
Extension=2
None=1

TOATAL AND BEST SCORE 15

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17
Q

Classification of Glacow Coma Scale
MILD
MODERATE
SEVERE

A

Mild–GCS 13-15
* Concussion or Mild TBI - Feeling dazed AND possible loss of consciousness for
up to 30 minutes or loss of memory for events before accident or focal neurological deficits
* Symptoms usually resolve within 72 hours
(NURSING INTERVENTION: Assess pt at basline and notify and report changes)

  • Moderate-GCS 9-12
    with up to 6 hr. loss of consciousness.
  • Post traumatic amnesia may last up to 24 hours

Severe-GCS 3-8
with greater than 6 hr. loss of consciousness
* Usually require treatment in critical care and have focal & diffuse injuries to
brain tissue, blood vessels &/or ventricles

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18
Q

MILD GCS

A

Mild–GCS 13-15
* Concussion or Mild TBI - Feeling dazed AND possible loss of consciousness for
up to 30 minutes or loss of memory for events before accident or focal neurological deficits
* Symptoms usually resolve within 72 hours
(NURSING INTERVENTION: Assess pt at basline and notify and report changes)

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19
Q

MODERATE GCS

A
  • Moderate-GCS 9-12 with up to 6 hr. loss of consciousness.
  • Post traumatic amnesia may last up to 24 hours
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20
Q

SEVERE GCS

A

Severe-GCS 3-8 with greater than 6 hr. loss of consciousness
* Usually require treatment in critical care and have focal & diffuse injuries to
brain tissue, blood vessels &/or ventricles

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21
Q

Diagnostic Tools used in Neurological Disorder?

A
  • CT/MRI * X-ray * Electroencephalography (EEG) * Lumbar Puncture * Cerebral angiography * Positron emission tomography (PET) * Electromyography (EMG) * Muscle and nerve biopsies * Blood cultures * Evoked response (Measure electrical
    signals to brain generated by hearing,
    touch, sight)
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22
Q

You are a nurse assigned to the Emegency department. You are assigned to 4 patients. What patient would be at highest risk for Traumatic Brain injury?
A. Your 21 year old client who is diagnosed with deep vein thrombosis
B. 75 year old client with a history of hypertension , who fell off the bed yesterday.
C. A pregnant woman who is 15 weeks gestation
D. a 20 year old college athlete. that plays basketball

A

B. 75 year old client with a history of hypertension , who fell off the bed yesterday.

Due to polypharmacy that includes aspirin and macular generation(loss of central vision) they walk into things and fall,

  • Brain injury is the fifth leading cause of death in older adults (CDC, 2020b).
  • The 65- to 75-year age-group has the second highest incidence of brain injury of all age-groups (CDC, 2020b).
  • Falls and motor vehicle crashes are the most common causes of brain injury (CDC, 2020b).
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23
Q

Are younger or older adults at risk for TBI
A.older
B.younger

A

A.older

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24
Q

What assessment finding warrants immediate attention for a patient who fell off the later yesterday?
A. Glasgow Coma Scale that has remained at 13 for 12 hours
B. Pinpoint pupils
C. Dolls Eye pupils
D. Tachycardia

A

C. Dolls Eye pupils,
Brain stem issue or asymmetrical pupils

always assess pupilsdoing cardinal gazes

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25
Q

Is TBi diagnosed easily and acutely?
A. Yes
B. No

A

B. No , it takes a while to be diagnosed
-can take months or years to be diagnosed

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26
Q

What is a complication for a patient who has sustained a traumatic brain injury?
A. Seizure
B. Diahrea
C. Hypoactive Bowel sounds
D. Weak and thread pulse

A

A. Seizure

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27
Q

What is the normal range for Increased Intracrnial pressure?
A. 30-40
B. 20-30
C. 10-20
D. 10-15

A

D. 10-15

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28
Q

Primary Brain Injury VS Secondary Brain Injury

A

Primary brain:
injury (focal and diffuse) results from mechanical injury at the time of the trauma

> Complications of further brain injury which leads to

Secondary brain injury:
Secondary injury to the brain includes any processes that occur after the initial injury and worsen or negatively influence patient outcomes.

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29
Q

OPEN VS CLOSED PRIMARY TBI

A

OPEN: Open TBI - occurs when the skull is fractured or pierced by a
penetrating object- the integrity of dura & brain compromised -

CLOSED:Closed TBI - integrity of the skull is not compromised

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30
Q

Findings of Secondary TBI

A

Any processes that occur after the initial injury and worsen or
negatively influences patient outcomes. * Most common are hypotension(MAP < 70), hypoxia(pO2 < 80),
intracranial hypertension and cerebral edema
HYPOTENSION
HYPOXIA
ISCHEMIA
CEREBRAL EDEMA, increased ICP which induces seizure

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31
Q

What is the best indicator of neurological status?

A

Level of consciousness

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32
Q

What are some warning signs of decreased neurological status?

A

-restless
-irritable
-decreased loc
-agitation

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33
Q

Nursing Interventions for for TBI

A

NO CLUSTER CARE
QUIET ENVIRONMENT
**DIM THE LIGHTS
DO NOT STARTLE PATIENT, it can cause stress and increase ICP

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34
Q

Posturing Disorders Decerbrate vs Decoricate

A

Extention and flexion is a sign of brain stem or midstem damage.

Decorticate posture – Flexor - Decerebrate posture – Extensor
- damage to midbrain/pons

35
Q

What is description of decorticate

A

A person whose elbows bend and fold their arms up toward their chest has decorticate posturing.(flex)

36
Q

What is description of decerbrate

A

A person whose limbs all extend away from their head has decerebrate posturing.

37
Q

S/S of MILD TBI

A

Physical Findings
* Appears dazed or stunned
* Loss of consciousness (if any) <30 minutes
* Headache
* Nausea
* Vomiting
* Balance or gait problems
* Dizziness
* Visual problems
* Fatigue
* Sensitivity to light
* Sensitivity to noise
Cognitive Findings
* Feeling mentally foggy
* Feeling slowed down
* Difficulty concentrating
* Difficulty remembering
* Amnesia about the events around the time of injury
Sleep Disturbances
* Drowsiness
* Sleeping less than usual
* Sleeping more than usual
* Trouble falling asleep

Emotional Changes
* Irritability
* Sadness
* Nervousness
* More “emotional”
* Depression

38
Q

Your patient has arrived on the mergency department unit and has sustained a neck injury? Which of the following nursing actions require further teaching?
A.Performing a head-neck tilt
B. Assessing lung sounds
C. Stablizing patients neck and spine
D. Log rolling the patient with multiple team members

A

A.Performing a head-neck tilt

39
Q

Patetn who has sustained a TBI will

A

often experience dysfunction in fianacial, social, and emotional status

40
Q

S/s of TBI

A

Amnesia (loss of memory) * Headache * Dizziness * Seizure * Loss of consciousness, sleepiness, drowsiness * Restlessness or irritability * Disorientation or confusion * Scalp bruising or tenderness * Personality changes * Diplopia * Gait changes

41
Q

Nursing Interventions for TBI Patients

A
  • First Priority–assessment of airway, breathing, circulation

Spinal precautions (make sure there is no damage to spine)

Vital signs, particularly fever

  • Full neurologic assessment
  • Prevent secondary brain injury
42
Q

What do we want to prevent for your patient who has sustained a traumatic head injury?
A.Temperature of 105 degrees
B.Heart rate of 99
C.SaO2 of 94
D. Respiration rate of 20

A

A.Temperature of 105 degrees

High temp can cause shivering and shivering can increase ICP which can induce secondary TBI

  • Vital signs, particularly fever

NORMALTEMP:18-65 yrs: 97.6-99.5°F

43
Q

Which sign and symptom should you report to th HCP
A. hypertension
B. tachycardia
C. restlessness
D. Glascow coma scale 13 from 15

A

C. restlessness

The most important variable to assess with any brain injury is LOC! A decrease or change in LOC is typically the first sign of deterioration in neurologic status. A decrease in arousal, increased sleepiness, and increased restlessness or combativeness are all signs of declining neurologic status.
Early indicators of a change in LOC include behavior changes (e.g., restlessness, irritability) and disorientation, which are often subtle in nature.

Report any of these signs and symptoms immediately to the primary health care provider or Rapid Response Team!

44
Q

What is cushings triiad?

A

The patient may have hypotension or hypertension. Cushing triad, a classic but very late sign of increased ICP, consists of severe hypertension, a widened pulse pressure (increasing difference between systolic and diastolic values), and bradycardia. This triad of cardiovascular changes usually indicates imminent death.

45
Q

S/s of cushings triad?

A

bradycardia
**increased systolic blood pressure
widened pulse pressure

46
Q

Which fluid and electrolye imbalance can cause seizures in patients who sustained a TBI?
A. Na 100.0
B. Potassium 5.2
C. Calcium 11
D. Magnesium 1.7

A

A. Na 100.0

Monitor sodium levels it can cause seizures

47
Q

What does Spinal precautions include?
A. vigorously shaking patient
B. Initiating the head chin tilt
C. Logrolling the patient
D. Hyperectending the patients neck

A

C. Logrolling the patient

Spine precautions require placing the patient supine and aligning the spinal column in a neutral position so there is no rotation, flexion, or extension

Patients with blunt trauma to the head or neck are typically transported from the scene of the injury to the hospital with a rigid cervical collar and a long spine board.

48
Q

SPINAL PREQUATIONS CONTINUED

A

(1) bedrest;
(2) no neck flexion with a pillow or roll;
(3) no thoracic or lumbar flexion;
(4) manual control of the cervical spine anytime the rigid collar is removed; and
(5) use of a “log-roll” procedure to reposition the patient

49
Q

Major Goals for patients who sustained TBI

A

Patent airway!

Adequate CPP
Fluid and electrolyte balance, particularly Soidum

Adequate nutrition, in initial tx may need TPN

. * Normal body temperature. * Skin integrity.
* Prevent secondary injury! * Prevent sleep deprivation. * Support the family. *
*Log roll patient knowledge about rehab. * No complications!
**MAP LESS

50
Q

Nursing intervention for total parental nutrition for patients who have sustained a TBI?

A

Change tubing and bag Q24 Hours, to prevent sepsis
monitor glucose

-at risk for dysphagia TI patient , we don’t want to induce aspiration

They will likely need TPN due to sustained injury that initiated a dysfunction in self-feeding

51
Q

Do patients who have sustained TBI need an interdisciplinary team?
A. No
B. Yes

A

B. Yes
to assure safe discharge for patient

52
Q

You notice a cloudy or clear fluid coming out of your patient’s nose and ears after sustaining TBI. What fluid would you suspect?
A. Cerebral Spinal Fluid
B. Cereumen
C. Mucus
D. Blood

A

A. Cerebral Spinal Fluid

53
Q

Is Cerbral Spinal fluid leak an emergency?
A. No
B. Yes

A

B. Yes

54
Q

How do you test for CSF leak?

A

-Take a brown paper bag
- let the paper dry.
you will notice a halo sign=csf leakage
(A RING OF BLOOD AND CEREBRAL SPINAL indicates glucose)
- Also called bullseye

55
Q

Pain management for patients who’ve sustained a TBI

A

-NO NARCOTICS
**-MONITOR FOR THE FIRST 24HRS AFTER TBI((
-ALWAYS ACETOMIPHEN

56
Q

What is a concussion?

A

a mild type of traumatic brain injury
-A concussion is a traumatic injury to the brain caused by a blow to the head and may or may not result in some period of unconsciousness.

Violent jarring of thing that results in diffuse and microscopic injury to the brain

  • Causes:
  • MVA, falls, shaking
57
Q

who is at risk for concussion?

A

Military personnel and people who participate in recreational or professional sports are especially at risk for concussions.

-shaken baby syndrome

Some patients report no immediate symptoms until later, which typically include impaired cognition (such as memory or thinking processes) and headache.

58
Q

What is post concussion syndrome?

A

The most common secondary injury from mild TBI, such as a concussion, is postconcussion syndrome. In this syndrome, the patient reports that headaches, impaired cognition, and dizziness continue to occur for weeks to months after the initial brain injury

59
Q

s/s for Post concussion Syndrome,(secondary brain injury)

A

Can last for a couple of months
* Amnesia,
* disorientation,
* *LOC,=first sign**
* headache,
* behavior & personality changes
* Lethargy
*Diplopia
*vertigo-
*dizziness

60
Q

Dx tools for Concussion

A

MRI or CT

61
Q

Should you let your client who has sustained a concussion sleep?
A. No
B. Yes

A

A. Nooooo

62
Q

What is the tx for headache for a client with concussion

A

ACETOMINOPHEN no sedation
- NO MORPHINE OR NARCOTICS

63
Q

What is a contusion

A

Injury is more serious than a concussion

Coup or Contracoup or Coup Controup
* Results in gross structural injury

  • Can accompany a skull fracture
64
Q

What is skull fracture?

A

Break in continuity of the skull or a separation at a
suture line
* Open vs Closed *
*
Basilar Skull Fracture – potentially serious due to proximity of the brain stem and internal carotid artery.

65
Q

s/s of Skull fracture

A
  • S/S depend on location and severity
  • Open non-depressed fx: irrigate, close, antibiotics * Depressed fx: surgical repair * Non-depressed fxs: observe
  • Rhinorrhea – leakage of CSF from nose * Otorrhea – leakage of CSF from ear * Halo test “Bulls eye”; glucose dipstick=posistive-csf
  • Periorbital ecchymosis – raccoon eyes
  • Battle’s sign; *periauricular ecchymosis – bruising
    of the mastoid process
  • Cranial nerve damage
66
Q

Are patients who’ve sustained a skull fracture at risk for CSF leakage?
A. No
B. Yes

A

B. Yes

  • Rhinorrhea – leakage of CSF from nose * Otorrhea – leakage of CSF from ear *
    dx
    Halo test “Bulls eye”; glucose dipstick

Periorbital ecchymosis – raccoon eyes * Battle’s sign; periauricular ecchymosis – bruising(bruising on-ear) of the mastoid process

  • Cranial nerve damage
67
Q

Can cranial nerves be damaged due to Skull fracture?
A. No
B. Yes

A

B. Yes

68
Q

Tx for Skull Fracture

A

*Open non-depressed fx: irrigate, close, antibiotics

*Depressed fx: surgical repair

*Non-depressed fxs: observe

69
Q

What should you monitor a client with a sull fracture?
A. combativeness
B. Alert and orented x4
C. Headache
D. Tachycardia

A

A. combativeness
agression,
restlessness,
irritatibilty

INITIATE RAPID RESPONSE TEAM

70
Q

Are patients with skull fractures included in spinal precautions?
A. yes
B.no

A

A. yes

Patients with blunt trauma to the head or neck are typically transported from the scene of the injury to the hospital with a rigid cervical collar and a long spine board.

The expected outcome is to prevent new and secondary spine injury. Spine precautions require placing the patient supine and aligning the spinal column in a neutral position so there is no rotation, flexion, or extension

71
Q

How many cranial nerves are there?
A. 5
B. 10
C. 12
D. 13

A

C. 12

72
Q

What is the function CRANIAL NERVE 1-Olfactory

A

smell

73
Q

What is the function CRANIAL NERVE 2-Optic

A

Central and peripheral vision

74
Q

What is the function CRANIAL NERVE 3-Oculomotor

A

Eye movement via medial and lateral rectus and inferior oblique and superior rectus
muscles; lid elevation via the levator muscle
-pupil constriction, cillary muscles

75
Q

What is the function CRANIAL NERVE 4-Trochlear

A

Eye movement via superior oblique muscles

76
Q

What is the function CRANIAL NERVE 5-Trigeminal

A

Sensory perception from skin of face and scalp and mucous membranes of mouth and nose, -muscle of chewing

77
Q

What is the function CRANIAL NERVE 6-Abducens

A

Eye movement via lateral rectus muscles

78
Q

What is the function CRANIAL NERVE 7-facial

A

Sensory: Pain and temperature from ear area; deep sensations from the face, taste from anterior two thirds of the tongue

Motor:Muscles of the face and scalp

Parasympathetic motor:Lacrimal, submandibular, and sublingual salivary glands

79
Q

What is the function CRANIAL NERVE 8-Vestibulocochlear

A

hearing and equillibrium

80
Q

What is the function CRANIAL NERVE 9- Glossopharyngeal

A

Sensory:Pain and temperature from ear; taste and sensations from posterior one third of tongue and pharynx
Motor:Skeletal muscles of the throat
Parasympathetic motor: Parotid glands

81
Q

What is the function CRANIAL NERVE 10-vagus

A

Sensory: Pain and temperature from ear, sensations from pharynx, larynx, thoracic and abdominal viscera

Motor:Muscles of the soft palate, larynx,
and pharynx (swallowing)

Parasympathetic motor: Thoracic and abdominal viscera; cells of secretory glands; cardiac and smooth muscle innervation to the level of the splenic flexure

82
Q

What is the function CRANIAL NERVE 11-Accessory

A

Skeletal muscles of the pharynx and larynx and sternocleidomastoid and trapezius muscles (swallowing)

83
Q

What is the function CRANIAL NERVE 12-Hypoglossal

A

Skeltal muscles in the tongue, swallowing

NUR 265 ADVANCED MED SURG (53 decks)

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