Week 6: Cerebral Alterations Part 2 Flashcards
In Head injury death occurs at what three points in time after injury?
- Immediately after the injury
- Within 2 hours after injury (related to initial ischemia and hypoxia)
- 3 weeks after injury (related to reprofusion)
Major complication of scalp laceration?
infection (but also profuse bleeding)
Types of Head Injury
- Linear (very small line) or depressed skull fracture
- Simple, compound, or comminuted
- Closed or open
- Direct and Indirect
- Coup (head goes forward quickly and the injury goes to the back of the brain) and Countercoup (head goes back quickly and injures the front of the brain)
Minor injury vs. Severe
Minor
- May loose conciousness
- transient period of confusion
- somnolence
- listlessness
- irritability
- pallor vomiting
Severe
- Increased ICP
- Bulging fontanel (infants)
- reinal hemorrhages
- extraocular palsises (CN111)
- hemiparesis
- quadraplegia
- increase temperature
- change in gait
- papilledema
Basal Skull fractures
- CSF leakage through nose or ear
- high risk for infection
- battle signs (bruising behind ear)
- raccoon sign (bruising around the eyes)
- possible injury to internal carotid artery
- permanent CSF leakage
Nursing Care of Skull Fractures
- Minimize CSF leak: bed flat, never suction orally, never insert NG tube, never use q-tips in nose/ears, caution patient not to blow nose
- Place sterile gauze/cotton ball around area
- Verify CSF leak: dextrosestik:positive for glucose
- Monitor closely: *respiratory status*
Temporary loss of consciousness
Mild Head Injury
obtunded for several hours
moderate head injury
in a coma
severe head injury
minor head trauma
sudden transient mechanical head injury that disrupts nerve actvity
- amnesia, headache, short duration, brief disruption in LOC
Post concussin syndrome
- 2 weeks to 2 months
- persistent headache
- lethargy
- personality and behavior changes
Concussion grading scale: Grade 1
- Transient confusion
- no loss of consciousness
- symptoms resolve in less than 15 minutes
Grade 2 concussion grading scale
- transient confusion
- no loss of consciousness
- symptoms last more than 15 minutes
concussion grading scale: Grade 3
- Any loss of consciousness, brief or prolonged
Concussion symptoms
- fatigue
- amnesia
- headache
- dizziness
- irritability (behavioral changes)
- memory disturbances
- seizures (rarely associated with later epilepsy)
Diagnostic testing for concussion
Ct of the head, EEG if suspicion of seizures, neuropsychological evaluation for memory issues
Contusion
bruising of brain tissue withing a focal area that maintains the integrity of the pia mater and arachnoid layers
lacerations
involve actual tearing of the brain tissue. Intracerebral hemorrhage is generally associated with cerbral laceration
Epidural hematoma
results from bleeding between the dura and the inner surgace of the skull. It is a neurologic emergency and of venous or arterial origin
Subdural hematoma
Occurs from bleeding between the dura matter and arachnoid layer of the menigeal covering of th ebrain
Types of subdural hematoma
- Subdural hematoma: usually venous in origin. Much slower to develop into a mass large enough to produce symptoms. May be caused by an arterial hemmorrhage
- Acute subdural hematoma: high mortality, signs within 48 hours of the injury. Associated with major trauma (Shearing forces). Patient appears drowsy and confused. Pupils dilate and become fixed
- Subacute subdural hematoma: Occurs within 2-1 days of the injury. Failure to regain consciousness may be an indicator
- Chronic subdural hematoma: Develops over weeks or months after a seemingly minor injury
Nursing interventions
- Monitor neurological status: GCS score, neurologic status, presence of CSF leaks
- Assist with ADLs
- Decrease Stimuli
- Patient/family teaching
Head injury nursing diagnosis
- Ineffective tissue perfusion
- Hyperthermia
- Acute pain
- Anxiety
- Impaired physical mobility
Head injury nursing management planning
- maintain adequate cerebral perfusion
- remain normothermic
- be free from pain, discomfort, and infection
- attain maximal cognitive, motor, and sensory function
Head Injury Nursing management nursing implementation
- Health Promotion: precent car and motorcycle accidents, wear safety helmets
- Acute Intervention: Maintain cerebral perfusion and prevent secondary cerebral ischemia. Monitor for changes in neurological status
- Ambulatory and Home Care: Nutrition, bowel and bladder management, spasticity, dysphagia, seizure disorders, family participation and education
- Bleeding into the fluid-filled areas (ventricles ) inside the brain
- IVH, the most common type
- Occurs mainly in preterm infants under 32 weeks of gestation
Intraventricular Hemorrhage of the Newborn
IVH causes
- Infants born before 30 weeks of pregnancy are at highest risk for such bleeding (smaller and younger, higher the risk bc blood vessels are premature and fragile)
- IVH is more common in premature babies who have had: respiratory distress syndrome, high BP, can occur in healthy premature babies born without injury
IVH Causes
- Rarely present at birth
- Develops in first several days of life, and rare after one month of age
- Falls into 4 grades, the higher the grade the more severe the bleeding
- Grade 1 &2 involve small amounts of bleeding and do not usually cause long term problems
- Grade 3 & 4 involve more severe bleeding
- Presses on or leaks into the brainm, blood clots form around that, leads to increased fluid volume creating hydrocephalus
Intravascular Patho of IVH
- Immature cerebral autoregulation
- Fluctuating cerebral blood flow (related to fluctuating arterial blood pressur)
- Increased cerebral blood flow due to hypercarbia and excess volume expansion
- Increased venous pressure
- Hypotention and reperfusion
- Coagulation abnormalities
Extravascular Patho of IVH
- Increased fibrinolytic activity
- poor vascular support in the cerebral tissue
- increased risk of hypoxia, hypercarbia, and acidosis due to immature respiratory system
IVH symptoms
- There may be no symptoms
- Breathing pauses
- Changes in BP and heart rate
- Decreased muscle tone
- Decreased reflexes
- Excessive sleep
- Lethargy
- Weak Suck
3 stages of clinical presentation of IVH
Catastrphic
- Acute IVH with bulgin fontanel, spil sutures, change in level of consciousness, pupillary and cranial nerve abnormalities, decerebrate posturing, and often with rapid decrease in blood pressure andor hematocrit.
Saltatory
- Gradual deterioration in neurological status, may be subtle abnormalities in level of consciousness, movement, tone, respiration and eye/position movement
Asymptomatic
- 25-50%, discovered on ultrasound. Fall in hematocrit or failure of hematocrit to rise wiht tranfusion should cause concern
IVH Treatment
- No current way to stop bleeding. Keep infant stable, treat symproms
- If swelling develops, spinal tap to relieve pressure. Surgery may be needed to place a tube or shunt to drain fluid
Grade 1 IVH
bleeding condined to periventricular area (germinal matrix)
Grade 2 IVH
Intraventricular bleeding less than 50%
Grade 3
intraventricular bleeding greater than 50%
Grade 4 IVH
Intra-Parenchymal echodensity (IPE) reperesents periventricular hemorrhagic infarction
psychogenic seizures triggers
- results from traumatic psychological experiences, sometimes from the forgotten past
- anxiety
- stress-induced
treatment for psycogenic seizures
psychotherapy and meds to treat underlying anxiety/stree. 70% resolve with treatment
Causes of meningitis and types and transmission
- inflammation of the membranes and the fluid space surronding the brain and spinal cord
Types:
- Septic: due to bacteria (strep pneumoniae, neisseria meningitis)
- Aseptic: due to viral infection, lymphoma, leukemia, or brain abscess
Transmission
- N. meningitis is transmitted by secretions or aerosol contamination and infection is most likely in dense community gorups such as college campuses
diagnostic testing for meningitis
- bacterial culture and gram staining of csf and blood are key diagnostic tests
- the presence of polysaccharide antigen in csf futher supports the diagnosis of bacterial meningitis
medical managment of meningitis
- prevention by vaccination against haemophilus influenzae and s pneumoniae for all children and all at-risk adults
- early administration of high doses of appropriate iv antibiotics (should cross bbb) for bacterial meningitis
- dexamethasone
- treatment dehydration, shock, and seizures
nursing managmenet of meningitis
- frequent/continual assessment including vs and LOC
- protect patient form injury related to seizure activity or altered LOC
- monitor daily weight, serum electrolutes, urine volume, specific gracity, and osmolality
- prevent complications associated with immobility
- infection control precautions
- supportive care
- measures to facilitate coping of patient and family
