week 2 Flashcards
Traumatic Head Injury
Result of a blow or jolt to the head
Result of penetration of the head by bullet or other foreign object
Classifications of Impairments/ Disabilities:
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%
Scalp Lacerations:
Most minor type of head trauma
Profuse bleeding
Major complication is infection
types of skull fractures:
Linear
Depressed
Comminuted
Open
closed head injury
Concussion Contusion Laceration Coup- Contrecoup injury Diffuse axonal injury
Mild Brain Injury
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
Moderate Brain Injury
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
Persons with Moderate and severe head injuries are never the same as before the injury
YEAH
Severe Brain Injury
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
SECONDARY INJURY
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)
Diplopia
double vision
Papilledema
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.
Factors that predict a poor outcome:
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
Elevated ICP may lead to
Inadequate cerebral perfusion
Cerebral herniation
Life threatening*
*leading cause of death from head trauma in patients who reach the hospital alive
Skull has three essential components:
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)
Increased ICP: Compensatory Mechanisms
Increased CSF absorption Decreased CSF production Increased venous outflow Changes in intracranial blood volume Slight compression of brain tissue
Increased ICP causes
Mass Lesions- Brain tumor, Hematoma, Hemorrhage
Head Injuries- Contusion, Posttraumatic brain swelling, Hemorrhage
Infections- Meningitis, Encephalitis
Vascular conditions- Cerebral infarct
Lead or arsenic intoxication
Clinical Manifestations of Elevated ICP
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
Cushing’s Response/Triad
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.
Basal skull fracture*
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
Clinical Manifestationsof Basal Skull Fracture
Battle’s sign
(postauricular ecchymosis)
Periorbital ecchymosis (raccoon eyes) Rhinorrhea
Otorrhea
Epidural Hematoma:
Bleeding between the dura and the inner surface of the skull
Usually arterial
epidural hematoma is a neurological emergency
Subdural Hematoma:
Venous bleeding between the dura mater and the arachnoid layer
Acute
Subacute
Chronic
Intracerebral Hematoma:
- Bleeding within the brain tissue
- Tearing of small arteries and veins
Subarachnoid hemorrhage (SAH) is the most common
- Tearing of small arteries and veins
Hydrocephalus
Abnormal increase in CSF volume
May lead to increased ICP
Brain Herniation
A result of elevated ICP
brain tissue shifts and herniates downward
herniation life-threatening
Penetrating Injuries
Complications:
Infection
Abscess
Meningitis
Diagnostic Studies
Computed Tomography (CT) Scan Magnetic Resonance Imaging (MRI) X-rays Positron Emission Tomography (PET scan) Transcranial Doppler studies GCS Ranchos Los Amigos Scale
Nursing Assessment
Neuro assessment including GCS
Head-to-toe assessment
CSF leak? (Halo sign or Dextrostix/Tes-Tape/Glucostick)
ICP? Cushing’s Triad
Signs of increasing ICP
impending cerebral disaster/ death and require prompt intervention.
Clients who have experienced head trauma/neuro damage
must be monitored closely for changes in neuro status or increasing ICP
Use neurologic recheck in the following sequence:
- LOC
- Motor function
- Pupillary response
- V/S
loc
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.
Levels of Consciousness
Full consciousness Confusion Lethargy (or somnolent) Stupor Coma
If the person is not fully alert, increase the amount of stimulus used in this order:
Name called Light touch on person’s arm Vigorous shake of shoulder Pain applied Record stimulus used and the person’s response to it.
Glasgow Coma Scale (GCS)
- 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.
Pupillary Response
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.
Check voluntary movement of each extremity by giving specific commands.
Ask the person to: lift eyebrows, frown, bare teeth. Note symmetric facial movements (cranial nerve VII)
Note person’s ability to follow commands
Exercise your own judgement if you should be checking:
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
Decerebrate
(extension)
Decorticate
(flexion)
hand and toes turned out
vs
flexed in
Measure TPR, BP, O2 sat.
Keep in mind the pulse and BP are late consequences of rising ICP
Pediatric Considerations
*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
Moderate to Severe Injury: Longer Term Challenges
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
Acquired Brain Injury Definition
Brain damage occurring after birth not related to:
a congenital disorder
a developmental disability or
a process of progressive damage
Traumatic Brain Injury
Falls, MVC, assault, sports injury
external force
Non-Traumatic Brain Injury
Hypoxia, Anoxia, Tumor, Toxins
internal process
Diffuse Axonal Injury (DAI)
Damage occurs after a mild, moderate, or severe brain injury
Manifestations- decreased LOC, increased ICP, Decerebrate or Decorticate posturing, and global cerebral edema
Early S/S of Increased ICP
Deterioration in LOC (e.g. confusion, restlessness, lethargy) Pupillary dysfunction Motor weakness, hemiparesis Sensory deficits Cranial nerve palsy Possible headache Possible seizure
Late S/S of Increased ICP
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)
Osmotic diuretics
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.
Corticosteroids
Corticosteroids are mainly used to reduce inflammation and suppress the immune system.
