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week 2 Flashcards

1
Q

Traumatic Head Injury

A

Result of a blow or jolt to the head

Result of penetration of the head by bullet or other foreign object

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2
Q

Classifications of Impairments/ Disabilities:

A 
Sensory/ Communication- 77.8%
Gross Motor Skills- 70.5%
Activities of Daily Living- 62.1%
Cognitive- 95.2%
Medical- 79.8%
Behavioral- 80.1%
Emotional- 76.5%
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3
Q

Scalp Lacerations:

A

Most minor type of head trauma
Profuse bleeding
Major complication is infection

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4
Q

types of skull fractures:

A

Linear
Depressed
Comminuted
Open

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5
Q

closed head injury

A 
Concussion
Contusion
Laceration
Coup- Contrecoup injury
Diffuse axonal injury
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6
Q

Mild Brain Injury

A

GCS 13-15

One or more of the following conditions occur following an injury:
Loss of consciousness less than 5 minutes
No Loss of consciousness, but may be confused, disoriented or feeling dazed
Headache
Nausea or vomiting (particularly vomiting more than once)
Fatigue or drowsiness
Difficulty sleeping or sleeping more than usual

Dizziness or loss of balance
Post-traumatic Amnesia (PTA) less than 1 hour
Memory or concentration problems
Mood changes or mood swings
Feeling depressed or anxious
Score of 13-15 on the Glasgow Coma Scale (GCS)
** mTBI often not recognized at initial time of injury

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7
Q

Moderate Brain Injury

A

Loss of consciousness up to 6 hours
GCS of 9-12
Abnormal brain imaging
PTA greater- up to 24 hours
Often requires ICU admission and further diagnostic testing
Significant cognitive impairments may exist

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8
Q

Persons with Moderate and severe head injuries are never the same as before the injury

A

YEAH

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9
Q

Severe Brain Injury

A

GCS of 3-8
Ongoing monitoring in ICU
Potential for Intracerebral lacerations, Intracranial hemorrhages, etc.
Secondary Injury may result from:
Hypotension, hypoxia, ischemia and cerebral edema

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10
Q

SECONDARY INJURY

A

Secondary Injury includes any processes that occur after the initial injury and worsen or negatively influence outcome.
Damage to the brain occurs primarily because the delivery of oxygen and glucose to brain is interrupted. (iggy, p. 1051)

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11
Q

Diplopia

A

double vision

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12
Q

Papilledema

A

s optic disc swelling that is caused by increased intracranial pressure. The swelling is usually bilateral and can occur over a period of hours to weeks.

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13
Q

Factors that predict a poor outcome:

A 
Intracranial hematoma
 Increasing age of the patient
 Abnormal motor responses
 Impaired or absent eye responses
 Early sustained hypotension, hypoxemia, or hypercapnia 
 ICP levels higher than 20 mm Hg
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14
Q

Elevated ICP may lead to

A

Inadequate cerebral perfusion
Cerebral herniation
Life threatening*

*leading cause of death from head trauma in patients who reach the hospital alive

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15
Q

Skull has three essential components:

A

Brain Tissue- 78%
Blood- 12%
Cerebrospinal fluid (CSF)- 10%

**all held within a rigid skull, therefore increases in one require a decrease in another in order to maintain normal ICP (10-15mmHg)

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16
Q

Increased ICP: Compensatory Mechanisms

A 
Increased CSF absorption
 Decreased CSF production
 Increased venous outflow
 Changes in intracranial blood volume 
 Slight compression of brain tissue
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17
Q

Increased ICP causes

A

Mass Lesions- Brain tumor, Hematoma, Hemorrhage
Head Injuries- Contusion, Posttraumatic brain swelling, Hemorrhage
Infections- Meningitis, Encephalitis
Vascular conditions- Cerebral infarct
Lead or arsenic intoxication

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18
Q

Clinical Manifestations of Elevated ICP

A 
Decreased LOC
N &V
Headache
Change in speech pattern (&/or slurred)
Aphasia
Cushing’s Triad
Decerebrate or decorticate posturing
Pupils non-reactive and either dilated or constricted
Seizures
Cranial nerve dysfunction
Behavioural Changes*:
Restless, irritable, confused
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19
Q

Cushing’s Response/Triad

A 
A compensatory response to rising ICP. 
A rising systolic pressure
A widening Pulse pressure
Bradycardia
Late signs of brain stem dysfunction,  correlates with decreasing brain compliance.
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20
Q

Basal skull fracture*

A

Many different possible fractures…Basal skull fracture is unique

Occurs at the base of the skull
Possible Clinical Signs:
CSF leakage from the nose
Blood behind eardrum
Bruising around eyes or behind ear
Loss of hearing, smell or vision; or double vision
Nerve damage-facial weakness
Potential for hemorrhage caused by damage to internal carotid artery, damage to CNs I, II, VII & VIII, and infection
If bleeding occurs into the foramen magnum-may see brainstem function changes (bradypnea, irregular respirations, hypertension, bradycardia, impaired balance, loss of vision)

CT: will show skull fracture in about 2/3 of head injury patients **often missed, therefore diagnosed based on clinical findings**
Treatment: 
Tend to heal themselves
Surgery to stop leakage if necessary
Careful monitoring
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21
Q

Clinical Manifestationsof Basal Skull Fracture

A

Battle’s sign
(postauricular ecchymosis)

 Periorbital ecchymosis (raccoon eyes)
Rhinorrhea

Otorrhea

22
Q

Epidural Hematoma:

A

Bleeding between the dura and the inner surface of the skull
Usually arterial
epidural hematoma is a neurological emergency

23
Q

Subdural Hematoma:

A

Venous bleeding between the dura mater and the arachnoid layer
Acute
Subacute
Chronic

24
Q

Intracerebral Hematoma:

A
  • Bleeding within the brain tissue
    • Tearing of small arteries and veins
      Subarachnoid hemorrhage (SAH) is the most common
25
Q

Hydrocephalus

A

Abnormal increase in CSF volume

May lead to increased ICP

26
Q

Brain Herniation

A

A result of elevated ICP
brain tissue shifts and herniates downward
herniation life-threatening

27
Q

Penetrating Injuries

A

Complications:
Infection
Abscess
Meningitis

28
Q

Diagnostic Studies

A 
Computed Tomography (CT) Scan
 Magnetic Resonance Imaging (MRI)
 X-rays
 Positron Emission Tomography (PET scan)
 Transcranial Doppler studies
 GCS
 Ranchos Los Amigos Scale
29
Q

Nursing Assessment

A

Neuro assessment including GCS
Head-to-toe assessment
CSF leak? (Halo sign or Dextrostix/Tes-Tape/Glucostick)
ICP? Cushing’s Triad

30
Q

Signs of increasing ICP

A

impending cerebral disaster/ death and require prompt intervention.

31
Q

Clients who have experienced head trauma/neuro damage

A

must be monitored closely for changes in neuro status or increasing ICP

32
Q

Use neurologic recheck in the following sequence:

A
  1. LOC
  2. Motor function
  3. Pupillary response
  4. V/S
33
Q

loc

A

change in LOC is the most important factor in the exam

most sensitive indication of change in neuro status
A change in consciousness may be subtle.

Note any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior.

34
Q

Levels of Consciousness

A 
Full consciousness
Confusion
Lethargy (or somnolent)
Stupor 
Coma
35
Q

If the person is not fully alert, increase the amount of stimulus used in this order:

A 
Name called
Light touch on person’s arm
Vigorous shake of shoulder
Pain applied
Record stimulus used and the person’s response to it.
36
Q

Glasgow Coma Scale (GCS)

A
  • scale is divided into three areas: eye opening, verbal response, motor response.
    ** is an objective assessment that defines the LOC by giving it a numeric value
    **Each area is rated separately,
    the three numbers are added,
    total score = brain’s functional level.

Fully alert score: 15

Coma score: 7 or less.

37
Q

Pupillary Response

A

Note size, shape and symmetry of pupils.

Shine a light into each pupil and note the direct and consensual light reflex

Both pupils should constrict briskly

Documenting pupil size is best expressed in millimeters.
Allow for the effects of any medication that could affect pupil size and reactivity.

In a brain-injured person, a sudden unilateral, dilated and nonreactive pupil is ominous.

Cranial nerve III runs parallel to the brain stem down, pressure on cranial nerve III causes pupil dilation.

38
Q

Check voluntary movement of each extremity by giving specific commands.

A

Ask the person to: lift eyebrows, frown, bare teeth. Note symmetric facial movements (cranial nerve VII)

Note person’s ability to follow commands

39
Q

Exercise your own judgement if you should be checking:

A

hand grasps
palmar drift
straight leg raises
Instead you can use the following techniques:

hold up one finger

push one foot at a time against your hand’s resistance

40
Q

Decerebrate
(extension)

Decorticate
(flexion)

A

hand and toes turned out
vs
flexed in

41
Q

Measure TPR, BP, O2 sat.

A

Keep in mind the pulse and BP are late consequences of rising ICP

42
Q

Pediatric Considerations

A

*Best Verbal Response may be assessed by:
Languaging at level of child
Recognition of family members, favourite toy or TV show
*Best Motor Response may be assessed by:
Using toys to encourage child to reach for items, observe grasp, co-ordination
*Best Pupillary Response
Allow child to play with flashlight, shine in own eyes, encourage child to look at parents/pictures.
*If unable to identify specific health challenge, look for:
Lethargy
Irritability
High pitched cry
Decreased appetite

43
Q

Moderate to Severe Injury: Longer Term Challenges

A

Mental and emotional changes often most difficulty
Personality change
Loss of concentration/memory
Decreased motivation, apathy
Euphoria, mood swings
Lack of awareness of seriousness of injury
Loss of social restraint, judgment, tact, and emotional control

44
Q

Acquired Brain Injury Definition

A

Brain damage occurring after birth not related to:
a congenital disorder
a developmental disability or
a process of progressive damage

45
Q

Traumatic Brain Injury

A

Falls, MVC, assault, sports injury

external force

46
Q

Non-Traumatic Brain Injury

A

Hypoxia, Anoxia, Tumor, Toxins

internal process

47
Q

Diffuse Axonal Injury (DAI)

A

Damage occurs after a mild, moderate, or severe brain injury

Manifestations- decreased LOC, increased ICP, Decerebrate or Decorticate posturing, and global cerebral edema

48
Q

Early S/S of Increased ICP

A 
Deterioration in LOC (e.g. confusion, restlessness, lethargy)
Pupillary dysfunction
Motor weakness, hemiparesis
Sensory deficits
Cranial nerve palsy
Possible headache
Possible seizure
49
Q

Late S/S of Increased ICP

A

Continued deterioration in LOC (coma)
Possible vomiting
Headache
Hemiplegia, decortication, or decerebration
Alteration in V/S
Respiration irregularities
Impaired brain stem reflexes (corneal, gag reflexes)

50
Q

Osmotic diuretics

A

is a type of diuretic that inhibits reabsorption of water and Na. They are pharmacologically inert substances that are given intravenously. They increase the osmolarity of blood and renal filtrate.

51
Q

Corticosteroids

A

Corticosteroids are mainly used to reduce inflammation and suppress the immune system.

PNH (18 decks)

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