Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

NURS 3512 - Class 7-12 > Week 10 - Head Injuries > Flashcards

Week 10 - Head Injuries Flashcards

1
Q

describe the continuum of head injuries

A
  • can be mild ex. concussion

- or sever ex. traumatic brain injury (TBI)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

what are examples of causes of head injuries (4

A
  • car accidents
  • falls
  • assaults
  • sports & recreation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

the presentation of head injuries depend on.. (2)

A
  • severity of injury

- location (frontal, occipital, parietal, basilar etc.)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

who are involved in the care of head injuries

A
  • neurosurgery physicians/team
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

what diagnostics are used for head injuries

A
  • CT head

- Xray of the cervical spine (high risk of vertebral fracture)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

describe when head CT’s are done for head injuries

A
  • at time of arrival/injury

- repeat CT scan 48 hr later and compare

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

what is a risk associated w head injuries

A
  • IICP
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

describe the prognosis associated w head injuries

A
  • very high risk of death
  • either occurs immediately after injury (d/t damage of brain structures or hemorrhage)
  • 2hr after injury (secondary to organ trauma)
  • if survive 2hr period, death usually does not occur until 3 weeks after event (d/t multiple organ failures)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

what is a basilar skull fracture

A
  • fracture that occurs at the base of the skull
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

what are 2 signs of a basilar skull fracture

A
  • battle sign

- raccoon eyes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

what is the battle sign

A
  • post auricular ecchymosis

- bruising around the ear

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

what is the racoon eyes sign

A
  • bilateral periorbital ecchymosis

- bruising around the eyes

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

what influences the clinical manifestations of skull fractures

A
  • location of the skull fracture
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

if the pt is awake with a skull fracture, what are common compliants by the pt? (4)

A
  • tinnitus
  • poor hearing
  • vertigo
  • facial paralysis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what is a complication of facial and skull fractures

A
  • dural tear ) CSF leak)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

what is a dural tear

A
  • tear of dura mater (membranes surround brain) = leak of CSF
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

what is it called when CSF leaks through the ear

A
  • ottorhea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

what is it called when CSF leaks through the nose

A
  • rhinorrhea
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

what is a risk associated with a dural tear (and therefore a facial and skull fracture)

A
  • meningitis risk
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

what safety concern is associated w skull fractures

A
  • risk of NG tube insertion going into the brain
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

what are ways to determine if nasal drainage is mucus or CSF

A
  • halo sign

- dextrose stirp test

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

describe the halo sign to determine if leakage is CSF

A
  • soak exudate w 4x4
  • watch for a few min to see if halo appears
  • blood will be in the center, with the CSF creating a halo around
23
Q

describe the dextrose strip test to determine if nasal drainage is CSF

A
  • CSF = rich in sugar
  • mucus = no sugar
  • use a strip test to see if has glucose or not

note: blood also rich in sugar, therefore if blood is in the drainage may get a false positive

24
Q

what is a focal head injury

A
  • head injury that occurs in a specific area ( not diffuse bleeding all over)
  • bruising of brain tissue within a focal area
25
Q

what signs are seen w a focal head injury (3)

A
  • focal signs
  • but can lead to overall IICP
  • seizures common
26
Q

what is the prognosis of a focal head injury

A
  • depends on severity of contusion & whether it continues to evolve
27
Q

what diagnostic is used for focal head injuries

A
  • CT scan (can detect the extent of bleeding)
28
Q

what is a contre-coup injury

A
  • an injury that occurs both at the site of trauma and the opposite side of the brain from the force of the impact
  • leads to multiple contusions
29
Q

what are priorities with a focal head injury (3)

A
  • CT
  • monitor for IICP
  • no treatment to stop brain bleeds
30
Q

what is a diffuse axonal injury

A
  • widespread axonal damage that occurs after a TBI

- shearing of neurons –> axons swell and disconnect d/t trauma

31
Q

describe the severity of DAI

A
  • can be mild (concussion)

- or severe

32
Q

describe the recovery of a pt with severe DAI

A
  • 90% remain in a vegetative state
33
Q

at what point after a TBI does DAI occur

A
  • 12-24 hrs after initial TBI
34
Q

what does DAI result in (3)

A
  • global cerebral edema
  • IICP
  • decerebrate posturing
35
Q

what is a complication of a head injury

A
  • hemorrhage
36
Q

what are two types of hemorrhage that can occur as a complication of head injury

A
  • epidural hematoma = emergent

- subdural hematoma

37
Q

what is an epidural hematoma

A
  • bleeding between the dura and skull
38
Q

describe the severity of an epidural hematoma

A
  • emergency

- usually arterial = bleeds fast = ICP increases fast

39
Q

what is the treatment for an epidural hematoma

A
  • immediate surgery to remove the bleed
40
Q

what is included in nursing care for an epidural hematoma (2)

A
  • nursing care for IICP

- will have a monitor and drain in place

41
Q

what is a subdural hematoma

A
  • bleeding that occurs between the dura and arachnoid space
42
Q

a subdural hematoma is usually… what does this mean

A
  • venous = less urgent
43
Q

what is an acute subdural hematoma? subacute? chronic?

A
  • acute = up to 48 h after TBI
  • subacute = within 48h to 2 weeks after TBI
  • chronic (weeks or months after injury)
44
Q

what is the treatment for subdural hematoma

A
  • surgery to remove bleed
45
Q

what is the nursing care for subdural hematoma

A
  • nursing care for IICP`
46
Q

what are the overall goals of head injury nursing mngmt (4)

A
  • maintain adequate cerebral perfusion
  • remain normothermic
  • be free from pain, discomfort, and infection
  • attain maximal cognitive motor & sensory function
47
Q

what are key nursing assessments for head injuries (3)

A
  • monitor changes in LOC and neuro status –> sometimes q2min
  • halo test for CSF leak
  • treat IICP
48
Q

what are initial, at the scene, emergency mngmt interventions (6)

A
  • calm, gentle approach
  • patent airway
  • stabilize cervical spine until xray
  • apply pressure to external bleeding
  • warm blankets
  • assess for rhinorrhea, otorrhea, scalp wounds
49
Q

what are emergency mngmt interventions once the pt has access to the hospital (11)

A
  • O2 via NP or re-breath mask
  • establish 2 large bore IVs
  • keep warm
  • frequent neuro VS checks
  • ongoing monitoring of VS, O2 sats, cardiac rhythm, GCS, pupils, limb strength
  • support pt & family
  • watch for pain & infection
  • if pt off baseline, CT
  • support other organ systems
  • meds
  • prep for surgery if needed
50
Q

what meds are used during emergency interventions for a pt w a head injury once at the hospital (3)

A
  • pain meds
  • prevent seizures
  • drugs to decrease ICP and increase CPP
51
Q

describe fluid admin in a pt w head injury

A
  • give cautiously
52
Q

describe ways to keep a pt w a head injury warm (3)

A
  • IV fluids
  • warming lights
  • warm blankets
53
Q

what is included in frequent VS neuro checks for a pt w head injury (2)

A
  • monitor for IICP

- monitor for decreased CPP

NURS 3512 - Class 7-12 (49 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions